Effects of Post-Stroke Rehabilitation on Older Adults: Nursing-Care

Introduction:

Literature review is systematically written presentation on given area of study or topic (Burns and Saunders, 2005), and this paper is a systematic review, investigating the effects of post-stroke rehabilitation with special reference to older adults (?65). The Stroke Association [TSA] (2010b) defined stroke as disturbance to the brain’s blood supply resulting in damage(s) to brain’s cells/tissues (Figure1).

The rationale (see appendix1) is partly because National Audit Office [NAO] (2005p.4) stated that, over 110,000 strokes and 20,000 transient ischaemic attacks [TIA] occurs annually in England. Additionally, over 300,000 people are living with stroke related disabilities and, over 75% of all stroke fatalities occur in older adults aged ?65 (DH, 2007p.13). Various policy documents also informed the choice of topic (appendix2). However, little evidence exists on the effectiveness of post-stroke rehabilitation in relation to this adult-cohort.

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Outcome parameters includes mortality rate, level of disabilities, mobility, speed of recovery, and Barthel Index [BI] scores on activities of daily living [ADL]. ADL is colloquially called activity of living [AL] in relation to nursing process however ADL is used in accordance with BI scale used in specialist stroke units [SSU] in England (SNPlacement, 2009).

There was paucity of studies on post-stroke rehabilitation in older adults though there is wealth of information on outcomes of different care structures. However, little evidential research exists that clarifies combination or individual rehabilitation pathways that better suited older adults. However, Stroke Unit Trialist’ Collaborations [SUTC] in 1993, 2001, and 2007 concluded that post-stroke fatality was lowest in Trusts with greater number of SSU care thus, nurses with advanced knowledge on stroke.

This write-up included only studies used in Cochrane collaborative reviews and meta-analysis, and similar collaborations. Consequently, reducing the risks associated with validity, reliability, generalizability, bias, and ethics often encountered when reviewing research studies (PHRU, 2006). Systematic approach, and various search engines were utilised for the literature searches (appendix3). The writer systematically organised the nine chosen research articles/studies (appendix4) into groups of three within three chapters:

• Chapter One: Specialist Stroke Units Versus General/Neurological Wards.
• Chapter Two: Specialist Stroke Units Versus Specialist Stroke Unit with Early Supported Discharge.
• Chapter Three: Efficacy of Specialist Stroke Unit Care on Post-Stroke Rehabilitation: A Way Forward for Older Adults?

Informed consent (NMC, 2008) was, obtained from gatekeepers (appendix4) prior to visiting an SSU in Southern England for empirical fact-finding in March 2011. The term “the writer” refers to the author of this review to avoid ambiguity of terminology (Polit and Beck, 2010).

Chapter one 

Specialist stroke units versus general / neurological wards

According to RCN (2007) rehabilitation is a holistic person-centred, action-based process which entails individual’s ability to learn adaptive ways of dealing with changes in life circumstances due to incapacitation resulting from conditions such as stroke. It is the process by which stroke survivors learn new skills and or relearn skills that are lost or rendered dormant due to damages to areas of the brain. For example, hand to mouth co-ordination in order to feed oneself, and relearning mobility with the aid of walking devices. Indeed, paralysis to one-side of the body often leads to survivors needing to learn how to perform ADL with one-side of the body. The primary characteristics of evidence-based rehabilitative regime entails repetitive practice of specific skills in a carefully coordinated, and well-focused manner similar to those utilised when learning a new skill such as swimming or riding so as to achieve mastery or best possible level allowed by ones condition. Post-stroke rehabilitation for most survivors can be a lifetime activity. Moreover, very few cases of rehabilitation are time-limited.

The key political influence on rehabilitation process for older adults is the National Service Framework (DH, 2001) which emphasises the importance of rehabilitation and the availability of rehabilitation services. It has had huge impacts on the rehabilitation service provision and treatment for older people in the UK since 2002. Rehabilitation can be a lifetime activity moreover very few cases of rehabilitation are time-limited.

Over the years, stroke patients were cared for in general/neurological wards (GW). However, during the past two decades, specialist stroke units (SSU) have emerged as a preferred treatment option for stroke patients mainly due to evidence from various meta-analytic studies (SUTC, 1999; 2001; 2007). The results suggest that SSU care has beneficial effects by reducing post-stroke mortality, need for institutionalization, and improving ADL and speed of recovery. Indeed, SUTC (2007) published meta-analysis with 6936 participants from 31 trials were analyzed to assess whether SSU care was consistently associated with improved outcomes. The authors concluded that patients who received SSU care were more likely to survival, remain independent, and living at home 12 months post-stroke accident. Langhorne et al., (2002) proposed that the basic characteristics of SSU are stroke specialist staff including nurses; dedicated units; multidisciplinary team [MDT] care, and systematic diagnostic evaluation; acute monitoring and treatment; early post-stroke mobilization; and early immediate start of rehabilitation (cited in Indredavik, 2008p.1). However, not all SSU have these detailed characteristics thus for the purpose of this analysis, irrespective of structure, all studies with units similar to defined characteristics are given the blanket term of SSU.

Kalra et al., (2000Study1) in their prospective RCT study compared the efficacy of SSU with stroke team or domiciliary care using 457 acute-stroke patients (48% women) with an average age of 76 years (appendix1). During the 12 month follow-up, the data suggests that there was low mortality or institutionalisation for patients treated on SSU compared to patients who were treated by the GW stroke team (21/152 [14%] versus 45/149 [30%]; p<0.001) or domiciliary stroke care (21/152 [14%] 34/144 [24%]; p<0.03) stroke. The results suggest that SSU were more effective than GW with stroke team or domiciliary stroke care in reducing mortality, dependency and, institutionalisation post-stroke. This was similar to the findings in the prospective comparative cohort study by Glader et al., (2001study2) which is a two years follow-up study that investigated rate of stroke-case-fatality, and patients’ level of independent assistance for primary ADL before and post-stroke (appendix4). The authors found that with regard to stroke-case-fatality there was 30.2% of SSU and 34.0% of GW treated patients. There was 25.4% and 29.1% respectively for rate of case fatalities for SSU and GW patients who were independent in primary ADL prior to stroke (OR, 1.18; CI, 1.06 TO 1.30). The 3376 participants that completed the questionnaire had mean age of 74.3 years (SD, 10.6) with 1.4 years in age difference between SSU and GW treated patients. More SSU treated patients were still living in their own homes, and most maintained independence with primary ADL. Indeed, following case adjustment for differences in case mix, SSU treatment remained an independent predictor for patients retaining independence of assistance with ADL two years post-stroke. Conversely, with regards to patients dependence on assistance for primary ADL defined by BI, 354 patients that required assistance with primary ADL had an average age of 78.5 years (SD=9.8). SSU and GW treated patients had average age of 79.0 versus 77.6 years respectively with p-value of p=0.19 which is not statistically significant. Indeed, patients cared for in SSU had statistically significant less pain compared to GW patients, this statistical significant difference remained after adjustment for differences in case mix prior to stroke (OR, 0.75; CI, 0.61 to 0.91).

Kalra et al., (2000study1) in their own study suggested that the reduced mortality or institutionalisation amongst SSU patients was attributed to reduction in post-stroke mortality. Moreover, the benefits of SSU care was further emphasized because, the proportion of survivors without severe disability at 12 months follow-up was statistically significantly higher for SSU patients compared with GW stroke team (129/152 [85%] versus 99/149 [66%]; p<0.001) or domiciliary stroke care (129/152 [85%]) versus (102/144[71%]; p=0.002). These differences were present at both 3 and 6 months follow-ups post-stroke. Therefore, the results further suggest that SSU are more effective than GW with stroke team or domiciliary stroke care in reducing mortality, dependency and, institutionalisation post-stroke. Indeed, the ADL barthel score (15-20) was best for SSU patients at 3 months follow-up (82%) compared to 70% of patients in GW with stroke team and, 74% of patients in the domiciliary stroke care.

Zhu et al., (2009study3) in a recent comparative retrospective cohort study on the impact of SSU on length of hospital stay and case fatality further demonstrated the efficacy of SSU to reduce stroke fatality and speed-up recovery. They found that for all stroke patients, the adjusted odds on length of hospital stay (>7days) was reduced by 22% (p<0.0001) on SSU compared to GW. Congestive heart, dementia, and peptic ulcer disease were the co-morbidities (p<0.05) that predicted duration of hospital stay. Indeed, SSU care significantly reduced overall in-hospital case fatality (adjusted OR, 0.70, p<0.0001). The authors observed that reduction in case fatality for SSU patients was similar to the 5% mortality reduction observed in the follow-up of a similar study by Candelise et al., (2007).

In summary, the studies by Kalra et al., (2000); Glader et al., (2001); and Zhu et al., (2009) supports the efficacy that SSU care characterised by admission to an SSU with stroke-directed nursing care, physio and occupational therapy, and assessment by a stroke neurologist is beneficial and the preferred post-stroke care pathway. These results were similar to those from SUTC (2002; 2007) reviews/ meta-analysis of SSU. Indeed, Jarman et al., (2004) research on whether there was a link between reduced in-hospital mortality rates, and acute SSU and early Computerised Tomography scan suggests that acute-SSU were associated with >10% lower odds of death.

The proposal here is that, nursing process model of care which entails assessment; care-planning; implementation; evaluation with assessment; and evaluation as a continuous process until discharge and beyond (Holland et al., 2004) were beneficial in reducing stroke fatality; institutionalization or faster improvements in patients ability to be more independent in ADL for SSU patients compared to GW patients post-stroke. Results from a National Sentinel Audit (NSA) of stoke for UK except Scotland (Rudd et al., 2005) arrived at similar conclusions. Additionally, the beneficial effects of SSU compared to GW can be conceptualised in terms of specialist stroke, rehabilitation nurses’ expertise thus superior clinical judgement (Tanner, 2006). Indeed, the 24/7 characteristic of clinical nursing allows nurses to get to know the patient as an individual thus creating the unique bond that enable nurses to care, based on empirical knowledge of the patient instead of fitting rehabilitation models to the patient based on written medical judgement alone (McCaffery et al., 2000).

If rehabilitation is a continuous process that could last a life-time, when does rehabilitation commence post-stroke Hypothetically speaking, what happens after patients are discharged from GW or SSU, and does rehabilitative nursing care continue within the community Are patients better off in the community once stable; are the beneficial effects of SSU due to the 24/7 stroke specialist nursing care given to patients within a structured, MDT staffed, purpose-built stroke unit/ward?

From an economic point of view, patients occupying hospital beds post-stroke with each bed costing over ?400 per night is quite expensive (SNPlacement, 2009) especially when such patient is stable and can continue receiving rehabilitative nursing care within the community preferable in their own home. Having established that SSU have better patient outcome compared to GW, in view of the economic implication, the next chapter will investigate SSU with early supported discharge as a possible solution.

Chapter two 

Spesialist stroke units with  early supported discharge versus specialist stroke units alone :

The Cochrane library (2000) classified SSU services that offer in-hospital patients an early discharge with a follow-up that consists of community-based rehabilitation as ‘early supported discharge’ [ESD]. NormalSSU may be defined as stroke unit treatment according to evidence-based recommendations (SUTC, 1997) combined with further inpatient rehabilitation when more long-term rehabilitation is necessary and a follow-up program organized by the primary healthcare system after discharge (Indredavik et al., 2000p.2990).

According to SUTC (2004) review, there are benefits to SSU care with ESD. Consequently, this chapter investigates the efficacy that ESD following treatment in SSU speeds-up recovery; reduces time spent in hospital; and empowers surviving patients to return faster to independence ADL. The later maybe attributed to the ideological belief that patients discharged home are able to continue their rehabilitation in familiar surroundings thus removing the institutional aspect of rehabilitative nursing care and general therapy (Kosh et al., (2000b).

Post-stroke discharge is a process at the end of the patient’s initial rehabilitation following stabilisation after a stroke. Because discharge planning is a joint responsibility, specialist stroke nurses in their role as patient advocate (NMC, 2008), and facilitator (Harms and Benson, 2003), actively liaise with other professionals in the best interest of the patient in accordance with NMC (2008) code.

Thorsen et al., (2005study4) evaluated the optimal effect of ESD and continued rehabilitation at home, in terms of patient outcome 5 years after stroke and changes over time. Amongst the 30 patients in the SSU with ESD (intervention group), there was significantly higher independence in extended ADL and, they were active in household chores compared to the 24 patients in the control group during evaluation five years post-stroke. Indeed, the results were similar to those from the study by Indredavik et al., (2000study5) which had a complex robust protocol of MDT post-discharge collaboration with each patient at the centre of every intervention and decision about his/ her care. The extended ESD post-discharge MDT is similar to a ‘community care service’ provision in the UK (DH, 2004). The study evaluated the short-term effects of an advanced SSU care service with essential ESD versus a normal standard SSU. The results suggests that at 6 weeks, 54.4% of the extendedSSU group and 45.6% of the normalSSU group were independent based on RS (P=0.118), and 56.3% versus 48.8% were independent based on BI (P=0.179). 33.1% of the extendedSSU patients were discharged to another institution (mainly rehabilitation clinics) versus 51.3% in the normalSSU group (p=0.001). Moreover, the proportion of patients at home was 74.4% (extendedSSU), and 55.6% (normalSSU) (P=0.0004), and the proportion in institutions was 23.1% versus 40.0%, respectively (P=0.001).

After 26 weeks, 65% (extendedSSU) versus 51.9% (normalSSU) group showed global independence (RS?2) (P=0.017), while 60.0% (extendedSSU) versus 49.4% (normalSSU) group were independent in ADL (BI ?95) (P=0.056). The OR for independence (extendedSSU versus normalSSU) were RS, 1.72 (95% CI, 1.10 to 2.70); BI, 1.54 (95% CI, 0.99 to 2.39). Additionally, 78.8% (extendedSSU group) versus 73.1% (normalSSU) were at home (P=0.239), while 13.1% versus 17.5% were in institutions (P=0.277). The average lengths of stay in an institution were 18.6 days (extendedSSU) and 31.1 days (normalSSU) (P=0.0324).

Additionally, Thorsen et al., (2005study4) study showed that, the Mean hospital stay was significantly shorter in home rehabilitated group [HRG] {HRG = extendedSSU} (14 versus 30 days; p=0.027). The percentage of patients independent in extended ADL was significantly higher in HRG compared to conventional rehabilitated group [CRG] {CRG = normalSSU}. HRG patients scored more favorably regarding motor capacity however, frenchay activities index [FAI] that assessed frequency of social activities was similar in the 2 groups. However, significantly more HRG patients were active in the items washing dishes (P=0.006), washing clothes (P=0.04), and reading books (P=0.01) (appendix4). There were similarities in both groups on data regarding falls (HRG 63%; CRG; 61%) and falls resulting in fractures (HRG19%; CRG 14%); and ?60% of patients had fallen during the 6 months period before the follow-up commenced. Indeed, patients improved independence in ADL found support in Kosh et al., (2000b) descriptive study on individualized intervention which suggests that patients experience through involvement and control in their own ESD encourages and empowers them to actively solve future related problems independently. Additionally, based on the findings from their study, Indredavik et al., (2000study5) suggested that extendedSSU with ESD improves functional outcome, and reduces the length of stay in institutions compared with treatment in normalSSU. This casts doubt on the 24/7 (presence of nurses) beneficial effects of specialist stroke nursing. However, Kosh et al., (2000b) theory on familiarity of environment goes a long way towards explaining the reason for the marked differences in patient outcome in favour of extendedSSU/HRG. Moreover, the writer believes that the nurse in the community still spends more time with the patient than all the other MDT members put together.

Indredavik et al., (2000study5) had a long-term follow-up of their study which was undertaken by Fj?rtoft et al., (2003study6) with the primary aim of evaluating the long-term effects of extendedSSU characterized by ESD. The authors data suggests that 56.3% (extendedSSU) versus 45.0% (normalSSU) were independent (RS?2) based on primary outcome of modified RS (P=0.044). The results showed that the number needed to treat (NNT) to achieve 1 independent patient in extendedSSU versus normalSSU was 9 (95% CI, 4.6 to 345). The OR for independence was 1.56 (95% CI, 1.01 to 2.44; p=0.045), with adjustment to independent variables, the effect of extendedSSU was even greater (OR 1.93; 95% CI, 1.12 TO3.32; P=0.018). There were no significant differences in BI score and patients final residence. Moreover, patients with moderate to severe stroke benefited most from the extendedSSU. Unlike the study by Indredavik et al., (2000study5), the number of patients residing at home was not significantly higher in the extendedSSU patients at 52 weeks (appendix4). It maybe deduced that in the long-run, all things being equal, the beneficial effects of extendedSSU over normalSSU though exists, are too minimal for statistical significance.

A subgroup analysis for patients in the study by Fj?rtoft et al., (2003study6) showed that the NNT to achieve 1 more independent patient in the extendedSSU group versus the normalSSU group was 7 (95% CI, 3.6 to 27.3). Additionally, 47% of the patients treated in the extendedSSU and 28% (normalSSU) were independent based on modified RS score (P=0.005). The average length of inpatient stay was 18.6 days (extendedSU group) and 31.1 days (normalSSU group) (P=0.0324). Using the fitted logistic regression model, the authors analyzed the relationship between the severity of stroke and the NNT in the extendedSSU group versus the normalSSU group to achieve 1 more independent patient. The authors analyzed the whole group, and patients were also divided into two age-groups: patients aged <75 years and patients aged ?80 years. Figures for the whole group suggests that, a baseline Scandinavian stroke scale [SSS] which according to Birschel et al., (2004) measures progression of stroke, score between 35 and 54 corresponds to a NNT <10. For older patients, the curves show the greatest benefit with SSS score >41 unlike the SSS score for younger patients which was between 28 and 50 (Fj?rtoft et al., 2003p.2689).

The results from these studies suggests that, irrespective of structure/pathway adopted, SSU care services are beneficial to stroke survivors in that it reduces, mortality, chances of post-stroke institutionalization, and or improves ADL. Additionally, when SSU is combined with ESD the benefits were even greater but mostly for patients with ‘mild’ to ‘moderate’ stroke. Indeed, these patients are often able to return to full pre-stroke ADL functionality. Based on the findings of the studies, extendedSSU with ESD improve functional outcome and reduces the length of stay in institutions compared with normalSSU. Moreover, the long-term studies suggests that extendedSSU care with ESD offers patients better long-term functional outcome after 12 months compared to patients offered normalSSU care services. It is the writer’s contention that, these results fly in the face of the ideology that 24/7 nurses presence was the catalyst for SSU beneficial effects because, extendedSSU occurred in the community without necessarily the 24/7 presence of nurses and nursing care. One fact remains constant, the 24/7 characteristic of SSU nursing allows nurses to get to know the patient as an individual thus creating the unique bond that enable nurses to offer more superior care (McCaffery et al., 2000).

ExtendedSSU offers patients better outcome with regards to ADL, and general functionality over time. Fj?rtoft et al., (2003study6) in their study, suggests that the older the adults, the greater the beneficial effects of extendedSSU compared to normalSSU. Indeed, the proposal here is that studies on extendedSSU utilised in this chapter could, inform future evidence-based care of post-stroke older adult (?65) patients. The UK Government not just the English NHS should take notice because extendedSSU may be the post-stroke rehabilitative care pathway that will offer older adults the best outcome, and for the Government, better economic outcome.

In view of the findings and proposals arrived at in this chapter, the next chapter will investigate the implications of post-stroke rehabilitative care of older adults by reviewing findings on stroke in the very old in relation to age related benefits; stroke in the very old; and extendedSSU.

Chapter three

Efficacy of stroke unit on post - stroke rehabilitation: A way forward for older adults?

For Smith (1999) one of the most difficult challenges facing nurses is to ensure that individual patient’s needs dominate within the hospital or healthcare professional’s programme, which can be difficult to achieve due to time, and financial constraints. Nurses 24/7 contact with patients within care-settings places them at the centre of all care-interventions and treatments prescribed for the stroke patient (RCN, 2004). Therefore, they are essential to the co-ordination of patient’s treatment and the care that the patient may require throughout the rehabilitation process in the care-setting and beyond. Rehabilitation framework contains components that take account of everyday skills, such as maintaining acceptable level of hygiene, dietary intake, and general mobility. In addition to these skills, the framework takes into account patient education and information the patient needs and, facilitates the patient to develop any additional knowledge. During rehabilitation, the nurse acts as the patient’s advocate, enabler, and empowerer placing the patient at the centre of care-interventions utilising nursing process to create care and rehabilitation plan tailored to individual patient needs. Rehabilitation nurses perform various roles (appendix6) including patient advocacy; facilitator; enabler; and empowerer (RCN, 2004).

We live in an aging society and aging has its own problems and with age, comes increases in co-morbid conditions and prevalence of stroke related conditions like arterial hypertension, atrial fibrilation, and dyslipidemia (Ellekja et al., 2001; Browner et al., 2001). Moreover, higher incidence of co-morbidities, decreases life expectancy, and alters metabolism (Saposnik and Black 2009). Though a sizeable number of strokes occur in older adults, there is worrying paucity of studies investigating effects of SSU care on older adults (?65 years). Roding (1986) proposed that with aging advancement, patients’ involvement in and control of their own rehabilitation becomes more important to self-worth therefore, reducing their control has an adverse effect on emotional and physical health. Kalra et al., (1993;1995) used non-randomized designs in their studies of significantly more older adults and, their results suggested that there are beneficial effects in SSU care of acute-stroke patients. How do we as the future nursing work force ensure that older adults are empowered and enabled to remain independent post-stroke therefore, are able to continue performing ADL independently, with reduced institutionalization, and or mortality?

Fagerberg et al., (2000study7) compared the effects of acute SSU care integrated with care continuum [this is called extendedSSU for current review] versus GW conventional treatment in a study of elderly stroke patients. They compared effects of GW treatment care versus effects of extendedSSU (acute-stroke unit) care integrated with geriatric care continuum (see appendix4). 162 patients who survived 12 months (95% CI, -10% to 16%) (101 (61%) and 49 (59%) post-stroke were randomized to extendedSSU and GW respectively.

They found that there were no significant differences in QALY or ADL, and after three months of extendedSSU care compared to GW, there was reduction in stroke fatality and institutionalization (28% versus 49%, respectively; 95% CI -40% to -3%) in patients with concomitant cardiac disease. However, after 12 months this effect was absent. 80% of extendedSSU group, and 72% of GW group (95% CI -4% to 18%) were discharged home. Indeed, results suggested that there was no significant effect on the number of patients living at home 12 months post-stroke. This was similar to two studies (Strand et al., 1985; Kaste et al., 1995) which proposed that extendedSSU care afforded patients positive outcomes in relation to functional state and need for institutionalization but, no effects on survival, and only transient effects on health-related QALY. Fagerberg et al., (2000study7) study suggests that the beneficial effects of acute-stroke care on degree of dependence and mortality were mainly present in those patients with severe stroke these are often older adults. Indeed, SUTC (1999) in a meta-analytic study suggested that, such favorable effects in older adults with severe stroke may have been overshadowed by patients with mild to moderate stroke in whom no obvious effect was obtained. For example, they found no significance on stroke fatality or institutional care in patients with mild stroke (95% CI, OR 0.57 to 1.24) compared with patients with severe stroke, in whom there was clearly significant effect of extendedSSU care (95% CI, OR 0.38 to 0.88). Fagerberg et al., (2000study7) concluded that extendedSSU neither led to improved ADL, nor increases in number of surviving older adults who were able to return home 12 months post-stroke. However, an effect on mortality or institutional care three months post-stroke was indicated in particular among elderly stroke patients with concomitant cardiac disease or severe stroke. Indeed, they found that elderly patients with stroke tend to delay seeking medical intervention following stroke onset which, suffices towards explaining the increase in acute-stroke in older adults apart from the biological explanations of natural aging effects (DH, 2007).

Saponsnik and Black (2009study8) research investigated hospital care case fatality disposition in the very elderly, and proposed that survival post-stroke decreased with age. For instance, stroke fatality at discharge by age-group were <69 (5.7%); 70-79 (8.6%); 80-89 (13.4%); >90 (24.2%). Indeed, for every 100 patients aged ?90 admitted with acute ischemic stroke, 38 died in hospital, 43 were discharged to institutions, and only 19 were discharged back to their pre-stroke residence. The risk adjusted fatality at discharge by age were <69 (6.3%); 70-79 (12.5%); 80-89 (22%); 36.1% (p<0.001). Moreover, older adults aged >90 are less likely (4.3 versus 13.0%; p<0.001) to be admitted to the intensive care unit [ICU], and discharged back to their pre-stroke residence (39.9% for >90s versus 57.3% for patients aged <90; p<0.001). This could be attributed to the ideology that due to age-related debilitation, ICU would be wasted on them as they have limited chance of full recovery thus, would not be cost-effective unlike in younger patients. After adjusting for covariates, the multivariable analysis showed that patients aged >90 were 5-8 times more likely to die, and there was a 55% (95% CI 48-60%) decrease in the odds of being discharged home in these patients compared to those aged 80-89 years. Risk-adjusted fatality at discharged among those >90 years was 6 times higher than in the youngest age group and 1.5 times higher than in those aged 80–89 years. Only 1 in 5 individuals >90 years were discharged home after an ischemic stroke versus 1 in 3 of those aged 80–89, and 3 in 4 for the youngest age group. Indeed, the data from this study informed the authors’ suggestion that, stroke patients aged >90 had higher mortality, increased incidence of hospitalization, and are list likely to be discharged to their pre-stroke residence. These results, suggests that the benefits of SSU decreases with age!

Saposnik et al., (2009study9) investigated whether the reduced mortality or institutionalization seen with SSU care was similar across all age groups. They found that, compared to patients admitted to GW (1892; 52.1%), SSU (1739; 47.9%) patients had lower case-fatality (10.2% versus 14.8%; P<0.0001) over a 30-days period with an ARR=4.6%; NNT=22. There were no significant differences in the mean organized care index score amongst different age-groups in access to SSU indeed, there was similar benefit for all age-groups when care in SSU was compared to care in GW (ARR for 30-day stroke fatality by age were <60 (4.5%); 60 to 69 (3.4%); 70 to 79 (5.3%); and >80 (5.5%). It was evident from the results that higher level of organized care positively correlates with increased stroke-survival thus reduced stroke-fatality or institutionalization. However, there is selection bias (Polit and Becks, 2010) because, patients who received palliative care intervention were less likely (40% versus 49%; P=0.008) than non-palliative patients to be admitted to SSU. Could this explain the increased beneficial effects of SSU, since palliative care patients were treated/ cared for in GW or similar setup Results from Fj?rtoft et al., (2003study6) in chapter two would disagree though it was premised on extendedSSU as opposed to standard.

Saposnik et al., (2009study9) 30-days stroke fatality by age-group suggests <59=6.7%; 60-69=7%, 70-79=10.9%, and >80=20.2%. 30-days risk-adjusted stroke fatality for organized care index scores was 16.6%=3; 21.9%=2; 29.1%=1; and 54.9%=0. Indeed, there were no substantial differences by age-groups in relation to SSU care benefits. In the multivariable analysis, SSU care remained an independent predictor of stroke fatality at 7 days (OR, 0.55; 95% CI, 0.40 to 0.77; c-statistics 0.79), and 30 days (OR, 0.66; 95% CI, 0.52 to 0.84; c-statistics 0.80) after adjusting for age, sex, stroke severity, Charlson index, and an age-by-SSU interaction term. The interaction terms examining age-by-SSU were not significant (P=0.80 for 7 days; P=0.98 for 30 days stroke fatality). After all analyses were investigated based on age modification, there was no evidence of effect. However, after adjustments for multiple prognostic factors, and exclusion of patients treated utilizing palliative care, the benefits of SSU care on survival remained. Similar findings were observed for the organized care index score (0 to 1 versus 2 to 3). For example, higher level of access to SSU care was associated with lower stroke fatality at 7 days (OR, 0.18; 95% CI, 0.13 to 0.25; c-statistics 0.83), and 30 days (OR, 0.31; 95% CI, 0.24 to 0.40; c-statistics 0.82). The interaction terms examining age-by-organized care index effect were again not significant (P=0.29 for 30-day stroke fatality and P=0.46 for 7-day stroke fatality) (Saposnik et al., 2009:p.3324). Therefore, the authors concluded that irrespective of patients’ age-cohort, SSU compared to GW care leads to significant reduction in stroke fatality or institutionalization.

Conclusion 

Nurses 24/7 presence is characterised by making them the primary link between the patient and the other members of the MDT (RCN, 2004). A successful rehabilitation uses a framework to make an integrated care pathway in which the patient, the MDT members, and the formal and informal carers can be involved. Indeed, stroke accident can occur at any age though older adults (?65) make-up the largest cohort of victims (DH, 2008).

Chapter one of this paper, critically reviewed the efficacy of SSU to reduce stroke fatality; reduce level of institutionalization; reduce length of in-hospital stay; and improve general recovery through ability to maintain primary ADL independently. Having established that SSU are beneficial, chapter two investigated the efficacy of SSU with early supported discharge [ESD] in relation to speedy recovery, independence in ADL (BI=?95%), and reduced post-stroke mortality. The better outcome from extendedSSU with ESD when compared to normalSSU cannot be attributed to 24/7 nursing alone because both extendedSSU and normalSSU had 24/7 nursing though there was better coordinated continuity in terms of discharge plan with rehabilitative nursing for extendedSSU. Therefore, the proposal here is that extendedSSU better patients’ outcome was mainly because specialist stroke nurses offered more one-to-one rehabilitative nursing care compared to those in the normalSSU.

Studies reviewed in chapter one, and two suggests that SSU care is, beneficial to stroke patients especially extendedSSU with ESD in adults. There is the matter of older adults, what with normal aging processes that tends to be degenerative thus resulting in possible (increased) vulnerable. However, studies in chapter two and three suggests that extendedSSU care similar to acute care of older adults’ is the best option for older adults (?65). This was supported by Indredavik (2009); SUTC, (2007).

The main outcome of this paper is that SSU care is the way forward for all stroke patients, and the best possible option for older adults. This is because 75% of all strokes occur in older adults (?65 years); and SUCT (1997; 2001; 2002; 2007) reviews have determinately suggested that SSU care is the best option for reduced level of stroke fatality, institutionalisation, or improved post-stroke ADL [BI scores].

The findings of this literature review is important for UK policy makers in relation to post-stroke rehabilitation care pathway for older adults because it goes some way towards establishing that extendedSSU is better option for older adults. However, further research are necessary before such results can inform evidence-based practice thus, policies on stroke care in older adults.

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