Search

Introduction: Urinary incontinence (UI) affects over half of people with stroke. It is unclear which methods are accurate in assessing presence and type of UI to inform clinical management. Diagnosis of UI based on inaccurate methods may lead to unnecessary interventions. The aims of this systematic review were to identify, for adults with stroke, clinically accurate methods to determine the presence of UI and type of UI. Method: We searched seven electronic databases and additional conference proceedings. To be included, studies had to be primary research comparing two or more methods, or use a reference test. Results: We identified 3846 studies with eight eligible for inclusion. We identified 11 assessment methods within the eight studies. Only five studies had sufficient comparator data for synthesis. Due to heterogeneity of data, results on the following methods were narratively synthesised: Core Lower Urinary Tract Symptom Score (CLSS), clinical history and physical examination, Barthel Activities of Daily Living Index, International Consultation Incontinence Questionnaire Short Form (ICiQ-SF) and urodynamic studies (UDS). Most studies were small and of low to medium quality. All reported differences in sensitivity, and none compared the same assessment methods. Conclusion: Current evidence is insufficient to support recommendations on the most accurate UI assessment for adults with stroke. Further research is needed.

Aims and Objectives To explore healthcare staff’s experiences of how dehydration is identified and managed in hospitalised patients after acute stroke, and facilitators and challenges to optimising hydration. Background Optimal hydration post-stroke reduces the risk of neurological deterioration and other complications. Patients are at risk of dehydration in acute stroke, particularly those with dysphagia. Design A descriptive qualitative study reported following the COREQ guidelines. Methods Semi-structured interviews, utilising patient vignettes, were conducted in 2018 (Apr-Oct) with a purposive sample of 30 multi-disciplinary staff members from two UK stroke units. Interviews were digitally recorded and transcribed verbatim. Content analysis identified common themes which were mapped to the Theoretical Domains Framework and the Behaviour Change Wheel. Results The themes mapped to twelve of the fourteen domains in the Theoretical Domains Framework. Participants believed that inadequate hydration management had potentially serious consequences, and described complex knowledge, skills and cognitive elements to effective hydration care. Participants felt that maintaining hydration was a multidisciplinary responsibility requiring good communication. Although the performance of initial dysphagia screening was reinforced by external audit, other areas of post-stroke hydration management were not; notably, there was no established method of assessing hydration. Barriers to maintaining good hydration included lack of staff, out-of-hours working patterns, low priority given to hydration, patients’ co-morbidities, and complex post-stroke disabilities such as dysphagia, aphasia, inattention and hemiparesis. Conclusion Findings highlighted the importance of assessing and maintaining hydration but identified barriers to, and variation in, clinical practice. To provide optimal care, barriers to the prevention and treatment of dehydration after stroke must be further understood

Aims and Objectives To explore healthcare staff’s experiences of how dehydration is identified and managed in hospitalised patients after acute stroke, and facilitators and challenges to optimising hydration. Background Optimal hydration post-stroke reduces the risk of neurological deterioration and other complications. Patients are at risk of dehydration in acute stroke, particularly those with dysphagia. Design A descriptive qualitative study reported following the COREQ guidelines. Methods Semi-structured interviews, utilising patient vignettes, were conducted in 2018 (Apr-Oct) with a purposive sample of 30 multi-disciplinary staff members from two UK stroke units. Interviews were digitally recorded and transcribed verbatim. Content analysis identified common themes which were mapped to the Theoretical Domains Framework and the Behaviour Change Wheel. Results The themes mapped to twelve of the fourteen domains in the Theoretical Domains Framework. Participants believed that inadequate hydration management had potentially serious consequences, and described complex knowledge, skills and cognitive elements to effective hydration care. Participants felt that maintaining hydration was a multidisciplinary responsibility requiring good communication. Although the performance of initial dysphagia screening was reinforced by external audit, other areas of post-stroke hydration management were not; notably, there was no established method of assessing hydration. Barriers to maintaining good hydration included lack of staff, out-of-hours working patterns, low priority given to hydration, patients’ co-morbidities, and complex post-stroke disabilities such as dysphagia, aphasia, inattention and hemiparesis. Conclusion Findings highlighted the importance of assessing and maintaining hydration but identified barriers to, and variation in, clinical practice. To provide optimal care, barriers to the prevention and treatment of dehydration after stroke must be further understood

Background Stroke can affect people’s ability to swallow, resulting in passage of some food and drink into the airway. This can cause choking, chest infection, malnutrition and dehydration, reduced rehabilitation, increased risk of anxiety and depression, longer hospital stay, increased likelihood of discharge to a care home, and increased risk of death. Early identification and management of disordered swallowing reduces risk of these difficulties. Objectives Primary objective • To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration associated with dysphagia in people with acute stroke Secondary objectives • To assess the influence of the following sources of heterogeneity on the diagnostic accuracy of bedside screening tools for dysphagia ‐ Patient demographics (e.g. age, gender) ‐ Time post stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke swallow screening tools are identified ‐ Definition of dysphagia used by the study ‐ Level of training of nursing staff (both grade and training in the screening tool) ‐ Low‐quality studies identified from the methodological quality checklist ‐ Type and threshold of index test ‐ Type of reference test Search methods In June 2017 and December 2019, we searched CENTRAL, MEDLINE, Embase, CINAHL, and the Health Technology Assessment (HTA) database via the Centre for Reviews and Dissemination; the reference lists of included studies; and grey literature sources. We contacted experts in the field to identify any ongoing studies and those potentially missed by the search strategy. Selection criteria We included studies that were single‐gate or two‐gate studies comparing a bedside screening tool administered by nurses or other healthcare professionals (HCPs) with expert or instrumental assessment for detection of aspiration associated with dysphagia in adults with acute stroke admitted to hospital. Dat

Objectives The aim of this national survey was to explore the impact of COVID‐19 public health measures on access to social support services and the effects of closures of services on the mental well‐being of older people and those affected by dementia. Methods A UK‐wide online and telephone survey was conducted with older adults, people with dementia, and carers between April and May 2020.The survey captured demographic and postcode data, social support service usage before and after COVID‐19 public health measures, current quality of life, depression, and anxiety. Multiple linear regression analysis was used to explore the relationship between social support service variations and anxiety and well‐being. Results 569 participants completed the survey (61 people with dementia, 285 unpaid carers, and 223 older adults). Paired samples t‐tests and X2‐tests showed that the mean hour of weekly social support service usage and the number of people having accessed various services was significantly reduced post COVID‐19. Multiple regression analyses showed that higher variations in social support service hours significantly predicted increased levels of anxiety in people with dementia and older adults, and lower levels of mental well‐being in unpaid carers and older adults. Conclusions Being unable to access social support services due to COVID contributed to worse quality of life and anxiety in those affected by dementia and older adults across the UK. Social support services need to be enabled to continue providing support in adapted formats, especially in light of continued public health restrictions for the foreseeable future. This article is protected by copyright. All rights reserved.

Background Urinary incontinence can affect 40% to 60% of people admitted to hospital after a stroke, with 25% still having problems when discharged from hospital and 15% remaining incontinent after one year. This is an update of a review published in 2005 and updated in 2008. Objectives To assess the effects of interventions for treating urinary incontinence after stroke in adults at least one‐month post‐stroke. Search methods We searched the Cochrane Incontinence and Cochrane Stroke Specialised Registers (searched 30 October 2017 and 1 November 2017 respectively), which contain trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearched journals and conference proceedings. Selection criteria We included randomised or quasi‐randomised controlled trials. Data collection and analysis Two review authors independently undertook data extraction, risk of bias assessment and implemented GRADE. Main results We included 20 trials (reporting 21 comparisons) with 1338 participants. Data for prespecified outcomes were not available except where reported below. Intervention versus no intervention/usual care Behavioural interventions: Low‐quality evidence suggests behavioural interventions may reduce the mean number of incontinent episodes in 24 hours (mean difference (MD) –1.00, 95% confidence interval (CI) –2.74 to 0.74; 1 trial; 18 participants; P = 0.26). Further, low‐quality evidence from two trials suggests that behavioural interventions may make little or no difference to quality of life (SMD ‐0.99, 95% CI ‐2.83 to 0.86; 55 participants). Specialised professional input interventions: One trial of moderate‐quality suggested structured assessment and management by continence nurse practitioners probably made little or no difference to the number of people continent three months after treatment (risk ratio (RR) 1.28, 95% CI 0.81 to 2.02; 12

Poor oral care can have serious mental, physical and social consequences, and adversely affect quality of life after a stroke. A prompt oral assessment facilitates the development of an oral care plan based on individual stroke patient's needs. Basic oral care should be combined with early diagnosis and referral for the management of dental pathology so that dentition, natural or prosthetic, can be maintained. Stroke patients often experience oral discomfort and pain, oral infections (especially oral candidiasis), and difficulties in denture‐wearing. Normal daily activities that affect oral hygiene, such as eating, drinking and tooth‐brushing, can be severely disrupted. Over time, lack of adequate oral care will lead to progression of dental caries and periodontal disease, which can result in tooth loss and pain. This impacts patients' ability to eat and their quality of life, and may complicate ongoing medical management.

This chapter discusses measures to reduce stroke risk and impact on several levels: population measures aimed at reducing stroke risk and raising stroke awareness; primary prevention for those at risk of stroke; and secondary prevention to reduce risk of recurrent stroke. Primary prevention, via identifying and addressing risk factors before stroke or transient ischaemic attack (TIA) occurs, is a major part of many primary care initiatives, but is challenging to implement successfully. After stroke or TIA, an individualised plan for secondary prevention should be implemented immediately and continued long‐term to reduce the risk of future stroke and other vascular events. The chapter considers interventions to address common medical and behavioural risk factors for stroke, challenges to reducing stroke risk for populations and individuals, interventions for specific medical conditions for both primary and secondary prevention, and management of ongoing stroke risk where no specific cause has been identified.

This chapter examines the causes and contributing factors of bladder and bowel problems in stroke, and discusses assessment and management protocols. The prevalence of urinary incontinence (UI) after stroke is high, with studies suggesting around half of people admitted to hospital experience UI, and a third a loss of bowel control. Although UI is common after stroke, it is always important to exclude transient causes early on in the assessment process. Urinary tract infection (UTI) is a frequent cause of UI, and urine should be tested for leucocytes and nitrites within 24 hours of admission. All patients admitted to hospital with stroke should have a nursing assessment, including urine testing, within 24 hours of admission to identify UI and detect UTI or other abnormality. Healthcare professionals can do much to help improve and manage bladder and bowel problems, starting with having a good understanding of key issues and completing an early assessment of problems.

This chapter describes the importance of stroke nursing in the context of wider systems. It also describes the stroke service context, setting out how stroke has developed to become recognised as a policy priority, with national strategies, service and management developments, and networks to support education and research. The costs of stroke are substantial, due to the complexity and chronic nature of this condition. The World Stroke Organization has released guidelines and a quality action plan framework to inform stroke policy and set strategic directions to elevate standards of stroke care. Research plays an important part in service development; support and facilitation of research are national priorities around the world. Various strategies are employed to support research capacity development and to maximise engagement at the stroke unit level and recruitment of individual stroke patients.

Meeting the palliative care needs of stroke patients requires stroke specialists to develop enhanced knowledge and skills in palliation in order to address the specific challenges that stroke presents. This requires investment from within the stroke field and a commitment to a more holistic approach to care which extends beyond rehabilitation goals. This chapter identifies a range of challenges in delivering palliative care for stroke patients. It considers generic palliative care pathways and tools, and their suitability in the context of stroke. The chapter presents case studies which illustrate how some of these care pathways and tools could be used with stroke patients. It discusses three palliative care approaches: the Liverpool Care Pathway; the Gold Standards Framework; and the Assessment, Management, Best practice, Engagement, and Recovery care bundle. The chapter concludes with recommendations to guide the development of improved palliative care in stroke.

Stroke can have many different effects on patients' mood, cognitions, and behaviour. The emotional outcome most often associated with stroke is depression (or depressed mood), and its frequency after stroke has led some to suggest that post‐stroke depression is a distinct type. The increased recognition of mood disorders, behavioural changes, and cognitive impairment and their effects on patients, has resulted in the development of new interventions, a greater number of professionals skilled to intervene, and increased research evidence on intervention effectiveness. Psychological disorder and distress continue to be under‐recognised, some disorders are incorrectly diagnosed and treated, and the relative lack of a research base means that nurses and doctors may be treating disorders in their patients without much certainty about the effectiveness of the interventions. Models of coping theories can help to explain patients' reactions.

This chapter focuses on the longer‐term needs and support for people with stroke and their carers, as well as potential interventions to meet these needs and improve well‐being. To respond to the longer‐term needs of survivors and carers, healthcare professionals should: understand the experience of living with stroke from a survivor and carer perspective; identify difficulties associated with self‐management or caring in the longer‐term; and be aware of the merits of different interventions for providing support to survivors and carers. It is therefore important that information and support interventions start as early as possible post‐stroke, to assist in the transition from hospital to home and prepare survivors and carers for their new circumstances and roles. A systematic review of the social consequences of stroke in working‐age people identified factors enabling return‐to‐work, including: vocational rehabilitation; flexibility and support in the workplace; social benefits; and family support.

Aims and objectives To explore the views and experiences of stroke survivors and carers about a systematic voiding programme for post-stroke incontinence. Background Urinary incontinence after stroke is common and associated with poorer functional outcome. Structured assessment and management are potentially effective interventions but it is important that there is a good understanding of stroke survivors’ and carers’ views of their acceptability and implementation. Design Qualitative study within a feasibility trial. Methods 16 participants (12 stroke survivors, 4 carers) were interviewed using a structured schedule shortly before discharge from one of six inpatient stroke units across six hospitals. Interviews were audiorecorded, transcribed verbatim, and thematic analysis was conducted. Findings Participants included seven male and five female stroke survivors (mean age 76 years), and four female carers (two wives, two daughters). Themes relating to the preliminary (assessment) phase of the programme were: physical impact, psychological impact, beliefs about incontinence, and the assessment process itself. Main themes relating to the implementation of the programme included: Timed voiding decisions, adapting the programme or the timed voiding schedule, and urinary incontinence management techniques. Participants felt that the programme helped them to re-establish a regular pattern of micturition and to regain autonomy. Conclusions The effectiveness of a systematic voiding programme may partly lie in its educational component, challenging patients’ and carers’ assumptions that post-stroke incontinence is inevitable. Individual adaptation of the programme, and the ability to incorporate it alongside other aspects of care, are likely to be key factors influencing implementation. Relevance to clinical practice Urinary incontinence is common after stroke. In order to maximise benefits from a systematic voiding programme, nurses should support stroke survivors to overt

Objective: To describe the bacterial profile of the oral flora during the first two weeks following a stroke, examining changes in the condition of the oral cavity and infections. Background: Dysphagia is common after a stroke and can lead to aspiration pneumonia. Oral flora changes associated with stroke have been implicated as a possible source of bacteria that can cause systemic infections. Materials and methods: Seventy-seven participants were recruited over a period of nine months. Fifty participants had a complete set of swabs taken from four different oral sites and saliva at three time points over a 14 day period. Molecular identification of bacteria was performed on pooled DNA extracted from swabs. Results: A total of 103 bacterial phylotypes were identified, 29 of which were not in the Human Oral Microbiome Database (HOMD). Fourteen of the twenty most common bacterial phylotypes found in the oral cavity were Streptococcal species with Streptococcus salivarius being the most common. The condition of the oral cavity worsened during the study period. Fifteen (30%) patients had at least one infection. Conclusions: It is unknown whether the 29 phylotypes identified that were not in the HOMD indicate a particular change in the oral flora associated with stroke, or the incomplete nature of the HOMD. The Holistic and Reliable Oral Assessment Tool detailed how the condition of the oral cavity following a stroke worsened over the fourteen days in hospital. Further research is needed to explore oral care methods to improve patient safety and comfort following a stroke.

Background Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation. Objectives Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke. Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of 'dose' of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention. Search methods We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016). Selection criteria Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal. Data collection and analysis Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane 'Risk of bias' tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information. Main results We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has

Introduction: The National Stroke Strategy, and the development of the Stroke-Specific Education Framework, emphasised the need for a skilled and knowledgeable workforce. The Francis and Keogh reports highlighted the importance of on-going continuing professional development. However, key policies do not cite explicit evidence of the value of education and training. This study aimed to systematically review the literature exploring the impact of healthcare professional education and training on the process and outcome of stroke patient care. Methods: An integrative review approach was used to summarise the literature. A search strategy including the MeSH terms stroke, education and health personnel was developed and adapted to search bibliographic databases. The search strategy's quality was tested using backwards and forwards citation searches. Results were screened on title, abstract, and full paper. Systematic data extraction and synthesis were conducted. Results: Following screening, 23 studies met the inclusion criteria. Staff group varied: pre-hospital staff (n=4), healthcare assistants, student nurses and nurses (n=10), multi-disciplinary teams (n=8), pharmacists (n=1); as did settings; pre-hospital and hyperacute (n=7), acute and rehabilitation (n=15), and community (n=1). The majority, 17 studies, demonstrated that education and training had a positive impact on a range of patient and process outcomes, however, methodological quality was variable ranging from single centre observational studies to cluster RCTs. Conclusion: Robust studies are needed to explore the impact of stroke education and training of health care staff on patient care so that investment in education and training can be more clearly linked to optimum health outcomes

The cluster-randomized controlled trial is a design increasingly used in prevention and health care evaluation studies and is highly relevant to stroke research. However, there are methodological issues that make it complex to implement. These are not always fully appreciated, with reviews continuing to reveal deficiencies. We searched PUBMED and CENTRAL databases to March 31, 2011 for cluster-randomized controlled trials in stroke. Two investigators independently reviewed citations for eligibility and extracted data on key aspects of each trial. Fifteen trials met the eligibility criteria. No trial fully met CONSORT cluster-randomized controlled trial guidelines, although good design and reporting practice were usually present. Twelve trials included the term ‘cluster-randomized’ (or ‘group-randomized’) in the title, and 12 trials stated the intraclass correlation coefficient used to plan the number of clusters and cluster size. However, few provided a clear, evidence-based justification for the choice of intraclass correlation coefficient, and only two-thirds reported the intraclass correlation coefficient for primary outcomes. Several trials appeared underpowered because of problems in determining an appropriate sample size, defining appropriate clusters, and recruiting and retaining clusters and patients. Cluster-randomized controlled trials are difficult to design and perform due to the combination of methodological and practical difficulties. It is important that further improvements are made to reporting cluster-randomized trials and intraclass correlation coefficients should be estimated using a standardized approach and reported consistently; this would be beneficial for stroke researchers when designing future cluster-randomized trials.

Background: Approximately 20% of stroke patients experience anxiety at some point after stroke. Objectives: To determine if any treatment for anxiety after stroke decreases the proportion of patients with anxiety disorders or symptoms, and to determine the effect of treatment on quality of life, disability, depression, social participation, risk of death or caregiver burden. Search methods: We searched the trials register of the Cochrane Stroke Group (October 2010), CENTRAL (The Cochrane Library 2010, Issue 4), MEDLINE (1950 to October 2010), EMBASE (1947 to October 2010), PsycINFO (1806 to October 2010), Allied and Complementary Medicine database (AMED) (1985 to October 2010), Cumulative Index to Nursing and Allied Health (CINAHL) (1982 to October 2010), Proquest Digital Dissertations (1861 to October 2010), and Psychological Database for Brain Impairment Treatment Efficacy (PsycBITE) (2004 to October 2010). In an effort to identify further published, unpublished and ongoing trials, we searched trial registries and major international stroke conference proceedings, scanned reference lists, and contacted select individuals known to the review team who are actively involved in psychological aspects of stroke research, and the Association of the British Pharmaceutical Industry. Selection criteria: Two review authors independently screened and selected titles and abstracts for inclusion in the review. Randomised trials of any intervention in patients with stroke where the treatment of anxiety was an outcome were eligible. Data collection and analysis: Two review authors independently extracted data for analysis. We performed a narrative review. A meta-analysis was planned but not carried out as studies were not of sufficient quality to warrant doing so. Main results: We included two trials (three interventions) involving 175 participants with co-morbid anxiety and depression in the review. Both trials used the Hamilton Anxiety Scale (HAM-A) to assess anxiety, and neith

Background: The active practice of task-specific motor activities is a component of current approaches to stroke rehabilitation. Objectives: To determine if repetitive task training after stroke improves global, upper or lower limb function, and if treatment effects are dependent on the amount, type or timing of practice. Search strategy: We searched the Cochrane Stroke Trials Register (October 2006), The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, PEDro, and OT Seeker (to September 2006), and OT search (to March 2006). We also searched for unpublished/non-English language trials, conference proceedings, combed reference lists, requested information on bulletin boards, and contacted trial authors. Selection criteria: Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal, and where the amount of practice could be quantified. Data collection and analysis: Two authors independently screened abstracts, extracted data and appraised trials. Assessment of methodological quality was undertaken for allocation concealment, blinding, loss to follow up and equivalence of treatment. We contacted trial authors for additional information. Main results: Fourteen trials with 17 intervention-control pairs and 659 participants were included. Primary outcomes: results were statistically significant for walking distance (mean difference (MD) 54.6, 95% CI 17.5 to 91.7); walking speed (standardised mean difference (SMD) 0.29, 95% CI 0.04 to 0.53); sit-to-stand (standard effect estimate 0.35, 95% CI 0.13 to 0.56); and of borderline statistical significance for functional ambulation (SMD 0.25, 95% CI 0.00 to 0.51), and global motor function (SMD 0.32, 95% CI -0.01 to 0.66). There were no statistically significant differences for hand/arm function, or sitting balance/reach. Sec