Spring Speakers Series: Assessing memory and thinking in stroke – it’s confusing

Dr Terry Quinn (Joint Stroke Association / CSO Senior Clinical Lecturer) has a clinical and research interest in post stroke cognitive decline. Supported by a Stroke Association Priority Program Grant he is pursuing a portfolio of work themed around how to assess cognition and mood in the Acute Stroke Unit. Terry will be sharing some of the findings from this and other work at the BGS Spring Meeting in Newcastle as part of a themed session on dementia. Terry tweets about all things cognitive @DrTerryQuinn and in his role as Coordinating editor of the Cochrane Dementia Group @cochraneDCIG

Specialist societies, clinical guidelines and audit standards all encourage us to assess cognition when patients present with stroke. Intuitively this seems like a sensible idea. We know that patients fear problems with memory and thinking more than they fear physical disability and we know that cognitive problems are extremely common in the post stroke period. What is less clear is how we should assess cognition in stroke. Continue reading

Researchers find key to stroke survival

nurseThe number of trained nurses available to treat patients immediately after a stroke is the most reliable health services predictor of survival according to research from the University of Aberdeen and University of East Anglia published in Age & Ageing.

Having the optimal number of trained nurses available to look after patients in an acute stroke unit was consistently found to be the best predictor of survival from stroke – after personal health factors were accounted for, such as age, stroke severity and blood pressure.

The study found that just one additional trained nurse per ten beds could reduce the chance of death after thirty days by up to twenty-eight per cent, and after one year by up to twelve per cent. Continue reading

Do studies of the weekend effect really allow for differences in illness severity?

For nearly 15 years from 1997 until 2011, David Barer and his stroke team colleagues kept a prospective register of all patients admitted to hospital in Gateshead with suspected acute stroke. This was used mainly for research but also allowed independent checks to be made on the official figures from the coding department, providing useful insights into diagnostic uncertainties, the reasons for coding errors and day-to-day and year-on-year changes in the numbers and clinical characteristics of stroke admissions.  In this study he analyses whether the apparent excess mortality among patients admitted at weekends might be due to differences in stroke severity or other factors which cannot be measured in studies relying on routine administrative data.

strokeThe long-rumoured but now notorious “weekend effect” recently received the seal of scientific respectability from two huge studies, analysing routine data on 20 million hospital admissions (and 1/2 million deaths) in England and Wales. They found a 10-15% increase in the risk of dying in the first month after weekend, compared with weekday admissions, even after adjusting for differences in overall “sickness levels” by sophisticated modelling of diagnostic and administrative data.  The authors of the larger study even included non-emergency admissions, despite the obvious imbalance between weekdays and weekends, arguing that their risk model could “explain” most of the mortality variation.  Continue reading

Geographic variation of inpatient care costs at the end of life

aaClaudia Geue is a health economist at the University of Glasgow with a special interest in the pattern of healthcare utilisation and associated expenditure at the end of life. In this blog she discusses her recent Age & Ageing paper on healthcare costs.

We know that the last months of life are characterised by high healthcare costs, in particular when we look at the costs for hospital admissions. What is less clear though is the question whether there are any geographic variations in costs at the end of life.

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The push to improve stroke services

14599057094_556c720cf5_oAdhi Vedamurthy is a consultant geriatrician with a special interest in stroke, and Chair of the BGS Wales Council.

It was a typical Monday morning in a district general hospital. Loads of elderly medical patients had spent the night in the emergency department waiting for a bed. About a dozen ambulances were outside the hospital unable to offload patients.

I had just done a third of my ward round with the foundation year one doctor when the bleep went off. A patient with potential need for thrombolysis had just arrived. Apart from the stroke nurse, there was no other suitable senior doctor available to assess the patient.

I abandon the ward round to assess the patient, organise the scan, push the trolley with the stroke nurse to take the patient to the stroke unit and initiate thrombolysis. This takes nearly an hour. During this time, the patients on the ward are still waiting for my assessment and management plan. Two discharges get delayed and a few scans were not booked on time and they had to wait for another day.

This scenario is very common in many hospitals where geriatricians have more than one role. Time is of the essence when treating stroke patients, but this comes at a cost if commissioners do not invest to improve services and expect existing services to stretch. This also applies to therapy services who are asked to prioritise stroke patients.

To meet targets, a patient with a suspected stroke (many do not have a stroke) must get a bed in a stroke unit within four hours. But it seems entirely acceptable for patients with heart failure, pneumonia, a fall, delirium, etc., who have far higher mortality, to spend hours on a trolley in the emergency department.

There is no argument that acute stroke is an emergency and should be treated accordingly. However this should not come at the expense of other services in geriatric medicine.

A majority of geriatricians in Wales felt that an improvement seen in stroke services has come at the cost of compromising services in geriatric medicine.

Is this the case in the other devolved nations? I would love to hear your views.

Saddling up at the Calgary Stroke Program

CSPSarah Blayney is a Clinical Fellow in the Calgary Stroke Program at Foothills Hospital, University of Calgary. She received a BGS SpR Travel Grant to help fund her fellowship.

As the branch flicked back and caught me full in the face, I saw another coming from the side just in time to throw my weight left and precariously low over the horse’s neck. We had left the trail some time ago after encountering more fallen trees after last week’s snowstorm; the temperatures had soared to the high twenties again but this far out into the mountains there was no one around to clear the trail. Narrowly avoiding my leg being crushed against a tree as we forged our own path through the undergrowth, I wondered quite what I’d let myself in for this weekend. The initial natural obstacles encountered on the lower level trails were nothing in comparison to those up here, and the gradient was punishing for both us and the horses.

Eventually we broke the tree line and took in a spectacular view of the valley below. Any breath left was soon gone after struggling up the last section: so steep here that we were out of the saddles and down onto our feet. After three hours of hard riding my legs were
in no shape to clamber up a rocky outcrop while trying to persuade several hundred pounds of horseflesh behind me to wait his turn, but a few minutes later I sank gratefully onto the coarse grass at the top. Once up there our horizon broadened further, taking
in the mountain ranges to the north and west. Far in the distance, a hunter’s rifle fired periodically and the echo bounced around the mountains for several seconds each time. It was the hardest and most exhilarating riding I’d ever done, and the view from the
top was outstanding.

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Treating dysphagia: understanding the need for training

5328790665_b4a675915d_oHelen Willis is a Dietitian at Wiltshire Farm Foods: in this blog she looks at caring for older people with dysphagia, and the importance of proper training

It is often the case that with such a media and governmental focus on health issues such as obesity, other nutritional issues get pushed aside and given little focus. One example is the very common swallowing condition, dysphagia.

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Leading The Way

11116578645_3cacb41a9d_oSarah Blayney is a Clinical Fellow in the Calgary Stroke Program at Foothills Hospital, University of Calgary. In this blog, she recounts her experience of attending the first BGS Leadership Conference in November.

After nearly nine months of trying to fit into an academic neurology department, it was a huge relief to find myself surrounded by geriatricians once again. My sense of adventure took me to Canada on a stroke fellowship earlier this year, in what I thought would be a refreshing break from the trials and tribulations of life as a medical registrar in today’s NHS. The calibre of stroke training is second to none, and learning to think like a ‘Calgary stroke neurologist’ has sharpened my clinical approach far more than I anticipated.

However I have also come to fully understand the meaning of silos within healthcare, and the effect this can have for patients with multiple medical problems.  The department is well led, with highly motivated teams across acute and rehab units, outpatients, research offices and clerical staff, but it pains me every time our service backs off from the care of a frail elderly patient deemed unlikely to benefit from admission to the acute stroke unit (though occasionally I sneak one in when I can). Our response time to acute stroke patients is excellent, but for those that turn out not to be stroke, it can mean a delay in getting them to the right place as well as multiple reviews by different people along the way.

It was in this frame of mind that I returned to the UK for a fortnight of courses and conferences to ensure a smooth CCT sign-off when I return in the spring.  Word had got round about the first BGS Management Course run last year and I was keen to get back for this year’s course if at all possible; it proved to be the highlight of my trip.  We are all too aware of the problems currently facing the NHS, but the pre-course reading list opened my eyes to the volume of resources being generated to combat these problems.  I find everything I have seen so far from the King’s Fund to be particularly practical and insightful, unlike some of the political statements that come from elsewhere. This set the tone neatly for a well thought out two days of discussions and workshops. Aspirations are important, but sharing best practice and brainstorming potential pitfalls is essential when it comes to rolling up our sleeves and making these aspirations real, and the course delivered just that.

Simulation is such a useful way of making the leap from theoretical discussion to a real life interaction, so roleplay and “Dragons Den” style workshops were a fun and very practical way of exploring some of the issues we may face as future consultants. Birmingham City Council obliged in making this even more true to life by issuing a parking ticket just before one such mock ‘management meeting’, very effectively raising the frustration levels of our acting medical director! The opportunity to ask questions, as well as be put on the spot, created a stimulating environment. The course timetable had clearly been planned to reinforce this, as regular coffee breaks allowed conversations to continue and develop outside of the structured sessions.

Hearing anecdotes on the second day from our course facilitators about their own experiences in developing new services was a tidy way of drawing together the principles we had explored earlier.  It also prepared me well for the task ahead of finding the right consultant job, and clarified my thoughts as to the direction my career may take in the next five years.  My other half recently challenged me on my use of the term ‘dynamic young geriatricians’ when I described to him the BGS course faculty, and this did give me pause for thought (as a surgical registrar who has encountered Dr Wyrko at work, he has his own ideas of what dynamic might mean in this context).  The last thing I would wish would be to appear ageist towards my older and wiser consultant colleagues, many of whom have taught me a great deal over the last nine years, but I am sure they would agree that the hospital world is changing.

We as a generation of trainees have been in the thick of it when it comes to the current state of acute hospital medicine, and have developed a different expectation of what our future working life will look like as a result.  My experiences as both a UK stroke registrar and a Canadian stroke fellow have only served to strengthen my conviction that our frail elderly patients deserve faster, better care than the NHS can currently offer in many places.  My two days under the expert coaching of Drs Gordon, Wyrko, Conroy, Blundell, Long and Oliver have provided the insight and skills to play my part in making this happen.

Image credit: Ascent Magazine via flickr.

Book review – “Geriatric Medicine: An Evidence Based Approach”

9780199689644_450Philip Braude is an ST6 in Geriatric Medicine, specialising in perioperative medicine.

Geriatric Medicine: An Evidence Based Approach, edited by Frank Lally and Christine Roffe, is written by an eminent list of international experts condensing key and often difficult issues in modern geriatrics to chapters of a few pages. It aims to be a “clinical reference for health care professionals” but is certainly not a comprehensive geriatric medicine text.

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Making difficult decisions about the benefits and risks of thrombolysis treatment

Dr Aoife De Brun is a Research Associate at the Institute of Health & Society at Newcastle Universityshutterstock_114405178

An online survey investigating factors that influence clinical decision-making regarding intravenous thrombolysis for patients with acute ischaemic stroke has been launched. The project is funded by the NIHR Health Service and Delivery Research Programme and is led by researchers from Newcastle University.

We are recruiting clinicians who are involved in making the final decision regarding thrombolysis for patients with acute ischemic stroke.  By understanding how clinicians make difficult trade-offs between the potential benefits and risks of thrombolysis, we can design strategies to better support risk communication, consent and decision-making with patients in clinical practice. Continue reading