Spring Speakers Series: An overview of post stroke visual impairment

Claire Howard is a Stroke Specialist Research Orthoptist based at Salford Royal Hospital and is part of the VISION research unit at University of Liverpool. She holds an NIHR clinical fellowship and is currently researching the area of adaptation to post stroke visual field loss. Her main field of interest is rehabilitation of visual impairment following stroke. She will be speaking at the upcoming BGS Spring Meeting in Nottingham.

The size of the problem: the point prevalence of visual impairment in stroke survivors has been reported as 72% (Rowe, Hepworth, Hanna, & Howard, 2016). This visual impairment can be the result of a range of different problems either individually or in combination; these problems include visual field loss, eye movement disorders, reduced / blurred vision and visual perception defects.  In the post stroke period, a person may be experiencing a visual impairment that is of new onset, or their visual problems may pre-exist the stroke. 

Practical palliative care after stroke

Dr Ruth England is a Consultant in Palliative Medicine at Royal Derby Hospital. She tweets @DrRuthEngland. She will be speaking at the upcoming BGS event Living and Dying Well with Frailty on 6 March in London. Please note this event has now SOLD OUT.

Palliative care is an active, holistic approach to those facing life-threatening illness. Good palliative care allows us ‘to live as well as possible for as long as possible’; and includes support for those approaching the end of their life.

In the UK, someone suffers a stroke every 5 minutes. Although there has been a decline in stroke mortality, it remains a leading cause of death in those aged over 65.  There a high risk of dying immediately after an event, and 40% of those affected by stroke die within a year. Long term survivors are likely to be burdened with ongoing physical, psychological and social issues.

Time for the BGS to help in Africa?

Richard Walker is a Consultant Geriatrician at North Tyneside General Hospital, and Honorary Professor of Ageing and International Health at Newcastle University. He has a research interest in non-communicable diseases in sub-Saharan Africa (SSA) and is Associate International Director for SSA for the Royal College of Physicians, London. He is the Clinical Lead for the Northumbria / Kilimanjaro Christian Medical Centre health link and Chair of the Movement Disorders Society African Task Force. In this blog article he discusses the growing challenge of ageing in Africa.

The ageing population in Africa is exploding. In Nigeria alone, for example, there are now more than 6 million people aged over 65 years. Despite this, worryingly, services are particularly ill prepared to meet the needs of this group. Compounding this challenge is the fact that there’s a real lack of Geriatrics’ teaching in undergraduate medical curricula in SSA. Furthermore, we found that there’s very few ‘Geriatricians’ in SSA outside South Africa, with most countries having none at all.

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.

Researchers find key to stroke survival

The 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.

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.

The 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. 

Geographic variation of inpatient care costs at the end of life

Claudia 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.

The push to improve stroke services

Adhi 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

Sarah 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.

Treating dysphagia: understanding the need for training

Helen 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.