Survival and rehabilitation following acute stroke.

Abstract

The outcome of acute stroke in 210 White adult patients admitted to Addington Hospital, Durban in 1983 and 1984 was investigated by means of retrospective case-note review. In addition, the level of functional independence of 35 people who, at the time of this study, were survivors of an initial acute stroke was assessed through household survey. The study was considered relevant and worthwhile for several reasons: 1. Stroke is an important contributor to morbidity and mortality in Whites in South Africa, however, l i t t l e information is available in respect of the outcome of sufferers of stroke who were admitted to the study hospital. 2. Knowledge of the needs of survivors of acute stroke is necessary if appropriate health care is to be provided. 3. Few community studies have been done in South Africa in which the status of stroke survivors has been established. The principle aims of the study were therefore: 1. To establish the survival of patients with acute stroke who were admitted to the study hospital. 2. To determine in survivors of an initial stroke their residual functional loss and hence to identify the supportive health care needs of this group. The most important findings of the study were as follows: 1. Of the 286 stroke admissions identified through the hospital's medical record retrieval system, stroke diagnosis according to the study definition could be confirmed in only 210 (73.4%) cases due to misplaced files or miscoded diagnoses. The need for improvement in the method of recording, storing and retrieving of patient information is indicated by these findings. The overall hospital fatality rate for stroke was 54%. Mortality was highest in the first week after admission (71%). The number of males and females, in respect of whom a final diagnosis of stroke was attributed, was almost equal. A significant difference (p < .000 2) in respect of age was noted between the sexes. The mean age of onset of stroke was 62.9 and 70.0 years for males and females respectively. The major diagnostic categories (haemorrhagic or occlusive) of stroke could only be ascertained in respect of 30% of cases. This was due to incomplete recording of clinical findings, and possibly, due to the absence of resident brain-scanning facilities at the time. Analysis of the results of the household interviews indicated that:-( I ) Of the 35 patients interviewed 13 (37%) were found to be fully independent in self-care and were mobile outside of the home. (ii) The patients' potential for improvement in an appreciable number of cases had been under-estimated by the hospital staff. Patient adjustment following hospital discharge appeared adversely affected by.-(i) Inadequate preparation for discharge, especially where patients were returning to their own homes. (ii) Inadequate explanation given to patients and their families of the meaning and implications of stroke. (iii)The non-involvement of the family during the period of hospitalization. (iv) The absence of appropriate follow-up after discharge. Stroke onset was a traumatic experience in all cases. Amongst the most important reasons given for reduced life-satisfaction post stroke were confinement to the home, reduced independence and unresolved loss (eg death of spouse, forced retirement). 8. In some cases it was f e l t that social isolation, general ill-health and old age were more significant problems in the lives of patients than the stroke itself. The advent of stroke merely exaggerated these problems. 9. The advantage of administering a standardized functional assessment at intervals during the rehabilitation of the patients became increasingly clear as the study progressed. It is proposed that functional assessment be considered as important as clinical assessment in the management of stroke patients. 10. Recommendations have been submitted concerning rehabilitation and the provision of supportive services for stroke patients. As the role of the nurse in short and long-term care is central to successful stroke outcome, emphasis has been placed on her role in the team. The main conclusions formulated in the study were:-1. Mortality from stroke is high but in survivors an appreciable proportion maintained functional independence. 2. Preparation of patients and their families is important to adjustment following discharge from hospital. 3. Supportive services are important to the maintenance of the stroke patient in the home environment. 4. A team approach, consisting of a wide range of health professionals is appropriate to the management of stroke. 5. Functional assessment is an important component of the clinical examination and should be done prior to discharge and subsequently at regular intervals to assess the patient's competence to exist in the current domestic environment.