Stroke Rehabilitation: Geriatric Rehab or Dedicated Stroke Rehab Units?

There is no doubt that the best outcomes from stroke are achieved with the utilization of a coordinated interdisciplinary approach. This starts from the moment a stroke victim is identified. There is some evidence that a coordinated approach to pre-admission care--i.e. public education, centralized intake to facilitate thrombolysis, availability of neuroradiology, etc.--has a favourable effect on subsequent stroke morbidity. There can also be no doubt that the proper experienced care of a stroke team in the acute hospital is vital to the final outcome. First, the team ensures that an accurate diagnosis is made, and that proper supportive care (nutrition, including swallowing assessment if necessary, early mobilization, attention to skin and continence issues, etc.) and secondary prevention measures (anticoagulation, aspirin, etc.) are commenced.

Some patients can be discharged from hospital directly to their homes, and rely on either outpatient or home rehabilitation programs (if appropriate outpatient diagnostic and follow-up services are available, acute hospital admission is sometimes not necessary in the first place). These are generally patients with minor or no residual deficits. I include education as part of the rehabilitation model, so no patient would be discharged without some form of rehabilitation, even if no traditional speech, physical or occupational therapy is required. Other patients have such severe strokes that, almost immediately, the prognosis is known to be dismal. These patients are usually referred directly to long-term care programs.

However, there is a large number of intermediary patients who benefit from a formal inpatient rehabilitation program. Almost all of these patients are older, which begs the question, 'Should they be admitted to a geriatric rehab program or a stroke program?' Despite being the director of a large and excellent geriatric rehab program, I feel that the bulk of stroke patients should be handled in dedicated stroke units. The reasons for this are straightforward. Geriatric units are, by definition, generalist units. We have to care for patients with multiple problems and multiple medical diagnoses. This is our strength, but also our weakness. Like most skills, stroke rehabilitation is made better by larger volumes and more focus. Geriatric units do well on the motor problems associated with stroke, as these are not that different from those of patients with falls, fractures and deconditioning, who are our bread and butter. However, complex perceptual deficits require a degree of expertise that often overwhelms non-specialized units. However, for selected cases, there is a place for geriatric units in stroke rehabilitation. These are elderly patients who already had functional problems, and then have a stroke, which serves as 'the straw that breaks the camel's back.' These cases usually require attention to multiple problems, not just the stroke, and are better suited to the generalist nature of geriatric rehab. If stroke rehab and geriatric rehab programs are physically close, back and forth consultations are facilitated (even well selected stroke rehab patients can develop geriatric-type syndromes).

In my institution, there is reasonable consensus on most patients. However, one group falls through the cracks. This is previously healthy patients who have had a severe stroke, but who do have the potential to benefit from rehab. These patients often have stroke syndromes that would challenge the most experienced of stroke rehab professionals, and are often beyond the skill set available in geriatric rehab. Unfortunately, the tyranny of length of stay (LOS) is the enemy of these patients. Too specialized for geriatric rehab, they require too many resources from stroke units. I feel that this represents the failure of proper population-based planning. We need to have enough 'long-stay' stroke rehab beds to accommodate these patients. It does not make sense to prevent the most skilled professionals from caring for the most difficult strokes.

This issue has numerous articles on stroke, contributed by an international line-up of authors. Drs. Kennedy and Buchan discuss acute therapy in ischemic stroke, while Dr. Patten gives us information on some of the psychosocial issues involved. There are also articles on tests (reaction time) that predict recovery from acute stroke (Loranger and Doyon), gender issues in stroke (Clark), and the management of dysphagia in patients post-stroke (Perry). Several authors review the use of medications for primary and secondary stroke prophylaxis, including an article on the treatment of hyperlipidemia (Aronow), thrombolysis in elderly patients (O'Mahony), antithrombotic drugs for secondary stroke prophylaxis (Bennett and Bennett) and new frontiers in the treatment of stroke (Gladstone et al).

As well, we have our usual potpourri of geriatric articles. The topic of our ethics column this month is the ethics of receiving our flu vaccination (Sheehan and Gordon). The mental health column focuses on an atypical psychotic disorder, Capgras Syndrome (Sloan). In the Biology of Aging column, Dr. Mattson provides information on neuroplasticity and how the brain adapts to aging. The cancer column examines quality surgical cancer care in Ontario (Gagliardi)--a topic that has recently been much in the news--and for our Dementia column, Drs. Tong and Corey-Bloom from the University of California San Diego, review galantamine, a new medication for the treatment of Alzheimer disease.

Enjoy this issue.