AHA/ASA issue statement on stroke care in patients with premorbid dementia, disability
Click Here to Manage Email Alerts
The American Heart Association/American Stroke Association have published a joint recommendation statement for the use of endovascular therapy and thrombolysis following stroke in patients with premorbid dementia or disability.
Published in Stroke, this statement was endorsed by the Society of NeuroInterventional Surgery and its educational value was affirmed by the American Academy of Neurology and American Association of Neurological Surgeons/Congress of Neurological Surgeons Cerebrovascular Section.
“The long-term consequences and costs of additional disabilities due to untreated stroke in people with preexisting neurological deficits are staggering,” Mayank Goyal, MD, PhD, clinical professor in the department of radiology and clinical neurosciences at the University of Calgary in Alberta, Canada, and chair of the scientific statement writing committee, said in a press release. “The statement cites previous research indicating 79% of people with pre-stroke disability lived an average of 16 months after a stroke, and one-third of them needed to move to an assisted living facility instead of returning home after hospitalization and treatment.”
A paucity of research in this population
The lack of definitive evidence on the benefits of endovascular therapy (EVT) and thrombolysis in this population is a source of uncertainty that may complicate treatment decisions, the committee wrote. The reasons for this encapsulate methodological, societal and investigator factors such as investigator biases, the influence of family members on the decision-making process, patient mobility, inaccuracies in diagnosing premorbid dementia or disability and variability in definitions of such impairments.
“The people carrying the greatest burden of illness have been traditionally excluded from research,” Goyal said in the release. “Expansion of the dialogue and proactive research on acute stroke therapies should include people with disability and dementia — to optimize their potential to return to their pre-stroke daily living and to reduce the potential long-term care and financial burdens.”
Recommendations for treatment decision making
The statement provided the following considerations for decision-making process for the use of EVT and thrombectomy following stroke in patients with premorbid disability or dementia.
In the pre-stroke, nonacute setting, the statement suggested physicians should:
- discuss quality of life and preferences for future care with both the patients and their families;
- encourage advance care planning for future emergencies, such as stroke; and
- examine the physician’s own personal biases making decisions in time-sensitive settings.
In the acute stroke setting, the statement suggested physicians should:
- acknowledge the full spectrum of post-stroke outcomes and avoid dichotomous thinking (good or bad);
- disclose the limited evidence about the magnitude of treatment effects among individuals with premorbid dementia and/or disability who experience a stroke;
- disclose the risks of treatment in this population compared with patients without pre-stroke disability and/or dementia;
- avoid routinely withholding therapies on the basis of pre-morbid dementia and/or disability alone, given the potential for mitigating further post-stroke disability; and
- seek to understand what the patient would value in such situations and recognize that it may be challenging to meaningfully achieve in the acute care setting.
In the post-acute care setting, the statement suggested physicians should:
- recognize that outcomes will not only depend on the immediate treatment decision but also the quality of stroke unit care and rehabilitation; and
- consider the patient's goals of care moving forward that may be influenced by treatment decision-making.
Please see the statement for full details on the committee’s recommendations for EVT and thrombolysis among patients with premorbid disability or dementia.
“By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, we can work toward a more inclusive paradigm of patient-centered care for this often-neglected patient population,” the committee wrote.
Reference:
- Stroke treatments safe and effective for people with existing disability or dementia. newsroom.heart.org/news/stroke-treatments-safe-and-effective-for-people-with-existing-disability-or-dementia. Published March 28, 2022. Accessed March 28, 2022.
Collapse
Read more about
Click Here to Manage Email Alerts