Do patients with severe poststroke communication difficulties have a higher incidence of falls during inpatient rehabilitation? A retrospective cohort study

Clinical Implications for Management of Falls in Hospital Patients with Communication Disability After Stroke: A Qualitative Meta-Synthesis

BACKGROUND

Falls in hospital are a common patient safety incident after stroke. Despite the reprevalence of communication disability following stroke, there is little guidance for health professionals to provide effective falls prevention strategies for this population.

OBJECTIVES

To provide a synthesis of findings across a selected set of related studies on falls in hospital patients with communication disabilities following stroke and guidance for health professionals to enhance falls prevention strategies for this group.

METHODS

A qualitative meta-synthesis of six integrated studies using a content thematic analysis.

RESULTS

Communication disability often lacks visibility in falls research, hospital policies, and clinical management. Whilst the relationship of communication disability as a risk factor for falls is unclear, communication disability contributes to falls and is a barrier to falls prevention and management. Suggestions for falls prevention include involving family members, tailored falls and stroke education programmes, and improved documentation of the functional impacts of communication disability.

CONCLUSION

In recognising the complexities of falls in patients with communication disability, health professionals could provide more targeted, patient-specific falls prevention plans. Further research, inclusive of patients with communication disability following stroke, could provide important insights into their falls and falls management. Research examining the effectiveness of falls prevention strategies for this group is indicated.

IMPLICATIONS FOR PATIENT CARE

Insights from this review could enhance falls prevention programmes for patients with communication disabilities after stroke.

IMPACT

This meta-synthesis combined a set of integrated studies to provide guidance for the management and prevention of falls in hospital patients with communication disabilities after stroke. Three interconnected content themes were identified: (a) An invisible problem: communication disability is invisible, and consideration of this in research and falls management has been lacking; (b) Painting the falls picture: the nature of communication disability and falls; and (c) A complex problem: the multiple impacts of communication disability on falls management. Falls prevention themes identified in the individual studies that specifically target the needs of patients with communication disability after stroke are presented as 'The Way Forward: Potential Falls Prevention Strategies to Improve Care for Hospital Patients with Communication Disability Following Stroke'. The integration of these findings into clinical practice should mean that (a) healthcare professionals provide more patient-specific falls prevention plans that include considerations of communication disability, and (b) hospital managers should take steps towards improving falls prevention and management policies to include patients with communication disability following stroke.

REPORTING METHOD

This review is reported according to the Standards for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

A Role for Health Literacy in Protecting People With Limited English Proficiency Against Falling: A Retrospective, Cohort Study

OBJECTIVE

To identify risk factors related to falls within the scope of speech-language pathology (SLP) using assessments from the Inpatient Rehabilitation Facility-Patient Assessment Instrument over a 4-month period in 4 inpatient rehabilitation facilities (IRFs).

DESIGN

Observational retrospective cohort study.

SETTING

Four IRFs as part of a larger learning health system.

PARTICIPANTS

Adults aged ≥18 years admitted to the IRFs from October 1, 2022 to February 28, 2023 were included.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

Occurrence of falls.

RESULTS

Analyses of 631 patient records revealed that the odds of falling were almost 3 times greater in people with limited English proficiency than in English speakers (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.09-6.85). People with limited English proficiency who reported poorer health literacy had 4 times higher odds of falling (OR, 3.90; 95% CI, 1.13-13.44) than English speakers who reported adequate health literacy. People with limited English proficiency who reported adequate health literacy had the same risk of falling as English speakers (OR, 0.98; 95% CI, 0.16-6.12), suggesting the protective role of health literacy for people with limited English proficiency.

CONCLUSIONS

Language barriers have a significant effect on falls among patients in IRFs. SLPs improving health literacy and providing language support may play a crucial role in mitigating fall risk, thereby enhancing patient safety and outcomes.

"We don't look too much into the communication disability": clinicians' views and experiences on the effect of communication disability on falls in hospital patients with stroke

PURPOSE

Difficulty with communicating basic needs and attracting the attention of health professionals may contribute to falls for patients with communication disability after stroke. The aim of this study was to explore the views of hospital-based health professionals on: (a) the effect of communication disability on falls in patients with stroke; (b) falls prevention strategies for patients with communication disability following stroke; and (c) the roles of speech pathologists in the assessment, management, and prevention of falls in this population.

MATERIALS AND METHODS

Online focus groups were conducted and analysed using content thematic analysis.

RESULTS

In total, 11 health professionals participated in four focus groups. Clinicians viewed that: (a) the effects of falls in patients with communication disability are far-reaching; (b) communication disability complicates falls risk assessment and falls management; (c) current falls prevention strategies do not meet the needs of patients with communication disability; and (d) strong relationships have a central role in decreasing falls in this population.

CONCLUSIONS

Health professionals articulate concerning gaps in falls prevention strategies for patients with communication disability. Further research should investigate strategies enabling falls prevention and management to be more inclusive of patients with communication disability following stroke and consider ways in which speech pathologists could contribute to this field.

Aphasia disrupts usual care: "I'm not mad, I'm not deaf" - the experiences of individuals with aphasia and family members in hospital

PURPOSE

Communication difficulties are highly prevalent in the stroke population, with implications for patient experience, safety and outcomes. This study explores the experiences of people with aphasia and family members regarding healthcare communication in acute and subacute stroke settings.

METHODS AND MATERIALS

A phenomenological approach was used to understand participants' experiences. Participants took part in a focus group and data were analysed using an inductive thematic approach.

RESULTS

For individuals with aphasia (n = 4) and family members (n = 2), five themes were generated: "aphasia makes it hard to communicate," "hospital staff focus on the patient's medical status only," "people with aphasia do not get the help they need to improve," "staff lack the skills to communicate with people with aphasia," and "staff are crucial to improving healthcare communication."

CONCLUSIONS

The stroke team has expertise in the medical management of stroke but struggle to communicate with patients with aphasia. Patients' experience of healthcare communication is often one-way and limited to following instructions, with missed opportunities to discuss core topics such as prognosis, rehabilitation, and person-specific needs. Patients and families assert that all members of the stroke healthcare team should be able to adapt communication to accommodate patients.

Need for Human Interaction and Acknowledging Communication-An Interview Study With Patients With Aphasia Following Stroke

AIM

To explore stroke patients' experiences of the communicative practice during their hospitalisation and describe strategies and supporting communication techniques applied by patients and nursing staff from the patient's perspective.

DESIGN

A qualitative descriptive study was undertaken.

METHODS

A qualitative approach was chosen; through a purposeful sample strategy, 13 semi-structed interviews with 12 patients who had aphasia following stroke, and one patient had dysarthria. The interviews were video-recorded and partially transcribed. Data were analysed according to Graneheim and Lundman's content analysis. Interview data were collected in 2022.

RESULTS

The analysis generated one overarching theme; Being acknowledged as an equal human being as it appeared to be a pervasive and underlying trait across the four categories; Waking up to a new communicative reality, A task-oriented communicative agenda, Misunderstandings as a communicative dead end and Establishing a communication-friendly environment: peace, patience and supporting techniques, describing the immediate and descriptive level. The patients did not seem to encounter a systematic approach to communication. They perceived the health care staff's communication as primarily task and purpose-oriented, lacking deeper conversations, which seemed to leave several with unmet emotional and psychological needs. Emotional, relational and existential aspects seemed interwoven in communication.

CONCLUSION

These findings contribute by illuminating an important patient perspective and ultimately, raising the point that from the perspective of patients the nursing staff's communication was primarily task and purpose oriented, and they lacked deeper conversations. Hence also raises the point that the use of supportive communication strategies alone will allow nursing staff to meet the existential needs of patients with aphasia. Supported communication needs to address compassionate and acknowledging aspects of communication. No Patient or Public Contribution in this paper.

Comparing acute hospital outcomes for people with post-stroke aphasia who do and do not require an interpreter

BACKGROUND

People with communication differences are known to have poorer hospital outcomes than their peers. However, the combined impact of aphasia and cultural/linguistic differences on care and outcomes after stroke remains unknown.

OBJECTIVES

To investigate the association between cultural/linguistic differences, defined as those requiring an interpreter, and the provision of acute evidence-based stroke care and in-hospital outcomes for people with aphasia.

METHODS

Cross-sectional, observational data collected in the Stroke Foundation National Audit of Acute Services (2017, 2019, 2021) were used. Multivariable regression models compared evidence-based care and in-hospital outcomes (e.g., length of stay) by interpreter status. Models were adjusted for sex, hospital location, stroke type and severity, with clustering by hospital.

RESULTS

Among 3122 people with aphasia (median age 78, 49% female) from 126 hospitals, 193 (6%) required an interpreter (median age 78, 55% female). Compared to people with aphasia not requiring an interpreter, those requiring an interpreter had similar care access but less often had their mood assessed (OR 0.50, 95% CI 0.32, 0.76), were more likely to have physiotherapy assessments (96% vs 90% p = 0.011) and carer training (OR 4.83, 95% CI 1.70, 13.70), had a 2 day longer median length of stay (8 days vs 6 days, p = 0.003), and were less likely to be independent on discharge (OR 0.54, 95% CI 0.33, 0.89).

CONCLUSIONS

Some differences exist in the management and outcomes for people with post-stroke aphasia who require an interpreter. Further research to explore their needs and the practical issues underpinning their clinical care pathways is required.

A novel multistep approach to standardize the reported risk factors for in-hospital falls: a proof-of-concept study

Background

Uncertainty and inconsistency in terminology regarding the risk factors (RFs) for in-hospital falls are present in the literature.

Objective

(1) To perform a literature review to identify the fall RFs among hospitalized adults; (2) to link the found RFs to the corresponding categories of international health classifications to reduce the heterogeneity of their definitions; (3) to perform a meta-analysis on the risk categories to identify the significant RFs; (4) to refine the final list of significant categories to avoid redundancies.

Methods

Four databases were investigated. We included observational studies assessing patients who had experienced in-hospital falls. Two independent reviewers performed the inclusion and extrapolation process and evaluated the methodological quality of the included studies. RFs were grouped into categories according to three health classifications (ICF, ICD-10, and ATC). Meta-analyses were performed to obtain an overall pooled odds ratio for each RF. Finally, protective RFs or redundant RFs across different classifications were excluded.

Results

Thirty-six articles were included in the meta-analysis. One thousand one hundred and eleven RFs were identified; 616 were linked to ICF classification, 450 to ICD-10, and 260 to ATC. The meta-analyses and subsequent refinement of the categories yielded 53 significant RFs. Overall, the initial number of RFs was reduced by about 21 times.

Conclusion

We identified 53 significant RF categories for in-hospital falls. These results provide proof of concept of the feasibility and validity of the proposed methodology. The list of significant RFs can be used as a template to build more accurate measurement instruments to predict in-hospital falls.

'Patient unable to express why he was on the floor, he has aphasia.' A content thematic analysis of medical records and incident reports on the falls of hospital patients with communication disability following stroke

BACKGROUND

People with communication disability following stroke are at risk of falls during inpatient rehabilitation. However, they are often excluded from hospital falls research, and little is known about the circumstances or outcomes of their falls to inform risk management strategies.

AIMS

To examine hospital medical records and incident reports relating to falls of patients with communication disability following stroke for content codes, categories and themes relating to communication.

METHODS & PROCEDURES

This medical record chart review examined data on 72 patients and 265 falls. A content thematic analysis was used to identify how patient communication is characterized in relation to falls, and their prevention and management strategies.

OUTCOMES & RESULTS

The data reflected that staff viewed patients having difficulty following simple instructions as contributing to falls. Gaining the attention of staff and communicating basic needs were also considered to be contributing factors for falls. Patients were often described as experiencing a fall when taking a risk or attempting to address an unmet basic need. Furthermore, written notes for patients with more severe communication disability reflected that the patient's communication impairments prevented staff from establishing the circumstances of some falls and complicated the assessment for injury following a fall.

CONCLUSIONS & IMPLICATIONS

The medical records and incident reports of patients with communication disability following stroke reveal that hospital staff recognize the impact of communication disability as potential risk factors for falls for this group. It was difficult for staff to report the circumstances of the fall for patients with severe communication disability. Despite the recognition of communication as a potential contributing factor, few medical record entries documented strategies related to communication interventions to improve patients' ability to understand instructions, gain attention or communicate basic needs.

WHAT THIS PAPER ADDS

What is already known on the subject People with stroke are at a high risk of falls during their hospital admission. However, little is known about the circumstances of their falls and the influence of communication disability on these falls. What this paper adds to existing knowledge Patients with communication disability have unique factors that contribute to their falls in the hospital. Patients were described as experiencing a fall when taking a risk or attempting to address an unmet need, and these falls were often related to a patient's difficulties communicating their basic needs, gaining attention from staff, and following simple instructions. What are the potential or actual clinical implications of this work? Communication disability as a risk factor for a fall, and fall prevention strategies tailored to the communication disability, were typically identified and documented by physiotherapists, occupational therapists and nursing staff. The inclusion of speech pathologists in fall risk assessment, management, and prevention strategies may provide crucial information regarding the patient's communication disability that may enhance their fall prevention plan.

Using Quality Indicator Codes to Identify Patients' Fall Risk in Inpatient Rehabilitation Facilities

OBJECTIVE

To discover if quality indicator (QI) codes are associated with patient falls in inpatient rehabilitation facilities (IRFs).

DESIGN

This retrospective cohort study explored differences between patients who fell and those who did not fall. We analyzed potential associations between QI codes and falls using univariable and multivariable logistic regression models.

SETTING

We collected data from electronic medical records at 4 IRFs.

PARTICIPANTS

In 2020, our 4 data collection sites admitted and discharged a total of 1742 patients older than 14 years . We only excluded patients (N=43) from statistical analysis if they were discharged before admission data had been assigned.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Using a data extraction report, we collected age, sex, race and ethnicity, diagnosis, falls, and QI codes for communication, self-care, and mobility performance. Staff documented communication codes on a 1-4 scale and self-care and mobility codes on a 1-6 scale, with higher codes representing greater independence.

RESULTS

Ninety-seven patients (5.71%) fell in the 4 IRFs over a 12-month period. The group who fell had lower QI codes for communication, self-care, and mobility. When adjusting for bed mobility, transfer, and stair-climbing ability, low performance with understanding, walking 10 feet, and toileting were significantly associated with falls. Patients with admission QI codes below 4 for understanding had 78% higher odds of falling. If they were assigned admission QI codes below 3 for walking 10 feet or toileting, they had 2 times greater odds of falling. We did not find a significant association between falls and patients' diagnosis, age, sex, or race and ethnicity in our sample.

CONCLUSIONS

Communication, self-care, and mobility QI codes appear to be significantly associated with falls. Future research should explore how to use these required codes to better identify patients likely to fall in IRFs.

Hospital policies on falls in relation to patients with communication disability: a scoping review and content analysis

Objective Falls in hospital are a significant public health issue and patients with communication disability have unique risk factors that have the potential to contribute to falls. The aim of this study is to determine how the content of hospital falls policies relate to patients with communication disability and to identify gaps in policy that need to be addressed. Methods A scoping review and content analysis of (a) policies and related documents, from a target health service in Victoria, Australia, and all relevant Australian state and territory health departments, and (b) national guidelines was performed. Data were analysed for content relating to inclusion of patients with communication disability. Results Communication disability is not captured as a risk factor for a fall in assessment tools. When included, aspects of communication disability were often conflated with cognitive impairments. There was little guidance for staff on adapting falls prevention education to suit the needs of patients with communication disability and limited identified role for speech pathologists. Conclusion This study suggests that a patient's communication disability is not visible in hospital falls policies and guidelines.

Elizabeth Usher memorial lecture: Beyond our practice borders-using a biopsychosocial framework to improve long-term outcomes for people living with aphasia

Purpose: Over 140 000 Australians live with aphasia after stroke, with this number of people living with aphasia increasing significantly when aphasia arising from traumatic brain injury, neoplasm, and infectious and progressive neurological diseases is also included. The resulting communication disability frequently compromises every aspect of daily life, significantly impacting everyday activity, employment, social participation, mental health, identity, and family functioning. Rehabilitation services rarely meet the needs of this group who have, for example, poorer healthcare outcomes than stroke peers without aphasia, nor address long-term recovery and support needs.Method: In this discussion paper, I argue that given the broad impacts of aphasia, a biopsychosocial approach to aphasia rehabilitation is required. Rehabilitation must include: interventions to improve the communication environment; programs that directly target identity, wellbeing, and mental health; and therapies focusing on functional activity, communication participation, and long-term self-management.Result: The evidence for these approaches is mounting and includes strongly stated consumer needs. I discuss the need for multidisciplinary involvement and argue that for speech-language pathologists to achieve such comprehensive service provision, an expanded scope of practice is required.Conclusion: There is a need to rethink standard therapy approaches, timeframes, and funding mechanisms. It is time to reflect on our practice borders to ask what must change and define how change can be achieved.

Acute post-stroke aphasia management: An implementation science study protocol using a behavioural approach to support practice change

BACKGROUND

Evidence should guide decisions in aphasia practice across the continuum of stroke care; however, evidence-practice gaps persist. This is particularly pertinent in the acute setting where 30% of people with stroke will have aphasia, and speech pathologists experience many challenges implementing evidence-based practice. This has important consequences for people with aphasia and their close others, as well as speech pathologists working in acute settings.

AIMS

This study protocol details how we will target practice change using a behavioural approach, with the aim of promoting the uptake of synthesized evidence in aphasia management post-stroke in the acute hospital setting.

METHODS & PROCEDURES

We will conduct a mixed-methods before-and-after study following the Knowledge-to-Action (KTA) framework. Researchers, speech pathologists and people with lived experience of aphasia will collaborate to identify and prioritize practice gaps, and develop and implement changes to clinical practice based on the Theoretical Domains Framework and Behaviour Change Wheel.

DISCUSSION

This study may provide a template for acute stroke services in how to use an implementation science approach to promote the application of synthesized evidence into routine clinical practice to ensure people with aphasia receive high-quality services. Collaboration among researchers, healthcare providers, people with aphasia and their close others ensures that the identification and targeting of practice gaps are driven by theory, lived experience and the local context.

WHAT THIS PAPER ADDS

What is already known on this subject Synthesized evidence, such as clinical guidelines and consensus statements, provides the highest level of evidence to inform clinical practice, yet discrepancies between delivered care and evidence remain. This discrepancy is of note in the acute setting where clinicians report many challenges implementing the best available evidence, combined with a high proportion of people with stroke who will have aphasia (30%). There are many reasons why evidence is not put into practice, and efforts to change clinical practice need to consider these barriers when developing interventions. What this paper adds to existing knowledge This study protocol details an implementation science approach to affect clinical practice change, informed by a collaboration of key stakeholders (researchers, speech pathologists, and people with aphasia and their close others). Protocol papers that focus on bridging the gap between evidence and practice are uncommon in communication disorders; moreover, explicit prioritization of practice gaps is a critical but often overlooked aspect of promoting evidence-based practice. What are the potential or actual clinical implications of this work? This protocol provides insights into how one study site identified and prioritized evidence-practice gaps using a participatory approach. We provide insights into how clinical practice change may occur by describing how we plan to identify priority evidence-practice gaps and develop an intervention to improve the use of aphasia evidence in routine practice. This protocol aims to share an implementation science approach to service improvement that may be replicated across other services.

The nature of inpatient rehabilitation for people with aphasia from culturally and linguistically diverse backgrounds: a scoping review

BACKGROUND

Due to language and cultural barriers, people with aphasia from culturally and linguistically diverse (CALD) backgrounds are at risk of disadvantage in their access to comprehensive care. They are at higher risk of poorer inpatient outcomes in addition to challenges in receiving appropriate aphasia assessment and intervention.

OBJECTIVES

This study aims to examine the extent and nature of what is known about the inpatient phase of aphasia rehabilitation for CALD stroke survivors and identify potential research gaps in the literature for investigation.

METHODS

A scoping review with systematic search was conducted in September 2020 following the PRISMA Scoping Review checklist. Five electronic databases were searched using a combination of terms pertaining to "aphasia," "inpatient care" and "CALD." Key variables were extracted from studies that met the inclusion criteria for analysis.

RESULTS

Eighteen studies were yielded. Data regarding the inpatient phase of care indicate that CALD people with aphasia do not always receive comprehensive assessment or intervention in all their languages that may impact their discharge destination and access to community services. Speech-language pathologists (SLPs) report numerous barriers to service provision for this population. No studies investigated the degree and nature of differences in outcomes between CALD and non-CALD stroke survivors with aphasia.

CONCLUSIONS

CALD stroke survivors with aphasia inconsistently access SLP services in hospital. Assessment is unlikely to be conducted in patient primary languages and therapy is usually provided in the language of SLPs. Further research is required to determine whether this impacts functional outcomes and health services.

Falls in Patients With Communication Disability Secondary to Stroke

Patients with stroke are at high risk of falls during inpatient rehabilitation admission. Communication disability is common following stroke; however, this population is often excluded from falls research. This study aimed to examine the falls of patients with communication disability following stroke, including the circumstances, contributing factors, and outcomes of the fall. This medical record review used the Generic Reference Model of patient safety as the analytical lens and data were analyzed descriptively. The study included 109 patients who experienced 308 falls. The most common type of fall was an "unwitnessed roll from bed." Patient factors contributed to half of all falls, injuries occurred in 15% of falls, and impacts to the hospital system included additional costs and staffing. Understanding the reasons why patients are attempting to get out of bed may identify ways to reduce the risk and incidence of falls in this population.

Communication partner training for healthcare workers engaging with people with aphasia: Enacting Sustainable Development Goal 17 in Austria, Egypt, Greece, India and Serbia

PURPOSE

This commentary describes how a grassroot-led partnership initiated by members of the organisations World Federation of NeuroRehabilitation and Collaboration of Aphasia Trialists is addressing the marginalisation of people with aphasia, through education and knowledge exchange related to communication partner training of health professionals.

RESULT

A partnership between academics and healthcare professionals across Austria, Denmark, Egypt, Ireland, Greece, India, Serbia and the United Kingdom was established in 2020. Through bimonthly online sessions in 2021-2022 a Danish communication partner training program was introduced while six teams adapted and translated the training and its materials to their local contexts.

CONCLUSION

A collaborative partnership enabled multiple translations of an existing communication partner training program for healthcare professionals working with people with aphasia to support a sustainable delivery model that is linguistic and culturally sensitive. This commentary paper focusses on Sustainable Development Goal (SDG) 17 and also addresses SDG 10.

Intersectionality of Race and Question-Asking in Women After Right Hemisphere Brain Damage

PURPOSE

Atypical pragmatic language can impede quality health care access. Right hemisphere brain damage (RHD) results in changes in pragmatic language use; however, little is known about whether there are racial/ethnic influences. Recent research indicated differences in question-asking when RHD survivors were compared with healthy controls, prompting the current examination of question production in women by race/ethnicity and the presence of RHD.

METHOD

Participants were eight Black and eight White women who sustained a single right hemisphere stroke at least 6 months prior to data collection (2016-2020), and eight Black and eight White control participants from the Right Hemisphere Damage Bank (https://rhd.talkbank.org). Videos of informal, first-encounter conversational discourse tasks were transcribed and coded. Analyses were conducted for frequency of questions and question type.

RESULTS

Race/ethnicity had a statistically significant effect on the total number of questions and number of content and polar questions. The mean total of questions, number of content questions, and mean number of polar questions for Black participants was significantly less than White participants. There was less variability in question type for Black participants than White participants, and a tendency for Black participants to ask fewer questions regardless of RHD or control status.

CONCLUSIONS

Acquisition of health information and ensuing health care might be less fruitful for Black women communicating with someone who may not know to conduct comprehension checks and be proactive in provision of information. To be culturally responsive to Black patients with communication disorders, providers might apply this awareness of reduced question-asking to their strategies to improve patient-provider communication.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21809475.

Striving Toward Equity in Health Care for People With Communication Disabilities

PURPOSE

Approximately 10% of the U.S. adult population has a speech, language, and/or voice disability, collectively referred to as communication disabilities. An increasing number of studies demonstrate that persons with communication disabilities have worse health and health care outcomes as compared to those without communication disabilities. Understanding the state of the science, including potential contributing factors is critical to begin to address the disparities.

METHOD

Applying a historical lens and integrating multiple models of disability provide a comprehensive perspective of the health and health care outcomes of persons with communication disabilities.

RESULTS

Three phases for addressing health care disparities exist: detecting, understanding, and reducing. Results from a 2012 National Health Interview Survey provide compelling population-level results of the health and health care disparities experienced by persons with communication disabilities. To understand the disparities, factors within the health care system, such as availability of communication aids and services, as well as provider and staff biases, assumptions, and lack of knowledge need to be considered. To date, few interventions exist to address disparities in care for persons with communication disabilities. Consequently, researchers need to engage with stakeholders in innovative study designs and methods to facilitate the rapid development, implementation, and dissemination of interventions that address the disparities.

CONCLUSION

To ensure equity for the large and growing population of persons with communication disabilities, researchers, policy makers, patients, and health care systems need to collaborate in identifying and addressing the factors contributing to health and health care disparities. Presentation Video: https://doi.org/10.23641/asha.21215804.

Characteristics of falls occurring during rehabilitation in an acute care hospital in older and non-older patients: A retrospective cohort study

Introduction

Although falls are often reported in hospitals and are common in older individuals, no reports on falls during rehabilitation exist. This study evaluated patients with falls occurring during rehabilitation and identified the characteristics of older and non-older patients.

Materials and methods

Our study retrospectively analyzed reports of falls occurring during rehabilitation at a university hospital from April 1, 2020 to March 31, 2022. The survey items included the number of falls in the hospital as a whole and during rehabilitation, age, gender, modified Rankin Scale (mRS) before admission and at the time of fall, functional independence measure (FIM) at admission, patient communication status at the time of fall, and whether a therapist was near the patient. Patients aged ≥ 65 were considered older; aged ≤ 64, non-older; and those with the same age, gender, and clinical department, randomly selected as non-falling patients.

Results

Thirty-five falls occurred during rehabilitation (14 in the non-older and 21 in the older patients), significantly lower than the 945 for the entire hospital, without any significant difference between non-older and older patients. No significant differences in mRS before admission and FIM at admission were noted for both groups in comparison with the non-falling patient group. Furthermore, gender, mRS, FIM, good communication status, and presence of therapist near the patient were similar between non-older and older patients (non-older 71.4%, older 52.4%). Most falls were minor adverse events that did not require additional treatment.

Conclusion

The rate of falls during rehabilitation was much lower than that during hospitalization, and many falls had minimal impact on the patient. It was also difficult to predict falls in daily life and communication situations, and there was no difference in characteristics between the older and non-older groups. Since more than half of the falls occurred during training with the therapist, it is necessary to reconsider the training content.

Understanding How Older Adults with Communication Difficulties Access Health Services: What We Can Learn from the National Health and Aging Trends Study (NHATS)

People with communication disorders face barriers to accessing safe and respectful healthcare. These barriers result in increased healthcare complications and inefficiencies, both of which contribute to increased healthcare costs. One obstacle to advocating for accommodations that could improve healthcare for this population is the absence of cost effectiveness studies of such accommodations specifically, as well as a paucity of data defining the needs of this population in general. The purpose of this study was to explore how people with communication and swallowing difficulties are characterized in the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries aged 65 and older, and how they manage their healthcare. Cross-sectional data from the NHATS rounds 5 to 9 (2015-2019) resulted in 8,038 unique respondents, 3,243 of who reported speech, memory, hearing, and/or swallowing difficulties. More than 90% of respondents with communication difficulties reported having a regular doctor. Less than 60% of respondents with communication difficulties had a family member or caregiver go to medical appointments with them, and around 70% of that subset of participants received help from that caregiver with communication during appointments. Fewer than 15% of respondents with communication difficulties used the internet for healthcare communication or information. Less than 5% of respondents across all communication difficulty categories had received rehabilitation services for communication in the year prior to their survey responses. While the information gleaned from NHATS points to likely gaps between the needs people with communication disorders may have for safe and accessible healthcare, and the support available, future research is needed to improve and clarify how communication disorders are defined and characterized in large-scale surveys to generate more interpretable data. These stronger empirical foundations are needed to support cost-effectiveness analyses to advocate for better communication accessibility of healthcare settings.

Functional standing frame programme early after severe sub-acute stroke (SPIRES): a randomised controlled feasibility trial

BACKGROUND

Early mobilisation (> 24 h post-stroke) is recommended for people with stroke. However, there is a paucity of evidence about how to implement early mobilisation for people who have had a severe stroke. Prolonged standing and task-specific training (sit-to-stand repetitions) have separately been evaluated in the literature; however, these functionally linked tasks have not been evaluated in combination for people with severe sub-acute stroke.

METHODS

The objective was to determine the feasibility of conducting a randomised controlled trial (RCT) of a functional standing frame programme compared with usual physiotherapy for people with severe sub-acute stroke. An assessor-blinded feasibility RCT with nested qualitative component (interviews and focus group) and process evaluation was adopted. Participants were aged ≥ 18 years with new diagnosis of severe sub-acute stroke (modified Rankin Scale (mRS) 4/5) from four Stroke Rehabilitation Units across South West England. Participants were randomised to receive either: (1) functional standing frame programme (30 min. standing plus sit-to-stand repetitions) plus 15 min of usual physiotherapy daily (intervention); (2) usual physiotherapy (45 min) daily (control). Both programmes were protocolised to be undertaken a minimum of five sessions per week for 3 weeks. Feasibility indicators included process, resource, management, and safety. Adherence, fidelity, and acceptability of the trial and intervention were evaluated using data recorded by therapists, observation of intervention and control sessions, interviews and one focus group. Patient measures of motor impairment, activities/participation, and quality of life were carried out by blinded assessors at baseline, 3, 15, 29, and 55 weeks post-randomisation.

RESULTS

Forty-five participants (51-96 years; 42% male, mRS 4 = 80% 5 = 20%) were randomised (n = 22 to intervention). Twenty-seven (60%) participants were followed-up at all time points. Twelve participants (27%) died during the trial; no deaths were related to the trial. Adherence to the minimum number of sessions was low: none of the participants completed all 21 sessions, and only 8 participants (18%) across both groups completed ≥ 15 sessions, over the 3 weeks; 39% intervention; 51% control sessions were completed; mean session duration 39 min (SD 19) control, 37 min intervention (SD 11). Intervention group: mean standing time 13 min (SD 9); mean sit-to-stand repetitions/session 5 (SD 4). Interviews were conducted with 10 participants, four relatives and six physiotherapists. Five physiotherapists attended a focus group.

CONCLUSIONS

The majority of progression criteria for this feasibility trial were met. However, adherence to the interventions was unacceptably low. This aspect of the trial design needs to be addressed prior to moving to a definitive RCT of this standing frame intervention in people with severe sub-acute stroke. Solutions have been identified to address these concerns.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN15412695 . Registration 19 December 2016.

Risk Factors Related to Falling in Patients after Stroke

Background:

The aim of this study was to identify the risk factors associated with falling in post stroke patients.

Methods:

This retrospective case-control study included 561 neurology patients hospitalized for a stroke and divided into two groups: falling patients and non-falling patients. They referred to the Special Hospital for Cerebrovascular Diseases “Sveti Sava” in Belgrade, Serbia, from 2018–2019. Logistic regression analysis was applied to examine socio-economic factors associated with predictors of unmet healthcare needs.

Results:

A significant difference was seen in the length of hospitalization of falling patients compared to the non-falling (P<0.001). We established statistically significant differences in mental status (P<0.001), sensibility (P=0.016), depressed mood (P<0.001), early (P=0.001) and medium insomnia (P=0.042), psychomotor slowness (P=0.030), somatic anxiety (P=0.044) and memory (P<0.001).

Conclusion:

Cerebrovascular disease distribution and the degree of neurological deficit primarily altered mental status, which could be recognized as one of the more important predictors for falling after stroke. The identification of risk factors may be a first step toward the design of intervention programs for preventing a future fall among hospitalized stroke patients.

Falls in hospital patients with acquired communication disability secondary to stroke: A systematic review and meta-analysis

BACKGROUND

Falls are a common safety incident in people with stroke. Studies report that between 14% and 65% of people with stroke fall at least once during their hospital admission. Risk factors for falls in people with stroke have been reported to include neglect, balance and dependence for activities of daily living. Communication disability has been identified as a risk factor for patient safety incidents in hospital that has not been closely examined as a potential risk factor for falls in people with stroke.

AIM

To determine the association between communication disability secondary to stroke and falls in people with stroke in hospital.

METHODS & PROCEDURES

Systematic searches of five electronic databases were conducted in June 2019 using the key concepts of 'falls' and 'stroke' (PROSPERO CRD 42019137199). Included studies provided comparative data of falls in patients with stroke with and without communication disability. The methodological quality of the studies was examined using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). Both a narrative synthesis and a meta-analysis were completed.

MAIN CONTRIBUTION

A total of 15 studies met the criteria for inclusion and 11 were included in a meta-analysis. Three studies found people with communication disability had an increased rate of falls in hospital. However, a meta-analysis showed no significant association between a non-specific classification of communication disability and an increased risk of falls. There was some indication from individual studies that higher risk of falls may be associated with severe communication disability, but there were insufficient data reported on the severity of the communication disability to draw robust conclusions.

CONCLUSION & IMPLICATIONS

The results of this systematic review suggest that a generic classification of communication disability following stroke is not a risk factor for falls. However, further research that is inclusive of this population and considers severity of communication disability more specifically is required. What this paper adds What is already known on the subject The association between communication disability following stroke and falls in hospital is unclear. The literature reports mixed results regarding the impact of a communication disability following stroke on falls risk or rates of falls during hospital admission. What this paper adds to existing knowledge This review is the first to bring together this diverse literature to examine the association between communication disability following stroke and falls in hospital. The results suggest that a generic classification of communication disability following stroke is not a risk factor for falls. What are the potential or actual clinical implications of this work? There is a possibility that moderate to severe communication disability may be related to falls in patients in hospital. Further research is indicated to be more inclusive of people with communication disability, including those with severe communication disability.

Aphasia disrupts usual care: the stroke team's perceptions of delivering healthcare to patients with aphasia

Purpose: Communication disability, including aphasia, is prevalent in the stroke population and impacts service delivery. This study explored the experiences of the multidisciplinary stroke team in delivering healthcare to patients with aphasia.Materials and methods: A phenomenological approach was used to understand the experiences of delivering healthcare services in the presence of aphasia. Healthcare professionals (n = 16) were recruited across acute and subacute stroke care, with a range of discipline backgrounds and experience. Participants took part in focus groups and data were analysed using an inductive thematic approach.Results: Five themes were evident: 1) aphasia is time consuming, 2) health professionals do not know how to help, 3) health professionals limit conversations with patients with aphasia, 4) health professionals want to know how to help, and 5) health professionals feel good after successful communication.Conclusions: Aphasia disrupts usual care. Health professionals want to help but are working in a non-optimal environment where communication and patient-centred care are not adequately resourced. A video abstract is available in Supplementary Material.IMPLICATIONS FOR REHABILITATIONCurrent hospital systems and ward culture make it difficult to offer patient-centred care to patients with aphasia.Health professionals want to help patients with aphasia but are working in an environment where patient-provider communication is not adequately resourced.As a result, health professionals dread, limit or avoid talking with patients with aphasia.Health professionals need support which may include ongoing education and on-the-job training, and a change in ward culture including key performance indicators focusing on patient-provider communication.

[Possibilities of neurotrophic therapy in early recovery after stroke]

The high prevalence and disability of patients with ischemic stroke make the further development of the rehabilitation system relevant. The implementation of neuroplasticity mechanisms is largely provided by neurotrophic factors. One of the most well-known neurotrophic drugs is cerebrolysin, the efficacy of which in patients with stroke has been confirmed in many clinical studies. A recent meta-analysis included 9 randomized, double-blind, placebo-controlled clinical studies of using cerebrolysin in 1879 patients with hemispheric ischemic stroke, where it was administered at a dose of 30-50 ml for at least 1 week (10-21 days) and therapy was started during 72 hours after stroke. Cerebrolysin has been shown to give patients a 60% chance of better outcomes after a stroke, improves early recovery and increases the likelihood of better recovery.