Better functional recovery after acute stroke in older patients managed in a new dedicated post-stroke geriatric unit compared to usual management

OBJECTIVES

A Stroke care Pathway dedicated to the ELders (SPEL) for patients with acute stroke was created in 2013 at the hospitals Pitié-Salpêtrière-Charles Foix (Paris, France). It is characterized by a stroke unit dedicated to emergency stroke care, and a post stroke geriatric unit (PSGU) including rehabilitation and management of geriatric syndromes. The aim of the study was to compare the functional recovery of patients transferred to PSGU versus other rehabilitation care in patients over 70 years of age after stroke.

DESIGN

A cohort observational study over a 4-year period.

SETTING

Hospitals Pitié-Salpêtrière and Charles Foix (Paris, France).

PARTICIPANTS

We studied patients over 70 years admitted to the participating stroke unit for acute stroke consecutively hospitalized from January 1, 2013, to January 1, 2017.

INTERVENTION

Patients transferred in the PSGU were compared to those admitted in other rehabilitation units.

MEASUREMENTS

The primary outcome was 3-month functional recovery after stroke. The secondary outcomes were the hospital length of stay and the returning home rate. A multivariable logistic regression was applied to adjust for confounding variables (age, sex, NIHSS score and Charlson's comorbidity score).

RESULTS

Among the 262 patients included in the study, those in the PGSU were significantly older, had a higher Charlson's comorbidity score and a higher initial NIHSS severity score. As compared to the other patients, functional recovery at 3 months was better in the PSGU (Rankin's score decreased by 0.80 points versus 0.41 points, p = 0.01). The average total length of stay was reduced by 16 days in the patients referred to the PSGU (p = 0.002). There was no significant difference in the returning home rate between the two groups (p = 0.88).

CONCLUSION

The SPEL which includes a post-stroke geriatric unit (PSGU) has been associated with improved recovery and had a positive impact in the management of older post-stroke patients.

[Anticoagulation use in older patients with atrial fibrillation in a cardio-geriatric unit]

OBJECTIVE

Older people with atrial fibrillation (AF) have an increased embolic risk but they are less frequently treated with anticoagulants. We wanted to assess our current practice in a specialized service.

PATIENTS AND METHODS

Prospective observational study including all patients older than 75 years admitted during 3 months in a cardio-geriatric unit. Patients' embolic risk (CHADS2 score), hemorrhagic risk (HAS-BLED score), anti-thrombotic treatment at arrival and any modification afterwards, were analyzed.

RESULTS

Thirty-four patients were included (mean age: 85 years). AF was known in 28 patients, of whom 20 were under anticoagulant therapy at their admission (10 fluindione, 9 warfarine, 1 dabigatran), 4 received aspirin and 4 no anti-thrombotic treatment. Only the treatment of one of these patients was modified, replacing aspirin by warfarin. AF was newly diagnosed in 6 patients, of whom anticoagulation were initiated in 4 patients (3 warfarine, 1 fluindione). Finally, 9 patients (26%) left the hospital without anticoagulant treatment. Reasons given by their attending doctors were: advanced dementia (4 patients), estimated excessive hemorrhagic risk (4), and estimated low embolic risk (1). There was a clear trend to initiate anticoagulation more frequently in patients with a newly diagnosed AF (P=0.09) CONCLUSIONS: A substantial proportion of older patients with AF do not receive anticoagulant therapy, even after having been admitted to a specialized service. Advanced dementia and hemorrhagic risk are the reasons most frequently given for that.