Why Aren’t We Treating Stroke as a Chronic Health Condition?

The health care industry approaches stroke as an acute transient event, with access to innovative and even standard treatments limited by money rather than the patient’s recovery potential.¹ Stroke has been classified by the United States Centers for Medicare and Medicaid Services (CMS) as a condition that lasts at least 1 year, requires ongoing medical attention, and limits activities of daily living.²A stroke impacts multiple systems resulting in lasting morbidities that will decrease life quality. If stroke is a chronic health condition, why aren’t we treating it as such?

Although we generally think of stroke as a medical problem of older adults, it is estimated that 10% to 20% of strokes occur between ages 18 to 50 years and rises by a factor of 100 from age 40 to 80.³ Young adults with strokes have been found to have a 15% cumulative incidence of a second stroke. Approximately 33% to 42% of stroke survivors will require assistance with daily living activities 3 to 6 months poststroke, and of those, 36% will report a disability after 5 years.⁴

CMS has classified stroke as a chronic condition and evidence suggests that it should not be treated as an acute transient event. But, we continue to focus on the first 60 to 90 days after the stroke. Formal therapy therefore frequently ends at 2 to 3 months poststroke despiteevidence that function and skills can improve with therapy any time poststroke and may even worsen without.⁵ The long-held belief is that recovery plateaus at 3 to 6 months. Perhaps, the financial constraints limiting long-term stroke rehabilitation are tied to that incorrect assumption.

Stroke Morbidity

Medical complications such as fatigue, depression, pain, and cognitive issues are associated with poorer functional outcome after adjusting for age and stroke severity. The greatest complication of a first stroke is the risk of further strokes. An individual who has a stroke has a 30% risk of a second stroke within 5 years, or about 9 times the risk as the general population.⁶

Poststroke depression (PSD) is not uncommon and is particularly concerning given its association with increased morbidity and mortality. Sleep disturbances, chronic pain, and hormonal dysregulation are likely to contribute to depression and may be a factor in a patient’s cognitive decline. Ultimately, medical complications are likely to interfere with rehabilitation, further contributing to lasting disability.

Neuroendocrine Alterations Following a Stroke

Hypopituitarism is frequently observed in stroke survivors. Disruption of the gonadal axis may result in decreased muscular weakness and decreased libido in men. Women may have decreased libido and decreased bone density. Disruption of the somatotroph axis will result in growth hormone deficiency with symptoms of fatigue, increased body fat, depression, and cognitive impairments.⁷ Thyroid axis deficiencies may be concomitant with chronic poststroke fatigue, cardiovascular disease, and poor clinical outcomes.⁸

Poststroke Fatigue

Despite functional recovery, sedentary behavior is greatly increased after a stroke augmenting the risk for secondary stroke. Approximately 36% to 51% of stroke survivors, including young adults, will experience poststroke fatigue defined as: “a feeling of exhaustion, weariness or lack of energy that can be overwhelming, and which can involve physical, emotional, cognitive and perceptual contributors.”⁹ Poststroke fatigue is not merely the sensation of tiredness and is not always relieved by rest. Although it may appear like apathy or depression, which may still be present, it is a separate entity and thus more difficult to treat.

Sleep Disturbances After Stroke

Sleep abnormalities are common after a stroke. Hypersomnia has been observed in 25% of individuals after a stroke and approximately 50% of stroke survivors will complain of insomnia.¹⁰

The prevalence of obstructive sleep apnea (OSA) in patients with stroke is over 70%.¹¹ It should be noted that OSA is often a preexisting condition and is a risk factor for sustaining a stroke.¹² Despite the prevalence of poststroke sleep disorders, only 6% of stroke survivors are offered formal sleep testing.¹³

Cognitive Impact of Stroke

Poststroke cognitive impairment (PCSI), defined as any cognitive impairment occurring with a clear temporal relationship to a stroke, is common during the first 6 months and most pronounced during the subacute period.¹⁴ It is a multi-domain disorder which includes memory, attention, executive function, and language and visual spatial dysfunction. Over 50% of stroke survivors report persistent cognitive impairment well beyond the initial poststroke year.¹⁵

The risk of dementia increases after first stroke and is augmented with recurrent strokes.¹⁶ Approximately 10% of patients have dementia before their first stroke, 10% developed new dementia afterward and more than a third developed dementia after a recurrent stroke. Approximately 30% of stroke survivors develop dementia within a year, and the dementia risk continues to increase beyond normal rates for the following years.¹⁷

Acetylcholinesterase inhibitors have been found to maintain a stable pattern of improved cognitive function in PSCI and vascular dementia.¹⁸ Memantine, a medicine in the class of NMDA receptor antagonists used to treat patients with mild to moderate vascular dementia, has resulted in significant improvements in some aspects of cognition without deterioration in behavior and global functioning.¹⁹ Although there is a role for pharmacology in PSCI and vascular dementia, clearly there is more work to be done.

Evidence for the Benefits of Continued Therapies

Although most providers frequently terminate therapy reimbursement when patients are not showing reasonable improvement within a particular timeframe, it has been argued that the apparent motor plateau is really a neuromuscular adaptation in which the individual becomes neurophysiologically accustomed to the various exercise regimens they know. Perhaps just like traditional exercise regimens, an apparent plateau is an indicator that the regimen needs to be modified.²⁰ Most stroke studies are limited to motor recovery perhaps because motor recovery is easily quantifiable.

Concluding Thoughts

Historically, stroke rehabilitation in the United States has been mostly limited to 90 days and/or when the patient appears to plateau, which is usually based solely on the domain of motor recovery. There is very little scientific evidence supporting these limits. Patients can continue to improve with continued therapy. A plateau is not always permanent and can be overcome by changing the therapeutic regimen. Have we been lulled into complacency by the concept of “this is as good as it gets”?

On the first day of school, future medical practitioners and therapists are taught to practice evidence-based medicine. The duration of antibiotic treatment, of renal dialysis, of chemotherapy and radiation for cancer are all backed by scientific evidence. The evidence for long-term rehabilitation for appropriate individuals is abundantly clear. So why aren’t we practicing that type of medicine in chronic strokes?

Dr Masel is the executive vice-president for medical affairs with the Centre for Neuroskills and is a clinical professor of neurology at the University of Texas Medical Branch in Galveston.

Dr Griesbach is the national director of clinical research for the Centre of Neuro Skills and a member of the research team for the Synaptics Foundation. Her work focuses on mechanisms that facilitate recovery and enhance rehabilitation following a brain injury, and she has authored over 40-peer reviewed publications on the topic.

References

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19. Orgogozo JM, Rigaud AS, Stöffler A, et al. Efficacy and safety of memantine in patients with mild to moderate vascular dementia: a randomized, placebo-controlled trial (MMM 300). Stroke. 2002;33(7):1834-1839.

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