• Assessment and management of the consequences of stroke. In: National Stroke Foundation. Clinical guidelines for acute stroke management. Melbourne (Australia): National Stroke Foundation; 2007 Oct. p. 30-8.

This is the current release of the guideline.

The levels of evidence supporting the recommendations (I-IV) and grades of recommendations (A-D and clinical practice points [CPP]) are defined at the end of the "Major Recommendations" field.

The original guideline document also includes a consumer rating that identifies aspects of care considered to be critical from a patient perspective.

Dysphagia

Patients should be screened for swallowing deficits before being given food, drink or oral medications. Screening should be undertaken by personnel specifically trained in swallowing screening. (Grade C, Level I [Perry & Love, 2001; Martino, Pron, & Diamant, 2000])

Patients should be screened within 24 hours of admission. (CPP)

Patients who fail the swallowing screening should be referred to a speech pathologist for a comprehensive assessment. (CPP)

Nutrition

Close monitoring of hydration status and appropriate fluid supplementation should be used to treat or prevent dehydration. (Grade B; Level I [Hodgkinson, Evans, & Wood, 2003])

All patients with acute stroke should be screened for malnutrition. (Grade B; Level II [Dennis et al., "Routine oral nutritional," 2005])

Those who are at risk of malnutrition, including those with dysphagia, should be referred to a dietitian for assessment and ongoing management. Assessment of nutritional status should include the use of validated nutrition assessment tools or measures. (CPP)

Nutritional supplementation should be offered to people whose nutritional status is poor or deteriorating. (Grade A; Level I [Milne, Avenell, & Potter, 2006])

Nasogastric (NG) feeding is the preferred method during the first month post stroke for people who do not recover a functional swallow. (Grade B; Level II [Dennis et al., "Effect of the timing and method," 2005])

Food intake should be monitored for all people with acute stroke. (CPP)

Early Mobilisation

Patients should be mobilised as early and as frequently as possible. (Grade B; Level II [Indredavik et al., 1999])

After assessment the physiotherapist should advise staff and carers of appropriate mobilising and transfer techniques. (CPP)

Early Therapy for Difficulties with Activities of Daily Living (ADL)

Patients with difficulties in occupational performance in daily activities should be treated by an occupational therapist or a specialist multidisciplinary team that includes an occupational therapist. (Grade B; Level I [Langhorne et al., 2002; Legg, Drummond, & Langhorne, 2006])

Patients with confirmed difficulties in occupational performance in personal tasks, instrumental activities, vocational activities or leisure activities should have a management plan formulated and documented to address these issues. (CPP)

The occupational therapist should advise staff and carers on techniques and equipment to maximise outcomes relating to functional performance in daily activities, sensorimotor, perceptual and cognitive capacities. (CPP)

Cognition and Perception

All patients should be screened for cognitive and perceptual deficits using a validated screening tool. (CPP)

Patients identified during screening should undertake full assessment and management by an appropriately trained health professional. (CPP)

Communication

All patients should be screened for communication deficits using a validated screening tool. (Grade C, Level I [Salter et al., 2006)])

Those with suspected communication difficulties should receive formal assessment by a speech pathologist. (CPP)

Patients with communication difficulties should be treated as early and as frequently as possible. (Grade C, Level I [Bhogal, Teasell, & Speechley, 2003] & Level III-2 [Robey, 1998])

All written health information should be available in an aphasia friendly format. (Grade D, Level IV [Rose, Worrall, & McKenna, 2003])

The speech pathologist should advise staff and family/carers of appropriate communication techniques. (Grade C, Level II [Kagan et al., 2001; Wertz et al., 1986])

Incontinence

All patients with suspected continence difficulties should be assessed by trained personnel using a structured functional assessment. (Grade B; Level II [Thomas et al., 2005])

A portable bladder ultrasound scan can be used to assist in diagnosis and management of urinary incontinence. (Grade B; Level I [Martin et al., 2006]).

Patients with confirmed continence difficulties should have a continence management plan formulated and documented. (Grade C; Level II [Thomas et al., 2005])

The use of indwelling catheters should be avoided as an initial management strategy. (CPP)

A post discharge continence management plan should be developed with the patient and carer prior to discharge and should include how to access continence resources in the community. (CPP)

Mood

Patients with suspected altered mood (e.g., depression, anxiety, emotional lability) should be assessed by trained personnel using a standardised scale. (Grade B; Level II & Level III-1 [Joubert et al., 2006; Aben et al., 2002; Lincoln et al., 2003; Williams et al., 2005; Benaim et al., 2004; Watkins et al., 2007])

Patients with stroke may be managed using a case management model after discharge to reduce post stroke depression. If used, services should incorporate education of the recognition and management of depression, screening and assistance to coordinate appropriate interventions via a medical practitioner. (Grade C; Level II [Joubert et al., 2006; Williams et al., 2007])

Routine use of antidepressants to prevent poststroke depression is not currently recommended. (Grade B; Level I [Anderson, Hackett, & House, 2004])

Antidepressants may be used for people with emotional lability. (Grade B; Level I [House et al., 2004])

Patients with depression or anxiety may be treated with antidepressants and/or psychological interventions to improve mood. (Grade B; Level I [Hackett, Anderson, & House, 2004])

Definitions:

Levels of Evidence

Grading of Recommendations

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Assessment and management of the consequences of stroke. In: National Stroke Foundation. Clinical guidelines for acute stroke management. Melbourne (Australia): National Stroke Foundation; 2007 Oct. p. 30-8.

Not applicable: The guideline was not adapted from another source.

2007 Oct

National Stroke Foundation (Australia) - Private Nonprofit Organization

Australian Government Department of Health and Ageing

Expert Working Group

Group Members: Dr Alan Barber, Neurologist, Auckland City Hospital; Dr Christopher Beer, Senior Lecturer, University of Western Australia and Geriatrician/Clinical Pharmacologist Royal Perth and Mercy Hospitals and Swan Health Service; Prof Justin Beilby, Executive Dean, Faculty of Health Sciences and Professor of General Practice, University of Adelaide; Assoc Prof Julie Bernhardt, Physiotherapist, National Stroke Research Institute; Prof Christopher Bladin, Neurologist, Box Hill Hospital; Ms Brenda Booth, Consumer, Working Aged Group with Stroke, NSW; Dr Julie Cichero, Speech Pathologist, Private Practice & University of Queensland; Ms Louise Corben, Occupational Therapy, Monash Medical Centre & Bruce Lefroy Centre Murdoch Children's Research Institute; Dr Denis Crimmins (Chair) Neurologist, Gosford Hospital; Dr Richard Gerraty, Neurologist, Alfred Hospital and Monash University; Mr Kelvin Hill, Manager, Guidelines Program, National Stroke Foundation; Dr Erin Lalor, Chief Executive Officer, National Stroke Foundation; Assoc Prof Christopher Levi, Neurologist, John Hunter Hospital; Prof Richard Lindley, Professor of Geriatric Medicine, University of Sydney and Westmead Hospital; Prof Sandy Middleton, School of Nursing (NSW & ACT), Australian Catholic University; Ms Fiona Simpson, Dietitian and Senior Research Fellow, Royal North Shore Hospital Sydney

All members of the working group completed and signed a declaration of potential conflicts of interest with development of these guidelines. Most had no perceived conflicts. The reasons provided for potential conflicts primarily involved receiving money from non commercial and commercial organisations specifically for undertaking clinical research. This was expected given the expertise of members of the working group in clinical research. Only a small number of members had received financial support from commercial companies for providing consultancy or lecturing.

Australian and New Zealand Society for Geriatric Medicine - Medical Specialty Society
Australian College of Rural and Remote Medicine - Professional Association
Australian Physiotherapy Association - Medical Specialty Society
BeyondBlue: The National Depression Initiative - National Government Agency [Non-U.S.]
Council of Ambulance Authorities (Australia) - Professional Association
Dietitians Association of Australia - Professional Association
Occupational Therapy Australia - Professional Association
Royal Australian and New Zealand College of Radiologists - Professional Association
Speech Pathology Australia - Medical Specialty Society
Stroke Society of Australasia - Disease Specific Society

This is the current release of the guideline.

This NGC summary was completed by ECRI Institute on November 26, 2008. The information was verified by the guideline developer on December 4, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.