After 3 months of rehabilitation, Mrs. D, whom we met in Case 17, “plateaus.” She has regained some speech but produces few words. Her right arm and leg are very weak. There is increased tone but no significant spasticity. Impaired plantar flexion in her paretic limb has left her with a foot drop. She has learned to transfer from chair to bed and toilet, can ambulate with a cane and contact guarding, but has difficulty getting to her feet without help. She seems to comprehend speech and follows commands regularly. She is able to feed herself if food is prepared, cut, and brought to her. She has diffi- culty dressing and grooming and requires assistance in handling her personal affairs. She has been living in a skilled nursing facility with a rehabilitation service, and wishes to live in her daughter’s home. The family is eager to have her live with them, and is prepared to pay for a home attendant if necessary.
Hypertension and heart rate are well controlled on metoprolol, hydrochlorothiazide, and losartan, and her INR is controlled on warfarin 4 mg daily.
Questions
1. How can the devices pictured (Figure 7) be useful to her?
2. What are some of the late complications and sequelae of stroke, and what can be done about them?
3. How can the patient’s activities of daily living be described? What can be done?
Case Studies in Geriatric Medicine, Judith C. Ahronheim et al. Published by Cambridge University Press. C
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Answers
1. Unique utensils exist so that people with only one useful hand can prepare and eat food. The device pictured in Figure 7A can assist the patient to cut her food on her own. It is being demonstrated on a cutting board that is adherent to the counter and will be of additional help if she wishes to prepare her own food. A commercially made plastic nonslip mat (Dycem® and others) can be placed under the plates and cutlery to prevent slipping and make them easier to grip. This material can be cut and mounted on objects such as cups and pieces of cutlery. Numerous other devices are available to assist hemiparetic people in improving their independence, including Velcro closures for shoes and garments, long-handled shoehorns, stocking pulls, and zipper pulls. These devices and others are also useful to patients with limitations due to other disorders, such as Parkinson’s disease, arthritis, fractures, and amputations.
The posterior leaf splint (Figure 7B) is lightweight and well tolerated. It is con- structed so that it will prevent involuntary plantar flexion and is a very useful “orthotic” in stroke patients whose hemiparesis includes weak dorsiflexion or ankle instability. If there is severe spasticity, this type of orthotic cannot be used. The pos- terior leaf splint is lightweight and better tolerated than a heavier metal brace.
The four-pronged “quad” cane (Figure 7C) will confer greater stability than an ordinary cane, and, if adequate, is preferred by patients to the more cumbersome and conspicuous walker, especially outside of the home. However, patients must be able to use this aid properly; for example, a poorly taught or cognitively impaired patient may fail to rest all four prongs on the ground, or may hold it backwards and trip over the base. In general, a cane should be held on the side opposite the deficit and planted firmly ahead before moving the impaired limb. Then, the first step is taken by the impaired leg and weight is planted. The sequence is: cane, impaired leg, strong leg. The height of the cane should be adjusted so the top is at the level of the femoral trochanter and the elbow is flexed 15–30 degrees.
Some patients will reserve a walker for inhome use, often preferring wheeled walkers which allow for more speedy ambulation. The wheeled walker is not as stable as a standard walker and patients with instability due to paretic limbs should generally avoid them.
Pain, stiffness, or weakness in joints or muscles responsible for extension at the knee and hip make it extremely difficult for people with a variety of disorders to get out of low chairs. Straight-backed armchairs are the best standard chairs for such patients, but the pictured seat-lift chair (Figure 7D) gives the patient additional mechanical assistance, and may be particularly useful for a patient with a weak arm.
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Toilet seats are even lower than standard chairs. The raised toilet seat (Figure 7E) will be very useful to this patient, and should be installed along with strategi- cally placed arm rails. Independence in toileting is one of the most important parts of rehabilitation because being put on and off a toilet can be emotionally devastating.
2. Contractures and pain often occur in paretic extremities. Early institution of range- of-motion exercises, treatment of accompanying pain, and splinting to counteract an imbalance between agonist and antagonist muscle groups can prevent contrac- tures. Antispasticity medications, such as baclofen and benzodiazepines, frequently exacerbate cognitive deficits in elderly patients, and must be used with extreme cau- tion. Chronic pain in paretic extremities can also be due to lesions involving the thalamus, or from mechanical disturbances resulting from spastic or flaccid paraly- sis of the arm. Mechanical factors include traction or compression neuropathy, shoulder subluxation, or rotator cuff tear, which is sometimes caused when care- givers move or position the patient improperly. Incorrect or prolonged use of an arm sling may result in adduction and internal rotation contracture and adhesive capsulitis of the shoulder. The “shoulder–hand” syndrome is a painful sequela of hemiplegic stroke. It is an abnormality in the sympathetic nervous system, thought to be a “reflex sympathetic dystrophy” related to mechanical damage to the shoul- der. Symptoms consist of progressive pain and decreased range of motion of the affected shoulder, along with swelling and coldness. The pain can be prevented with local steroids or systemic analgesia, accompanied by regular range-of-motion exercises.
Stroke patients are at a high risk of falling. The risk is due not only to weakness or spasticity in the leg, but also to visual field deficits, cognitive impairments, and spatial–perceptual deficits. Impaired dorsiflexion with foot drop commonly occurs in hemiparetic patients and can increase the risk of falls by causing tripping.
Immobilized patients are likely to develop skin ulcers at pressure points. Normal people shift position automatically, even during sleep, thereby preventing critical increases in capillary pressure that eventually lead to skin breakdown. Paralysis prevents this automatic protective shifting of position. The risk of pressure sores increases with age because of age-related skin changes, including thinning of the skin, decreased subcutaneous fat over bony prominences, and sluggish wound heal- ing. The presence of contractures predisposes to pressure ulcers in unexpected sites. The mainstay in the prevention and treatment of pressure sores is the relief of pressure and avoidance of friction and excessive moisture. Although patients who must sit for prolonged periods or are bedbound often benefit from “waffle”-style, air-filled, or other cushions or mattresses that distribute pressure, it is imperative to assist the patient in frequent position changes as this is the best preventive maneuver and will promote comfort. Skin ulcers are discussed further in Case 29.
Poststroke depression occurs in 20–60% of patients, but may respond well to treatment with supportive therapy, medication, or electroconvulsive therapy. Unfortunately, it is often unrecognized or left untreated. Dementia often occurs at the time of major hemispheric stroke, but progressive dementia is generally due to coexisting Alzheimer’s disease or other neurodegenerative disorder.
Deep vein thrombosis commonly develops in paralyzed legs and may produce pulmonary emboli. Nonparetic limbs may also be at risk in patients with spatial neglect of the affected side. They not only bump into objects in that side of space, but also fail to move the paretic limb passively. They sometimes lack insight into their deficits, which exacerbates the problem. Since speech is usually unimpaired in people with right-sided brain lesions, observers and caregivers tend to underesti- mate the patient’s deficits.
Urinary incontinence is a common complication of stroke, but, in elderly stroke patients, the etiology is more commonly functional, related to immobility super- imposed on pre-existing detrusor instability (see Case 33).
Seizures may develop at stroke onset or days to months later. Most poststroke seizures occur within the first 24 hours, and are more common in hemorrhagic than nonhemorrhagic stroke, but, among the latter, a second peak in incidence occurs 6–12 months later. When seizures develop late, they are more likely to be recur- rent (“epilepsy”), probably because they are related to scarring and an established irritable focus. Poststroke seizures tend to be of the partial variety and, since those that occur early on are rarely recurrent, long-term anticonvulsant treatment is not always needed.
3. “ADL” is the expression used to refer to a patient’s ability to perform activities of daily living. ADL assessment includes ability to toilet, dress, groom, bathe, ambu- late, transfer, and feed. A more sensitive set of functional measures are the IADLs (instrumental activities of daily living), which include cooking, shopping, handling finances, keeping house, using the telephone, and ability to use transportation. The IADL scale is relevant to community-dwelling elderly, or recovering stroke or fracture patients that are being considered for discharge home, while the ADL scale would perhaps be more relevant for the patient who required institutionalization or around-the-clock home care.
The present patient should undergo physical therapy, in order to maximize physi- cal function, occupational therapy, in order to become able to perform specific tasks, and speech therapy, in order to maximize verbal performance. When neurologic and functional return have leveled off, the patient is said to “plateau.” At this point, rehabilitation goals are directed at the maintenance of physical and psychologic function.
This patient needs assistance with ADLs as well as IADLs. Although the family is willing to pay for a home attendant, government entitlements in the United States
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would make it prudent for the patient to pay for this out of her own savings (see Case 6). Care through a certified home care agency might be restricted (e.g. an aid could remind the patient to take medications but not administer them). Privately paid home attendants are not restricted in the type of care they can provide but are also not subject to standards of training.
Care could be augmented by one or more home visits by a geriatrician and a geriatric assessment team. Since she has limited mobility, it would be easier for the patient and her family if they did not have to transport her to the office. The team could see first hand how the patient manages in her own environment and assess the need for any further equipment or any environmental modifications. One could also review her medications and assess the interactions between the patient, the family, and the home attendant.
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