Elderly Stroke Rehabilitation: Overcoming the Complications and Its Associated Challenges

A discussion but no solutions provided. So overall, completely useless for survivors. 
Elderly Stroke Rehabilitation: Overcoming the Complications and Its Associated Challenges
SiewKwaonLui 1 andMinhHaNguyen2 1DepartmentofRehabilitationMedicine,Singapore General Hospital,20CollegeRoad,AcademiaLevel4,Singapore169856 2DepartmentofGeriatricMedicine,Singapore General Hospital,20CollegeRoad,AcademiaLevel3,Singapore169856 CorrespondenceshouldbeaddressedtoSiewKwaonLui;lui.siew.kwaon@sgh.com.sg Received 2 April 2018; Accepted 22 May 2018; Published 13 June 2018 Academic Editor:Carlos Fernandez-Viadero Copyright©2018SiewKwaonLuiandMinhHaNguyen.This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
There have been many advances in management of cerebrovascular diseases. However, stroke is still one of the leading causes of disabilities and mortality worldwide with significant socioeconomic burden. This review summarizes the consequences of stroke in the elderly, predictors of stroke rehabilitation outcomes, role of rehabilitation in neuronal recovery, importance of stroke rehabilitation units, and types of rehabilitation resources and services available in Singapore. We also present the challenges faced by the elderly stroke survivors in the local setting and propose strategies to overcome the barriers to rehabilitation in this aging population.
1. Background Despite advances in modern medicine, medications, and medical technology, stroke diseases impose a substantial mortality and morbidity risk to the individual with increased economic burden to the society. Globally, stroke is the second leading cause of death after ischemic heart disease, with approximately 6.7 million stroke deaths in 2015 [1]. In Singapore,despite decreasing trend, cerebrovascular diseases are still the fourth leading cause of death, with a prevalence of 6.6%in2016[2]. As the population rapidly ages, the burden of stroke is expected to increase significantly, posing challenges to limited healthcare resources. As such, there is an urgent need to develop an optimal stroke disease management plan, incorporating a comprehensive stroke rehabilitation program.
2. Consequences of Stroke in Elderly Stroke Survivors The incidence of stroke disease increases with age, in both men and women with approximately 50% of all strokes
occurringinpeopleoverage75and30%overage85[1,3,4]. Stroke is among the top leading causes of disability and reduced quality of life[5]. Elderly patients are at higher risk of mortality, poorer functional outcomes, prolonged length of hospital stay, and institutionalization[6]. Motor impairment is the most common deficit after stroke, which either happens as a direct consequence of the lack of signal transmission from cerebral cortex or as a slowly accumulating process of the cerebral injuries or muscle atrophy due to learned disuse [7, 8]. Divani et al. reported the risk of falling and fall-related injuries were higher in stroke elders [9]. Risk factors associated with increased fall risks in stroke survivors include poor general health, time from first stroke, psychiatric problems, urinary incontinence,pain, motor impairment, and a history of recurrent falls [9]. Risk factors associated with fall related injuries are female gender, poor general health, past injury from fall, psychiatric problems, urinary incontinence, impaired hearing, pain, motor impairment, and presence of multiple strokes [9]. Motor function deficits, increased fall risks, and fall-related injuries can significantly affect the patients’ mobility, and their daily living activities which limit
Hindawi Current Gerontology and Geriatrics Research Volume 2018, Article ID 9853837, 9 pages https://doi.org/10.1155/2018/9853837
2 Current Gerontology and Geriatrics Research
their participation in social events and other professional activities. Post stroke cognitive impairment is common and can affect up to one-third of stroke survivors [10, 11]. However, subtle cognitive impairment may not appear apparent, especially when the stroke survivor seems to have recovered functionally in other aspects [10, 11]. In most cases, these deficits are persistent and usually have progressively worsened[12].Post stroke cognitive impairment is also more common in those with recurrent strokes [13]. It often coexists with other neuropsychological problems including language disorders,fatigue,depression, and apathy[13]. The mechanisms of post stroke cognitive impairment could be either directly due to cerebral vascular injury or indirectly due to an associated asymptomatic Alzheimer pathology or white matter changes from small vessel disease [14]. Factors independently associated with dementia in stroke survivors include atrial fibrillation, previous stroke, myocardial infarction, hypertension, diabetes mellitus, and previous transient ischemic attack [15]. The combined motor and cognitive impairments significantly increase risks of long term functional disability and increase healthcare cost as reflected by an increase in hospital readmission rates and mortality rates [16]. Bladder and bowel dysfunction are common and cause significant distress to stroke survivors. Post stroke urinary incontinence or retention has been shown to affect about 30% of stroke survivors [17]. Urinary incontinence is an important marker of stroke severity and has been linked with functional dependency, increased risk of institutionalization, and mortality[17]. Risk factors for post stroke urinary retention include cognitive impairment, diabetes mellitus, aphasia, poor functional status on admission, and urinary tract infection[18]. Common gastrointestinal symptoms after stroke include dysphagia, heartburn, abdominal pain, fecal incontinence, bleeding gastrointestinal tract, and constipation [19]. Among these, constipation is the most common bowel dysfunction with the incidence ranging from 29% to 79%in stroke survivors and more prevalent in hemorrhagic stroke patients [20]. Although fecal incontinence is less common with a prevalence of 11% at 1 year after stroke, it is associated with increased risk of nursing home admission and 1-yearmortalityrate[21]. Infection is a serious complication after a stroke despite optimal management. The reported prevalence of post stroke infection ranges from 5% to 65%, depending on the study population, study design, and the definition of infection[22]. Mortality rate is higher in stroke patients with any type of infection, particularly higher in patients with pneumonia and patients with urinary tract infection [23]. Among the survivors, stroke associated infection is also an independent risk factor for poor outcome at discharge and at 1 year [23]. The association between post stroke infection and poor outcome is likely related to a delay in rehabilitation due to prolonged hospital stay and immobilization as well as general frailty [22]. More importantly, evidence from experimental studies suggests that infection also promotes antigen presentation and autoimmunity against the brain which worsens the outcome[24].
Following a stroke, patients may have impaired mobility which predisposes them to pressure sores and deep vein thrombosis(DVT). Pressure ulcer results from an imbalance between external mechanical forces acting on skin and soft tissue and the internal susceptibility of skin and its underlying soft tissue to injury. Pressure ulcer is associated with increased post stroke mortality in both genders and patientsaged60yearsorolder[25]. Stroke patients also have an increased risk of developing deep DVT and pulmonary embolism due to immobility and raised prothrombotic activity [26]. The major risk factors of post stroke DVT include advanced age, male gender, congestive heart failure, malignancy, and fluid and electrolyte disorders[27,28]. Pain is a frequent but often neglected complication of stroke[29,30]. It can happen immediately, weeks, or months after a stroke event and can span a spectrum from irritating headache to debilitating limb pain secondary to complex regional pain syndrome, spasticity or joint subluxation, and /or contractures [29]. Pain, together with depression and fatigue, is associated with increased risk of cognitive impairment, functional dependence, and reduced quality of life in stroke survivors[30,31]. Reported risk factors for the development of post stroke pain include female gender,older age at stroke onset, history of alcohol use and depression, anatomical location of stroke and presence of clinical features such as spasticity, reduced upper extremity movement, and sensory deficits[32].