National Clinical Guidelines and Recommendations for the Care of People With Stroke and Transient Ischaemic Attack

Irish Heart Foundation: Council for Stroke. (2010).

Dublin (Ireland): Irish Heart Foundation, 1-117.

This guideline provides recommendations for the assessment and management of individuals after stroke. The included recommendations were developed using various guidelines. More information can be found in the Notes on This Article section.

Irish Heart Foundation (Ireland)

This guideline includes recommendations from other clinical guidelines; the complete list can be found on page 5 of the full text. Additionally, the data from this guideline can be found elsewhere in the Evidence Maps. See the Associated Article section below for more details.

Recommendations regarding clinical bedside assessment for dysphagia are as follows: <ul> <li>If referred, the specialist assessment of swallowing, conducted by a speech-language pathologist trained in dysphagia management, should be conducted within 24 hours of admission and no more than 72 hours afterwards.</li> <li>It is recommended that the clinical bedside assessment is developed and tested by Logemann or a similar tool.</li> <li>"Patients with dysphagia should be monitored daily in the first week to identify rapid recovery. Observations should be recorded as part of the care plan" (p. 68).</li> </ul>

Individuals with limited or unreliable communication due to unclear or unintelligible speech after stroke should be assessed for dysarthria by a speech-language pathologist to identify the nature, severity, and cause of the speech impairment.

Recommendations for the acute management of dysphagia are as follows: <ul> <li>Diet modification and use of postures or maneuvers are standard interventions for dysphagia following stroke as they have demonstrated to effective for certain individuals.</li> <li>Following a full swallowing assessment, individuals should be advised on diet modification and compensatory techniques.</li> <li>Individuals with stroke should have a choice of dishes and any texture-modified food should be attractively presented.</li> <li>It is recommended that clinicians work closely with nursing colleagues who take primary responsibility for maintaining good oral hygiene in individuals with dysphagia.</li> </ul>

Recommendations for the instrumental assessment of dysphagia are as follows: <ul> <li>A clinical bedside assessment may be used to determine a need for additional instrumental assessment. A reliable and cost-effective instrumental swallow evaluation should be available for all patients following acute stroke due to the limitations of clinical evaluations, such as inability to detect silent aspiration and poor information on the efficacy of an intervention.</li> <li>"The modified barium swallow test (videoflouroscopy) and fibreoptic endoscopic evaluation of swallow are both valid methods for assessing dysphagia. The clinician should consider which is the most appropriate for different patients in different settings" (p. 68).</li> <li>"There is insufficient evidence to recommend cervical auscultation for evaluating risk of aspiration and pharyngeal stage dysphagia" (p. 68).</li> </ul>

"A small number of patients with persistent dysphagia recover late and benefit from review and change in the management of their feeding" (p. 69). Individuals with persistent dysphagia should be regularly reviewed by a professional trained in the management of dysphagia (i.e., speech-language pathologist) at frequency appropriate to the individual's swallowing function.

The following recommendations were provided on the assessment and management of attention and concentration impairments in patients with stroke: <ul> <li>Patients who are easily distracted or are unable to concentrate should receive a formal assessment for their focused, sustained, and divided attention.</li> <li>Patients with impaired attention should have cognitive demands reduced.</li> <li>Learned activities should have opportunities for repeated practice and compensatory strategies should also be taught.</li> </ul>

Recommendations for the screening and assessment of dysphagia in the acute care setting are as follows: <ul> <li>"Until a safe swallowing method has been established, all patients with identified swallowing difficulties should receive hydration (and nutrition within 24-48 hours) by alternative means" (p. 63).</li> <li>Before being given any food or drink, all patients with stroke should be screened for dysphagia. A water swallow test should be included as part of the screening.</li> <li>Following screening, if no difficulties were indicated, then the patient can be allowed to eat and drink. If difficulties were identified from the screening or if swallowing difficulties arise, then the patients should be referred for a full clinical assessment by a professional with expertise in dysphagia management such as a speech-language pathologist.</li> <li>To identify increased risk of developing aspiration pneumonia, co-morbidities and other risk factors (e.g., smoking, respiratory disease) should be considered when collecting clinical history.&nbsp;</li> <li>"Following basic dysphagia training speech and language therapists are not qualified to conduct or interpret videofluoroscopies independently. They are however expected to be aware of the need for further instrumental assessment (e.g., videofluoroscopy, fiberoptic endoscopic evaluation of swallowing [FEES])" (p. 66).</li> <li>Patients unable to complete a full screening procedure should be monitored daily to avoid delay in referral for a full clinical assessment by a speech-language pathologist.</li> </ul>

Recommendations for the assessment and management of executive function impairments after stroke are as follows: <ul> <li>A formal assessment should be conducted for patients demonstrating difficulty with decision-making, planning or initiating tasks, or disinhibition of inappropriate verbal and/or behavioral responses.</li> <li>Patients should be taught external compensatory strategies, such as electronic pagers, organizers, or written checklists.</li> <li>Family and staff should be counseled and educated on the nature and extent of the impairment, and on ways to support the person with executive functioning impairments.</li> </ul>

General recommendations for multidisciplinary stroke teams are as follows: <ul> <li>All hospitals receiving acute medical admissions of patients with potential stroke and specialized stroke units should have access to a comprehensive multidisciplinary team (MDT), including a speech-language therapist.&nbsp;</li> <li>The stroke unit MDT should meet weekly to exchange clinical information, agree on management plans, and set rehabilitation goals with the patients and their caregivers. Members of the MDT should also be actively involved in the discharge planning process with the patients and their caregivers.&nbsp;</li> <li>A speech-language pathologist should train the MDT in the following swallowing screening procedures: risk factors for dysphagia; early signs of dysphagia; observation of eating and drinking habits; conducting a water swallow test; monitoring of hydration of weight and nutritional risk.</li> </ul>

All patients should receive initial assessments from the following disciplines, using an agreed upon procedure or protocol, within 24 to 48 hours of admission: <ul> <li>physical therapy;</li> <li>occupational therapy;&nbsp;</li> <li>nutrition; and</li> <li>speech-language therapy.&nbsp;</li> </ul> <p>Assessments should be comprehensive (including goal setting), completed within five working days, and documented in the patients' notes. If possible, clinicians should regularly consult with patients about the extent to which patients wish to have family, significant others, and/or caregivers involved in the assessment process.</p>

Expert staff, including a speech-language pathologist, should train staff, caregivers, and patients in feeding techniques. Elements of training include <ul> <li>diet modification;</li> <li>positioning;</li> <li>food placement;</li> <li>management of behavior and environment;</li> <li>oral care;</li> <li>management of choking; and&nbsp;</li> <li>identification of signs and symptoms of dysphagia (e.g., wet vocal quality, recurring respiratory tract infections).</li> </ul>

The following recommendations were provided for the assessment of patients with unilateral visual neglect and perceptual impairments after stroke: <ul> <li>Patients identified with a stroke affecting the right hemisphere should be considered at risk of reduced awareness on the left.</li> <li>Any patient with demonstrated, or suspected, visual field or perceptual impairment should receive a formal assessment using a standardized test battery and measurement of functional performance.</li> <li>The assessment battery, along with clinical observations, should provide information on how the neglect affects the patient&rsquo;s space (e.g., intrapersonal, near extra-personal, far extra-personal).</li> </ul>

Recommendations for stroke rehabilitation and the goal-setting process are as follows: <ul> <li>Every individual with stroke should participate in setting goals unless they choose not to or are unable to participate because of the severity of their cognitive and linguistic impairments.</li> <li>Individuals indicated to have severe cognitive-linguistic impairments require a specialist approach to consent to intervention. Patients with a communication disability, such as aphasia, dysarthria, and/or apraxia of speech, should have the goal setting process adapted to facilitate their participation.</li> <li>Patients should receive as much appropriate therapy as they are willing and able to tolerate. In the early stages of rehabilitation, patients should receive a minimum of 45 minutes daily of each required therapy.</li> <li>Patients should be educated on the nature and process of goal setting and be helped to define and articulate their personal goals. Goals should be meaningful and relevant to the patients, challenging but achievable, and include both short-term (days/weeks) and long-term (weeks/months) targets.&nbsp;</li> </ul>

Recommendations for the treatment of dysarthria in patients after stroke are as follows: <ul> <li>Individuals with dysarthria after stroke should be taught strategies to improve the clarity of their speech.&nbsp;</li> <li>If speech remains unintelligible and limits communication, then an assessment for an appropriate alternative and augmentative communication system (e.g., letter board, communication aids) should be conducted.</li> <li>Communication partners such as family and staff should be taught how to assist the individual&rsquo;s communication.</li> </ul>

The following recommendations were provided for the screening and assessment of communication disorders (e.g., aphasia) in patients after stroke: <ul> <li>Speech-language pathologists (SLPs) should formally assess patients' language and communication if they were indicated to have aphasia following a screening or clinical observation. Should a patient be diagnosed with aphasia, an SLP should educate the patient, family, and clinical team on the nature and severity of the impairment.</li> <li>Patients presenting with a left hemisphere stroke should be screened using a validated aphasia screening measure, such as the Sheffield Aphasia Screening Test or Frenchay Aphasia Screening Test.</li> <li>Patients with aphasia should be re-assessed as to the nature and severity of the impairment at appropriate intervals.</li> <li>Patients with aphasia should be assessed for the most appropriate method of alternative communication (e.g., gesture, drawing, writing, communication aids). Family and the clinical team should be informed of the method of communication.</li> </ul>

Recommendations for the management of patients with aphasia after stroke are follows: <ul> <li>Treatment for patients with aphasia should be aimed at reducing identified language impairments while continuing to progress towards their goals.</li> <li>If tolerated, all patients with aphasia should be considered for early intensive speech and language intervention (e.g., 2 to 8 hours per week).</li> <li>All communication partners should be taught the most effective communication strategies for that person with aphasia, including alternative methods of communication.</li> <li>Educational materials should be interactive, timely, up-to-date, provided in a variety of accessible languages and formats (e.g., written, oral, aphasia-friendly, group counselling approach), and specific to the patient, family, and caregiver needs and impairments.</li> <li>Patients with chronic aphasia should be considered for further treatment for a specific intervention (e.g., group, individual).</li> <li>Decisions about mental capacity for patients with aphasia should be made with a multidisciplinary team, including a speech-language pathologist. SLPs should be involved in attempts to establish effective communication if the primary reason.</li> <li>SLPs should be consulted when clinicians use standardized screening and assessment tools to evaluate other stroke-related impairments in patients with aphasia to determine the tools' suitability and results. This is especially important for tools relying on intact verbal skills and interpreting results from such tools should be done with caution.</li> </ul>

Recommendation for the screening and assessment of cognitive impairments after stroke are as follows: <ul> <li>A simple, standardized screening tool should be used to screen all stroke patients for cognitive impairment.&nbsp;</li> <li>If patients are not progressing as expected during rehabilitation, then a more detailed cognitive assessment should be conducted.</li> <li>All multidisciplinary members should consider the patient&rsquo;s cognitive status to appropriately plan and deliver treatment.</li> <li>An assessment of safety risks should be included in the discharge plan when a patient&rsquo;s cognitive impairment(s) persists.&nbsp;</li> <li>A formal cognitive assessment should be conducted when individuals with stroke are planning to return to cognitively demanding activities, such as working or driving.&nbsp;</li> </ul>

Patients requiring long-term tube feeding should be reviewed regularly by a specialist speech and language therapist to assess for the return of a functional swallow.

Recommendations for the assessment and management of apraxia of speech in patients after stroke are as follows: <ul> <li>Patients demonstrating difficulty articulating words should receive a formal assessment for apraxia of speech and receive treatment to maximize intelligibility.</li> <li>Patients with severe communication difficulties, but with reasonable cognition and language function, should be assessed for appropriate alternative and augmentative communication aids.</li> <li>Communication partners (e.g., family, staff) should be educated on how to assist with the communication of the individual with apraxia of speech.</li> </ul>

Within three hours of admission, all patients with stroke should be screened for their: <ul> <li>ability to swallow (using a validated screening test administered by an appropriately trained person);</li> <li>ability to communicate;</li> <li>immediate needs for mobilization, moving, and handling;</li> <li>bladder control;</li> <li>risk of developing skin pressure ulcers;</li> <li>capacity to understand and follow instructions;</li> <li>nutritional status;</li> <li>ability to hear; and</li> <li>ability to see.</li> </ul>

The following recommendations were provided for the management of patients with unilateral visual neglect and perceptual impairments after stroke: <ul> <li>Compensatory strategies should be taught to any patient exhibiting impaired attention on one side.</li> <li>"All staff and visitors should be advised to approach the patient and position themselves on the patient's affected side to increase the patient's awareness of their affected side" (p. 53).</li> </ul>

Recommendations for the assessment and management of cognitive communication disorders in individuals after non-dominant hemisphere stroke are as follows: <ul> <li>Patients with suspected cognitive-communication deficits should be referred to a speech-language pathologist for assessment.</li> <li>The treatment plan should be individualized based on goals and needs to address the individual&rsquo;s ability to communicate efficiently and effectively.</li> <li>Counseling and education should be provided to family and caregivers about the individual&rsquo;s cognitive-communication abilities and deficits.</li> <li>Due to the complex nature of cognitive deficits, it is recommended that speech-language pathologists, occupational therapists, clinical psychologists, and other members of the multidisciplinary team should work closely together when assessing individuals with suspected cognitive impairments.</li> </ul>

A typical screening procedure for swallowing includes <ul> <li>initial observation of the patient&rsquo;s consciousness level;</li> <li>observation of postural control;</li> <li>observations of oral hygiene;</li> <li>observations of control of oral secretions;</li> <li>water swallow test (if appropriate); and</li> <li>screening protocols must result in a clear pathway of action (e.g., onward referral, nil by mouth, commence oral diet).</li> </ul>