According to a new American Heart Association scientific statement, people with dementia or a pre-existing disability who receive timely and appropriate treatment for ischemic stroke (caused by a blood clot) may avoid additional disability and the subsequent health and financial impacts of stroke. The scientific statement, which published online today in the Association’s journal Strokeis an expert analysis of current research and may inform future clinical practice guidelines.
The statement reports that people with preexisting disability and dementia often experience delays in having their stroke symptoms recognized. In addition, when being assessed, the challenges of their disabilities or dementia may cloud the stroke assessment process, which may lead to clinicians thinking the stroke is more severe and beyond the window for optimal treatment. This often results in delayed treatment or no treatment, which, in turn may lead to additional disabilities and less likelihood to return to pre-stroke levels of daily living skills.
“The long-term consequences and costs of additional disabilities due to untreated stroke in people with pre-existing neurological deficits are staggering,” said Mayank Goyal, M.D., Ph.D., chair of the scientific statement writing committee and clinical professor in the department of radiology and clinical neurosciences at the University of Calgary in Alberta, Canada. The statement cites previous research indicating 79% of people with pre-stroke disability lived an average of 16 months after a stroke, and one-third of them needed to move to an assisted living facility instead of returning home after hospitalization and treatment.
Some evidence suggests people with pre-stroke dementia or disability also have a higher risk of death after clot-busting medications for stroke, however, the findings are inconsistent and require additional research. The statement notes that treatment risk is unique for each individual and would be higher for people with preexisting disability or dementia who have had previous microbleeds or white matter damage in the brain, visible on brain imaging such as a CT or MRI.
Several biases, such as ableism or therapeutic nihilism (believing there’s no hope for effective treatment), may influence health care decision-making when considering stroke treatment for people with a disability or dementia. The writing group suggests increased awareness of potential biases and the statement’s guidance may help physicians improve patient-centered stroke care for all people including those who have a pre-existing disability or dementia.
In the U.S., 22% of adults report having a physical, cognitive or intellectual disability. Understanding the best treatment options for ischemic stroke (caused by a blood clot) that minimizes additional disability and reduces long-term health and economic consequences is essential.
The statement offers an approach to care for people with disability or dementia that includes discussions about treatment options and personal priorities and preferences for stroke care. Providers should:
- Prior to a stroke, discuss quality of life concerns and future care preferences with individuals with a disability or dementia and their families and develop plans for potential health emergencies including stroke.
- Examine personal biases that may influence decisions about treatment under time-pressured situations.
- Discuss individual risks and avoid routinely withholding stroke treatment to people with a disability or dementia.
- Understand the benefits of treatment in reducing risks for additional disability and other long-term impacts.
- Following a stroke, acknowledge the spectrum of possible outcomes – not just “good” or “bad” – and discuss the uncertainty about treatment effects, including the higher potential risk of death compared to people without existing disability or dementia, with the individual and their family.
- Adopt patient-centered care: Seek to understand individual’s values, goals and beliefs that may affect care after a stroke, recognizing these values will vary by individual and are influenced by age, ethnicity, religious beliefs and more.
The statement also calls for inclusion of people with disability or dementia in stroke research and more information about how to balance the uncertain benefits and risks of therapy when caring for people with a disability or dementia.
“The people carrying the greatest burden of illness have been traditionally excluded from research,” said Goyal. “Expansion of the dialogue and pro-active research on acute stroke therapies should include people with disability and dementia – to optimize their potential to return to their pre-stroke daily living and to reduce the potential long-term care and financial burdens.”
The statement was developed by the volunteer writing committee on behalf of the American Heart Association’s Stroke Council. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. The educational benefit of the statement is affirmed by the American Association of Neurological Surgeons/Congress of Neurological Surgeons. The statement is endorsed by the Society of Neurointerventional Surgery.
American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic, and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association’s official clinical practice recommendations.
The writing committee includes Chair Mayank Goyal, M.D., Ph.D.; Vice Chair Justin F. Fraser, M.D., FAHA; Aravind Ganesh, M.D., D.Phil.; Gillian L. Gordon Perue, M.B.B.S., D.M.; Sepideh Amin-Hanjani, M.D., FAHA; Thabele M. Leslie-Mazwi, M.D.; Steven M. Greenberg, M.D., Ph.D., FAHA; Philippe Couillard, M.D.; and Negar Asdaghi, M.D., M.Sc., FAHA. Authors’ disclosures are listed in the manuscript.
The Association receives funding primarily from individuals. Foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.