Characterisation of young stroke presentations, pathways of care, and support for ‘invisible’ difficulties: a retrospective clinical audit study

Michaela Grech; Toni Withiel; Marlena Klaic; Caroline A. Fisher; Leonie Simpson; Dana Wong

doi:10.1071/IB23059

RESEARCH ARTICLE (Open Access)

Next Contents Vol 25(3)

Characterisation of young stroke presentations, pathways of care, and support for ‘invisible’ difficulties: a retrospective clinical audit study

Michaela Grech

^A ^* , Toni Withiel

^B , Marlena Klaic

^C , Caroline A. Fisher

^B , Leonie Simpson ^B and Dana Wong

^A

+ Author Affiliations

- Author Affiliations

^A School of Psychology and Public Health, La Trobe University, Melbourne, Vic, Australia.

^B Allied Health Department, The Royal Melbourne Hospital, Vic, Australia.

^C Melbourne School of Health Sciences, The University of Melbourne, Vic, Australia.

^* Correspondence to: m.grech@latrobe.edu.au

Handling Editor: Jennifer Fleming

Brain Impairment 25, IB23059 https://doi.org/10.1071/IB23059

Submitted: 18 October 2022 Accepted: 31 May 2024 Published: 28 June 2024

© 2024 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of the Australasian Society for the Study of Brain Impairment. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Background

Young stroke survivors are likely to be discharged home from acute hospital care without rehabilitation more quickly than older survivors, but it is not clear why. File-audit studies capturing real-world clinical practice are lacking for this cohort. We aimed to compare characteristics and care pathways of young and older survivors and describe stroke presentations and predictors of pathways of care in young survivors (≤45 years), including a focus on care received for ‘invisible’ (cognitive, psychological) difficulties.

Methods

A retrospective audit of 847 medical records (67 young stroke survivors, mean age = 36 years; 780 older patients, mean age = 70 years) was completed for stroke survivors admitted to an Australian tertiary hospital. Stroke characteristics and presence of cognitive difficulties (identified through clinician opinion or cognitive screening) were used to predict length of stay and discharge destination in young stroke survivors.

Results

There were no differences in length of stay between young and older survivors, however, young stroke survivors were more likely to be discharged home without rehabilitation (though this may be due to milder strokes observed in young stroke survivors). For young stroke survivors, stroke severity and age predicted discharge destination, while cognitive difficulties predicted longer length of stay. While almost all young survivors were offered occupational therapy and physiotherapy, none received psychological input (clinical, health or neuropsychology).

Conclusions

Cognitive and psychological needs of young stroke survivors may remain largely unmet by a service model designed for older people. Findings can inform service development or models of care, such as the new Australian Young Stroke Service designed to better meet the needs of young survivors.

Keywords: cognitive difficulties, invisible difficulties, length of stay, pathways of care, rehabilitation, stroke, working age, young stroke survivors.

References

Adams Jr HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh 3rd EE (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment. Stroke 24(1), 35-41.
| Crossref | Google Scholar | PubMed |

Al-Jadid MS, Robert AA (2010) Determinants of length of stay in an inpatient stroke rehabilitation unit in Saudi Arabia. Saudi Medical Journal 31(2), 189-192.
| Google Scholar | PubMed |

Andrew NE, Kilkenny M, Naylor R, Purvis T, Lalor E, Moloczij N, Cadilhac DA, on behalf of the, National Stroke Foundation (2014) Understanding long-term unmet needs in Australian survivors of stroke. International Journal of Stroke: Official Journal of the International Stroke Society 9(Suppl A100), 106-112.
| Crossref | Google Scholar | PubMed |

Australian Institute of Health and Welfare (2016) Stroke. (AIHW: Canberra, ACT, Australia). Available at https://www.aihw.gov.au/getmedia/c420f6f1-0464-4f43-b55a-62f995a0f8f3/ah16-3-6-stroke.pdf.aspx

Bamford J, Sandercock P, Dennis M, Burn J, Warlow C (1991) Classification and natural history of clinically identifiable subtypes of cerebral infarction. The Lancet 337(8756), 1521-1526.
| Crossref | Google Scholar | PubMed |

Barlas YN, Putaala J, Waje‐Andreassen U, Vassilopoulou S, Nardi K, Odier C, et al. (2013) Etiology of first‐ever ischaemic stroke in European young adults: the 15 cities young stroke study. European Journal of Neurology 20(11), 1431-1439.
| Crossref | Google Scholar |

Bindawas SM, Vennu V, Mawajdeh H, Alhaidary H (2017) Functional outcomes by age after inpatient stroke rehabilitation in Saudi Arabia. Clinical Interventions in Aging 12, 1791-1797.
| Crossref | Google Scholar | PubMed |

Brott T, Adams Jr HP, Olinger CP, Marler JR, Barsan WG, Biller J, et al. (1989) Measurements of acute cerebral infarction: a clinical examination scale. Stroke 20(7), 864-870.
| Crossref | Google Scholar | PubMed |

Chiong W, Kim AS, Huang IA, Farahany NA, Josephson SA (2014) Inability to consent does not diminish the desirability of stroke thrombolysis. Annals of Neurology 76(2), 296-304.
| Crossref | Google Scholar | PubMed |

Deloitte Access Economics (2020) ‘No postcode untouched: Stroke in Australia 2020.’ (Stroke Foundation) Available at https://strokefoundation.org.au/media/juuba3qm/no-postcode-untouched-30-october-final-report.pdf

Dewey HM, Bernhardt J (2007) Acute stroke patients – early hospital management. Australian Family Physician 36(11), 904-912.
| Google Scholar | PubMed |

Diamond PT, Felsenthal G, Macciocchi SN, Butler DH, Lally-Cassady D (1996) Effect of cognitive impairment on rehabilitation outcome. American Journal of Physical Medicine & Rehabilitation 75(1), 40-43.
| Crossref | Google Scholar | PubMed |

Dixon G, Thornton EW, Young CA (2007) Perceptions of self-efficacy and rehabilitation among neurologically disabled adults. Clinical Rehabilitation 21(3), 230-240.
| Crossref | Google Scholar | PubMed |

Downer MB, Li L, Carter S, Beebe S, Rothwell PM (2023) Associations of multimorbidity with stroke severity, subtype, premorbid disability, and early mortality: Oxford vascular study. Neurology 101, e645-e652.
| Crossref | Google Scholar | PubMed |

Dutrieux RD, van Eijk M, van Mierlo ML, van Heugten CM, Visser-Meily JMA, Achterberg WP (2016) Discharge home after acute stroke: differences between older and younger patients. Journal of Rehabilitation Medicine 48(1), 14-18.
| Crossref | Google Scholar | PubMed |

Edwards JD, Kapoor A, Linkewich E, Swartz RH (2017) Return to work after young stroke: a systematic review. International Journal of Stroke 13(3), 243-256.
| Crossref | Google Scholar |

Elwan ME, Al-emam AI, Munir AN, Melake MS (2021) Does the second ischemic stroke herald a higher proportional risk for cognitive and physical impairment than the first-ever one? The Egyptian Journal of Neurology, Psychiatry and Neurosurgery 57(1), 149.
| Crossref | Google Scholar |

Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, Brott T, Cohen G, Davis S, Donnan G, Grotta J, Howard G, Kaste M, Koga M, von Kummer R, Lansberg M, Lindley RI, Murray G, Olivot JM, Parsons M, et al. (2014) Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet (London, England) 384(9958), 1929-1935.
| Crossref | Google Scholar | PubMed |

Fabrizio P, Magnani FG, Marcello G, Gerardo S, Ovadia D, Massimiliano S, Stefano M, Sandro B, Micieli GR, Agostoni EC, Giovanna B, Gabriella B (2020) Neuropsychological assessment in acute stroke patients. Neurological Sciences 41(5), 1259-1266.
| Crossref | Google Scholar |

Fang Y, Mpofu E, Athanasou J (2017) Reducing depressive or anxiety symptoms in post-stroke patients: pilot trial of a constructive integrative psychosocial intervention. International Journal of Health Sciences 11(4), 53-58.
| Google Scholar | PubMed |

Farrell B, Godwin J, Richards S, Warlow C (1991) The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. Journal of Neurology, Neurosurgery, and Psychiatry 54(12), 1044-1054.
| Crossref | Google Scholar | PubMed |

Feng W, Hendry RM, Adams RJ (2010) Risk of recurrent stroke, myocardial infarction, or death in hospitalized stroke patients. Neurology 74(7), 588-593.
| Crossref | Google Scholar | PubMed |

Folstein MF, Folstein SE, McHugh PR (1975) “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12(3), 189-198.
| Crossref | Google Scholar | PubMed |

Fonarow GC, Pan W, Saver JL, Smith EE, Reeves MJ, Broderick JP, Kleindorfer DO, Sacco RL, Olson DM, Hernandez AF, Peterson ED, Schwamm LH (2012) Comparison of 30-Day Mortality Models for Profiling Hospital Performance in Acute Ischemic Stroke With vs Without Adjustment for Stroke Severity. JAMA 308(3),.
| Crossref | Google Scholar |

Furlan NE, Luvizutto GJ, Hamamoto Filho PT, Zanati Bazan SG, Modolo GP, Ferreira NC, Miranda LA, de Souza JT, Winckler FC, Vidal E, de Freitas C, Martin LC, Bazan R (2021) The impact of age on mortality and disability in patients with ischemic stroke who underwent cerebral reperfusion therapy: a Brazilian cohort study. Frontiers in Aging Neuroscience 13, 649902.
| Crossref | Google Scholar | PubMed |

Ghasemian-Shirvan E, Farnad L, Mosayebi-Samani M, Verstraelen S, Meesen R, Kuo MF, Nitsche MA (2020) Age-related differences of motor cortex plasticity in adults: a transcranial direct current stimulation study. Brain Stimulation 13(6), 1588-1599.
| Crossref | Google Scholar | PubMed |

Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, Dávalos A, Majoie CB, van der Lugt A, de Miquel MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, et al. (2016) Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet (London, England) 387(10029), 1723-1731.
| Crossref | Google Scholar | PubMed |

Graham JR, Pereira S, Teasell R (2011) Aphasia and return to work in younger stroke survivors. Aphasiology 25(8), 952-960.
| Crossref | Google Scholar |

Griffiths D, Sturm J (2011) Epidemiology and etiology of young stroke. Stroke Research and Treatment 201, 209370.
| Crossref | Google Scholar |

Jacobs BS, Boden-Albala B, Lin IF, Sacco RL (2002) Stroke in the young in the northern Manhattan stroke study. Stroke 33(12), 2789-2793.
| Crossref | Google Scholar | PubMed |

Kapoor A, Scott C, Lanctot KL, Herrmann N, Murray BJ, Thorpe KE, Lien K, Sicard M, Swartz RH (2019) Symptoms of depression and cognitive impairment in young adults after stroke/transient ischemic attack. Psychiatry Research 279, 361-363.
| Crossref | Google Scholar | PubMed |

Kato Y, Hayashi T, Tanahashi N, Kobayashi S, Japan Standard Stroke Registry Study Group (2015) Cardioembolic stroke is the most serious problem in the aging society: Japan standard stroke registry study. Journal of Stroke and Cerebrovascular Diseases 24(4), 811-814.
| Crossref | Google Scholar | PubMed |

Keating J, Borschmann K, Johns H, Churilov L, Bernhardt J (2021) Young stroke survivors’ preferred methods of meeting their unique needs: shaping better care. Neurology 96(13), e1701-e1710.
| Crossref | Google Scholar | PubMed |

Kersten P, Low JT, Ashburn A, George SL, McLellan DL (2002) The unmet needs of young people who have had a stroke: results of a national UK survey. Disability and Rehabilitation 24(16), 860-866.
| Crossref | Google Scholar | PubMed |

Kneebone II (2016) Stepped psychological care after stroke. Disability and Rehabilitation 38(18), 1836-1843.
| Crossref | Google Scholar | PubMed |

Kogan E, Twyman K, Heap J, Milentijevic D, Lin JH, Alberts M (2020) Assessing stroke severity using electronic health record data: a machine learning approach. BMC Medical Informatics and Decision Making 20(1), 8.
| Crossref | Google Scholar | PubMed |

Kwok CS, Clark A, Ford GA, Durairaj R, Dixit AK, Davis J, et al. (2012) Association between prestroke disability and inpatient mortality and length of acute hospital stay after acute stroke. Journal of the American Geriatrics Society 60(4), 726-732.
| Crossref | Google Scholar | PubMed |

Lannin NA, Anderson CS, Kim J, Kilkenny M, Bernhardt J, Levi C, Dewey HM, Bladin C, Hand P, Castley H, Hill K, Faux S, Grimley R, Grabsch B, Middleton S, Donnan G, Cadilhac DA (2017) Treatment and outcomes of working aged adults with stroke: results from a national prospective registry. Neuroepidemiology 49(3-4), 113-120.
| Crossref | Google Scholar | PubMed |

Lawrence M (2010) Young adults’ experience of stroke: a qualitative review of the literature. British Journal of Nursing 19(4), 241-248.
| Crossref | Google Scholar | PubMed |

Lin CL, Lin PH, Chou LW, Lan SJ, Meng NH, Lo SF, Wu HD (2009) Model-based prediction of length of stay for rehabilitating stroke patients. Journal of the Formosan Medical Association 108(8), 653-662.
| Crossref | Google Scholar | PubMed |

Lutski M, Zucker I, Shohat T, Tanne D (2017) Characteristics and outcomes of young patients with first-ever ischemic stroke compared to older patients: The National Acute Stroke Israeli Registry. Frontiers in Neurology 8, 421.
| Crossref | Google Scholar | PubMed |

Maaijwee NA, Rutten-Jacobs LC, Schaapsmeerders P, Van Dijk EJ, de Leeuw FE (2014) Ischaemic stroke in young adults: risk factors and long-term consequences. Nature Reviews Neurology 10(6), 315-325.
| Crossref | Google Scholar | PubMed |

Maaijwee NAMM, Tendolkar I, Rutten‐Jacobs LCA, Arntz RM, Schaapsmeerders P, Dorresteijn LD, Schoonderwaldt HC, van Dijk EJ, de Leeuw F‐E (2016) Long‐term depressive symptoms and anxiety after transient ischaemic attack or ischaemic stroke in young adults. European Journal of Neurology 23(8), 1262-1268.
| Crossref | Google Scholar |

Maino A, Rosendaal FR, Algra A, Peyvandi F, Siegerink B (2015) Hypercoagulability is a stronger risk factor for ischaemic stroke than for myocardial infarction: a systematic review. PLoS One 10(8), e0133523.
| Crossref | Google Scholar | PubMed |

Marini C, Totaro R, De Santis F, Ciancarelli I, Baldassarre M, Carolei A (2001) Stroke in young adults in the community-based L’Aquila registry. Stroke 32(1), 52-56.
| Crossref | Google Scholar |

Marini C, Russo T, Felzani G (2011) Incidence of stroke in young adults: A review. Stroke Research and Treatment 78(5), 408-413.
| Crossref | Google Scholar |

Morris R (2011) The psychology of stroke in young adults: the roles of service provision and return to work. Stroke Research and Treatment 2011, 534812.
| Crossref | Google Scholar | PubMed |

Mutai H, Furukawa T, Araki K, Misawa K, Hanihara T (2012) Factors associated with functional recovery and home discharge in stroke patients admitted to a convalescent rehabilitation ward. Geriatrics & Gerontology International 12(2), 215-222.
| Crossref | Google Scholar | PubMed |

Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H (2005) The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society 53(4), 695-699.
| Crossref | Google Scholar | PubMed |

Oxley TJ, Mocco J, Majidi S, Kellner CP, Shoirah H, Singh IP, De Leacy RA, Shigematsu T, Ladner TR, Yaeger KA, Skliut M, Weinberger J, Dangayach NS, Bederson JB, Tuhrim S, Fifi JT (2020) Large-vessel stroke as a presenting feature of Covid-19 in the young. The New England Journal of Medicine 382(20), e60.
| Crossref | Google Scholar | PubMed |

Paker N, Buğdaycı D, Tekdöş D, Kaya B, Dere C (2010) Impact of cognitive impairment on functional outcome in stroke. Stroke Research and Treatment 2010, 652612.
| Crossref | Google Scholar | PubMed |

Park DC, Bischof GN (2013) The aging mind: neuroplasticity in response to cognitive training. Dialogues in clinical neuroscience 15(1), 109-119.
| Crossref | Google Scholar | PubMed |

Röding J, Lindström B, Malm J, Öhman A (2003) Frustrated and invisible – younger stroke patients’ experiences of the rehabilitation process. Disability and Rehabilitation 25(15), 867-874.
| Crossref | Google Scholar | PubMed |

Sadler E, Daniel K, Wolfe CD, McKevitt C (2014) Navigating stroke care: the experiences of younger stroke survivors. Disability and Rehabilitation 36(22), 1911-1917.
| Crossref | Google Scholar | PubMed |

Saposnik G, Black SE, Hakim A, Fang J, Tu JV, Kapral MK, on behalf of the Investigators of the Registry of the Canadian Stroke Network (RCSN) and the Stroke Outcomes Research Canada (SORCan) Working Group (2009) Age disparities in stroke quality of care and delivery of health services. Stroke 40(10), 3328-3335.
| Crossref | Google Scholar | PubMed |

Smajlović D (2015) Strokes in young adults: epidemiology and prevention. Vascular Health and risk Management 11, 157-164.
| Crossref | Google Scholar | PubMed |

Smajlović D, Salihović D, Ibrahimagić OC, Sinanović O (2013) Characteristics of stroke in young adults in Tuzla Canton, Bosnia and Herzegovina. Collegium Antropologicum 37(2), 515-519.
| Google Scholar | PubMed |

Stolwyk RJ, Mihaljcic T, Wong DK, Chapman JE, Rogers JM (2021) Poststroke cognitive impairment negatively impacts activity and participation outcomes: a systematic review and meta-analysis. Stroke 52, 748-760.
| Crossref | Google Scholar | PubMed |

Stroke Foundation (2021) National Stroke Audit – Acute Services Report 2021. (Melbourne, Australia) Available at https://informme.org.au/media/0bzk42xf/2021_acute-services-national-report.pdf

Stroke Foundation (2023) Clinical Guidelines for Stroke Management. Available at https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management [accessed 13 November 2023]

Subha PP, Pillai Geethakumari SM, Athira M, Nujum ZT (2015) Pattern and risk factors of stroke in the young among stroke patients admitted in medical college hospital, Thiruvananthapuram. Annals of Indian Academy of Neurology 18(1), 20-23.
| Crossref | Google Scholar | PubMed |

Tabachnick B, Fidell L (2013) ‘Using multivariate statistics’, 6th edn. (Pearson New International Edition)

Teasell RW, McRae MP, Finestone HM (2000) Social issues in the rehabilitation of younger stroke patients. Archives of Physical Medicine and Rehabilitation 81(2), 205-209.
| Crossref | Google Scholar | PubMed |

Tooth L, McKenna K, Goh K, Varghese P (2005) Length of stay, discharge destination, and functional improvement: utility of the Australian National Subacute and Nonacute Patient Casemix Classification. Stroke 36(7), 1519-1525.
| Crossref | Google Scholar | PubMed |

Varona JF, Bermejo F, Guerra JM, Molina JA (2004) Long-term prognosis of ischemic stroke in young adults. Journal of Neurology 251(12), 1507-1514.
| Crossref | Google Scholar | PubMed |

Waje-Andreassen U, Thomassen L, Jusufovic M, Power KN, Eide GE, Vedeler CA, Naess H (2013) Ischaemic stroke at a young age is a serious event—final results of a population-based long-term follow-up in Western Norway. European Journal of Neurology 20(5), 818-823.
| Crossref | Google Scholar | PubMed |

Walterfang M, Velakoulis D, Gibbs A, Lloyd J (2003) The NUCOG: construction and piloting of a cognitive screening instrument in a neuropsychiatric unit. Australasian Psychiatry 11(3), 325-329.
| Crossref | Google Scholar |

Withiel TD, Wong D, Ponsford JL, Cadilhac DA, New P, Mihaljcic T, Stolwyk RJ (2019) Comparing memory group training and computerized cognitive training for improving memory function following stroke: a Phase II randomized controlled trial. Journal of Rehabilitation Medicine 51, 343-351.
| Crossref | Google Scholar | PubMed |

Wolfenden B, Grace M (2015) Vulnerability and post-stroke experiences of working-age survivors during recovery. SAGE Open 5(4), 215824401561287.
| Crossref | Google Scholar |

Wong D, Kempnich C, Bradshaw J, Grayson S, Lillywhite L, O’Shea M, Kim J, Stolwyk R, Cadilhac DA (2021) Real world implementation of a group-based memory rehabilitation program into stroke services: a knowledge translation evaluation. Topics in Stroke Rehabilitation 28(6), 410-421.
| Crossref | Google Scholar | PubMed |

Wu L, Ashton CM (1997) Chart review. A need for reappraisal. Evaluation & the Health Professions 20(2), 146-163.
| Crossref | Google Scholar | PubMed |