Stroke Recovery: Deciding When To Discharge Patients

The decision to discharge a stroke patient from the hospital is a critical aspect of their recovery journey. Stroke patients often experience physical and cognitive impairments that necessitate ongoing care and support. The timing of discharge is influenced by various factors, including the patient's functional abilities, rehabilitation progress, and availability of support systems.

After a stroke, patients typically undergo an initial assessment and stabilization in the emergency department, followed by intensive care or acute care. The rehabilitation process begins early, often within 24 hours of the stroke, and involves a multidisciplinary team of specialists. The rehabilitation team works to evaluate the patient's condition and develop a personalized plan to address their specific needs.

The length of a hospital stay after a stroke usually ranges from five to seven days. During this time, the stroke care team assesses the patient's condition and determines an appropriate rehabilitation plan. The long-term effects of a stroke vary depending on its severity and the area of the brain affected. These effects may include cognitive, physical, and emotional symptoms, such as memory problems, weakness, paralysis, depression, and difficulty swallowing.

The rehabilitation process focuses on helping patients regain their ability to perform activities of daily living (ADL), such as bathing and preparing food. It is important for patients to work towards their personal goals and practice their new skills outside of therapy sessions. Additionally, the psychological and emotional impacts of a stroke on both patients and caregivers are significant, and support from rehabilitation psychologists and neuropsychologists may be beneficial.

When a patient is ready to be discharged from the hospital, the care team develops a discharge plan based on their level of functional impairment. The patient may continue their rehabilitation in an inpatient or independent rehabilitation facility, a subacute rehabilitation facility, or at home with outpatient rehabilitation services. It is not necessary for patients to achieve full health before being discharged, as they can continue their recovery journey in their home environment with family support.

The first three months after a stroke are considered the most crucial for recovery, with most patients making significant progress during this period. Spontaneous recovery, where lost skills or abilities suddenly return, may also occur during this time. However, setbacks, such as pneumonia, heart attacks, or subsequent strokes, can interrupt the rehabilitation process, and it is important to adjust goals accordingly.

The goal of rehabilitation is to restore function as closely as possible to pre-stroke levels or develop compensation strategies to manage impairments. This may include learning new ways to perform tasks, such as holding a toothpaste tube with the strong hand to unscrew the cap.

Even after the initial months of intensive rehabilitation, ongoing follow-up with specialists is crucial for continued progress. This may include regular check-ins with a primary care physician, rehabilitation physician, physical and occupational therapists, speech therapists, neurologists, and rehabilitation psychologists.

In summary, the discharge of a stroke patient involves a comprehensive evaluation of their condition, the development of a personalized rehabilitation plan, and ongoing support to ensure their continued recovery and well-being.

When to initiate rehabilitation

Rehabilitation should be initiated as soon as possible after a stroke, ideally within 24 hours of the stroke occurring, according to Johns Hopkins stroke rehabilitation specialist Preeti Raghavan, M.D. The rehabilitation team includes physiatrists, neurologists, physical and occupational therapists, speech-language pathologists and nurses, who meet daily to discuss the patient’s condition. Therapy may be delivered as often as every hour during the first day or two.

The typical length of a hospital stay after a stroke is five to seven days. During this time, the stroke care team will evaluate the effects of the stroke, which will determine the rehabilitation plan. The long-term effects of a stroke vary from person to person, depending on the stroke’s severity and the area of the brain affected. These may include:

• Cognitive symptoms like memory problems and trouble speaking
• Physical symptoms such as weakness, paralysis and difficulty swallowing
• Emotional symptoms like depression and impulsivity
• Heavy fatigue and trouble sleeping

Therapy sessions are conducted up to six times each day while the patient is at the hospital, which helps evaluate the damage caused by the stroke and jump-start the recovery.

Rehabilitation priorities include activities of daily living (ADL), such as bathing or preparing food. Patients should also talk with their care team about activities important to them, such as performing a work-related skill or a hobby, to help set recovery goals. While therapy is vital, it is equally important to practice these activities independently.

A stroke can also have serious cognitive and emotional impacts for both patients and caregivers. Rehabilitation psychologists and neuropsychologists can screen for these challenges and create a plan to improve cognitive function and develop resilience in the face of what could be permanent lifestyle changes.

Preparing the home environment

After a stroke, patients may experience difficulties with everyday tasks and activities. Here are some ways to prepare the home environment to facilitate their recovery:

• Mobility and Fall Prevention: Make changes to the home to improve mobility and reduce the risk of falls. Install grab bars, shower seats, and non-slip mats in bathrooms. Ensure there is adequate lighting in hallways and staircases. Remove tripping hazards such as loose rugs or cables. Consider installing a ramp at the entrance if necessary.
• Assistive Devices: Consult with a therapist about the need for assistive devices such as a cane, walker, or wheelchair. Ensure that doorways and hallways are wide enough to accommodate these devices.
• Furniture Arrangement: Rearrange furniture to create clear pathways and provide ample space for movement, especially in areas where the patient will be spending a lot of time, such as the bedroom and living room.
• Clothing and Dressing: Choose clothing that is easy to put on and take off, such as shirts with front openings and elastic waistbands. Adapt clothing with Velcro fasteners instead of buttons or zippers. Place clothes within easy reach in the closet or dresser.
• Kitchen and Dining Area: Make necessary modifications in the kitchen to ensure safety and accessibility. Store frequently used items at waist level to reduce the need for reaching or bending. Use adaptive utensils and dishes, such as plates with lips and cups with lids, to facilitate eating and drinking.
• Communication Devices: If the patient has speech or language difficulties, consider using communication devices such as whiteboards, picture cards, or electronic devices with text-to-speech functions. Ensure that these devices are easily accessible and visible.
• Home Therapy Area: If the patient will be receiving therapy at home, designate a space for therapy sessions and equipment. This area should be free from distractions and provide enough room for movement and exercises.
• Stress Management: Create a calm and relaxing environment to support stress management. Reduce noise and distractions, especially during rest periods. Consider playing soothing music or nature sounds.
• Healthy Food Options: Stock the kitchen with healthy food options recommended by the patient's healthcare provider or dietitian. Include plenty of fruits, vegetables, lean proteins, and whole grains. Avoid processed foods, high-sodium snacks, and sugary treats.

Medication management

• Have all prescriptions filled before leaving the hospital: It is important to have all the necessary medications readily available upon returning home. This includes medications for blood pressure control, cholesterol management, and blood clot prevention. Ensure you understand the purpose of each medication and the correct dosage and timing for taking them.
• Follow instructions from your healthcare provider: Take medications exactly as directed by your doctor or healthcare provider. Do not skip doses or stop taking any of the prescribed medications without consulting your doctor first. These medications are crucial for your recovery and preventing another stroke.
• Do not take any additional drugs, supplements, vitamins, or herbs without consulting your doctor: Mixing certain substances can lead to dangerous interactions or interfere with the effectiveness of your prescribed medications. Always check with your doctor or pharmacist before taking anything new, even if it is a natural supplement or vitamin.
• Be cautious with blood thinners: If you are taking a blood thinner, such as warfarin (Coumadin), you may require additional blood tests to monitor your health. These medications can increase the risk of bleeding, so be cautious and inform your doctor if you experience any unusual bleeding or bruising.
• Manage swallowing difficulties: If you have trouble swallowing, it is essential to follow a special diet that makes eating safer. Choking or coughing while eating is a sign of swallowing problems. Work with your healthcare team to learn tips and techniques for making feeding and swallowing easier and safer.
• Maintain a healthy diet: Avoid salty, fatty, and fast foods. These can negatively impact your heart and blood vessels. Instead, focus on eating plenty of fruits, vegetables, and whole grains. Limit alcohol consumption to a maximum of one drink per day for women and two drinks per day for men, but check with your doctor to ensure it is safe for you to drink alcohol.
• Stay up to date with vaccinations: Keep your vaccinations current, including an annual flu shot. Ask your doctor if you need a pneumococcal vaccination to prevent pneumococcal infections.
• Avoid smoking: Smoking is a significant risk factor for strokes. If you smoke, ask your doctor for help quitting. Ensure that no one smokes inside your home to maintain a healthy living environment.
• Manage stress: Try to minimise stressful situations and find healthy ways to cope with stress. If you feel constantly stressed or experience sadness or depression, talk to your doctor or a mental health professional.

Remember to always follow your healthcare provider's instructions and reach out with any questions or concerns about your medication regimen.

Managing physical and mental health

At the Hospital

Initially, you will receive treatment to prevent further damage to the brain and help the heart, lungs, and other vital organs heal. Once your condition is stable, doctors will run tests and start treatment to aid your recovery and prevent another stroke. You may be kept in a special unit dedicated to helping people recover from strokes.

At Home

You may experience problems with:

• Moving one side of the body
• Sensation or awareness of one part of the body
• Talking or understanding others
• Seeing to one side (hemianopia)

You may need help with daily activities that you used to do alone before the stroke.

Physical Health

• Exercise: Begin an exercise program. Ask your healthcare provider about how to get started and how much activity you should aim for daily or weekly. Simple activities like walking or gardening can be beneficial.
• Diet: Your healthcare provider will guide you on the dietary changes you need to make. They may advise that you consult a registered dietitian for help with adjustments. These changes can improve your cholesterol, blood pressure, and blood sugar levels. Changes may include:
• Reducing the amount of fat, cholesterol, and salt in your diet
• Eating more vegetables and fruits
• Eating more lean proteins, such as fish, poultry, beans, and legumes
• Eating less red meat and processed meat
• Using low-fat dairy products
• Limiting vegetable oils, nut oils, sweets, and processed foods
• Alcohol consumption: Limit your alcohol intake.
• Smoking: If you smoke, quit now. Joining a stop-smoking program can improve your chances of success. Ask your healthcare provider about medications or other methods to help you quit.

Mental Health

• Depression: Depression after a stroke is common as you adjust to the changes in your life. It may develop soon after the stroke or up to two years later. Talk to your family, friends, or healthcare provider about seeking professional help if you feel depressed.
• Stress: Learn stress management methods to help you cope with stress in your daily life.

Follow-up

Keep all your medical appointments for close follow-up, as this is crucial to stroke rehabilitation and recovery. Some medications require blood tests to check for progress or problems, so be sure to keep any follow-up appointments for blood work ordered by your healthcare providers.

Ongoing care and support

After a stroke, patients often require ongoing care and support to manage the physical, cognitive, and emotional impacts of the stroke. Here are some key aspects of ongoing care and support for stroke patients:

• Rehabilitation: Rehabilitation is a crucial aspect of ongoing care for stroke patients. This includes physical therapy, occupational therapy, and speech therapy to help patients regain function and compensate for any impairments. Rehabilitation should be started as early as possible and continued for several months to promote recovery.
• Medication Management: Stroke patients may be prescribed various medications to control blood pressure, cholesterol, and blood clotting, as well as to prevent another stroke. It is important to take these medications exactly as directed and to avoid taking any other drugs, supplements, or herbs without consulting a healthcare provider.
• Lifestyle Modifications: Stroke patients are typically advised to make lifestyle changes, such as quitting smoking, limiting alcohol intake, and adopting a healthy diet to reduce the risk of another stroke.
• Follow-up Appointments: Close follow-up with healthcare providers is essential for stroke rehabilitation and recovery. Patients should keep follow-up appointments to monitor their progress, adjust treatments, and prevent future strokes.
• Support for Caregivers: Caregivers of stroke patients also need support and education to manage the care of the patient effectively. This includes training on how to assist with daily activities, managing the patient's medications, and recognising and managing any emotional or behavioural changes in the patient.
• Mental Health Support: Stroke can have a significant impact on a person's mental health. Depression is common after a stroke, and patients may benefit from psychological support or counselling to cope with the emotional and lifestyle changes that come with stroke recovery.
• Community Resources: Stroke patients and their caregivers can benefit from community resources, such as support groups, home healthcare services, and social services. These resources can provide additional support, education, and assistance during the recovery process.
• Long-term Monitoring: Even after the initial recovery period, stroke patients may require ongoing monitoring by a neurologist or rehabilitation physician to manage any long-term impairments or complications. This may include regular follow-up appointments and adjustments to the treatment plan as needed.

Frequently asked questions