Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

PURPOSE: This scientific statement provides an overview of the evidence on physical activity and exercise recommendations for stroke survivors. Evidence suggests that stroke survivors experience physical deconditioning and lead sedentary lifestyles. Therefore, this updated scientific statement serves as an overall guide for practitioners to gain a better understanding of the benefits of physical activity and recommendations for prescribing exercise for stroke survivors across all stages of recovery. METHODS: Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and indicate gaps in current knowledge. RESULTS: Physical inactivity after stroke is highly prevalent. The assessed body of evidence clearly supports the use of exercise training (both aerobic and strength training) for stroke survivors. Exercise training improves functional capacity, the ability to perform activities of daily living, and quality of life, and it reduces the risk for subsequent cardiovascular events. Physical activity goals and exercise prescription for stroke survivors need to be customized for the individual to maximize long-term adherence. CONCLUSIONS: The recommendation from this writing group is that physical activity and exercise prescription should be incorporated into the management of stroke survivors. The promotion of physical activity in stroke survivors should emphasize low- to moderate-intensity aerobic activity, muscle-strengthening activity, reduction of sedentary behavior, and risk management for secondary prevention of stroke.

The short physical performance battery as a predictor of functional capacity after stroke.

BACKGROUND: The short physical performance battery is a widely used instrument for quantifying lower extremity function in older adults. However, its utility for predicting endurance-based measures of functional performance that are more difficult to conduct in clinical settings is unknown. An understanding of this could be particularly relevant in mobility impaired stroke survivors, for whom establishing the predictive strength of simpler to perform measures would aid in tracking broader categories of functional disability. This cross-sectional study was conducted to determine whether the short physical performance battery is related to functional measures with a strong endurance component. METHODS: Functional measures (short physical performance battery, peak aerobic capacity, and 6-minute walk) were obtained and compared for the first time in stroke survivors with hemiparetic gait. Pearson correlation coefficients were used to assess strength of the relationships (α P < .05). RESULTS: Forty-three stroke participants performed a standardized short physical performance battery. Forty-one of the subjects completed a 6-minute walk, and 40 completed a peak treadmill test. Mean short physical performance battery (6.3 ± 2.5 [mean ± SD]), 6-minute walk (242 ± 115 meters), and peak aerobic capacity (17.4 ± 5.4 mL/kg/min) indicated subjects had moderate to severely impaired lower extremity functional performance. The short physical performance battery was related to both 6-minute walk (r = 0.76; P < .0001) and peak fitness (r = 0.52; P < .001). CONCLUSIONS: Our results show that the short physical performance battery may be reflective of endurance-based, longer-distance performance measures that would be difficult to perform in standard clinical stroke settings. Additional studies are needed to explore the value of using the short physical performance battery to assess rehabilitation-related functional progression after stroke.

Age-Friendly Health Systems and Meeting the Principles of High Reliability Organizations in the VHA.

Background: The Veterans Health Administration (VHA) is the largest integrated health care system in the US, providing care to more than 9 million enrolled veterans. In February 2019, the VHA identified key actionable steps to become a high reliability organization (HRO), transforming how employees think about patient safety and care quality. The VHA is also working toward becoming the largest age-friendly health system in the US to be recognized by the Institute for Healthcare Improvement for its commitment to providing care guided by the 4Ms (what matters, medication, mentation, and mobility), causing no harm, and aligning care with what matters to older veterans. Observations: In this article, we describe how the Age-Friendly Health Systems (AFHS) movement supports the culture shift observed in HROs. AFHS use the 4Ms as a framework to be implemented in every care setting. The 4Ms are used in conjunction with the 3 pillars (leadership commitment, culture of safety, and continuous process improvement) and 5 principles (sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to clinical expertise, and commitment to resilience) that guide an HRO. We also share an HRO case study that is representative of many Community Living Centers involved in AFHS. Conclusions: AFHS empower VHA teams to honor veterans' care preferences and values, supporting their independence, dignity, and quality of life across care settings. The adoption of AFHS brings evidence-based practices to the point of care by addressing common pitfalls in the care of older adults, drawing attention to, and calling for action on inappropriate medication use, physical inactivity, and assessment of the vulnerable brain. The 4Ms also serve as a framework to continuously improve care and cause zero harm, reinforcing HRO pillars and principles across the VHA and ensuring that older adults reliably receive the evidence-based, high-quality care they deserve.

Age-friendly care in the Veterans Health Administration: Past, present, and future.

The Veterans Health Administration (VHA) has long recognized the need for age-friendly care. VHA leadership anticipated the impact of aging World War II veterans on VA healthcare systems and in 1975 developed Geriatric Research, Education, and Clinical Centers (GRECCs) to meet this need. GRECCs catalyzed a series of innovations in geriatric models of care that span the continuum of care, most of which endure. These innovative care models also contributed to the evidence base supporting the present-day Age-Friendly Health Systems movement, with which VHA is inherently aligned. As both a provider of and payor for care, VHA is strongly incentivized to promote coordination across the continuum of care, with resultant cost savings. VHA is also a major contributor to developing the workforce that is essential for the provision of age-friendly care. As VHA continues to develop and refine innovative geriatric models of care, policymakers and non-VHA health care systems should look to VHA programs as exemplars for the development and implementation of age-friendly care.

The Worksite Heart Health Improvement Project (WHHIP): feasibility and efficacy.

OBJECTIVE: Test the feasibility and efficacy of the Worksite Heart Health Improvement Project (WHHIP). DESIGN: The WHHIP was a quasi-experimental 6-month pilot performed in 2 long-term care facilities. SAMPLE: Thirty-nine female minority nursing assistants participated in this study with a mean age of 42.39 (SD = 12.79) years. MEASUREMENTS: Measures were collected at baseline, 3, and 6 months and included blood pressure, lipid panel, body mass index, physical activity levels, diet behaviors, depressive symptoms, and self-efficacy outcomes. INTERVENTION: The 3-month WHHIP intervention included 3 components: environmental and policy assessment; education; and on-going motivation. The control site received education only. RESULTS: Subject participation averaged 47% and 58% in exercise and diet related activities, respectively. Generalized estimating equations showed the treatment group showed significant improvements in depressive symptoms (p = .012), systolic blood pressure (p = .028), total cholesterol (p = .002) and triglycerides (p = .011) over time. The treatment group also showed trends for improvement in diet behaviors (p = .069) and diastolic blood pressure (p = .073). CONCLUSIONS: This study provided feasibility evidence for the WHHIP and preliminary evidence that the WHHIP can improve heart healthy behaviors and subsequent outcomes among nursing assistants in long-term care settings.

Delirium: a very common problem you may not recognize.

Older adults with multiple pre-existing conditions are admitted to hospitals with acute illnesses and injuries every day. Delirium is not recognized by clinicians across health care settings. With awareness of risk factors and knowledge of delirium, nurses can play a pivotal role in the early identification, treatment, and, most important, prevention of delirium in older adults. Nurses often display a lack of knowledge related to delirium and the complex symptoms that appear differently in the presence of other complicating co-morbid conditions in aging adults. Nurses play a crucial role in keeping patients safe and ensuring optimal outcomes, regardless of the setting. With the growing population of older adults and the expected increases in chronic illness and dementia, delirium is a problem nurses are likely to experience in all practice settings. Knowing what to look for facilitates recognizing the risk and acting early to minimize (or even prevent) delirium.

Exercise intervention research in stroke: optimizing outcomes through treatment fidelity.

BACKGROUND: Demonstrating the treatment fidelity of an intervention is a key methodological requirement of any trial testing the impact of the intervention. PURPOSE: The purpose of this report was to serve as a model for evaluating treatment fidelity in stroke exercise intervention studies and to provide evidence for treatment fidelity in the Exercise Training for Hemiparetic Stroke Intervention Development Study. METHODS: Treatment fidelity was evaluated based on study design, training of interventionists, and delivery and receipt of the intervention. RESULTS: There were some concerns about design fidelity as the control group and intervention group traveled to the study location together and received different exercise programs in the same facility. With regard to training of interventionists, observations were utilized to help maintain adherence to the protocol. There was strong support for the delivery and receipt of the intervention with participants exposed to the anticipated number of exercise sessions. As per study protocol, there was evidence that progress toward the proposed physical activity goal was made. Treatment fidelity findings are reported using cumulative data rather than at points throughout the study. Thus the findings may be conservative with regard adherence, for example, to time spent in exercise. CONCLUSION: In addition to assurance of true testing of the intervention in this study, treatment fidelity of this work provides a useful model for replication and critically important information to better understand the type, dose, and length of exposure to exercise interventions that is needed to optimize stroke recovery.

Pilot testing of the PRAISEDD intervention among African American and low-income older adults.

BACKGROUND AND RESEARCH OBJECTIVE: The incidence of cardiovascular disease (CVD) is particularly high among African American (AA) older adults, and these individuals are least likely to have access to CVD prevention activities. The purpose of this study was to test the feasibility of People Reducing Risk and Improving Strength through Exercise, Diet and Drug Adherence (PRAISEDD), which is geared at increasing adherence to CVD prevention behaviors among AA and low-income older adults. METHODS: This feasibility study was conducted in a senior housing site, using a single-group repeated-measures design and testing physical activity, diet, medication adherence beliefs and behaviors, and blood pressure at baseline and after a 12-week intervention period. Of 22 participants, mean (SD) age was 76.4 (7.6) years, and most were female (64%) and AA (86%). An intention-to-treat analysis was used. RESULTS: There were significant decreases in systolic (P = .02) and diastolic blood pressure (P = .01) and a nonsignificant trend toward improvement in cholesterol intake (P = .09). There were no changes in time spent in moderate-level physical activity, sodium intake, medication adherence, or self-efficacy and outcome expectations across all 3 behaviors. CONCLUSION: The PRAISEDD intervention was feasible in a group of AA and low-income older adults and, after 12 weeks, resulted in improvements in blood pressure. Future research is needed to test a revised PRAISEDD intervention using a randomized controlled design, a larger sample, and a longer follow-up period. The PRAISEDD intervention should be revised to incorporate environmental and policy changes that influence CVD prevention behaviors and explore the impact of social networking as it relates to diffusion of the intervention among participants in low-income housing facilities.

Using theory to develop an exercise intervention for patients post stroke.

Stroke remains a leading cause of disability for older adults. While is it well established in the literature that exercise programs can have significant benefit, many stroke survivors do not receive specific recommendations for exercise or lack the motivation to continue exercising following discharge from rehabilitation. This article describes an exercise intervention developed for subacute stroke survivors that utilizes the self-efficacy theory framework. The rationale for selection of this theoretical framework and specific examples of interventions linked to components of the model are provided. The article describes the motivational/educational program and the sequential follow-up designed to prepare stroke survivors to increase exercise behavior. Theoretical frameworks are useful tools for guiding and organizing research investigations from literature review through development and implementation of the intervention to interpretation of findings.

Motivators for treadmill exercise after stroke.

PURPOSE: The purpose of this qualitative study was to explore factors that motivated older adults with ischemic stroke to engage in a task-oriented treadmill aerobic exercise (T-AEX) intervention study. METHOD: Participants included community-dwelling individuals post stroke with mild-to-moderate hemiparetic gait deficits who completed a 6-month T-AEX study. A total of 29 participants attended focus groups or individual telephone interviews. RESULTS: Thirty-nine codes were identified and were reduced to 8 themes: personal goals supported by 7 codes, psychological benefits supported by 8 codes, physical benefits supported by 10 codes, research-associated supervised treadmill exercise benefits supported by 5 codes, objective and verbal encouragement received supported by 4 codes, social support related to exercise supported by 2 codes, improvement in instrumental activities of daily living supported by 2 codes, and self-determination supported by 1 code. All themes reflected factors that influenced subjects' willingness to participate in the study and adhere to the exercise intervention. Of the themes identified, personal goals, physical benefits, and psychological benefits occurred most frequently. CONCLUSION: This qualitative study provides information that may be used to enhance motivation to exercise in individuals with stroke and promote carryover and integration of exercise behaviors into everyday life.

A Pilot Primary Stroke Prevention Program for Elderly Korean Americans.

BACKGROUND: Stroke is a significant health issue with devastating consequences among older adults in the United States. However, it can be prevented by improving stroke knowledge and managing risk factors. Many stroke education programs have been shown to be effective. Unfortunately, a minority of older adults, such as older Korean Americans, have not benefited from the programs because of language barriers. OBJECTIVE: The purpose of this study was to examine the feasibility and preliminary impact of a primary stroke prevention program on stroke knowledge, healthy eating, and physical activity behaviors among Korean Americans. METHODS: A randomized controlled pilot trial was conducted. A total of 73 persons were randomly assigned to either an intervention group (n = 37) or a control group (n = 36). The intervention program included in-person lectures and discussions. Sociodemographic data were analyzed using descriptive statistics. Analyses of covariance and logistic regression analysis were used to evaluate the effects of the intervention program. RESULTS: The mean age of participants was 71.49 ± 6.25 years, and most participants were female (74.0%) and married (65.8%). Upon intervention completion, the intervention group showed greater improvements than the control group in stroke knowledge and intake of sodium and total fats (F = 11.89, P = .001, ηp = 0.151; F = 4.04, P = .048, ηp = 0.057; and F = 4.51, P = .037,= ηp = 0.062, respectively). Step counts showed marginal effects (F = 3.27, P = .075, ηp = 0.049). CONCLUSION: This study demonstrated feasibility and effectiveness of the program to improve stroke knowledge and healthy behaviors in elderly Korean Americans.

The Consortium of E-Learning in Geriatrics Instruction.

This paper describes the activities of the Consortium of E-Learning in Geriatrics Instruction (CELGI), a group dedicated to creating, using, and evaluating e-learning to enhance geriatrics education. E-learning provides a relatively new approach to addressing geriatrics educators' concerns, such as the shortage of professionals trained to care for older people, overcrowded medical curricula, the move to transfer teaching venues to community settings, and the switch to competency-based education models. However, this innovative education technology is facing a number of challenges as its use and influence grow, including proof of effectiveness and efficiency. CELGI was created in response to these challenges, with the goal of facilitating the development and portability of e-learning materials for geriatrics educators. Members represent medical and nursing schools, the Department of Veterans Affairs healthcare system, long-term care facilities, and other institutions that rely on continuing streams of quality health education. CELGI concentrates on providing a coordinated approach to formulating and adapting specifications, standards, and guidelines; developing education and training in e-learning competencies; developing e-learning products; evaluating the effect of e-learning materials; and disseminating these materials. The vision of consortium members is that e-learning for geriatric education will become the benchmark for valid and successful e-learning throughout medical education.

Cardiovascular risk in survivors of stroke.

BACKGROUND: Stroke survivors are at significant risk for recurrent stroke and cardiovascular disease. Inadequately managed modifiable risk factors increase the threat of recurrent stroke, development of new comorbidities, and double the risk of premature mortality. The purpose of this study was to determine the prevalence of modifiable cardiovascular risk factors in stroke survivors who completed a research screening evaluation for entry into exercise rehabilitation studies. The sample collected between January 2001 and June 2005 evaluated 364 community-dwelling men and women aged 34 to 88 years living in Baltimore, Maryland. METHODS: Each participant's risk profile was evaluated from data obtained during a medical history and physical examination and from laboratory analysis of a fasting blood sample. Current practice guidelines were used to define risk categories. RESULTS: Ninety-nine percent of participants had at least one suboptimally controlled risk factor. Ninety-one percent had two or more concurrent risk factors inadequately treated. Eighty percent of the participants had prehypertension or hypertension, 67% were overweight or obese, 60% had suboptimal low-density lipoprotein, 45% had impaired fasting glucose, 34% had low high-density lipoprotein, and 14% were current smokers, while reportedly receiving routine medical care. CONCLUSIONS: These findings confirm that cardiovascular risk factors remain inadequately managed in stroke survivors, increasing the chance for repeat stroke and cardiovascular event. Systematic assessment of this vulnerable population is imperative at every healthcare encounter.

Post-stroke consultation service: a nurse-managed model for care delivery.

In 1989, a multidisciplinary consultation service devoted to providing primary care and rehabilitative care services to stroke survivors in the home was developed and tested at the University of Pennsylvania. This nurse-managed service, Post-Stroke Consultation Service, used the expertise of a nurse practitioner, geriatrician, physiatrist, physical therapists, home health care nurses, specialty care providers, families, and stroke survivors to develop and implement a plan of care that optimized health and function and would be sustainable over time. The service and its impact are described.

Confidentiality challenges and good clinical practices in human subjects research: striking a balance.

The Health Insurance Portability and Accountability Act (HIPPA) has been fully implemented in clinical practice and research settings. Although subject confidentiality has always been a concern, clinical researchers must now take extra care to attend to the mandates of privacy while also minding good clinical practice guidelines. Unanticipated conflicts may arise as a result of these dual priorities. This article presents two examples of potential challenges to confidentiality with comment from the bioethical perspective.

Stroke prevention and management in older adults.

Stroke is the third leading cause of death and a foremost cause of serious, long-term disability in the United States. As cardiovascular and metabolic disease incidence rises with age, older people are more likely to experience strokes. Age is the single most important risk factor for stroke. For each successive 10 years after age 55, the stroke rate more than doubles in both men and women. However, stroke is not an inevitable consequence of aging. By identifying and modifying risk factors in older people, nurses can partner with other providers to reduce the incidence, morbidity, and mortality associated with stroke in older adults. Control of hypertension, resolution of dyslipidemia, management of diabetes mellitus, anticoagulation for atrial fibrillation, promotion of exercise and healthy diet, and cessation of cigarette smoking are of particular importance in older adults. Recognition of stroke symptoms, access to emergency evaluation and treatments, and participation in comprehensive rehabilitation may determine stroke outcomes in aging. This article presents stroke risk factors and primary and secondary prevention in the context of aging, with special considerations in the identification and management of acute stroke, recovery, and rehabilitation for older adults who survive stroke.