Transitioning to home and beyond following stroke: a prospective cohort study of outcomes and needs.

INTRODUCTION: Understanding of the needs of people with stroke at hospital discharge and in the first six-months is limited. This study aim was to profile and document the needs of people with stroke at hospital discharge to home and thereafter. METHODS: A prospective cohort study recruiting individuals with stroke, from three hospitals, who transitioned home, either directly, through rehabilitation, or with early supported discharge teams. Their outcomes (global-health, cognition, function, quality of life, needs) were described using validated questionnaires and a needs survey, at 7-10 days, and at 3-, and 6-months, post-discharge. RESULTS: 72 patients were available at hospital discharge; mean age 70 (SD 13); 61% female; median NIHSS score of 4 (IQR 0-20). 62 (86%), 54 (75%), and 45 (63%) individuals were available respectively at each data collection time-point. Perceived disability was considerable at hospital discharge (51% with mRS ≥ 3), and while it improved at 3-months, it increased thereafter (35% with mRS ≥ 3 at 6-months). Mean physical health and social functioning were "fair" at hospital discharge and ongoing; while HR-QOL, although improved over time, remained impaired at 6-months (0.69+/-0.28). At 6-months cognitive impairment was present in 40%. Unmet needs included involvement in transition planning and care decisions, with ongoing rehabilitation, information, and support needs. The median number of unmet needs at discharge to home was four (range:1-9), and three (range:1-7) at 6-months. CONCLUSION: Stroke community reintegration is challenging for people with stroke and their families, with high levels of unmet need. Profiling outcomes and unmet needs for people with stroke at hospital-to-home transition and onwards are crucial for shaping the development of effective support interventions to be delivered at this juncture. ISRCTN REGISTRATION: 02/08/2022; ISRCTN44633579.

Occupational therapists' assessment and reporting of functional cognition in stroke care.

PURPOSE: To investigate how functional cognition of people post-stroke is evaluated and reported by occupational therapists in Ireland. Functional cognition refers to the use and integration of cognitive skills for daily function. METHODS: This study used a qualitative design. Six focus groups and one individual interview were conducted with 20 occupational therapists purposively sampled for variation across different clinical grades. Data were analysed according to the Braun and Clark thematic analysis framework. RESULTS: Participants felt that assessment of functional cognition was an integral feature of occupational therapy assessment in stroke care but acknowledged that terminology used by occupational therapists for functional cognition was inconsistent. Non-standardised observational assessment was routinely used by participants. Challenges were reported with respect to written documentation of non-standardised observations. Participants reported that use of standardised cognitive assessments required considered clinical reasoning before administration. Standardised performance-based assessments were not widely implemented by participants. CONCLUSION: Occupational therapists in Ireland reported a multi-component assessment process to evaluate functional cognition post-stroke. Establishing practice guidelines for the assessment of functional cognition may be of benefit to occupational therapists working in stroke care. Further research is needed to quantify procedures in this assessment process to account for variation in practice.

The assessment of functional cognition in stroke rehabilitation is integral to occupational therapy practice.Occupational therapists described the assessment of functional cognition as a multi-component assessment drawing from three main modalities: standardised cognitive assessments; non-standardised observations; and performance-based assessments.Professional education in, and practice guidelines, for the assessment and reporting of functional cognition could be beneficial for occupational therapists in stroke care to streamline their assessment and reporting of functional cognition.

Priorities for developing stroke care in Ireland from the perspectives of stroke survivors, family carers and professionals involved in stroke care: A mixed methods study.

INTRODUCTION: Increasing numbers of people are living with stroke, due to population ageing and improved survival, leading to a need for evidence to inform future policy decision-making. This study aimed to engage with stakeholders in Ireland to identify priorities for stroke services development. METHODS: A sequential mixed methods design was used. Phase 1 (qualitative) was exploratory, involving initial priority gathering via an online qualitative survey and interviews, with stroke survivors, family/main carers, and professionals working in stroke care. Framework analysis was used to generate a long-list of improvements to stroke services. Phase 2 involved a quantitative survey, where stakeholders selected five priority improvements from the long-list. Results were discussed in a stakeholder meeting. RESULTS: In-depth interviews were completed with 18 survivors, 13 carers and 8 professionals, while 80 professionals took part in a qualitative survey (phase 1). Priority areas of care were identified and a long-list of 45 priority improvements was generated. In phase 2, 34 survivors, 19 family carers and 42 professionals completed a survey. The highest priority improvements (selected by >20% of respondents) were access to specialist neuro-rehabilitation, ongoing support for life after stroke, recruitment/retention of specialist staff, improved information and support for health system navigation, and access to specialist acute care. Stroke survivors/carers prioritised exploring ways to improve access for strokes with atypical presentation, while professionals prioritised specialist inpatient rehabilitation and early supported discharge. Neither group prioritised stroke prevention. Based on discussions in the stakeholder meeting (n = 12), it was decided that support for mental health should also be included as a priority. DISCUSSION: The development of stroke services benefits from exploring the priorities of those receiving and delivering stroke care. Findings emphasise the need for equitable access to high quality adequately-staffed services, particularly post-discharge, that are easy to navigate, with good communication, and effective information provision.

Healthcare professionals' experiences of delivering a stroke Early Supported Discharge service - An example from Ireland.

OBJECTIVE: To explore healthcare professionals' experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic. DESIGN: Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis. SETTING: Nine Early Supported Discharge service sites in Ireland. PARTICIPANTS: Purposive sampling identified 16 healthcare professionals. RESULTS: Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families. CONCLUSIONS: Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.

Comprehensive geriatric assessment-where are we now, where do we need to be in the context of global ageing?

Comprehensive geriatric assessment (CGA) is the cornerstone of modern geriatric medicine and the framework around which conventional and new models of care for older people are developed. Whilst there are a substantial number of reviews synthesising the evidence on patient and service outcomes from CGA, as an intervention it remains poorly described. There is a lack of detail on how a CGA plan is coordinated, delivered and followed up, especially outside of acute care. This commentary reflects on the authors' experience of extracting data from 57 published studies on CGA. CGA as an intervention is akin to a 'black box' in terms of describing and measuring participants' interactions with CGA activity in terms of time, frequency and amount (dose) received. There is also a lack of detail on how newly established CGA teams become effective, interdisciplinary, high functioning and sustainable teams. The CGA knowledge-do gap persists with a need to draw from complex system theory and implementation science frameworks to better describe the intervention and understand the influence of the organisation and health service within which CGA is operationalised. Equally, the voice of older people, families and staff is critical in the conduct and evaluation of CGA, and how it evolves as a model to meet the growing needs of ageing populations.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke.

OBJECTIVE: Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals. METHOD: A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis. RESULTS: Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD. CONCLUSION: The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

"Older People Want to Be in Their Own Homes": A Service Evaluation of Patient and Carer Feedback after Pathfinder Responded to Their Emergency Calls.

OBJECTIVE: Older people experience high rates of adverse outcomes following emergency department (ED) presentation. There is growing evidence to support alternative care pathways for certain types of emergency medical services (EMS) calls. Pathfinder is one such service and targets patients aged 65 years and over, whose presenting issues can be safely managed at home by immediate paramedic, occupational therapy, and/or physiotherapy interventions. The aim of this service evaluation was to understand how older people feel about being treated at home as a result of EMS calls and to understand their experiences of the Pathfinder service. METHODS: This was a thematic analysis of open-ended responses recorded from telephone interviews during routine service evaluation with service users (patients or their next-of-kin). RESULTS: Of 573 service users, telephone interviews were conducted with 429 (75%). Five primary themes were identified: (1) professionalism of the multidisciplinary clinical team; (2) "the right service, in the right place, at the right time"; (3) role of Pathfinder in "getting the ball rolling"; (4) lasting effects of the experience on the patient and his or her next-of-kin; (5) value of skilled communication with the older person. CONCLUSION: Older people and their next-of-kin voiced a clear preference for hospital avoidance, and strongly valued the opportunity to be treated in their homes at the time of an EMS call rather than default conveyance to the ED. They appreciated the importance of a skilled multidisciplinary team with a follow-up service that effectively positions itself between the acute hospital and community services.

A phase III, multi-arm multi-stage covariate-adjusted response-adaptive randomized trial to determine optimal early mobility training after stroke (AVERT DOSE).

RATIONALE: The evidence base for acute post-stroke rehabilitation is inadequate and global guideline recommendations vary. AIM: To define optimal early mobility intervention regimens for ischemic stroke patients of mild and moderate severity. HYPOTHESES: Compared with a prespecified reference arm, the optimal dose regimen(s) will result in more participants experiencing little or no disability (mRS 0-2) at 3 months post-stroke (primary), fewer deaths at 3 months, fewer and less severe complications during the intervention period, faster recovery of unassisted walking, and better quality of life at 3 months (secondary). We also hypothesize that these regimens will be more cost-effective. SAMPLE SIZE ESTIMATES: For the primary outcome, recruitment of 1300 mild and 1400 moderate participants will yield 80% power to detect a 10% risk difference. METHODS AND DESIGN: Multi-arm multi-stage covariate-adjusted response-adaptive randomized trial of mobility training commenced within 48 h of stroke in mild (NIHSS < 7) and moderate (NIHSS 8-16) stroke patient strata, with analysis of blinded outcomes at 3 (primary) and 6 months. Eligibility criteria are broad, while excluding those with severe premorbid disability (mRS > 2) and hemorrhagic stroke. With four arms per stratum (reference arm retained throughout), only the single treatment arm demonstrating the highest proportion of favorable outcomes at the first stage will proceed to the second stage in each stratum, resulting in a final comparison with the reference arm. Three prognostic covariates of age, geographic region and reperfusion interventions, as well as previously observed mRS 0-2 responses inform the adaptive randomization procedure. Participants randomized receive prespecified mobility training regimens (functional task-specific), provided by physiotherapists/nurses until discharge or 14 days. Interventions replace usual mobility training. Fifty hospitals in seven countries (Australia, Malaysia, United Kingdom, Ireland, India, Brazil, Singapore) are expected to participate. SUMMARY: Our novel adaptive trial design will evaluate a wider variety of mobility regimes than a traditional two-arm design. The data-driven adaptions during the trial will enable a more efficient evaluation to determine the optimal early mobility intervention for patients with mild and moderate ischemic stroke.

Designing stroke services for the delivery of cognitive rehabilitation: A qualitative study with stroke rehabilitation professionals.

This qualitative study explored the potential to deliver cognitive rehabilitation for post-stroke cognitive impairment (PSCI), with a specific focus on barriers and facilitators to its delivery from the perspective of Irish stroke rehabilitation professionals. Sixteen semi-structured interviews were completed with healthcare professionals in both hospital and community settings. The sample comprised physiotherapists, occupational therapists, nurses, a stroke physician, a psychologist, a neuropsychologist, a speech and language therapist, a dietician, and a public health nurse. Interviews were audio-recorded and analysed in NVivo using inductive Thematic Analysis. Barriers and facilitators to the delivery of cognitive rehabilitation were identified and described under four key themes: (i) Cognitive screening; (ii) Cognitive rehabilitation: no one size fits all; (iii) Psychology: the lost dimension of stroke rehabilitation; and (iv) Joining the dots in the community. Staffing required to deliver cognitive rehabilitation for PSCI was highlighted as under-resourced in the Republic of Ireland. Inadequate resourcing of neuropsychology and stroke-related psychological services, in particular, has had negative implications for the delivery of cognitive rehabilitation. Stroke-specific cognitive rehabilitation expertise is virtually inaccessible in the community, highlighting an urgent need for investment in specialist rehabilitation teams to deliver cognitive rehabilitation in this setting.

A protocol to evaluate the impact of embedding Public and Patient Involvement in a structured PhD program for stroke care.

Background: Embedding Public and Patient Involvement (PPI) in postgraduate research has been recognized as an important component of post-graduate training, providing research scholars with an awareness and a skillset in an area which prepares them for future roles as healthcare researchers. Improving Pathways for Acute STroke And Rehabilitation (iPASTAR) is a structured PhD training program [Collaborative Doctoral Award (CDA)] which aims to design a person-centered stroke pathway throughout the trajectory of stroke care, to optimize post-stroke health and wellbeing. PPI is embedded at all stages. Purpose: The iPASTAR research programme was strongly informed by a round-table PPI consultation process with individuals who experienced stroke and who provided broad representation across ages, gender, geographical locations (urban and rural) and the PhD themed areas of acute care, early supported discharge and lifestyle-based interventions after stroke. Four PhD scholars taking part in the CDA-iPASTAR now work collaboratively with four stroke champions, supported by a wider PPI advisory panel. Methods: This study will evaluate the process and impact of embedding PPI during a PhD program. We will conduct a longitudinal mixed-methods evaluation, conducting focus groups at 24, 36, and 48 months to explore the experiences of the key stakeholders involved. The participants will include PhD scholars, PPI partners (PPI Advisory Group and PPI Champions), PhD supervisors and a PPI manager. An independent researcher will conduct the evaluation. We will include focus groups, individual interviews and participant reflections. Qualitative data will be analyzed using thematic and content analysis, quantitative data will be analyzed using descriptive statistics. Discussion: PPI and patient voice initiatives bring together researchers, family, and people with health care issues into meaningful dialogue and allow the development of a patient-voice learning network. Embedding PPI training within a PhD program can build meaningful capacity in PPI partnerships in stroke research.

Enhancing Existing Formal Home Care to Improve and Maintain Functional Status in Older Adults: Results of a Feasibility Study on the Implementation of Care to Move (CTM) in an Irish Healthcare Setting.

Background: Care to Move (CTM) provides a series of consistent 'movement prompts' to embed into existing movements of daily living. We explored the feasibility of incorporating CTM approaches in home care settings. Methods: Feasibility study of the CTM approach in older adults receiving home care. Recruitment, retention and attrition (three time points), adherence, costs to deliver and data loss analyzed and differentiated pre and post the COVID-19 pandemic. Secondary outcomes, including functional status, physical activity, balance confidence, quality of life, cost to implement CTM. Results: Fifty-five home care clients (69.6% of eligible sample) participated. Twenty were unable to start due to COVID-19 disruptions and health issues, leaving 35 clients recruited, mostly women (85.7%), mean age 82.8 years. COVID-19 disruption impacted on the study, there was 60% retention to T2 assessments (8-weeks) and 13 of 35 (37.1%) completed T3 assessments (6-months). There were improvements with small to medium effect sizes in quality of life, physical function, balance confidence and self-efficacy. Managers were supportive of the roll-out of CTM. The implementation cost was estimated at EUR 280 per carer and annual running costs at EUR 75 per carer. Conclusion: Embedding CTM within home support services is acceptable and feasible. Data gathered can power a definitive trial.

Effectiveness of interventions to support the transition home after acute stroke: a systematic review and meta-analysis.

BACKGROUND: Effective support interventions to manage the transition to home after stroke are still mostly unknown. AIM: The purpose of this systematic review was to investigate the effectiveness of support interventions at transition from organised stroke services to independent living at home. METHODS: The Cochrane Central Register of Controlled Trials, six databases including MEDLINE and Embase, trial registries, grey literature, and Google Scholar were all searched, up to June 2021. We included randomised controlled trials enrolling people with stroke to receive either standard care or any type of support intervention from organised stroke services to home. The primary outcome was functional status. Two authors determined eligibility, extracted data, evaluated risk of bias (ROB2), and verified the evidence (GRADE). Where possible we performed meta-analyses using Risk Ratios (RR) or Mean Differences (MD). RESULTS: We included 17 studies. Support interventions led to important improvements in functional status, as determined by the Barthel Index up, to 3-months (MD 7.87 points, 95%CI:6.84 to 19.16; 620 participants; five studies; I2 = 77%). Results showed modest but significant functional gains in the medium to long-term (6-12 month follow up, MD 2.91 points, 95%CI:0.03 to 5.81; 1207 participants; six studies; I2 = 84%). Certainty of evidence was low. Support interventions may enhance quality of life for up to 3-months (MD 1.3,95% CI:0.84 to 1.76), and reduce depression (SMD -0.1,95% CI:-0.29 to - 0.05) and anxiety (MD -1.18,95% CI:-1.84 to - 0.52) at 6-12 months. Effects on further secondary outcomes are still unclear. CONCLUSIONS: Incorporating support interventions as people who have experienced a stroke transition from hospital to home can improve functional status and other outcomes. Due to study heterogeneity, the essential components of effective transition of care interventions are still unknown. Adoption of core outcome sets in stroke research would allow for greater comparison across studies. Application of a development and evaluation framework engaging stakeholders would increase understanding of priorities for stroke survivors, and inform the key components of an intervention at transition from hospital-to-home. TRIAL REGISTRATION: CRD42021237397 - https://www.crd.york.ac.uk/prospero.

Scoring the Clinical Frailty Scale in the Emergency Department: The Home FIRsT Experience.

We evaluated predictors of the Clinical Frailty Scale (CFS) scored by an interdisciplinary team (Home FIRsT) performing comprehensive geriatric assessment (CGA) in our Emergency Department (ED). This was a retrospective observational study (service evaluation) utilising ED-based CGA data routinely collected by Home FIRsT between January and October 2020. A linear regression model was computed to establish independent predictors of CFS. This was complemented by a classification and regression tree (CRT) to evaluate the main predictors. There were 799 Home FIRsT episodes, of which 740 were unique patients. The CFS was scored on 658 (89%) (median 4, range 1-8; mean age 81 years, 61% women). Independent predictors of higher CFS were older age (p<0.001), history of dementia (p<0.001), mobility (p≤0.007), disability (p<0.001), and higher acuity of illness (p=0.009). Disability and mobility were the main classifiers in the CRT. Results suggest appropriate CFS scoring informed by functional baseline.

Examining the factors associated with community ambulation in an older adult day hospital population.

PURPOSE: The ability of an older adult to walk independently in their community assists with maintaining independence, a healthy lifestyle and a good quality of life. In clinical practice, outdoor mobility is often one of the first activities, where a decline is observed. The aim of this study was to examine the factors associated with community ambulation in community dwelling older adults attending a day hospital. METHODS: This was a cross-sectional observational study design. Inclusion criteria were community dwelling older adults, over 65 years, attending a day hospital and able to ambulate at least 10 m with or without an assistive device. The primary outcome measure was a community ambulation questionnaire. A range of other outcome measures were completed assessing motor, cognitive, executive function and behavioural domains. Multivariate logistic regression was employed to identify independent predictors of community ambulation. RESULTS: 161 participants completed this study. The median age was 83 years (IQR 9), 64% were female and 49.1% lived alone. 55.3% of participants were classified as independent community ambulators. Mean gait speed was 0.8 m/s, median TUG score was 16.6 s and median frailty was 4 (IRQ 2) using the Clinical Frail Scale. Self-efficacy (p < 0.001) and gait speed (p = 0.030) were independently associated with community ambulation. CONCLUSIONS: The findings demonstrate the complexity and multifactorial nature of community ambulation in older adults. This suggests the need to adopt a broader approach to the management of older adults, to promote the achievement of independent community ambulation.

The impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in Ireland: a cross-sectional nationally representative study.

BACKGROUND: Cognitive impairment after stroke is associated with poorer health outcomes and increased need for long-term care. The aim of this study was to determine the impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in older adults in Ireland. METHODS: This cross-sectional study involved secondary data analysis of 8,175 community-dwelling adults (50 + years), from wave 1 of The Irish Longitudinal Study on Ageing (TILDA). Participants who had been diagnosed with stroke by a doctor were identified through self-report in wave 1. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA). The main outcome of the study was healthcare utilisation, including General Practitioner (GP) visits, emergency department visits, outpatient clinic visits, number of nights admitted to hospital, and use of rehabilitation services. The data were analysed using multivariate adjusted negative binomial regression and logistic regression. Incidence-rate ratios (IRR), odds ratios (OR) and 95% confidence intervals (CI) are presented. RESULTS: The adjusted regression analyses were based on 5,859 participants who completed a cognitive assessment. After adjusting for demographic and clinical covariates, stroke was independently associated with an increase in GP visits [IRR (95% CI): 1.27 (1.07, 1.50)], and outpatient service utilisation [IRR: 1.49 (1.05, 2.12)]. Although participants with poor cognitive function also visited the GP more frequently than participants with normal cognitive function [IRR: 1.07 (1.04, 1.09)], utilisation of outpatient services was lower in this population [IRR: 0.92 (0.88, 0.97)]. PSCI was also associated with a significant decrease in outpatient service utilisation [IRR: 0.75 (0.57, 0.99)]. CONCLUSIONS: Stroke was associated with higher utilisation of GP and outpatient services. While poor cognitive function was also associated with more frequent GP visits, outpatient service utilisation was lower in participants with poor cognitive function, indicating that cognitive impairment may be a barrier to outpatient care. In Ireland, the lack of appropriate neurological or cognitive rehabilitation services appears to result in significant unaddressed need among individuals with cognitive impairment, regardless of stroke status.

A prospective assessment of gait kinematics and related clinical examination measures in cerebral palsy crouch gait.

Background While prospectively assessed crouch gait in cerebral palsy (CP) does not necessarily progress, prospective changes in clinical examination measures have not been reported. This study prospectively examined the association between selected clinical examination variables and change in crouch gait in a cohort with bilateral CP. Methods Inclusion criteria were a diagnosis of ambulant bilateral CP, knee flexion at mid-stance >19 0 and a minimum of two-years between gait analyses. The change in kinematic variables was assessed using Statistical Parameter Mapping (SPM) and changes in clinical measures using appropriate paired tests. Linear regression examined the association between progression of crouch and clinical examination variables. Results There was no mean change in crouch in 27 participants over 3.29 years. However, there was significant variability within this group. Clinical hamstring tightness (60.00 0 to 70.48 0, p<0.01) and external knee rotation during stance (SPM analysis, p<0.001) increased but there was no association between changes in clinical examination variables and changes in crouch (p-values 0.06 - 0.89).    Conclusions This prospective study found no association between the changes in clinical examination variables and changes in crouch highlighting the likely multi-factorial aetiology of this gait pattern and the need for larger prospective studies. The variability crouch gait progression among the 27 participants highlights the pitfall of group mean values in such a heterogeneous population.

Inclusion of stroke patients in expanded cardiac rehabilitation services: a cross-national qualitative study with cardiac and stroke rehabilitation professionals.

PURPOSE: This qualitative study explored healthcare professionals' views in relation to the potential expansion of cardiac rehabilitation services to include stroke patients, thereby becoming a cardiovascular rehabilitation model. DESIGN AND METHODS: 23 semi-structured interviews were completed with hospital and community-based stroke and cardiac rehabilitation professionals in Switzerland (n = 7) and Ireland (n = 19). The sample comprised physiotherapists, occupational therapists, speech and language therapists, stroke physicians, cardiologists, psychologists, dieticians and nurses. Interviews were audio-recorded and the transcripts were analysed in NVivo using inductive Thematic Analysis. RESULTS: Barriers and facilitators to cardiovascular rehabilitation were captured under four broad themes; (i) Cardiac rehabilitation as "low-hanging fruit," (ii) Cognitive impairment ("the elephant in the room"), (iii) Adapted cardiac rehabilitation for mild stroke, and (iv) Resistance to change. CONCLUSIONS: Hybrid cardiac rehabilitation programmes could be tailored to deliver stroke-specific education, exercises and multidisciplinary expertise. Post-stroke cognitive impairment was identified as a key barrier to participation in cardiac rehabilitation. A cognitive rehabilitation intervention could potentially be delivered as part of cardiac rehabilitation, to address the cognitive needs of stroke and cardiac patients.Implications for rehabilitationThe cardiac rehabilitation model has the potential to be expanded to include mild stroke patients given the commonality of secondary prevention needs.Up to half of stroke survivors are affected by post-stroke cognitive impairment, consequently mild stroke patients may not be such an "easy fit" for cardiac rehabilitation.A cardiovascular programme which includes common rehabilitation modules, in addition to stroke- and cardiac-specific content is recommended.A cognitive rehabilitation module could potentially be added as part of the cardiac rehabilitation programme to address the cognitive needs of stroke and cardiac patients.

StrokeCog Markov Model: Projected Prevalent and Incident Cases of Stroke and Poststroke Cognitive Impairment to 2035 in Ireland.

BACKGROUND AND PURPOSE: Cognitive impairment no dementia (CIND) and dementia are common stroke outcomes, with significant health and societal implications for aging populations. These outcomes are not included in current epidemiological models. We aimed to develop an epidemiological model to project incidence and prevalence of stroke, poststroke CIND and dementia, and life expectancy, in Ireland to 2035, informing policy and service planning. METHODS: We developed a probabilistic Markov model (the StrokeCog model) applied to the Irish population aged 40 to 89 years to 2035. Data sources included official population and hospital-episode statistics, longitudinal cohort studies, and published estimates. Key assumptions were varied in sensitivity analysis. Results were externally validated against independent sources. The model tracks poststroke progression into health states characterized by no cognitive impairment, CIND, dementia, disability, stroke recurrence, and death. RESULTS: We projected 69 051 people with prevalent stroke in Ireland in 2035 (22.0 per 1000 population [95% CI, 20.8-23.1]), with 25 274 (8.0 per 1000 population [95% CI, 7.1-9.0]) of those projected to have poststroke CIND, and 12 442 having poststroke dementia (4.0 per 1000 population [95% CI, 3.2-4.8]). We projected 8725 annual incident strokes in 2035 (2.8 per 1000 population [95% CI, 2.7-2.9]), with 3832 of these having CIND (1.2 per 1000 population [95% CI, 1.1-1.3]), and 1715 with dementia (0.5 per 1000 population [95% CI, 0.5-0.6]). Life expectancy for stroke survivors at age 50 was 23.4 years (95% CI, 22.3-24.5) for women and 20.7 (95% CI, 19.5-21.9) for men. CONCLUSIONS: This novel epidemiological model of stroke, poststroke CIND, and dementia draws on the best available evidence. Sensitivity analysis indicated that findings were robust to assumptions, and where there was uncertainty a conservative approach was taken. The StrokeCog model is a useful tool for service planning and cost-effectiveness analysis and is available for adaptation to other national contexts.

Using accelerometers in the assessment of sarcopenia in older adults attending a day hospital service in Ireland.

OBJECTIVES: The aim of this study was to describe the associations between sarcopenia and variables derived from wrist accelerometry in community-dwelling older adults attending a day hospital service in Ireland. METHODS: An observational cross-sectional study was carried out using a consecutive series of older adults attending a day hospital service. Sarcopenia was diagnosed using the latest European Working Group of Sarcopenia in Older People guidelines. Accelerometers were worn by each participant for a 7-day period on their non-dominant wrist. RESULTS: Thirty-eight out of forty-one participants (93%) met the accelerometer wear time criterion and were included in statistical analyses. Included participants had a mean age of 81.1 years (standard deviation 6.2). Both sarcopenia (Grip) and sarcopenia (Lower limb) were associated with increased time spent in low physical activity and reduced average of Kcals per hour. Only sarcopenia (Lower limb) was associated with increased time in sedentary behaviour as well as reduced number of steps taken in a week. CONCLUSIONS: Accelerometer data can be used in an older day hospital population to track physical activity levels and sedentary behaviours. The assessment tool used to assess muscle strength and the cut-off criteria for physical activity behaviour influences the association with sarcopenia.

The association between gait analysis measures associated with crouch gait, functional health status and daily activity levels in cerebral palsy.

PURPOSE: The aim of this study was to examine the relationship between gait analysis measures associated with crouch gait, functional health status and daily activity in ambulant cerebral palsy (CP). METHODS: Three-dimensional gait analysis was carried out on 35 ambulant participants with bilateral CP crouch gait (knee flexion at mid-stance (KFMS) ⩾ 190). KFMS, knee-flexion at initial contact, gait speed and step-lengths were extracted for analysis. Steps/day and sedentary time/day were assessed using an ActivPAL accelerometer. Functional health status was assessed using the five relevant domains of the Pediatric Outcomes Data Collection Instrument (PODCI) questionnaire. Associations between variables were assessed with correlation coefficients and multivariable linear regression. RESULTS: There were no significant correlations between KFMS and PODCI domains (ρ=-0.008-0.110) or daily activity (ρ=-0.297-0.237) variables. In contrast, multivariable analysis found that step-length was independently associated with the Sports and Physical Function (p= 0.030), Transfers and Basic Mobility (p= 0.041) and Global Function (< 0.001) domains of the PODCI assessment. Gait speed was independently associated with mean steps/day (p< 0.001). CONCLUSIONS: Step length and gait speed are more strongly associated with functional health status and daily activity than knee flexion during stance in children and adolescents with CP crouch gait.