Access to inpatient mood management services after stroke in Australian acute and rehabilitation hospitals.

OBJECTIVE: Post-stroke mental health impairments are common, but under-assessed and under-treated. We aim to describe trends in the provision of mood management to patients with stroke, and describe factors associated with adoption of national mood management recommendations for stroke within Australian hospitals. DESIGN: Secondary analysis of cross-sectional data from the biennial Stroke Foundation Audit Program. SETTING: Participating acute (2011-2021) and rehabilitation hospitals (2012-2020) in Australia. PARTICIPANTS: In the acute audit, 22,937 stroke cases were included from 133 hospitals. In the rehabilitation audit, 15,891 stroke cases were included from 127 hospitals. MAIN MEASURES: Hospital- and patient-level mood management processes. RESULTS: Among 133 acute hospitals (22,937 stroke episodes), improvements were made between 2011 and 2021 in utilization of mood screening (17% [2011], 33% [2021]; p < 0.001) and access to psychologists during hospital stay (18% [2011], 45% [2021]; p < 0.001). There was no change in access to a psychologist among those with a mood impairment (p = 0.34). Among 127 rehabilitation hospitals (15,891 stroke episodes) improvements were observed for mood screening (35% [2012], 61% [2020]; p < 0.001), and access to a psychologist during hospital stay (38% [2012], 68% [2020]; p < 0.001) and among those with a mood-impairment (30% [2012], 50% [2020]; p < 0.001). Factors associated with receiving mood management processes included: younger age, not requiring an interpreter and longer length of stay. CONCLUSIONS: Adherence to mood management recommendations has improved over 10 years within Australian hospitals. Those aged over 65, requiring an interpreter, or with shorter hospital stays are at risk of missing out on appropriate mood management.

Protocol of a randomized controlled trial investigating the effectiveness of Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS).

RATIONALE: To address unmet needs, electronic messages to support person-centered goal attainment and secondary prevention may avoid hospital presentations/readmissions after stroke, but evidence is limited. HYPOTHESIS: Compared to control participants, there will be a 10% lower proportion of intervention participants who represent to hospital (emergency/admission) within 90 days of randomization. METHODS AND DESIGN: Multicenter, double-blind, randomized controlled trial with intention-to-treat analysis. The intervention group receives 12 weeks of personalized, goal-centered, and administrative electronic messages, while the control group only receive administrative messages. The trial includes a process evaluation, assessment of treatment fidelity, and an economic evaluation. Participants: Confirmed stroke (modified Rankin Score: 0-4), aged ≥18 years with internet/mobile phone access, discharged directly home from hospital. Randomization: 1:1 computer-generated, stratified by age and baseline disability. Outcomes assessments: Collected at 90 days and 12 months following randomization. OUTCOMES: Primary outcomes include hospital emergency presentations/admissions within 90 days of randomization. Secondary outcomes include goal attainment, self-efficacy, mood, unmet needs, disability, quality-of-life, recurrent stroke/cardiovascular events/deaths at 90 days and 12 months, and death and cost-effectiveness at 12 months. Sample size: To test our primary hypothesis, we estimated a sample size of 890 participants (445 per group) with 80% power and two-tailed significance threshold of α = 0.05. Given uncertainty for the effect size of this novel intervention, the sample size will be adaptively re-estimated when outcomes for n = 668 are obtained, with maximum sample capped at 1100. DISCUSSION: We will provide new evidence on the potential effectiveness, implementation, and cost-effectiveness of a tailored eHealth intervention for survivors of stroke.

Pilot randomised clinical trial of an eHealth, self-management support intervention (iVERVE) for stroke: feasibility assessment in survivors 12-24 months post-event.

BACKGROUND: Electronic communication is used in various populations to achieve health goals, but evidence in stroke is lacking. We pilot tested the feasibility and potential effectiveness of a novel personalised electronic self-management intervention to support person-centred goal attainment and secondary prevention after stroke. METHODS: A phase I, prospective, randomised controlled pilot trial (1:1 allocation) with assessor blinding, intention-to-treat analysis, and a process evaluation. Community-based survivors of stroke were recruited from participants in the Australian Stroke Clinical Registry (AuSCR) who had indicated their willingness to be contacted for research studies. Inclusion criteria include 1-2 years following hospital admission for stroke and living within 50 km of Monash University (Melbourne). Person-centred goals were set with facilitation by a clinician using a standardised template. The intervention group received electronic support messages aligned to their goals over 4 weeks. The control group received only 2-3 electronic administrative messages. Primary outcomes were study retention, goal attainment (assessed using Goal Attainment Scaling method) and satisfaction. Secondary outcomes were self-management (Health Education Impact Questionnaire: 8 domains), quality of life, mood and acceptability. RESULTS: Of 340 invitations sent from AuSCR, 73 responded, 68 were eligible and 57 (84%) completed the baseline assessment. At the goal-setting stage, 54/68 (79%) were randomised (median 16 months after stroke): 25 to intervention (median age 69 years; 40% female) and 29 to control (median age 68 years; 38% female). Forty-five (83%) participants completed the outcome follow-up assessment. At follow-up, goal attainment (mean GAS-T score ≥ 50) in the intervention group was achieved for goals related to function, participation and environment (control: environment only). Most intervention participants provided positive feedback and reported that the iVERVE messages were easy to understand (92%) and assisted them in achieving their goals (77%). We found preliminary evidence of non-significant improvements between the groups for most self-management domains (e.g. social integration and support: ß coefficient 0.34; 95% CI - 0.14 to 0.83) and several quality-of-life domains in favour of the intervention group. CONCLUSION: These findings support the need for further randomised effectiveness trials of the iVERVE program to be tested in people with new stroke. TRIAL REGISTRATION: ANZCTR, ACTRN12618001519246 . Registered on 11 September 2018-retrospectively registered.

The Stroke and Carer Optimal Health Program (SCOHP) to enhance psychosocial health: study protocol for a randomized controlled trial.

BACKGROUND: Stroke is a leading cause of disability and distress, and often profoundly affects the quality of life of stroke survivors and their carers. With the support of carers, many stroke survivors are returning to live in the community despite the presence of disability and ongoing challenges. The sudden and catastrophic changes caused by stroke affects the mental, emotional and social health of both stroke survivors and carers. The aim of this study is to evaluate a Stroke and Carer Optimal Health Program (SCOHP) that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of stroke survivors and their carers. METHODS: This study is a prospective randomised controlled trial. It will include a total of 168 stroke survivors and carers randomly allocated into an intervention group (SCOHP) or a control group (usual care). Participants randomised to the intervention group will receive nine (8 + 1 booster) sessions guided by a structured workbook. The primary outcome measures for stroke survivors and carers will be health-related quality of life (AQoL-6D and EQ-5D) and self-efficacy (GSE). Secondary outcome measures will include: anxiety and depression (HADS); coping (Brief COPE); work and social adjustment (WSAS); carer strain (MCSI); carer satisfaction (CASI); and treatment evaluation (TEI-SF and CEQ). Process evaluation and a health economic cost analysis will also be conducted. DISCUSSION: We believe that this is an innovative intervention that engages the stroke survivor and carer and will be significant in improving the psychosocial health, increasing independence and reducing treatment-related costs in this vulnerable patient-carer dyad. In addition, we expect that the intervention will assist carers and stroke survivors to negotiate the complexity of health services across the trajectory of care and provide practical skills to improve self-management. TRIAL REGISTRATION: ACTRN12615001046594 . Registered on 7 October 2015.

Screening for mild cognitive impairment in patients with heart failure: Montreal cognitive assessment versus mini mental state exam.

BACKGROUND: Cognitive impairments occur frequently in patients with chronic heart failure (CHF), resulting in worse health outcomes than expected. These impairments can remain undetected unless specifically screened. There are limited sensitive screening measures available in nursing practice to identify mild cognitive impairment (MCI). AIM: To compare the Montreal Cognitive Assessment (MoCA) with the Mini Mental State Exam (MMSE) in screening for MCI in CHF patients. METHODS: The MMSE and MoCA were administered to 93 hospitalized CHF patients (70±11 years), without a history of neurocognitive problems. Patients with low MoCA scores (<26) were compared to those with low MMSE scores (<27). Two different parameters were examined between the MoCA and the MMSE: level of MCI agreement (Kappa coefficient) and task errors on assessed cognitive domains (χ2 test). RESULTS: Statistically more patients had low MoCA scores compared with low MMSE scores (66 vs. 30, p=0.02). The MoCA classified 38 (41%) patients as cognitively impaired that were not classified by the MMSE. A significantly low level of agreement was found (κ=0.25, p=0.001) between the MMSE and MoCA in identifying patients with scores suggestive of MCI. More task errors were observed on the MoCA cognitive domains compared with the MMSE cognitive domains. In 68% of patients with low cognitive scores, visuospatial task errors were observed on tasks from the MoCA compared with 22% on a similar task of the MMSE. CONCLUSION: The MoCA, a screening tool for MCI, identified subtle but potentially clinically relevant cognitive dysfunctions with greater frequency than MMSE.

Does cognitive impairment predict poor self-care in patients with heart failure?

AIMS: Cognitive impairment occurs often in patients with chronic heart failure (CHF) and may contribute to sub-optimal self-care. This study aimed to test the impact of cognitive impairment on self-care. METHODS AND RESULTS: In 93 consecutive patients hospitalized with CHF, self-care (Self-Care of Heart Failure Index) was assessed. Multiple regression analysis was used to test a model of variables hypothesized to predict self-care maintenance, management, and confidence. Variables in the model were mild cognitive impairment (MCI; Mini-Mental State Exam and Montreal Cognitive Assessment), depressive symptoms (Cardiac Depression Scale), age, gender, social isolation, education level, new diagnosis, and co-morbid illnesses. Sixty-eight patients (75%) were coded as having MCI and had significantly lower self-care management (eta(2)= 0.07, P < 0.01) and self-confidence scores (eta(2)= 0.05, P < 0.05). In multivariate analysis, MCI, co-morbidity index, and NYHA class III or IV explained 20% of the variance in self-care management (P < 0.01); MCI made the largest contribution explaining 9% of the variance. Increasing age and symptoms of depression explained 13% of the variance in self-care confidence scores (P < 0.01). CONCLUSION: Cognitive impairment, a hidden co-morbidity, may impede patients' ability to make appropriate self-care decisions. Screening for MCI may alert health professionals to those at greater risk of failed self-care.