Clinical Pearls for Stroke Prevention in Geriatric Population

Stroke Prevention Clinic

Objectives

• Stroke Prevention clinic scopes and services• Introduce the signs of stroke: newest FAST tool from Heart

and Stroke Foundation• The importance of secondary prevention after a TIA• Risk factors and management of stroke in geriatric population• Basic Antithrombotics principles and nursing implications• Common Post stroke positioning, mobility, and safety

Ontario Stroke Networks

• Ontario’s 11 regional stroke networks support the 14 LHINs

• Each stroke network is a collaborative partnership of health care organizations and providers

• Central LHIN Stroke Prevention Network:

1 Regional Stroke Center 5 Stroke Prevention Clinic

MHSPC

HumberSPC

NYGSPC

MSHSPC

SRHCSPC

MackenzieHealth

Regional Stroke Center

2008 Best Practice Recommendations for Stroke Care

Stroke prevention clinics Provide a comprehensive interdisciplinary approach to prevention of first or recurrent stroke, conduct detailed assessments by a range of healthcare disciplines, facilitate timely access to appropriate diagnostics and interventions, and provide education to patients and families. They also promote continuity of care between acute care facilities, the patient and their primary care providers”.

Stroke Prevention Clinic Model

Life style modifications and self-management: Link clients back to local Cardiovascular Rehab services

Comparison of Stroke Signs

(CIHI, 2011)

FAST TOOL

Risk of Stroke Within 90 Days of a TIA

Stroke Risk Factors

Non-modifiable Factors• Age over 60• Gender• Ethnic• Family history of Stroke• Family history of coronary artery

disease

Modifiable Factors• Hypertension• Dyslipidemia• Diabetes• Heart disease (ischemic, a-fib)• Carotid stenosis• Smoking• Obese• Inactivity• Excessive alcohol use• Sleep apnea: ↑HTN, ↑diabetes, ↑heart diseases,

↑carotid thickness, ↑depression• Stress

Risk Management in Stroke Prevention

• Blood pressure in geriatric population ≤150/90• Hemoglobin A1C <6.0% for non-diabetic • Hemoglobin A1C<7.0% for diabetic • LDL 50% reduction or below 2• Antiplatelet therapy • Treat atrial fibrillation• Treat sleep apnea with CPAP • Smoking cessation• Chronic disease management: Diabetes Education Center, Geriatric services, etc • Cardiac rehabilitation program and weight management• Other services: SLP, PT, OT, CCAC, vascular surgeon referral, etc

Oral Antithrombotic Therapy in Ischemic Stroke Patients

Oral Antithrombotic

Antiplatelet

Oral Anticoagulants

Vitamin K antagonists

DOACs

ASA

Aggrenox

Plavix

Useful facts about Direct-acting Oral anticoagulants

• Generally more favorable benefit/risk profile vs. warfarin, with sharply reduced intracranial bleeding

• Lack of antidote• Concomitant aspirin use increases bleeding• Don’t work for all• anticoagulation indications (e.g. prosthetic cardiac valves)• Each has different dosing and special issues• INRs / prothrombin times are not useful to monitor• Elderly patients do well on DOACs

Nursing implications • Short half-life require timely medication administration and

medication adherence• Missed Dose → ↑thrombotic event: administer the dose as soon as

possible on the same day. • Grapefruit juice may also increase plasma concentrations of

XARELTO and should be avoided (FDA, 2009)• Meal consumption increase Xarelto’s bioavailability for larger dose:

15 mg and 20 mg tablets should be taken with the evening meal • Avoid administration of Xarelto via a method that could deposit drug

directly into the proximal small intestine (e.g., feeding tube) which can result in reduced absorption and related drug exposure.

• Monitor signs and symptoms of bleeding, especially in clients with antiplatelets /NASIDs

References• CIHI. (2011). Warning signs and symptoms of stroke. Retrieved from

http://www.cihi.ca/cihi-ext-portal/internet/en/document/types+of+care/hospital+care/acute+care/RELEASE_12JULY12_FIG2

• Food and Drug Administration (2009). Review of Xarelto. Retrieved from http://www.accessdata.fda.gov/drugsatfda_docs/nda/2011/022406Orig1s000ClinPharmR.pdf

• Gottschalk, R. (2014). Sleep apnea and stroke. Retrieved from http://www.heartandstroke.on.ca/atf/cf/%7B33C6FA68-B56B-4760-ABC6-D85B2D02EE71%7D/GOTTSCHALK-Sleep-Apnea-and-Stroke-F1-05.pdf

Hart, R. G. (2014). New oral anticoagulants for atrial fibrillation: 4 things that primary professional should know. Retrieved from http://www.heartandstroke.on.ca/atf/cf/%7B33C6FA68-B56B-4760-ABC6-D85B2D02EE71%7D/GOTTSCHALK-Sleep-Apnea-and-Stroke-F1-05.pdf

• Hear and Stroke Foundation. (2014). Stroke signs. Retrieved from http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483937/k.ED98/Stroke__Stroke_Warning_Signs.htm?gclid=CjwKEAjw9bKpBRD-geiF8OHz4EcSJACO4O7Tgi3l5qeh9QC4vOc-mg0nXUR1UQe2OBS-7KbXECjOMRoC_Vfw_wcB

• Food and Drug Administration ( 2011). Xarelto (Rivaroxabab) tablet label. Retrieved from http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/202439s001lbl.pdf