For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost
ObjectivesDespite the growing importance of stroke in developing countries, little is known of stroke burden in survivors. The authors investigated the prevalence of self-reported stroke, stroke-related disability, dependence and care-giver strain in Latin America (LA), China and India.MethodsCross-sectional surveys were conducted on individuals aged 65+ (n=15 022) living in specified catchment areas. Self-reported stroke diagnosis, disability, care needs and care giver burden were assessed using a standardised protocol. For those reporting stroke, the correlates of disability, dependence and care-giver burden were estimated at each site using Poisson or linear regression, and combined meta-analytically.ResultsThe prevalence of self-reported stroke ranged between 6% and 9% across most LA sites and urban China, but was much lower in urban India (1.9%), and in rural sites in India (1.1%), China (1.6%) and Peru (2.7%). The proportion of stroke survivors needing care varied between 20% and 39% in LA sites but was higher in rural China (44%), urban China (54%) and rural India (73%). Comorbid dementia and depression were the main correlates of disability and dependence.ConclusionThe prevalence of stroke in urban LA and Chinese sites is nearly as high as in industrialised countries. High levels of disability and dependence in the other mainly rural and less-developed sites suggest underascertainment of less severe cases as one likely explanation for the lower prevalence in those settings. As the health transition proceeds, a further increase in numbers of older stroke survivors is to be anticipated. In addition to prevention, stroke rehabilitation and long-term care needs should be addressed.
Exercise programs significantly improve balance and mobility in patients with balance problems, independent of strategy. Enhanced balance training may, in addition, improve confidence and quality of life but needs further investigation.
Prism adaptation to rightward optical shifts during visually guided pointing is considered a promising intervention in right-hemisphere stroke patients with left spatial neglect. Conventionally, prism adaptation is assessed via aftereffects, on subjective straight ahead (SSA) pointing with eyes closed; or by visual open-loop pointing (VOL), i.e. pointing to a visual target without seeing the hand. Previous data suggest indirectly that prism aftereffects in neglect patients may be larger (pathologically so) when assessed by SSA than by VOL. But these measures have never been directly compared within the same patients after identical prism exposure. Accordingly we implemented both measures here within the same group of 13 neglect patients and 13 controls. Prism aftereffects were much larger for SSA than VOL in neglect patients, falling outside the normative range only for SSA. This may arise because the SSA task can itself involve aspects of neglect that may be ameliorated by the prism intervention, hence showing abnormal changes after prisms. The extent of SSA change after prisms varied between patients, and correlated with improvements on a standard cancellation measure for neglect. The lesions of patients who did versus did not show neglect improvement immediately after prisms provide an initial indication that lack of improvement may potentially relate to cortical damage in right intraparietal sulcus and white matter damage in inferior parietal lobe and middle frontal gyrus. Future studies of possible rehabilitative impact from prisms upon neglect may need to consider carefully how to measure prism adaptation per se, separately from any impact of such adaptation upon manifestations of neglect.
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