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Feeding with acknowledged risk is appropriate for patients unsuitable for tube feeding who have an unsafe swallow that is unlikely to improve. However, without excellent multidisciplinary decision making and communication, patients may spend unnecessarily long 'nil by mouth' (NBM) and advance feeding/care plans may not be made or communicated. The FORWARD bundle (Feeding via the Oral Route With Acknowledged Risk of Deterioration) was sequentially co-designed and embedded across different services using 'plan-do-study-act' methodology to systematise best practice. Care before and after FORWARD was evaluated using a time-series analysis of 80 patients who had been risk-fed. Time NBM without tube feeding improved from 2 to 0 days (p=0.02) with signifi cantly better documentation of capacity assessments and discussions with next of kin. There were sustained trends to improved rates of best interest discussions and communication of feeding plans to downstream care providers. The signifi cance and applicability of these fi ndings is discussed.

Falls are a common and serious, but potentially preventable, problem after stroke. Avoiding falls requires balance, which is a fl uid and dynamic physical skill. There are a number of perceptual, neurological, and mechanical mechanisms underlying our ability to balance, and they are complex and heterogeneous. Depending on where strokes occur in the brain, balance may be affected in different ways. It is important to identify stroke patients who are at risk of falls in order to optimize prevention, and a number of stroke-specifi c risk factors have been identifi ed, but the available assessment scales have only limited sensitivity and specifi city. If management of falls risk in stroke is to be effective, assessments have to identify the precise and individual mechanisms underlying balance problems, and then specifi c management has to be targeted at these defi cits. The consequences of falls after stroke can be severe and include loss of confi dence and loss of independence, as well as serious injury including fractures. Stroke patients are at greater risk of osteoporosis, particularly on the hemiplegic side, which occurs rapidly following paresis. Management of falls risk post-stroke should also include timely assessment of bone health and the associated fracture risk. Keywords Key Messages• Following a stroke, falls risk is increased over and above the falls risk associated with ageing. • The assessment of stroke patients who are at risk of falls should be multidisciplinary, so too should the delivery of interventions designed to prevent them. • Bone density is lost rapidly in the hemiparetic limb following a stroke, with resultant increased fracture risk.• Along with osteoporosis drug treatment, exercise, nutrition, and addressing falls risk are important strategies to reduce fracture risk.

There is increasing evidence to suggest that atrial fibrillation is associated with a heightened risk of dementia. The mechanism of interaction is unclear. Atrial fibrillation-induced cerebral infarcts, hypoperfusion, systemic inflammation, and anticoagulant therapy-induced cerebral microbleeds, have been proposed to explain the link between these conditions. An understanding of the pathogenesis of atrial fibrillation-associated cognitive decline may enable the development of treatment strategies targeted towards the prevention of dementia in atrial fibrillation patients. The aim of this review is to explore the impact that existing atrial fibrillation treatment strategies may have on cognition and the putative mechanisms linking the two conditions. This review examines how components of the ‘Atrial Fibrillation Better Care pathway’ (stroke risk reduction, rhythm control, rate control, and risk factor management) may influence the trajectory of atrial fibrillation-associated cognitive decline. The requirements for further prospective studies to understand the mechanistic link between atrial fibrillation and dementia and to develop treatment strategies targeted towards the prevention of atrial fibrillation-associated cognitive decline, are highlighted.

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Dysphagia after stroke is common and has a significant impact on disability, institutionalisation and mortality. Patients who cannot achieve nutrition from food and fluids orally should be considered for a modified diet and/or tube feeding, taking into account their wishes and best interests. This article describes the issues in managing such patients, including feeding with acknowledged risk. The specialist stroke nurse plays a central role in the successful implementation of these strategies, particularly with regard to patient and carer education, monitoring and compliance.

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