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A special issue of Healthcare (ISSN 2227-9032). This special issue belongs to the section "Chronic Care".

Deadline for manuscript submissions: closed (15 February 2025) | Viewed by 16392

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Special Issue Editors

Prof. Dr. Dominique A. Cadilhac

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Guest Editor

School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC 3168, Australia
Interests: stroke; cerebrovascular disease; program evaluation; improvement science; economic evaluation
Special Issues, Collections and Topics in MDPI journals

Dr. Olivia Brancatisano

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Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3168, Australia
Interests: stroke; ageing; neurological disorders; community rehabilitation; lifestyle interventions; secondary prevention

Dr. Tharshanah Thayabaranathan

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Guest Editor

School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC 3168, Australia
Interests: stroke; cerebrovascular disease; cardiovascular disease; disease prevention; lifestyle interventions; disease epidemiology

Special Issue Information

Dear Colleagues,

Globally, stroke continues to be a leading cause of death and long-term disability. Annually, stroke affects approximately 15 million people; 75% of strokes occur in adults aged 65 years or older. Due to the greater prevalence of comorbid conditions in the older population, the consequences of stroke in those cases are more severe. Although the overall incidence of stroke is declining in many high-income countries, the absolute number of strokes continues to increase because of the ageing population in high-income and low- as well as middle-income countries, in addition to improved survival. Primary and secondary prevention, or recovery-focused interventions in the community, may reduce the impact of stroke and improve the quality of life in older adults, but evidence is often limited to solutions trialed in high-income countries. The use of technology is also expanding the ability to reach more people in providing support following care in hospitals after stroke.

This Special Issue seeks empirical and review papers related to any of these themes, and is not intended to exclude other topics that may be relevant to stroke and ageing. Early phase or pilot projects for prevention, education, or rehabilitation after stroke in older adults, as well as projects highlighting technology-based interventions to support people in the community after stroke or those focused on consumer involvement, will also be considered.

Prof. Dr. Dominique A. Cadilhac
Dr. Olivia Brancatisano
Dr. Tharshanah Thayabaranathan
Guest Editors

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Healthcare is an international peer-reviewed open access semimonthly journal published by MDPI.

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Keywords

Stroke
Prevention
Quality of life
Care transitions
Self-management

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Published Papers (10 papers)

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19 pages, 1711 KiB

Open AccessArticle

Prepare: Improving End-of-Life Care Practice in Stroke Care: Insights from a National Survey and Semi-Structured Interviews

by C. Elizabeth Lightbody, Clare Gordon, Christopher Burton, Catherine Davidson, Damian Jenkinson, Aasima Saeed Patel, Freja Jo Petrie, Alison Rouncefield-Swales, Nikola Sprigg, Katherine Stewart, Mehrunisha Suleman, Caroline Leigh Watkins, Clare Thetford and PREPARE Study Research Team

Healthcare 2025, 13(8), 848; https://doi.org/10.3390/healthcare13080848 - 8 Apr 2025

Viewed by 332

Abstract

Background: Stroke has high mortality. Challenges in providing end-of-life care include uncertainty among healthcare professionals about when to start care. While generic tools and guidelines exist, which outline components of quality end-of life care, they may not fully address stroke’s unpredictable trajectories, complicating care planning. Objective: To enhance understanding of end-of-life care post-stroke. Methods: We undertook an explanatory sequential mixed methods approach, including a cross-sectional survey and semi-structured interviews. All 286 United Kingdom (UK) National Health Service (NHS) hospitals providing inpatient stroke care were approached for participation in an on-line cross-sectional survey. The survey of healthcare professionals from UK stroke units was used to map current stroke end-of-life care and models of care. Fourteen staff who completed the survey and agreed to a future interview were purposively selected. The semi-structured interviews with healthcare professionals involved in delivering end-of-life care post-stroke were conducted and interpreted using the Theoretical Domains Framework. We aimed to enhance our understanding of the experiences, expectations, challenges and barriers in providing end-of-life care post-stroke, including effective clinical decision-making. Results: Across 108 responding survey sites, 317 responses were received. Results showed a lack of structured tools and approaches, an absence of stroke-specific guidance and variable delivery of end-of-life care post-stroke. Thirteen staff (nurses, occupational therapists, medical stroke consultants, and a speech and language therapist) agreed to be interviewed. The data provided a fuller understanding of the context within which end-of-life care post-stroke is delivered. The varied challenges faced include: uncertain prognosis, complex decision-making process, varying skill levels, staffing levels, the hospital environment, emotional strain on both families and staff, inequitable access to specialist palliative care, and difficulties associated with different models of care (stroke service structures and cultural context). Conclusions: Provision of end-of-life care post-stroke is complex, challenging, uncertain, and inconsistent. There is limited evidence or guidance to support healthcare professionals. There is a need for implementation support, which includes education, to better enable quality and more consistent end-of-life care post-stroke. Further research is required to assess interventions that can support end-of-life care post-stroke to aid clinicians in providing quality palliative care for stroke patients. Full article

(This article belongs to the Special Issue Stroke and Ageing)

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24 pages, 1781 KiB

Open AccessArticle

Accelerating the Delivery of Psychological Therapies After Stroke: A Feasibility Stepped-Wedge Cluster Randomised Controlled Trial

by C. Elizabeth Lightbody, Kulsum Patel, Emma-Joy Holland, Chris J. Sutton, Christopher Brown, Svetlana V. Tishkovskaya, Audrey Bowen, Jessica Read, Shirley Thomas, Temitayo Roberts and Caroline L. Watkins

Healthcare 2025, 13(7), 824; https://doi.org/10.3390/healthcare13070824 - 4 Apr 2025

Viewed by 244

Abstract

Background: Psychological problems post-stroke are common and debilitating, yet insufficient evidence-based psychological support exists for stroke survivors, either in stroke or general mental health services. Many stroke survivors with significant needs remain unsupported. To address this problem, we need pathways to identify, treat and manage psychological difficulties after stroke. The Accelerating Delivery of Psychological Therapies after Stroke (ADOPTS) study aimed to explore the feasibility of collaboratively developing, implementing and evaluating intervention packages (IPs) to facilitate access to, and increase the provision of, psychological support post-stroke. Methods: Stakeholder groups were formed across four sites in north-west England, comprising stroke and psychological services, to collaboratively develop site-specific IPs incorporating a psychological care pathway, staff training, a staff manual for stroke-specific psychological support and supervision. A feasibility stepped-wedge cluster randomised trial recruited patients admitted with stroke during the usual care (pre-implementation of the IP) and intervention (post-implementation) periods. The feasibility of IP implementation and their potential usefulness were evaluated through assessing wellbeing and the support received, and through a process evaluation incorporating interviews with staff, patients and carers. Feasibility evaluation included the recruitment rate and attrition rate; exploratory analysis (mixed-effects linear or logistic regression models) was used to assess the ‘promise’ of the intervention in achieving psychological distress outcomes (mood (PHQ-9), anxiety (GAD-7)), assessed using validated measures at 6 weeks and 6 months. Results: IPs were collaboratively developed at each site but implementation took longer than the per-study-protocol duration of three months. Nineteen training sessions (152 attendees) were delivered for nursing, therapy, NHS Talking Therapies and voluntary staff. Nursing staff were underrepresented due to difficulties with releasing staff. Manuals were developed for each site, incorporating a mood screening and referral algorithm, but these were not finalised at one site. Stroke and NHS Talking Therapies champions were identified in each site to facilitate cross-service staff supervision. A total of 270 patients were recruited over 14 months (133 usual care, 137 intervention), with 227 and 198 at 6 weeks and 6 months, respectively. Stroke staff found the training, manual and pathway helpful, and reported greater confidence in managing and referring psychological issues. NHS Talking Therapies staff found the training useful for adapting their therapy. However, the intervention took longer to implement in all sites, requiring an additional time period to be added to the stepped-wedge design. Conclusions: It is feasible to collaboratively develop and implement IPs for post-stroke psychological support. However, an alternative to the stepped-wedge design used here would be more appropriate for a future study. This study was registered in ISRCTN—the UK’s Clinical Study Registry (trial registration: ISRCTN12868810, registration date: 4 February 2016). Full article

(This article belongs to the Special Issue Stroke and Ageing)

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14 pages, 236 KiB

Open AccessArticle

Analysis of Grip Strength Thresholds for Stroke Management and Prevention in South Korean Older Adults

by Jong Hyeon Lee

Healthcare 2025, 13(7), 781; https://doi.org/10.3390/healthcare13070781 - 31 Mar 2025

Viewed by 256

Abstract

Background/Objectives: Muscle weakness in older adults is associated with cardiovascular disease and all-cause mortality. However, its association with stroke prevalence remains underexplored. This study aimed to analyze the absolute grip strength (AGS) and weight-adjusted relative grip strength (RGS) thresholds for stroke prediction in South Korean older adults and to assess their sex-specific predictive ability. Methods: Data from 5185 older adults (2231 men; 2954 women) from the Korea National Health and Nutrition Examination Survey (KNHNES, 2014–2018) were analyzed using complex sampling methods. Receiver operating characteristic (ROC) curve analysis was performed to determine AGS and RGS thresholds and predictive performance, while multivariate logistic regression was used to adjust for confounders and to assess independent effects. Results: In older men, both the AGS and RGS demonstrated significant predictive ability for stroke, with AUCs of 0.637 and 0.623, respectively. In women, the AGS (AUC: 0.608) and RGS (AUC: 0.615) were predictive; however, only the RGS was significant for stroke management (odds ratio (OR): 3.026; 95% confidence interval (CI), 1.541–5.943). In men, AGS (OR: 3.544, 95% CI, 2.094–5.998) and RGS (OR: 2.585, 95% CI, 1.529–4.369) were significant. The stroke prediction thresholds were AGS 28.55 kg and RGS 0.47 for men and RGS 0.36 for women. Conclusions: The AGS and RGS provide practical indicators for stroke risk prediction based on sex-specific differences, highlighting their potential for public health and clinical applications. Future studies should investigate the stroke type, severity, and additional functional fitness indices. Full article

(This article belongs to the Special Issue Stroke and Ageing)

13 pages, 618 KiB

Open AccessArticle

Mediation Role of Behavioral Decision-Making Between Self-Efficacy and Self-Management Among Elderly Stroke Survivors in China: Cross-Sectional Study

by Xiaoxuan Wang, Hu Jiang, Zhixin Zhao, Noubessi Tchekwagep Kevine, Baoxia An, Zhiguang Ping, Beilei Lin and Zhenxiang Zhang

Healthcare 2025, 13(7), 704; https://doi.org/10.3390/healthcare13070704 - 23 Mar 2025

Viewed by 296

Abstract

Background: Identifying the factors that impact self-management is crucial, as elderly stroke survivors frequently face challenges in self-management. Self-efficacy and behavioral decision-making are reported as influencing factors of self-management, but their relationship within the elderly population remains unconfirmed. This study aimed to explore whether self-efficacy impacts self-management through the mediating role of behavioral decision-making among elderly stroke survivors. Methods: A cross-sectional design and convenience sampling method were used in this study. A total of 291 elderly stroke survivors were recruited from a tertiary hospital in Henan Province, China, between March and July of 2024. Questionnaires were distributed to collect sociodemographic, self-efficacy, behavioral decision-making, and self-management data. A path analysis and correlation analysis were used to analyze the data. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Results: Elderly stroke survivors reported having a moderate level of self-management. There was a positive correlation between self-efficacy, behavioral decision-making, and self-management (all p < 0.01). The mediation model indicated that behavioral decision-making mediated the association of self-efficacy and self-management in the regression model (95% CI 0.03 to 0.14), and the effect value was 0.08. It was also confirmed that behavioral decision-making mediated the impact of self-efficacy and self-management, accounting for 25.81% of the total effect. Conclusion: Self-efficacy is not solely a key factor influencing self-management in elderly stroke survivors, but it also improves their self-management behaviors by facilitating behavioral decision-making. As a result, healthcare professionals should consider self-efficacy and behavioral decision-making as crucial elements for assessing elderly stroke survivors during discharge and follow-up. Full article

(This article belongs to the Special Issue Stroke and Ageing)

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14 pages, 1149 KiB

Open AccessArticle

Co-Designed Cardiac Rehabilitation for the Secondary Prevention of Stroke (CARESS): A Pilot Program Evaluation

by Sabah Rehman, Seamus Barker, Kim Jose, Michele Callisaya, Helen Castley, Martin G. Schultz, Myles N. Moore, Dawn B. Simpson, Gregory M. Peterson and Seana Gall

Healthcare 2024, 12(7), 776; https://doi.org/10.3390/healthcare12070776 - 3 Apr 2024

Viewed by 1716

Abstract

Structured health system-based programs, such as cardiac rehabilitation, may reduce the risk of recurrent stroke. This study aimed to co-design and evaluate a structured program of rehabilitation, developed based on insights from focus groups involving stroke survivors and health professionals. Conducted in Tasmania, Australia in 2019, the 7-week program comprised one hour of group exercise and one hour of education each week. Functional capacity (6 min walk test), fatigue, symptoms of depression (Patient Health Questionnaire), and lifestyle were assessed pre- and post-program, with a historical control group for comparison. Propensity score matching determined the average treatment effect (ATE) of the program. Key themes from the co-design focus groups included the need for coordinated care, improved psychosocial management, and including carers and peers in programs. Of the 23 people approached, 10 participants (70% men, mean age 67.4 ± 8.6 years) completed the program without adverse events. ATE analysis revealed improvements in functional capacity (139 m, 95% CI 44, 234) and fatigue (−5 units, 95% CI −9, −1), with a small improvement in symptoms of depression (−0.8 units, 95% CI −1.8, 0.2) compared to controls. The co-designed program demonstrated feasibility, acceptability, and positive outcomes, suggesting its potential to support stroke survivors. Full article

(This article belongs to the Special Issue Stroke and Ageing)

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15 pages, 251 KiB

Open AccessArticle

Aphasia Depression and Psychological Therapy (ADaPT): Perspectives of People with Post-Stroke Aphasia on Participating in a Modified Cognitive Behavioral Therapy

by Caroline Baker, Sonia Thomas, Priscilla Tjokrowijoto, Brooke Ryan, Ian Kneebone and Renerus Stolwyk

Healthcare 2024, 12(7), 771; https://doi.org/10.3390/healthcare12070771 - 2 Apr 2024

Cited by 2 | Viewed by 3423

Abstract

Aphasia, a communication disability commonly caused by stroke, can profoundly affect a person’s mood and identity. We explored the experiences of stroke survivors with aphasia and depression who received a modified cognitive behavioral therapy (CBT)-based psychological intervention. The therapy is manualized with a flexible treatment protocol, including 10 individually based therapy sessions (+2 booster sessions) either via telehealth or in person. Six participants with chronic aphasia (60% of the total sample) participated in in-depth interviews that were analyzed using reflexive thematic analysis. Two core themes were derived from the data: the first theme, helpful elements of therapy—doing enjoyable activities, new ways of thinking, problem solving, working with the experienced therapist, and using telehealth; and the second theme, making progress—mood, communication, acceptance of the ‘new me’, and improving relationships. All participants found the therapy to be helpful in managing mood problems with various elements being beneficial depending on the individual, highlighting the importance of tailoring the intervention. Therefore, delivering modified CBT to individuals with aphasia is likely to be acceptable both in person and through telehealth. Further evaluation of the intervention and its impact on mood would be beneficial. Full article

(This article belongs to the Special Issue Stroke and Ageing)

12 pages, 611 KiB

Open AccessEditor’s ChoiceArticle

Evaluating Feasibility of a Secondary Stroke Prevention Program

by Stephanie Hunter, Kimberley Vogel, Shane O’Leary and Jannette Maree Blennerhassett

Healthcare 2023, 11(19), 2673; https://doi.org/10.3390/healthcare11192673 - 2 Oct 2023

Cited by 2 | Viewed by 2346

Abstract

Healthy lifestyles including exercise and diet can reduce stroke risk, but stroke survivors often lack guidance to modify their lifestyles after hospital discharge. We evaluated the implementation of a new, secondary stroke prevention program involving supervised exercise, multidisciplinary education and coaching to address modifiable risk factors. The group-based program involved face-to-face and telehealth sessions. The primary outcomes were feasibility, examined via service information (referrals, uptake, participant demographics and costs), and participant acceptability (satisfaction and attendance). Secondary outcomes examined self-reported changes in lifestyle factors and pre–post scores on standardized clinical tests (e.g., waist circumference and 6-Minute Walk (6MWT)). We ran seven programs in 12 months, and 37 people participated. Attendance for education sessions was 79%, and 30/37 participants completed the full program. No adverse events occurred. Participant satisfaction was high for ‘relevance’ (100%), ‘felt safe to exercise’ (96%) and ‘intend to continue’ (96%). Most participants (88%) changed (on average) 2.5 lifestyle factors (diet, exercise, smoking and alcohol). Changes in clinical outcomes seemed promising, with some being statistically significant, e.g., 6MWT (MD 59 m, 95% CI 38 m to 80,159 m, p < 0.001) and waist circumference (MD −2.1 cm, 95%CI −3.9 cm to −1.4 cm, p < 0.001). The program was feasible to deliver, acceptable to participants and seemed beneficial for health. Access to similar programs may assist in secondary stroke prevention. Full article

(This article belongs to the Special Issue Stroke and Ageing)

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17 pages, 573 KiB

Open AccessArticle

Improving Practice for Urinary Continence Care on Adult Acute Medical and Rehabilitation Wards: A Multi-Site, Co-Created Implementation Study

by Dianne Lesley Marsden, Kerry Boyle, Jaclyn Birnie, Amanda Buzio, Joshua Dizon, Judith Dunne, Sandra Greensill, Kelvin Hill, Sandra Lever, Fiona Minett, Sally Ormond, Jodi Shipp, Jennifer Steel, Amanda Styles, John Wiggers, Dominique Ann-Michele Cadilhac and Jed Duff

Healthcare 2023, 11(9), 1241; https://doi.org/10.3390/healthcare11091241 - 26 Apr 2023

Viewed by 2501

Abstract

Many adult inpatients experience urinary continence issues; however, we lack evidence on effective interventions for inpatient continence care. We conducted a before and after implementation study. We implemented our guideline-based intervention using strategies targeting identified barriers and evaluated the impact on urinary continence care provided by inpatient clinicians. Fifteen wards (acute = 3, rehabilitation = 7, acute and rehabilitation = 5) at 12 hospitals (metropolitan = 4, regional = 8) participated. We screened 2298 consecutive adult medical records for evidence of urinary continence symptoms over three 3-month periods: before implementation (T₀: n = 849), after the 6-month implementation period (T₁: n = 740), and after a 6-month maintenance period (T₂: n = 709). The records of symptomatic inpatients were audited for continence assessment, diagnosis, and management plans. All wards contributed data at T₀, and 11/15 wards contributed at T₁ and T₂ (dropouts due to COVID-19). Approximately 26% of stroke, 33% acute medical, and 50% of rehabilitation inpatients were symptomatic. The proportions of symptomatic patients (T₀: n = 283, T₁: n = 241, T₂: n = 256) receiving recommended care were: assessment T₀ = 38%, T₁ = 63%, T₂ = 68%; diagnosis T₀ = 30%, T₁ = 70%, T₂ = 71%; management plan T₀ = 7%, T₁ = 24%, T₂ = 24%. Overall, there were 4-fold increased odds for receiving assessments and management plans and 6-fold greater odds for diagnosis. These improvements were sustained at T₂. This intervention has improved inpatient continence care. Full article

(This article belongs to the Special Issue Stroke and Ageing)

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22 pages, 591 KiB

Open AccessProject Report

“When the Word Is Too Big, It’s Just Too Hard”: Stroke Survivors’ Perspectives About Health Literacy and Delivery of Health Information

by Dana Wong, Lauren M. Sanders, Alison Beauchamp, Claire Formby, Emma E. Smith, Creina Hansen, Kathryn McKinley, Karella De Jongh and Karen Borschmann

Healthcare 2025, 13(5), 541; https://doi.org/10.3390/healthcare13050541 - 3 Mar 2025

Viewed by 626

Abstract

Background: Health literacy can impact comprehension, recall, and implementation of stroke-related information, especially in the context of cognitive and communication impairments, cultural-linguistic diversity, or ageing. Yet there are few published lived experience perspectives to inform tailoring of health information. Objectives: We aimed to (i) explore perspectives about the impact of health literacy on information needs and preferences of stroke survivors with diverse characteristics; and (ii) identify ways to better tailor information delivery for stroke survivors with low health literacy. Methods: This qualitative study was conducted using the Ophelia (Optimising Health Literacy and Access) methodology. First, health literacy information was collected from participants. Hierarchical cluster analysis was used to identify different health literacy profiles within the participant sample. Four profiles were identified, from which four case vignettes were created. Second, focus groups and interviews were conducted to explore the health information needs and preferences of the case vignettes. Qualitative data were analysed with reflexive thematic analysis. Results: Nineteen people participated (median (IQR) age = 65 (49, 69), 10 (53%) female); five used interpreters. Participants represented diverse socioeconomic, cultural, and stroke-related characteristics, and generally had low health literacy. Four qualitative themes were generated highlighting the impact of Individual knowledge, capacity, and beliefs about stroke and health services on people’s capacity to engage with stroke-related information; Tailoring and personalisation of information delivery to the patient’s knowledge, capacity, and beliefs; Having a support network to rely on; and patients Feeling like I am in safe hands of clinicians and services. Conclusions: Findings provide several important directions for improving accessible stroke information delivery suitable for people with all levels of health literacy, and to optimise patient understanding, recall, and implementation of healthcare information. Full article

(This article belongs to the Special Issue Stroke and Ageing)

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16 pages, 1039 KiB

Open AccessProtocol

A Network of Sites and Upskilled Therapists to Deliver Best-Practice Stroke Rehabilitation of the Arm: Protocol for a Knowledge Translation Study

by Leeanne M. Carey, Liana S. Cahill, Jannette M. Blennerhassett, Michael Nilsson, Natasha A. Lannin, Vincent Thijs, Susan Hillier, Dominique A. Cadilhac, Geoffrey A. Donnan, Meg E. Morris, Leonid Churilov, Marion Walker, Shanthi Ramanathan, Michael Pollack, Esther May, Geoffrey C. Cloud, Sharon McGowan, Tissa Wijeratne, Marc Budge, Fiona McKinnon, John Olver, Toni Hogg, Michael Murray, Brendon Haslam, Irene Koukoulas, Brittni Nielsen, Yvonne Mak-Yuen, Megan Turville, Cheryl Neilson, Anna Butler, Joosup Kim and Thomas A. Matyas Show full author list Hide full author list

Healthcare 2023, 11(23), 3080; https://doi.org/10.3390/healthcare11233080 - 1 Dec 2023

Viewed by 2593

Abstract

Implementation of evidence-informed rehabilitation of the upper limb is variable, and outcomes for stroke survivors are often suboptimal. We established a national partnership of clinicians, survivors of stroke, researchers, healthcare organizations, and policy makers to facilitate change. The objectives of this study are to increase access to best-evidence rehabilitation of the upper limb and improve outcomes for stroke survivors. This prospective pragmatic, knowledge translation study involves four new specialist therapy centers to deliver best-evidence upper-limb sensory rehabilitation (known as SENSe therapy) for survivors of stroke in the community. A knowledge-transfer intervention will be used to upskill therapists and guide implementation. Specialist centers will deliver SENSe therapy, an effective and recommended therapy, to stroke survivors in the community. Outcomes include number of successful deliveries of SENSe therapy by credentialled therapists; improved somatosensory function for stroke survivors; improved performance in self-selected activities, arm use, and quality of life; treatment fidelity and confidence to deliver therapy; and for future implementation, expert therapist effect and cost-effectiveness. In summary, we will determine the effect of a national partnership to increase access to evidence-based upper-limb sensory rehabilitation following stroke. If effective, this knowledge-transfer intervention could be used to optimize the delivery of other complex, evidence-based rehabilitation interventions. Full article

(This article belongs to the Special Issue Stroke and Ageing)

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