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Section 4.2

Complications Following Acute Stroke

Venous thrombo-embolism risk, temperature, mobilization, continence, nutrition, and oral care should be addressed in all hospitalized stroke patients. Appropriate management strategies should be implemented for areas of concern identified during screening. Discharge planning should be included as part of the initial assessment and ongoing care of acute stroke patients.

 

4.2.1   Venous thromboembolism prophylaxis

All stroke patients should be assessed for their risk of developing venous thromboembolism (deep vein thrombosis and pulmonary embolism). Patients at high risk include those who are unable to move one or both lower limbs and those who are unable to mobilize independently; a previous history of venous thromboembolism; dehydration; and comorbidities such as malignant disease.

  1. Early mobilization and adequate hydration should be encouraged for all acute stroke patients to help prevent venous thromboembolism [Evidence Level C].
  2. Patients at high risk of venous thromboembolism should be started on venous thrombo-embolism prophylaxis immediately [Evidence Level A].
    1. Low molecular weight heparin should be considered for patients with acute ischemic stroke at high risk of venous thromboembolism; or unfractionated heparin for patients with renal failure [Evidence Level B].
    2. The use of anti-embolism stockings alone for post-stroke venous thrombo-embolism prophylaxis is not recommended [Evidence Level A]. 275
  3. There is insufficient evidence on the safety and efficacy of anticoagulant deep vein thrombosis prophylaxis after intracerebral hemorrhage [Evidence Level C]. Antithrombotics and anticoagulants should be avoided for at least 48 hours after onset [Evidence Level C].

4.2.2   Temperature Management

  1. Temperature should be monitored as part of routine vital sign assessments, every four hours for first 48 hours and then as per ward routine or based on clinical judgment [Evidence Level C].
  2.  For temperature greater than 37.5° Celsius, increase frequency of monitoring, initiate temperature-reducing measures, investigate possible infection such as pneumonia or urinary tract infection [Evidence Level C], and initiate antipyretic and antimicrobial therapy as required [Evidence Level B].

 

4.2.3  Mobilization

Mobilization is defined as “the process of getting a patient to move in the bed, sit up, stand, and eventually walk.”14

  1. All patients admitted to hospital with acute stroke should be mobilized as early and as frequently as possible [Evidence Level B] (AU), and preferably within 24 hours of stroke symptom onset, unless contraindicated [Evidence Level C].Some contraindications to early mobilization include, but may not be restricted to,  unstable medical conditions, low oxygen saturation, and lower limb fracture or injury.276
  2.  All patients admitted to hospital with acute stroke should be assessed by rehabilitation professionals as soon as possible after admission [Evidence Level A], preferably within the first 24 to 48 hours [Evidence Level C].
    Refer to Section 5 for additional information.

4.2.4 Continence

  1. All stroke patients should be screened for urinary incontinence and retention (with or without overflow), fecal incontinence, and constipation (time and frequency) [Evidence Level C].
  2. The use of a portable ultrasound is recommended as the preferred noninvasive painless method for assessing post-void residual [Evidence Level C].
  3. Possible contributing factors surrounding continence management should be assessed, including medications, nutrition, diet, mobility, activity, cognition, environment and communication [Evidence Level C]. This should include assessing the stroke patient for urinary tract infections to determine a possible transient cause of urinary retention [Evidence Level C].
  4. Stroke patients with urinary incontinence should be assessed by trained personnel using a structured functional assessment [Evidence Level B].
  5. The use of indwelling catheters should be avoided due to the risk of urinary tract infection [Evidence Level A]. If used, indwelling catheters should be assessed daily and removed as soon as possible [Evidence Level A]. Excellent pericare and infection prevention strategies should be implemented to minimize risk of infections [Evidence Level C].
  6. A bladder-training program should be implemented in patients who are incontinent of urine [Evidence Level C], including timed and prompted toileting on a consistent schedule [Evidence Level B].
  7. Appropriate intermittent catheterization schedules should be established based on amount of post-void residual (Evidence Level B).
  8. A bowel management program should be implemented for stroke patients with persistent constipation or bowel incontinence [Evidence Level A].

 

4.2.5 Nutrition and Dysphagia

  1. The nutritional and hydration status of stroke patients should be screened within the first 48 hours of admission using a valid screening tool [Evidence Level B].
  2. Results from the screening process should be used to guide appropriate referral to a dietitian for further assessment and ongoing management of nutritional and hydration status [Evidence Level C].
  3. Stroke patients with suspected nutritional concerns, hydration deficits, dysphagia, or other comorbidities that may affect nutrition (such as diabetes) should be referred to a dietitian for:
    1. recommendations to meet nutrient and fluid needs orally while supporting alterations in food texture and fluid consistency recommended by a speech-language pathologist or other trained professional [Evidence Level C].
    2. consideration of enteral nutrition support (tube feeding) within seven days of admission for patients who are unable to meet their nutrient and fluid requirements orally. This decision should be made collaboratively with the interprofessional team, the patient, and the caregivers and family [Evidence Level B].

Refer to recommendation 6.1 for additional information.

4.2.6   Oral care

  1.  Upon or soon after admission, all stroke patients should have an oral/dental assessment, including screening for signs of dental disease, level of oral care, and appliances [Evidence Level C].
  2. For patients wearing a full or partial denture it should be determined if they have the neuromotor skills to safely wear and use the appliance(s) [Evidence Level C].
  3. An appropriate oral care protocol should be used for every patient with stroke, including those who use dentures [Evidence Level C]. The oral care protocol should be consistent with the Canadian Dental Association recommendations [Evidence Level B], and should address areas such as frequency of oral care (twice per day or more); types of oral care products (toothpaste, floss, and mouthwash); and management for patients with dysphagia.277
  4. If concerns with implementing an oral care protocol are identified, consider consulting a dentist, occupational therapist, speech-language pathologist, and/or a dental hygienist [Evidence Level C].
  5. If concerns are identified with oral health and/or appliances, patients should be referred to a dentist for consultation and management as soon as possible [Evidence Level C].

 

Note: For 2010, the recommendation on Discharge Planning has been moved to Section 6.

    Rationale

    Acute stroke accounts for one of the longest length of stay of all illnesses in Canadian hospitals and places a significant burden on inpatient resources, which increases further when complications arise. Acute stroke patients are at risk for complications during the early phase of recovery. The priorities for inpatient care are management of stroke sequelae to optimize recovery, prevention of post-stroke complications that may interfere with the recovery process, and prevention of stroke recurrence.

    System Implications
    • Standardized evidence-based protocols for optimal inpatient care of all acute stroke patients, regardless of where they are treated in the healthcare facility (stroke unit or other ward).
    • Ongoing professional development and educational opportunities for all healthcare professionals who care for acute stroke patients.
    • Referral systems to ensure rapid access to specialty care such as dentistry.
    Performance Measures
    1. Percentage of patients with stroke who experience complications (venous thrombo-embolism, pulmonary embolus, secondary cerebral hemorrhage, gastrointestinal bleed, pressure ulcers, urinary tract infection, pneumonia, seizures or convulsions) during inpatient stay.
    2. Length of stay for stroke patients admitted to hospital (core).

    Measurement Notes

    • Risk adjustment to account for other comorbidities, age, and gender.
    • Length-of-stay analysis should be stratified by presence or absence of in-hospital complications to look for the impact of a complication on length of stay.
    • Refer to the Canadian Stroke Strategy Performance Measurement Manual 2008 for additional performance measures for each specific component of inpatient care.
    Implementation Resources and Knowledge Transfer Tools
    Summary of the Evidence

    Complications following stroke have been well documented in the literature. McLean (2004) reports that depression (26%), patient falls (20%), shoulder pain (24%) and urinary tract infections (15%) are the most common complications observed in hospital.278 Care of stroke patients in the hyperacute and acute phases of care require attention and diligence in many areas including reduction of complications such as venous-thromboembolism, fever, pressure ulcers and contractures, pneumonia and continence issues.216

     

    Venous thrombo-embolism: The risk of venous thromboembolism in patients hospitalized with stroke is 20–50 percent.13 Additional pre-existing risk factors may increase the risk of venous thromboembolism and pulmonary embolism and should be addressed individually in each patient admitted with an acute stroke. Recommendations for the routine use of prophylactic anticoagulation for venous thrombo-embolism in stroke patients are controversial.30The benefit of prophylaxis with an anticoagulant low-density unfractionated heparin or low molecular weight heparin should be weighed against the risk of serious bleeding complications in patients with additional risk factors for venous thromboembolism.

    The Royal College of Physicians guidelines states that prophylactic anticoagulation should not be used routinely (Grade A recommendation).39 Although subcutaneous heparin and low-molecular-weight heparin may prevent venous thrombo-embolism, this beneficial effect may be counterbalanced by an increased risk of intracranial hemorrhage. The American Stroke Association (ASA) and the Scottish Intercollegiate Guidelines Network both recommend prophylactic administration of heparin, low-molecular-weight heparin, or heparinoids to prevent venous thrombo-embolism in immobilized people following a stroke (Grade A recommendations). 1,5,31

    The PREVAIL study investigated optimal treatment for venous thrombo-embolism prophylaxis to compare the efficacy and safety of enoxaparin with that of unfractionated heparin for patients with stroke.279One thousand, seven hundred and sixty-two patients with acute ischemic stroke who were unable to walk unassisted were randomly assigned within 48 hours of symptoms to receive either enoxaparin (40 mg subcutaneously once daily) or unfractionated heparin (5000 U subcutaneously every 12 hours for 10 days). Patients were stratified by National Institutes of Health Stroke Scale score (severe stroke ≥14, less severe stroke

    extracranial hemorrhage was small and closely similar between groups (enoxaparin 11 [1%] vs. unfractionated heparin 6 [1%]; p=0.23). Sherman noted no difference for symptomatic intracranial hemorrhage between groups (4 [1%] vs. 6 [1%], respectively; p=0.55); the rate of major extracranial bleeding was higher with enoxaparin than with unfractionated heparin (7 [1%] vs. 0; p=0.015). It was suggested that for patients with acute ischemic stroke, enoxaparin is preferable to unfractionated heparin.

    The recommendation around the use of external compression stockings has been removed from this edition of the Canadian Best Practice Guidelines. In past editions external compression stockings were a recommended intervention that could be used for patients with acute ischemic stroke at high risk of venous thromboembolism in the absence of contraindications. This was based on evidence that showed external compression stockings are effective for surgical patients.280 However, two more systematic reviews concluded there is currently insufficient evidence of the effectiveness of physical methods to prevent DVT. 281,282Of importance, a recent randomized controlled trial study (CLOTS trial 1) has shown that thigh length compression stockings do not significantly reduce the risk of deep vein thrombosis after stroke.275 The CLOTS trial 1 was a multi-centre study in which 2518 patients were recruited within 3 days of admission after stroke. The primary outcome was a symptomatic or asymptomatic DVT in the popliteal or femoral veins. The primary outcome occurred in 126 (10.0% patients) allocated to thigh-length graduated compression stockings and in 133 (10.5%) in patients who were not treated with graduated compression stockings. Graduated compression stockings were not significant in reducing the risk of the occurrence of DVT (0.5%) compared with no graduated compression stockings. Graduated compression stockings did not affect secondary outcomes including PE and death. Also, graduated compression stockings were not effective in subgroups, such as patients treated early, those with leg weakness and those not given concomitant anticoagulation. However, the use of graduated compression stockings was associated with an increased risk of skin breaks, ulcers, blisters and necrosis.

    The use of LMWH was associated with a significant risk reduction for any VTE (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.41 to 0.70; p < 0.001). Limiting the analysis to proximal VTEs also indicated that LMWHs were superior (OR with LMWH vs UFH, 0.53; 95% CI, 0.37 to 0.75; p < 0.001). LMWH use led to fewer PEs as well (OR, 0.26; 95% CI, 0.07 to 0.95; p = 0.042). There were no differences in rates of overall bleeding, intracranial hemorrhage, or mortality based on the type of agent employed. Restricting the analysis to the reports employing enoxaparin did not alter their findings.283

    One trial has assessed the use of intermittent pneumatic compression (IPC) in conjunction with elastic stockings.284 The study reported a reduced incidence of asymptomatic DVT for patients with ICH in an ICU setting. However, the study was too small to detect clinical/symptomatic DVT differences between the groups and a higher number of patients in the intervention group discontinued treatment. The ongoing study CLOTS trial 3 may provide direction around the use of intermittent pneumatic compression.

    Definitive research evidence is lacking for the use of anticoagulants and antithrombotics for deep vein thrombosis prophylaxis after intracerebral hemorrhage.285 The use of anticoagulants may increase the risk of worsening the initial hematoma. Orken and colleagues investigated the safety of low dose low molecular weight heparin (LMWH) for DVT prophylaxis in patients with ICH and the effect of heparin on the enlargement of hemorrhage.286 Seventy-five primary ICH patients were randomized to subcutaneous LMWH (Enoxaparin sodium 40mg/d) or long compression stockings (CS) after the first 48 hours. All patients had cranial computed tomography (CT) scan at admittance, 1, 3, 7 and 21 days, as well as CT pulmonary angiography and bilateral lower extremity venous Doppler on day seven. Hematoma volumes were calculated on the initial and follow-up CTs with ABC/2 method.   The study did not find any hematoma enlargement at 72 hours, 7 and 21 days in either group. In addition, no other systemic bleeding complications were observed in LMWH group. Four asymptomatic DVTs were detected (3 in LMWH and 1 in CS group). As a result of the study, investigators were able to calculate the rate of asymptomatic DVT an dPE in ICH patients, at 4% and 2.5% in the LMWH group. The investigators concluded that low-dose heparin treatment after 48 hours of stroke in ICH patients was not associated with an increased hematoma growth, however, sample size was small and should be considered for DVT and PE prophylaxis.

    Tetri and colleagues conducted a retrospective review of 407 ICH patients in which 232 had received anticoagulant therapy for DVT prophylaxis using enoxaparin.287 They found similar three-month mortality rates of 19% in the treated group compared to 21% in the group who did not receive prophylaxis.  Hematoma enlargements occurred in 9% and 7% of the treated and untreated patients, whereas

    symptomatic venous thromboembolic complications were observed in 3% and 2%, respectively.  The investigators discuss the fact that the safety of earlier initiation of prophylaxis in the ICH population is unknown and a randomized trial is needed to generate evidence to better guide clinicians.

    Temperature management: Increased body temperature following stroke has been reported to result in increased morbidity and mortality and generally poorer  recovery and neurological outcomes.288-294The fever may be secondary to a cause of stroke, such as infective endocarditis, or may represent a complication, such as pneumonia. Monitoring temperature and managing fever are important components of post stroke care to minimize the potential negative impact of fever. Jones and colleagues found that the evidence supports the need for monitoring and recording of blood pressure, oxygen saturation (including consideration of positioning), blood glucose, and body temperature in the acute phase of stroke.295 This review reinforced the importance of monitoring physiological parameters in the acute phase of stroke, providing support to the recommendation that monitoring should play a key role within nursing care.

    Saini and colleagues (2010) conducted a study to evaluate the effect of temperature and timing of hyperthermia on outcome after ischemic stroke.288Their analysis included data from 5305 patients in acute stroke trials from the Virtual International Stroke Trials Archive (VISTA) data set were analyzed. Data for temperatures at baseline, eighth, 24th, 48th, and 72nd hours, and seventh day were assessed in relation to outcome (poor versus good) based on the modified Rankin Scale at 3 months. Hyperthermia was defined as temperature >37.2 degrees C and poor outcome as 90-day modified Rankin Scale >2. The average age of patients was 68.0+/-11.9 years, 2380 (44.9%) were females, and 42.3 percent (2233) received thrombolysis using recombinant tissue plasminogen activator. After adjustment, hyperthermia was a statistically significant predictor of poor outcome. The hazard ratios (95% CI) for poor outcome in relation to hyperthermia at different time points were: baseline 1.2 (1.0 to 1.4), eighth hour 1.7 (1.2 to 2.2), 24th hour 1.5 (1.2 to 1.9), 48th hour 2.0 (1.5 to 2.6), 72nd hour 2.2 (1.7 to 2.9), and seventh day 2.7 (2.0 to 3.8). Gender, stroke severity (National Institutes of Health Stroke Scale score >16), white blood cell count, and antibiotic use were significantly associated with hyperthermia (P< or =0.01). The investigators concluded hyperthermia in acute ischemic stroke is associated with a poor clinical outcome. The later the hyperthermia occurs within the first week, the worse the prognosis. Severity of stroke and inflammation are important determinants of hyperthermia after ischemic stroke.

    Mobilization: The goal of early mobilization following stroke is to prevent complications such as pressure sores, painful shoulders, and respiratory complications.266, 296 It is described as one of the “simplest yet most important components of stroke unit care”. 297Health professionals require a research-based approach to deliver safe and effective care to acute stroke patients, including early mobilization, and for early mobilization post stroke, this research base is lacking. In spite of this absence, several well-developed stroke guidelines promote early mobilization following stroke.10, 16,29,34 In addition, early mobilization is frequently identified as a component of stroke unit.298,299 Diserens and colleagues (2006) noted in his systematic review that early mobilization protocols are poorly defined and need to be stratified to better evaluate their clinical effectiveness.300 They define ‘early’ mobilization as activities within the first three days following stroke. They define ‘mobilization’ as “any physical activity of the body initiated by either the patient or the environment, independent of body position and, if appropriate, the position in which mobilisation is performed (flat, sitting, upright) should be added” (page 184). Based on their review, they concluded there is a clear benefit of early rehabilitation after stroke that usually includes rapid mobilization in bed and out of bed.

    The AVERT trial (A Very Early Rehabilitation Trial for Stroke) is underway with the intent of providing further clarity on this topic. At this time, the safety and feasibility report for AVERT has been published and the full trial is ongoing.297 A 2009 Cochrane review was only able to include a single study, which was the AVERT safety and feasibility trial of 71 patients.296 The study found that fewer patients who received very early mobilization (within 24 hours) were dead or disabled at three months, however, this was not statistically significant. A secondary analysis examined complication rates at 3 months comparing the intervention and standard care groups.276In this Phase II study there were no significant differences in complication rates between the two groups. Overall, most patients (81.6%) experienced at least one complication, most commonly falls. Another component of the AVERT trial measured patient quality of life at one-year following a stroke using the Assessment of Quality of Life scale (AQoL).301 The group who received very early mobilization reported a higher median overall AQoL score (0.32)  compared to standard care  patients

    (0.24). This group difference was not significant (p = 0.17), but it was significant at the 75th percentile (p = 0.003) in favour of early mobilization group. Early mobilization patients also reported higher quality of life than standard care patients in the physical function related 'Independent Living' domain of the AQoL (p = 0.03 adjusted for age; p = 0.04 adjusted for stroke severity).

    Bernhardt’s review (2008) identified the variations in practice for the timing of mobilization following stroke, citing a range from 24 hours to several days.302A Canadian survey study assessed functional mobility training for individuals admitted to acute care following a stroke event.303 One third of the 18 responding acute care settings reported that there were no written guidelines related to mobilization or positioning following a stroke and few sites reported provision of stroke-specific education. Arias and Smith (2007) examined practices for early mobilization of acute stroke patients through a survey in the United Kingdom.304 It was noted that although early mobilization in acute stroke care is recommended in a range of European, American and United Kingdom policy guidelines as a strategy to minimize or prevent complications, the evidence base to support early mobilization in acute stroke is missing. There is a need for a coordinated and consistent approach to early mobilization and physical care for stroke patients in the acute care setting.

     

    Continence: The prevalence of urinary incontinence is difficult to estimate, but it is thought to range between 10 and 20 percent, with higher rates of incontinence expected for women.216,305-307A  Cochrane review (2008) suggested that rates can be as high as 40 to 60 percent of people admitted to hospital following a stroke event, with 25% still having problems at time of discharge.306 Similar ranges are reported in the 2009 edition of the Evidence-Based Review of Stroke Rehabilitation. More alarming still, 15% of these patients remain incontinent at one year post-stroke. The review set out to determine optimal treatment techniques of urinary incontinence after stroke. Twelve trials (total n= 724) were included in the review: three trials assessed behavioral interventions, two assessed professional input interventions, three small trials examined complementary therapies as interventions and three small trials investigated pharmacotherapy and hormonal interventions. The authors concluded that the data was insufficient to effectively guide continence care after stroke, although there was evidence that professional input through structured assessment and management of care may reduce urinary incontinence following stroke. There is a wide range of interventions suggested for dealing with this distressing issue and better evidence is required.

    Dumoulin et al. (2007) examined the extent to which occupational and physical therapists identified, assessed and treated urinary incontinence following stroke.307 The aim of the study was to assess the extent to which the actual practices of rehabilitation professionals reflected best practice recommendations in Canada. Occupational therapists (n= 663) and physical therapists (n=656) were randomly selected to participate in a telephone interview. Only 39 percent of occupational therapists and 41 percent of physical therapists identified urinary incontinence after stroke as a problem. Fewer than 20 percent of occupational therapists and 15 percent of physical therapists used best-practice assessments, while only two percent and three percent used best practice interventions respectively. Variables identified to explain between six and nine percent of the variance included: working in Ontario, allocated learning time, and university teaching.

    Nutrition and Dysphagia: The FOOD trial (2005) aimed to establish whether routine oral nutritional supplements improve outcome after stroke.308 The trials are a family of three pragmatic, multicenter, randomised controlled trials. Outcomes of stroke patients who could swallow and who were randomly allocated normal hospital diet or normal hospital diet plus oral nutritional supplements until hospital discharge were measured, primary outcome being death or poor outcome (modified Rankin scale [MRS] grade 3–5), six months after enrolment, measured unaware of treatment allocation. Over the course of the study, 4023 patients were enrolled across 15 countries. Only 314 (8%) patients were judged to be undernourished at baseline. Supplemented diet was associated with an absolute reduction in risk of death of 0.7% (95% CI –1.4 to 2.7) and an increased risk of death or poor outcome of 0.7 percent (–2.3 to 3.8). The anticipated 4% absolute benefit for death or poor outcome from routine oral nutritional supplements for mainly well nourished stroke patients in hospital could not be confirmed. The FOOD trial results would be compatible with a 1 percent or 2 percent absolute benefit or harm from oral supplements. These results did not support a policy of routine oral supplementation after stroke.

    Another FOOD trial investigation (2005) examined acute treatment of dysphagic patients.309 In one trial,

    patients enrolled within seven days of admission were randomly allocated to early enteral tube feeding or no tube feeding for more than seven days (early versus avoid).In the other, patients were allocated percutaneous endoscopic gastrostomy or nasogastric feeding. In this trial, patients (n=859) were enrolled into the early versus avoid trial. Early tube feeding was associated with an absolute reduction in risk of death of 5.8 percent (95% CI –0.8 to 12.5, p=0.09) and a reduction in death or poor outcome of 1.2 percent (–4.2 to 6.6, p=0.7). In the percutaneous endoscopic gastrostomy vs. nasogastric tube trial, 321 patients were enrolled by 47 hospitals in 11 countries. Percutaneous endoscopic gastrostomy feeding was associated with an absolute increase in risk of death of 1.0 percent (–10.0 to 11.9, p=0.9) and an increased risk of death or poor outcome of 7.8 percent (0.0 to 15.5, p=0.05). Early tube feeding might reduce case fatality, but with an increase in the proportion of patients surviving with poor outcome. The results did not support a policy of early initiation of percutaneous endoscopic gastrostomy feeding in dysphagic stroke patients.

    Martineau et al. (2005) assessed the nutritional status of patients (n=73) admitted to an acute stroke unit using the scored patient generated subjective global assessment.310 At time of admission 19.2 percent of patients were malnourished. Malnourished patients, in comparison to nourished patients, had longer lengths of stay (13 vs. 8 days), increased complications (50% vs. 14%), increased frequency of dysphagia (71% vs. 32%), and enteral feeding (93% vs. 59%). No association was found between nutritional status and discharge destination.

    Horn et al. (2005) examined the association of patient characteristics, rehabilitation therapies, neurotropic medications, nutritional support, and timing of initiation of rehabilitation with functional outcomes and discharge destination for inpatient stroke rehabilitation patients (n=830).311 Enteral feeding was identified as an activity associated with better outcome post-stroke.

    Oral Care: Poor oral hygiene has been linked with the development of aspiration pneumonia due to bacterial colonization in the mouth.213 Aerobic gram-negative bacilli has been shown to be common in the mouths of stroke patients and is also correlated with dysphagia. In addition, physical weakness following stroke can prevent patients from being independent in completing their own oral care.313Dry mouth, oral ulcers and stomatitis may be caused by medication following a stroke. Patients with dysphagia are also at a high risk due to reduced cough sensation and greater potential for aspiration of their own saliva.314

    A Cochrane Database Systematic Review was carried out to compare the effectiveness of staff-led oral care interventions with standard care in improving oral hygiene in patients post-stroke.315Only one study (n= 67 stroke patients) identified stroke-specific treatment information, comparing an oral healthcare education training program delivered to nursing home care assistants to delayed training intervention in the control group. Results indicated that denture plaque scores were significantly reduced up to six months post-intervention (p

    Brady et al. (2007) showed limited evidence suggesting that training can change staff knowledge and attitude toward oral care and has a positive impact on patient’s oral hygiene as measured by denture cleanliness.316 Six months post-intervention the benefits were still evident despite high professional turnover in nursing homes.

    An overview of provision of oral care in stroke care settings in Scotland was conducted demonstrating that access to staff training, assessments, protocols, and oral hygiene material varied considerably between units.317 This overview presented a baseline for the development of oral care protocols in specialized stroke settings. Also, a study examining the oral health condition of elderly stroke survivors at discharge into the community found that, in comparison to a control group, individuals who survived a stroke had significantly higher plaque and bleeding scores at time of discharge. This effect remained evident six months following discharge to the community.318