2009 Stroke Council Award and Lecture—Stroke: A Chronic Disease
Stroke is managed as an acute illness, with mean lengths of stay of less than 5 days in acute-care hospitals. Recovery has been reported to be most dramatic in the first month and to plateau by 3 to 6 months. However, stroke is a chronic condition with multiple risk factors (diabetes, heart disease, hypertension, vascular cognitive impairments, depression, limited physical activity, and falls) for continued decline in health functional status and quality of life. Fewer than 50% of individuals with stroke have their stroke risk factors assessed, treated, or controlled; only 75% of individuals persist with secondary-prevention medications described at discharge; poststroke depression is underdiagnosed and undertreated; the level of physical activity in individuals with mild impairment after stroke is less than half that of healthy older individuals; and the risk of falls and fracture is 2 to 7 times higher in stroke survivors. Among individuals who receive inpatient rehabilitation services, recovery of walking speed is not sufficient to sustain physical activity and participation. Even among those among those with a high degree of early functional recovery, there are modest annual declines in function. Care management after acute stroke is highly variable and fragmented, and major quality-improvement initiatives to improve stroke outcomes (Paul Coverdale Registry and AHA Get With the Guidelines) do not extend beyond the acute-care hospital stay. There is an immediate need to develop more integrated and innovative poststroke management programs. The efforts to develop quality-improvement programs and quality indicators of care for acute care should be paralleled in chronic management after acute stroke.