AL27 • Alabama Nurses 2026-2027

Table of Contents

AL27 • Alabama Nurses 2026-2027

How to Receive Credit

NetCE 5 Hour Course #34655 • Diabetic Hypoglycemia

34655 • Diabetic Hypoglycemia

1. INTRODUCTION

2. AN OVERVIEW OF HYPOGLYCEMIA

3. RISK FACTORS

4. SIGNS AND SYMPTOMS OF HYPOGLYCEMIA

5. CAUSES OF HYPOGLYCEMIA

6. TREATMENT OF HYPOGLYCEMIA

7. PATIENT EDUCATION

8. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 10 Hour Course #90285 • Ischemic Stroke

90285 • Ischemic Stroke

1. INTRODUCTION

2. OVERVIEW OF CEREBROVASCULAR DISEASE

3. PREVENTION

4. EARLY STROKE MANAGEMENT

5. TREATMENT

6. REHABILITATION

7. SECONDARY PREVENTION: EVIDENCE-BASED RECOMMENDATIONS

8. CASE STUDY

9. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 9 Hour Course #97210 • Managing Disruptive Patients

97210 • Managing Disruptive Patients

1. INTRODUCTION

2. FACTORS THAT MAY INCREASE THE RISK OF VIOLENCE

3. PREVENTION OF WORKPLACE VIOLENCE

4. PREVENTION AND EARLY DETECTION

5. PRELIMINARY ACTIONS

6. NONCOMPLIANCE

7. NONADHERENCE

8. MANIPULATIVE BEHAVIORS

9. GLOSSARY OF TERMS

10. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

AL27 • Alabama Nurses 2026-2027

Diane Thompson, RN, MSN, CDE, CLNC

John M. Leonard, MD

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

AL27 • Alabama Nurses 2026-2027

Expiration Date: 10/31/2027

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

34655 • Diabetic Hypoglycemia

Diane Thompson, RN, MSN, CDE, CLNC

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

The occurrence of hypoglycemia can be traumatic for the patient as well as the healthcare professional caring for them. Hypoglycemia is significantly problematic for people with diabetes. Patients experience short-term effects and, in some cases, long-term adverse results. Startlingly, it is not uncommon for the individual to have a lack of warning of the hypoglycemic episode. With this in mind, a strong understanding of the pathophysiology, assessment, and treatment is needed for healthcare professionals caring for this population. Early recognition and understanding of the cause of this complication is imperative for appropriate treatment, prevention, and reduced adverse outcomes. Healthcare professionals are increasingly required to do more with less, and solid evaluation and assessment skills are vital to safe practice in the home, long-term care, and acute care settings.

Table of Contents

34655 • Diabetic Hypoglycemia

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. AN OVERVIEW OF HYPOGLYCEMIA

PHYSIOLOGY OF FUEL METABOLISM

PATHOPHYSIOLOGY OF HYPOGLYCEMIA

3. RISK FACTORS

INSULIN

WEIGHT LOSS AND WEIGHT-LOSS SURGERY

ALCOHOL USE

HAAF

HORMONES AND PREGNANCY

AGING

DEPRESSION

CULTURAL AND ECONOMIC FACTORS

COMPLEMENTARY AND ALTERNATIVE THERAPIES

4. SIGNS AND SYMPTOMS OF HYPOGLYCEMIA

CASE STUDY

5. CAUSES OF HYPOGLYCEMIA

ORAL MEDICATIONS

INSULIN

INSULIN PUMP THERAPY

EXERCISE

PATIENT ISSUES

6. TREATMENT OF HYPOGLYCEMIA

7. PATIENT EDUCATION

ORAL MEDICATIONS

INSULIN

PHYSICAL ACTIVITY

NOCTURNAL HYPOGLYCEMIA

PATIENT BEHAVIORS

8. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

34655 • Diabetic Hypoglycemia

Education Category. Infection Control / Internal Medicine

Release Date. 03/01/2026

Expiration Date. 02/28/2029

Course Overview

The occurrence of hypoglycemia can be traumatic for the patient as well as the healthcare professional caring for them. Hypoglycemia is significantly problematic for people with diabetes. Patients experience short-term effects and, in some cases, long-term adverse results. Startlingly, it is not uncommon for the individual to have a lack of warning of the hypoglycemic episode. With this in mind, a strong understanding of the pathophysiology, assessment, and treatment is needed for healthcare professionals caring for this population. Early recognition and understanding of the cause of this complication is imperative for appropriate treatment, prevention, and reduced adverse outcomes. Healthcare professionals are increasingly required to do more with less, and solid evaluation and assessment skills are vital to safe practice in the home, long-term care, and acute care settings.

Audience

This course is designed for nurses in any healthcare venue and dietitians with a desire to better understand the causes, recognition, and treatment of hypoglycemia in a variety of settings.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is approved to offer continuing education through the Florida Board of Nursing Home Administrators, Provider #50-2405. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

NetCE designates this continuing education activity for 5 ANCC contact hour(s). NetCE designates this continuing education activity for 5 pharmacotherapeutic/pharmacology contact hour(s). NetCE designates this continuing education activity for 6 hours for Alabama nurses. NetCE is authorized by IACET to offer 0.5 CEU(s) for this program. AACN Synergy CERP Category A.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Course Objective

The purpose of this course is to provide nurses and healthcare professionals with a foundation of understanding hypoglycemia in order to assure the highest quality of care is provided to patients.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define hypoglycemia and its effects on community health.

2. Describe the pathophysiology of hypoglycemia.

3. Outline risk factors for hypoglycemic events, including the use of specific herbal medications.

4. List signs and symptoms of hypoglycemia.

5. Identify causes of hypoglycemia, including medications and non-medication-related factors.

6. Compare treatment options for hypoglycemia.

7. Describe education topics to incorporate into patient teaching regarding hypoglycemia prevention.

Faculty

Diane Thompson, RN, MSN, CDE, CLNC, has an extensive history in nursing and nursing education. She possesses a strong background in diabetes and cardiac care, starting her professional career at the cardiac care area of the Cleveland Clinic in Cleveland, Ohio. Ms. Thompson took the knowledge and experience she learned from the Cleveland Clinic and transferred it into the home health arena in rural Ohio, after which she moved to Florida and obtained further knowledge while working as a PRN nurse in all areas, including medical/surgical, intensive care, emergency, critical care, and cardiology. With a desire to have a specific area to concentrate her profession, Ms. Thompson accepted a position as a pneumonia case manager, which led into a diabetes case manager career.

Ms. Thompson has been employed in diabetes care since 2001, when she was hired as a diabetes case manager. After the completion of 1,000 hours of education to diabetes patients, Ms. Thompson earned her certification as a diabetes educator in 2003. From 2006 to 2018, Ms. Thompson was the Director of Diabetes Healthways at Munroe Regional Medical Center in Ocala, Florida. As the director of the diabetes center, Ms. Thompson was responsible for the hospital diabetes clinicians, hospital wound care clinicians, and out-patient education program. Today, she is the nurse manager of a heart, vascular, and pulmonary ambulatory clinic at Metro Health System in Cleveland, Ohio. Ms. Thompson has also lectured at the local, state, and national level regarding diabetes and the hospital management of hyperglycemia. Ms. Thompson is a member of the ADA, AADE, Florida Nurses Association, and the National Alliance of Certified Legal Nurse Consultants.

Ms. Thompson acknowledges her family as her greatest accomplishment. She is a wife of more than 30 years and a mother of a daughter and son, of which she is very proud. Ms. Thompson credits her husband for the support needed to set a goal and achieve it. He has been by her side through nursing school and completion of her Bachelor's degree and Master's degree, which she was awarded in 2015 from Jacksonville University in Florida.

Faculty Disclosure

Contributing faculty, Diane Thompson, RN, MSN, CDE, CLNC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Mary Franks, MSN, APRN, FNP-C

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Diabetes is a complex, multifaceted disease state, and healthcare providers involved in the care of patients with diabetes require in-depth knowledge of all aspects of the disease [1]. Optimal glycemic control and management for patients with diabetes has been proven to decrease both macrovascular complications (e.g., cardiovascular disease, peripheral vascular disease, cerebrovascular disease) and microvascular complications (e.g., nephropathy, neuropathy, retinopathy) [2,3]. These findings are supported by the results of the Diabetes Prevention Program Outcomes Study and other large-scale studies [4]. Unfortunately, available diabetes treatment regimens are imperfect. Often considered a fact of the disease, iatrogenic hypoglycemia (commonly driven by insulin) is a limiting factor in successful, optimal glycemic control and management [5,6,7,8]. Hypoglycemia occurs with both type 1 and type 2 diabetes but impacts those with type 1 diabetes with lower glycated hemoglobin (HbA1c) percentages more prevalently than those with other forms of the disease [9]. This is due to specific defenses against the falling plasma glucose concentrations that continue in individuals with functioning pancreatic alpha and beta cells [10].

Patients with type 1 diabetes striving to achieve glycemic control may have symptomatic hypoglycemia up to 10 times per week, with asymptomatic events occurring more often [11]. On average, type 1 diabetes patients suffer an average of two episodes of symptomatic hypoglycemia per week, often at night [10]. An estimated 4% to 10% of deaths among individuals with type 1 diabetes are attributed to hypoglycemia [12]. Studies have revealed a wide range of episodic hypoglycemia in patients with type 1 diabetes, from 62 to 170 episodes per 100 patient-years with tight glycemic control [13]. These estimates, however, are often based on reported episodes, which may be lower than actual events because they are generally limited to severe episodes that require medical treatment. In contrast, the same studies revealed that patients with type 2 diabetes experienced between 3 and 73 hypoglycemic episodes per 100 patient-years [13].

2. AN OVERVIEW OF HYPOGLYCEMIA

Identifying a definitive and concrete blood glucose level that indicates hypoglycemia has been controversial. Similar to the adjustments needed for survival with chronic acidosis or chronic anemia, the body of those with chronic hyperglycemia can adapt to regulate vital operations and maintain function [13]. Patients with uncontrolled diabetes may function with elevated blood glucose levels, causing symptoms of hypoglycemia when the levels are brought back within an acceptable range [5].

Hypoglycemia is defined as a blood glucose level of less than 70 mg/dL and the start of cognitive alteration [6]. Cognitive impairment is classically observed in patients with functioning autonomic and central nervous systems when blood glucose levels fall to less than 54 mg/dL [6]. Hypoglycemia is generally best diagnosed utilizing the Whipple triad: autonomic and/or central nervous system symptoms, a low plasma glucose concentration, and relief of symptoms with treatment [13,14]. It is important to remember that symptoms of hypoglycemia can instigate anxiety and fear [1].

PHYSIOLOGY OF FUEL METABOLISM

Glucose regulation is maintained by a sophisticated mechanism of regulatory and counter-regulatory reactions. When an individual consumes food, specifically carbohydrates, sugars are released into the blood circulatory system [1]. The chemical reactions to this sugar introduction help maintain homeostasis in the body.

Phases of Insulin Response

The concentration of plasma glucose is dependent on the rate glucose enters the circulation in contrast to the rate it is removed [15]. The fuel homeostasis within the body can be explained in a five-phase approach. Phase 1, the absorptive or fed state, occurs immediately and up to 3.9 hours after consumption of food. During this phase, the circulating glucose predominantly comes from an exogenous source. Plasma insulin levels are elevated, glucagon levels are minimal, and triglycerides are synthesized in the liver. Insulin impedes the breakdown of glycogen and triglyceride reservoirs. The brain and other glucose-dependent organs utilize some of the glucose absorbed from the intestinal tract, and the excess glucose is stored in the liver, muscle, adipose tissue, and other tissues for use later.

Phase 2 occurs 4 to 15.9 hours after consumption of food and is referred to as the postabsorptive state. In phase 2, blood glucose originates from the breakdown of glycogen and hepatic gluconeogenesis. There is a decrease in plasma insulin levels, and glucagon levels begin to increase. Anabolism (energy storage) ends in this phase and catabolism (energy production) begins. There is a mobilization of carbohydrate and lipid stores. Hepatic glycogen breakdown provides maintenance of circulating plasma glucose to ensure an adequate supply of glucose to the brain and other organs. Adipocyte triglyceride begins to breakdown, and free fatty acids are released into the circulatory system for use by the liver and skeletal muscle as the primary energy source and as a substrate for gluconeogenesis. The brain continues to utilize glucose, provided mainly by gluconeogenesis, due to its inability to use free fatty acids.

Phase 3 is the early starvation state. About 16 to 47.9 hours after the consumption of food, the blood glucose is generated from hepatic gluconeogenesis and glycogenolysis. Gluconeogenesis continues to generate most of the hepatic glucose. In this phase of starvation, lactate makes up half of the gluconeogenesis substrate along with amino acids (specifically alanine) and glycerol. The secretion of insulin is suppressed and counter-regulatory hormone (glucagon, cortisol, growth hormone, and epinephrine) secretion is stimulated.

Phase 4 begins 48 hours to 23 days after food consumption. During this preliminary prolonged starvation state, blood glucose originates from hepatic and renal gluconeogenesis. Within 60 hours of starvation, gluconeogenesis provides more than 97% of hepatic glucose output. The secretion of insulin is distinctly diminished and counter-regulatory hormone secretion is stimulated.

Phase 5, or the secondary prolonged starvation state, begins 24 days after food consumption. Blood glucose during this phase originates from hepatic and renal gluconeogenesis, just as in phase 4. However, in phase 5 the rate of glucose being utilized by the brain and the rate of gluconeogenesis diminishes.

The relationship between the glucoregulatory and counter-regulatory hormones and the many factors that contribute to the fuel metabolism should be considered. There is a sophisticated relationship between the metabolic-regulatory hormones insulin (a glucoregulatory hormone), glucagon, and epinephrine (counter-regulatory hormones). When insulin is elevated, glucagon and epinephrine are suppressed [16]. This process occurs to prevent the continued rise of endogenous glucose levels. Conversely when insulin levels decline in response to diminished circulating glucose levels, glucagon and epinephrine respond by increasing. These relationships are maintained when normal homeostasis is maintained. In the presence of diabetes, there is a disruption of this homeostasis [17].

PATHOPHYSIOLOGY OF HYPOGLYCEMIA

Hypoglycemia is a result of one of two different issues: hyperinsulinemia (resulting from too much exogenous insulin, an insulin-secreting pancreatic tumor, or excessive oral diabetes medication) or iatrogenic issues (alteration in glucose counter-regulation) [13]. Hypoglycemia can be a complication of insulin therapy in both type 1 and type 2 diabetes or of oral medications that stimulate the pancreatic beta cells in the islets of Langerhans [18]. Symptoms of hypoglycemia tend to have a greater severity when they are the result of hyperinsulinemia due to the prevention in the formation of alternative fuels, such as free fatty acids or ketones [9].

Iatrogenic hypoglycemia is the consequence of the relationship of relative insulin surplus (also referred to as absolute insulin surplus) and compromised physiologic and behavioral responses to falling plasma glucose levels in patients with type 1 diabetes and patients with insulin-deficient type 2 diabetes [5,14]. Normally, a decrease in insulin release is the first physiologic defense. An increase in glucagon production is the second, and the third physiologic defense is epinephrine [16]. Epinephrine limits the clearance of glucose in insulin-sensitive tissues. The result of each of these defenses is a sympathoadrenal response, primarily a sympathetic neural response, to hypoglycemia initiating neurogenic symptoms. As a result, behavioral protections, such as hunger, take effect [1]. In some cases, these natural defenses may be compromised.

Chronic hypoglycemia can result in hypoglycemia-associated autonomic failure (HAAF), a syndrome characterized by both defective glucose counter-regulation and hypoglycemia unawareness. This response is common in patients with type 1 diabetes, but can also occur in patients with advanced type 2 diabetes. In patients with HAAF, the epinephrine response to ensuing hypoglycemia is decreased, with adjustments in insulin and glucagon absent [19]. These patients will also experience fewer symptoms of low blood glucose levels due to a decrease in the sympathoadrenal response, resulting in an unawareness of the condition or the need to correct it [13]. Tight control of blood glucose levels and avoidance of hypoglycemia can reverse HAAF within two to three weeks [19].

Research has also indicated that recurrent hypoglycemia can result in increased nitric oxide production by the ventromedial hypothalamus, a mechanism that triggers response to hypoglycemia in patients with HAAF [20]. However, prolonged or excessive nitric oxide production causes an impaired counter-regulatory response. In an animal study, blocking this action with the use of the antioxidant N-acetylcysteine prevented the development of an impaired counter-regulatory response [20].

Nocturnal Hypoglycemia

Nocturnal hypoglycemia is another concern for some diabetes patients. Sleep impairs the counter-regulatory response to hypoglycemia in individuals with or without diabetes [21]. This impairment is caused by a decreased epinephrine response to dropping blood glucose levels during sleep. The result is an increased susceptibility to asymptomatic nocturnal hypoglycemia, particularly for patients with type 1 diabetes. Because it has been established that recurrent hypoglycemia can result in further deficits in counter-regulatory hormone responses, regular nocturnal hypoglycemia can trigger a cycle of hypoglycemia, impaired counter regulatory responses, and decreased awareness of low blood glucose levels while awake or asleep. Patients who experience recurrent asymptomatic nocturnal hypoglycemia are at increased risk for more frequent and severe hypoglycemia [9].

Some patients will experience a rebound reaction to hypoglycemia known as the Somogyi phenomenon [22]. This condition almost exclusively occurs in patients who take long-acting insulin and occurs most often following nocturnal hypoglycemia [22]. Untreated hypoglycemia or a rapid decrease in blood glucose triggers a release of counter-regulatory hormones, resulting in an episode of hyperglycemia and a period of insulin resistance that can persist for hours to days. The insulin resistance and hyperglycemia can lead to ketonuria or ketonemia [1].

The Somogyi effect has not been demonstrated with continuous glucose monitoring data, although there is evidence that it may occur in subgroups of patients with type 1 diabetes [23,24,25].

3. RISK FACTORS

The first step in developing a plan for the prevention and treatment of hypoglycemia is having a solid knowledge of risk factors and strategies to avoid or address those factors [6]. Reduction of hypoglycemia risk factors is an important aspect of the education process for patients with either type 1 or type 2 diabetes. Hypoglycemia risk reduction involves addressing the issues of hypoglycemia at every patient contact [6]. The principals of aggressive glycemic control are necessary to prevent hypoglycemia and include patient education, frequent self-monitoring of blood glucose (SMBG), flexible insulin (or other medication) regimens, individualized glycemic goals, and continuous professional guidance [6,26]. Finally, healthcare providers should consider both conventional risk factors and those indicative of compromised defenses against hypoglycemia and adjust treatment accordingly [10].

INSULIN

Inaccurately timed, an incorrect type, or excessive doses of insulin can result in hypoglycemia. In addition, there can be a diminished exogenous glucose source as a result of a missed meal, skipped snack, extended fast, or exercise [1,6]. The duration of insulin therapy may also be a risk factor for hypoglycemia [27].

WEIGHT LOSS AND WEIGHT-LOSS SURGERY

When patients with diabetes experience weight loss, there is a corresponding increase in insulin sensitivity. Along with weight loss, improved fitness enhances insulin sensitivity by increasing muscle mass and optimizing glucose utilization. If these patients continue on a pre-weight-loss medication or insulin regimen, there is a greater potential of hypoglycemia [10]. Hypoglycemia is a frequent complication for people with diabetes who have undergone metabolic surgery, especially Roux-en-Y gastric bypass, due to the excessive postmeal endogenous insulin secretion. It typically emerges months to years after surgery [6].

ALCOHOL USE

Evidence Based Practice Recommendation

According to the Academy of Nutrition and Dietetics, alcohol consumption may place adults with diabetes at increased risk for delayed hypoglycemia, especially if using insulin or insulin secretagogues. Therefore, adults with diabetes should be advised that if they choose to drink alcohol, they should do so in moderation (i.e., one drink per day or less for adult women and two drinks per day or less for adult men).

https://www.andeal.org/topic.cfm?menu=5305&cat=5595

Last Accessed: February 25, 2026

Level of Evidence/Strength of Recommendation: Weak, Conditional

Use of alcohol also increases the risk of experiencing hypoglycemia. Ethanol impedes gluconeogenesis and inhibits cortisol and hormone responses to hypoglycemia. Severe hypoglycemia can occur when ethanol consumption is coupled with lack of food or overnight fast, resulting in glycogen depletion [9]. Hypoglycemia can be prevented in this case by eating while ingesting any alcohol and limiting alcohol intake [28].

HAAF

As discussed, iatrogenic hypoglycemia is the result of the interplay of relative insulin excess and compromised physiologic and behavioral defenses against dropping plasma glucose concentrations. Risk factors for HAAF include insulin deficiencies, a history of severe hypoglycemia or hypoglycemia unawareness, and aggressive glycemic control therapy [10]. Individuals at risk for hypoglycemia should be screened annually for HAAF. Validated questionnaires for assessing impaired hypoglycemia awareness are available. At a minimum, simply asking the patient "Can you always feel when your blood glucose is low?" can indicate if a more detailed evaluation is needed [6].

HORMONES AND PREGNANCY

Women with diabetes who are of child-bearing age should be acutely aware of potential hypoglycemic episodes. Women are at an increased risk of hypoglycemic events at specific points in their lives, such as at the start of each menstrual cycle, as a result of decreased levels of progesterone. After conception and early in the first trimester, the risk of hypoglycemia is amplified as a result of increases in peripheral utilization and storage of glucose. Late in the third trimester, nocturnal hypoglycemia becomes a concern, as a bedtime snack may be insufficient to meet the intensified fetal demands for glucose. Lastly, during the postpartum phase, the risk of hypoglycemia results from the loss of placental hormones [1].

AGING

As the aging process progresses, an individual's risk of hypoglycemia increases as a result of various behavioral and physical changes. The production of counter-regulatory hormones that are so important to preventing hypoglycemia begins to slow [13]. Additionally, elderly patients frequently are prescribed many medications for various conditions, making polypharmacy a concern. Polypharmacy is relatively common among patients with type 1 and type 2 diabetes due to the multiple comorbidities associated with the disease. However, drugs may interact and increase the risk for hypoglycemia [29].

Behavioral changes, including cognitive decline and changes in eating habits, can also affect hypoglycemia risk [6,30,31]. Elderly patients often have erratic nourishment or caloric intake, and this coupled with oral medications that increase insulin secretion or exogenous insulin significantly increases the potential for hypoglycemia [1]. Even when adequate calories are consumed, the older adult's intestinal absorption of those calories is slowed. As a patient ages, the adrenergic response to low blood glucose diminishes or disappears [13]. Additionally, the preliminary symptoms of hypoglycemia, for instance lack of motor skills or confusion, may be misdiagnosed or unrecognized [29].

Young children also are vulnerable to hypoglycemia due to their reduced ability to recognize hypoglycemic symptoms and effectively communicate their needs [6].

DEPRESSION

In one study of more than 4,000 patients, individuals with diabetes and major depressive disorder were found to be more likely to experience frequent episodes of hypoglycemia than those without depression [32]. In addition, the time to first severe episode of hypoglycemia is shorter in depressed patients. Diabetes distress, while distinct from depression, has unique relationships with glycemia and other outcomes and, once identified, should be acknowledged, addressed, and routinely monitored [6]. It may be helpful to introduce brief coping strategies (e.g., mindful breathing, cognitive reframing) and to highlight past successes to reinforce resilience. When appropriate, referral for follow-up care is recommended [6].

CULTURAL AND ECONOMIC FACTORS

In general, food insecurity, low annual household income, housing instability or living in a socioeconomically deprived area, and being underinsured increases the risk of emergency department visits and hospitalizations for hypoglycemia-related events. Clinicians should also be aware of cultural practices that may influence glycemic management and should recommend that patients with diabetes participate in developmentally and culturally appropriate diabetes self-management education and support [6].

COMPLEMENTARY AND ALTERNATIVE THERAPIES

It is imperative to investigate individuals' use of any alternate therapies due to concerns associated with the usage. Research has demonstrated that less than 40% of individuals inform their primary care providers of their use of complementary or alternative therapy [33,34]. Furthermore, patients with diabetes who used some form of complementary or alternative therapy in the past year for treatment and/or wellness varies; the majority of research shows that between 25% and 40% of patients with diabetes use complementary and alternative modalities, while some smaller studies have shown use as high as 88% [35,36,37,38]. Therefore, inquiring about the use of these therapies, particularly the use of herbal medications, should be incorporated into each instance of patient contact.

The use of some complementary or alternative therapies can increase the risk of hypoglycemia and may be a concern for many reasons. Some concerns include:

- Potential side effects

- Drug interactions

- Product variability

- Lack of product standardization

- Possibility of contamination

- Possibility of misidentification

Side effects and drug interactions are the two most significant areas of concern. Serious side effects have been experienced by patients taking complementary therapies, and the risk of drug interactions is a particular concern for patients with existing conditions, such as diabetes. Concomitant use of complementary therapies in these patients may result in toxicity secondary to exaggerated or subtherapeutic effects of their medication [39].

There are a variety of botanical or complementary therapies that pose a specific risk of hypoglycemia in patients with diabetes. These include cinnamon, fenugreek, bitter melon, ginseng, nopal, aloe, banaba, caiapo, bilberry, and milk thistle [40].

Cinnamon

Cinnamon is derived from the bark of an evergreen tree that grows in tropical climates. This product has an active compound, hydroxychalcone, that may lower blood glucose and lipid levels in patients with diabetes, although research has been mixed [41,42]. Some patients will take cinnamon to help control blood glucose levels despite the lack of proof of efficacy. It is possible that the effects of hydroxychalcone may potentiate the effects of secretagogue agents, increasing the risk of hypoglycemia [39].

Fenugreek

Fenugreek is a member of the Leguminosae family along with chickpeas, green peas, and peanuts. Historically, this herb was used to induce labor, but today it is used for diabetes, loss of appetite, and stimulation of milk production in breastfeeding women [43]. The active compounds of fenugreek include saponins and glycosides, and the seeds contain alkaloids, 4-hydroxyisoleucine, and fenugreekine, which delay gastric emptying, resulting in slow carbohydrate absorption, glucose transport inhibition, increased insulin receptors, improved peripheral glucose utilization, and possible stimulation of insulin secretion [39]. In diabetes patients, these effects may result in hypoglycemia [40].

Bitter Melon

Bitter melon is a vegetable cultivated in India, Asia, South America, and Africa and may also be known as bitter gourd, bitter apple, bitter cucumber, karolla, or karela. It is the most widely used diabetes treatment in Ayurveda, a form of traditional medicine originating in India [44,45]. The active compounds in this vegetable include momordin, charantin, polypeptide P, and vicine. Use of bitter melon, usually in the form of juice or tea, can cause hypoglycemia, hypoglycemia-induced coma, increased tissue uptake of glucose, inhibition of enzymes involved in glucose production, and enhanced glucose oxidation of glucose-6-phosphate-dehydrogenase pathways [39]. Specific attention is required and intensive education is necessary when bitter melon is taken in conjunction with an insulin secretagogue [1].

Ginseng

Ginseng is a popular botanical product traditionally used to support overall health and the immune system [46]. The active ingredient in ginseng is ginsenoside, which decreases carbohydrate absorption in portal circulation and may increase glucose transport and modulation of insulin secretion when taken with an insulin secretagogue [40]. However, it is important to note that there is no conclusive evidence supporting any health benefits of ginseng [46]. A 2022 review of 20 studies (1,295 participants) found that Asian ginseng improved many cardiometabolic factors in people with prediabetes and diabetes, including fasting blood glucose levels, total cholesterol, and certain inflammatory markers. However, research on the use of Asian ginseng for improving blood sugar control in people with diabetes is overall inconclusive and conflicting [46].

Nopal

Nopal, also known as prickly pear, is a member of the cactus family and is a food source in Mexico. It is also used as an antihyperglycemic in Mexican culture [47]. The active compounds in nopales are mucopolysaccharide fibers and pectin, which slow the absorption of carbohydrate, decrease lipid absorption, and increase insulin sensitivity [39,47]. As a result, there may be an improvement in blood glucose levels without hypoglycemia, but further research is necessary to confirm the efficacy and safety of this use. In the United States, the use of nopal is usually limited to Mexican and Native American populations [1].

Aloe Vera

Aloe vera is a common desert plant belonging to the family Liliaceae. The gel of aloe leaves has traditionally been used topically to soothe and heal wounds [48]. The active chemical constituent of aloe is glucomannan, a polysaccharide similar to guar gum and glycoprotein. Glucomannan has the potential to increase and promote glucose uptake. As a result, hypoglycemia can occur when aloe is consumed, particularly when used in combination with a secretagogue [39].

Banaba

Banaba is a type of crape myrtle commonly found in the Philippines, India, Malaysia, and Australia [39]. Commonly used as a tea to treat diabetes and promote weight loss, banaba has the chemical components corsolic acid and ellagitannin, which stimulate glucose uptake [40]. Banaba also has an insulin-like activity secondary to activation of insulin receptor tyrosine kinase or inhibition of tyrosine phosphate. Concurrent use of banaba and oral diabetes medication or insulin may result in an increased risk for hypoglycemia [39].

Caiapo

Caiapo is a form of white sweet potato cultivated in the mountains of Japan and South America. The botanical product is commonly used by Native Americans to decrease thirst and promote weight loss [39]. The active compound in caiapo is acidic glycoprotein, which decreases insulin resistance and improves insulin sensitivity. As a result, there is an increased potential for hypoglycemia, particularly when used with a secretagogue.

Bilberry

Bilberry is a plant related to the American blueberry, huckleberry, and cranberry. Two forms of bilberry may be used: the berry and the leaf. The fruit is used for circulatory problems, diarrhea, eye disorders, and menstrual cramps, while the leaf is used for other conditions, including diabetes [49]. The active compounds of bilberry leaf are anthocyanosides and chromium [39]. These components increase the potential for hypoglycemia due to the decreased vascular permeability and redistribution of microvascular blood flow. Research is still being completed to determine the exact mechanism by which bilberry lowers blood glucose [40].

Milk Thistle

Milk thistle is related to daisies and other thistles and has been used extensively for various hepatic disorders [50]. The active components are silybin, silychristin, and silydianin. These compounds inhibit the hepatotoxin-binding hepatocyte membrane receptors and decrease glutathione oxidation [39]. The resultant blood glucose-lowering effects and potential for hypoglycemia are being studied [1].

Case Study

Patient A arrives at her primary care provider's office for a routine examination. She is a Native American woman, 45 years of age, who is 5 feet 4 inches tall and weighs 205 pounds, with a body mass index of 35.3 kg/m2. Her physician is concerned because of her family history of type 2 diabetes, heart disease, and stroke. Patient A has a past medical history of hypertension and hyperlipidemia. Her blood work reveals an HbA1c of 8.0% (estimated average glucose: 183 mg/dL) and a fasting blood glucose level of 173 mg/dL. A diagnosis of type 2 diabetes is confirmed by further blood work. Patient A is reluctant to start medications and asks her primary care provider if he knows of any alternative therapies she could use instead. After a thorough explanation regarding the benefits of glycemic control in respect to her family and personal past medical history, Patient A agrees to start taking metformin. She is also referred to a diabetes self-management education program recognized by the American Diabetes Association (ADA) for information regarding SMBG, medication management, exercise, blood glucose goals and behavior change, and culturally sensitive meal planning.

Patient A returns in three months for a follow-up evaluation of her progress. Her HbA1c remains 8.0% (estimated average glucose: 183 mg/dL), and she states her fasting blood glucose levels are 185–220 mg/dL. She states she has been adherent to her meal plan and has been working outside more often to increase her activity level. She appears frustrated with the lack of improvement.

Her primary care provider decides to add a sulfonylurea to the patient's therapy to increase insulin production. Patient A is started on glipizide 10 mg twice per day. Additional education is completed regarding the action of glipizide as well as the potential side effects and the importance of eating meals on a consistent schedule to prevent hypoglycemia. The patient and her daughter were both instructed on recognition of signs and symptoms of hypoglycemia and treatment options. Patient A is able to verbalize all instructions given.

One month later, Patient A's daughter calls the primary care provider in the mid-morning to report that her mother was working out in the yard and became dizzy, shaky, sweaty, and confused. She is instructed to check Patient A's blood glucose level and treat for possible hypoglycemia. After the patient's blood glucose levels are stabilized, the daughter is told to bring the patient to the clinic. The initial blood glucose level is 43 mg/dL. After Patient A consumes 6 ounces of orange juice, the blood glucose is rechecked in 15 minutes. The result is 87 mg/dL.

At the clinic, the certified diabetes educator assesses Patient A's medication understanding and adherence. No adverse practices are identified, so further information gathering is completed.

Rationale and comments : From the information gathered so far, it is unclear what caused Patient A's hypoglycemia. Additional areas should be explored, including:

- Timing of medication and meals

- Breakfast intake

- Blood glucose level prior to working in the yard

- Other episodes of hypoglycemia

- Fasting blood glucose levels

The diabetes educator requests Patient A recall her breakfast, which reveals the intake of two scrambled eggs, one slice of whole-wheat toast with butter, half of a banana, 8 ounces of fat-free milk, and a cup of tea. The educator also inquires about any use of holistic or herbal remedies. Patient A becomes quiet and is hesitant to answer, but finally reveals she has been drinking bilberry tea every morning and using nopal and bitter melon in most of her meals. The patient indicates she did not share this with her primary care provider because she did not feel it was important. The diabetes educator informs Patient A about the potential interactions of many herbal medications and the impact they could be having on her diabetes and other conditions. The importance of including these medications in her conversations with all of her healthcare providers is stressed. As a result, Patient A's primary care provider decides to decrease her glipizide to 5 mg twice a day. The patient is also instructed to call the diabetes nurse with a week of blood glucose levels to determine the success of the change in therapy.

4. SIGNS AND SYMPTOMS OF HYPOGLYCEMIA

Hypoglycemia is a serious and real threat to diabetes patients. Patient education must emphasize the early recognition of hypoglycemic states to assure the condition is treated promptly [51].

Symptoms of hypoglycemia are categorized by the acute response and progress in severity of the reaction. Initially, symptoms of hypoglycemia are a result of adrenergic effects that occur secondary to the release of catecholamine. These symptoms include sweating, weakness, shakiness, tremors, anxiety, faintness, tachycardia, and palpitations [6,52].

As hypoglycemia progresses and plasma blood glucose levels continue to decrease, the reaction to the lack of glucose becomes more severe. Symptoms in this stage are the result of the deficit of glucose in the central nervous system and include confusion, irritability, diplopia, inappropriate affect, motor incoordination, headache, abnormal behavior, weakness, and convulsions. The most severe of the central nervous system symptoms are diabetic coma and death [52].

More than half of all severe hypoglycemia episodes occur during sleep, when symptoms are less likely to be detected or recognized [22]. Nocturnal hypoglycemia most typically is caused by excessive insulin therapy and, with great cause for concern, usually does not awaken the person. Patients should be aware of symptoms that may indicate nocturnal hypoglycemia, such as morning headaches, feeling "foggy" in the morning, difficulty awakening, psychological changes, exhaustion, restlessness while sleeping, night sweats, nightmares, and loud respirations [9]. Additionally, unusually high blood glucose levels after breakfast or lunch or detection of a small amount of ketones but no glucose in the morning urine are signs of nocturnal hypoglycemia [22].

CASE STUDY

Patient B is a White adolescent, 15 years of age, with a five-year history of type 1 diabetes. He is on multiple daily injections of insulin glargine for his background insulin and a rapid-acting insulin analog for meal and correction boluses. Patient B has experienced a roller-coaster effect with his glucose levels, and he has had difficulty in school recently due to fatigue and headaches. Patient B states he has not been sleeping well at night and wakes up exhausted. When asked to recall his blood glucose levels, he states his morning glucose levels have ranged between 189 mg/dL and 215 mg/dL. The primary care physician suspects nocturnal hypoglycemia and possible Somogyi phenomenon.

Rationale and comments : Nocturnal hypoglycemia is indicated by several signs and symptoms. The patient has experienced:

- Headaches and fatigue

- High blood glucose levels in the morning

- Waking up exhausted

These are all signs of nocturnal hypoglycemia.

The physician instructs Patient B to assess his blood glucose level at 3 a.m. to identify if Somogyi phenomenon is an issue. She also prescribes the use of a continuous glucose sensor to assess blood glucose patterns and hyperglycemia/hypoglycemia events that may be occurring without being noticed.

5. CAUSES OF HYPOGLYCEMIA

The frequency of hypoglycemia in patients with diabetes is due primarily to abnormalities in glucose counter-regulation. There is a multitude of potential causes of hypoglycemia, including, but not limited to, excessive oral and injectable medications, physical activity, illness, and inappropriate patient practices [1].

ORAL MEDICATIONS

The appropriate use of diabetes medications requires an understanding of the mechanisms of action of each agent. This understanding should decrease incidents of hypoglycemia. Patients taking oral medications for diabetes who may be at an increased risk for hypoglycemia are often thin, are taking an insulin secretagogue, and/or have erratic eating patterns. This is especially true when a patient is taking medications with a rapid onset of action.

Sulfonylurea medications, such as glyburide, glipizide, and glimepiride, are associated with an increased risk for hypoglycemia due to their mechanisms of action. Sulfonylurea preparations appear to acutely lower blood glucose levels by stimulating the release of insulin from the pancreas, an effect dependent upon functioning beta cells in the pancreatic islets [53,54]. These agents close the energy-sensitive potassium channel in the cell membrane of the pancreatic beta cell. By accomplishing this, there is an increased amount of available insulin [51]. It is important to note that individuals with impaired first-phase insulin release will experience a diminished effect from sulfonylurea therapy [1].

The nonsulfonylurea secretagogues, or glinides, are hypoglycemic agents with the potential to reduce blood glucose levels to below normal. Within this classification of hypoglycemic agents there are two medications: repaglinide and nateglinide [54,55]. These agents lower blood glucose levels by stimulating the release of insulin from functioning beta cells in the pancreas. Insulin release is glucose-dependent and diminishes at low glucose concentrations. These agents are most effective when taken just prior to the first intake of a meal [55]. This results in a greater insulin release during the first phase.

INSULIN

Insulin can be divided into two categories: basal and bolus. Healthy pancreatic beta cells release insulin into the blood stream throughout the day. This basal or background insulin enables stored fat and glucose to be released in the correct amounts to enable adequate metabolism during times when a person is not eating. This steady insulin level throughout the day regulates glucose production by the liver, the production and release of fat as fuel, and the entry of particular amino acids into cells for the creation of enzymes and structural proteins. Individuals without diabetes release about half of their total daily insulin requirements as background insulin to fulfill these needs [22]. As food is consumed, it is converted to glucose and other energy precursors by the digestive system. In response to rising blood glucose levels, the beta cells of the pancreas are stimulated to produce and release insulin. This is known as bolus insulin release [1].

When an individual's pancreatic beta cells are no longer proficient in producing enough or any insulin, exogenous insulin is required [1]. This can be accomplished utilizing many differing preparations. Previous therapies were formulated from beef or pork insulin, which were the only available synthetic forms of human insulin. Today, recombinant human insulin is available and is used by most persons requiring insulin therapy. The modern human recombinant insulin differs from the pork insulin by only one amino acid and beef preparations by three amino acids [22]. Insulin injections, in small amounts, provide the body with the needed hormone to adjust to plasma glucose levels. However, unregulated and sustained hyperinsulinemia is common with exogenous insulin [10].

Unfortunately, hypoglycemia is the most important limiting factor for insulin adjustments to improve glycemic control. The risk of hypoglycemia depends on multiple factors, including age, weight, degree of insulin resistance, duration of the disease process, duration of insulin therapy, degree of glycemic control, and past history of episodes. In addition, there are casual factors that can instigate an episode of hypoglycemia, such as over administration of insulin, dietary transgressions, unplanned strenuous exercise while taking insulin, excessive alcohol intake, and hypoglycemia unawareness [6]. According to various studies, the annual incidence of severe hypoglycemia in the person with type 2 diabetes is 2% to 13% [56,57]. Although the severe hypoglycemia experienced by the insulin-treated type 2 diabetes group is not trivial, the rate of severe hypoglycemia demonstrated by the type 1 diabetes individual during the Diabetes Control and Complication Trial was far greater. Of individuals treated with intensive insulin therapy during this study, 65% suffered severe hypoglycemic reactions requiring assistance from another individual for recovery [13].

Patients using insulin for the treatment of diabetes require extensive education regarding preparation and administration, as inaccurate dosing is a significant threat. If a patient is unable to fully visualize the small incremental markings on the syringe, the chance of dosing error is increased. The result of medication errors can be severe hypoglycemia, seizures, and possibly even death. For patients with poor vision, the insulin pen may be a better option and may increase the safety for the individual. Patients should demonstrate their techniques for preparation, site selection and preparation, and administration. This allows for a thorough assessment of potential risk factors for hypoglycemia [1].

The development of hypoglycemia is a concern for all individuals on an insulin therapy regimen. Education should include information regarding oral and injectable combination medication management, exercise considerations, and specific patient-centered issues to maintain safe use of medications in daily life [1].

Evidence Based Practice Recommendation

For individuals using fixed insulin doses (or insulin secretagogues), the Academy of Nutrition and Dietetics asserts that consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce risk for hypoglycemia.

https://www.andeal.org/topic.cfm?menu=5305&cat=5595

Last Accessed: February 25, 2026

Level of Evidence/Strength of Recommendation: Fair, Conditional

Insulin alone or in combination with another antihyperglycemic agent increase the potential for an adverse hypoglycemia reaction [58]. Preventative measures include not skipping meals, eating prior to exercise, and appropriately timing insulin bolus therapy [58,59].

Accurate and frequent SMBG is recommended for all patients who use insulin. SMBG can help prevent hypoglycemia and provide information relevant to adjusting food intake, activity level, and medication [6]. Patients should report frequent blood glucose levels below 70 mg/dL to their primary care provider [60]. This will allow for the fine tuning of the insulin regimen, which should result in optimized glycemic control and reduction of adverse outcomes [1]. Nocturnal hypoglycemia can be an issue for patients taking insulin, and those who have or who are suspected to have nocturnal hypoglycemia as a result of insulin therapy should monitor their blood glucose levels [1].

For patients on an insulin regimen, exercise can significantly increase the potential for hypoglycemia [61]. Education related to exercise should focus on the assessment of pre-exercise blood glucose levels and determination if additional carbohydrates are needed. The risk for hypoglycemia increases as the duration or intensity of the activity increases. SMBG also can be used to monitor how psychological and physical stressors influence glycemic responses [62]. Correlating SMBG results with the presence of stressors can help the patient manage them better for glycemic control.

Case Study

Patient I is an African American man, 72 years of age, with a 15-year history of type 2 diabetes. He has experienced diabetes-related complications, including a transient ischemic attack, angioplasty for coronary heart disease, renal impairment, and hypertension. His glycemic control has diminished steadily over the past two years to a current HbA1c of 8.9% (estimated average glucose: 209 mg/dL). Patient I has been very hesitant to start insulin therapy because of the experiences of past family members. He states, "As soon as I start on the needle, my life is over." After multiple educational opportunities regarding the benefits of good glycemic control and how it can diminish the adverse effects of his diabetes, Patient I ultimately agrees to a change in treatment therapy to include insulin injections. The physician prescribes neutral protamine Hagedorn (NPH) insulin 10 units twice per day due to cost factors over the more expensive long-acting insulin.

One morning, Patient I's wife calls emergency services reporting that Patient I is combative, confused, sweating, and beginning to lose consciousness. She is able to pour a large glass of orange juice in his mouth. She states, "I wanted to make sure it worked, so I put 5 tablespoons of sugar in it." When the patient arrives in the emergency department his blood glucose level is 357 mg/dL and he is complaining of chest pain. The decision is made to admit Patient I for further observation and glucose management. He is ordered weight-based insulin correction for glucose control. His NPH insulin is put on hold. The next morning, Patient I has a blood glucose level of 313 mg/dL. His glucose is covered, and the physician orders his home dose of NPH insulin 10 units. Patient I refuses his dose because it made him, "sicker than I was before. I was brought here because it doesn't work." The nurse explains the action of the insulin in relationship to his blood glucose levels and the action of the NPH, again stressing the benefits of adequate glucose control and the detrimental effects of hyperglycemia. The patient remains adamant that he is not going to take insulin again. His primary care provider discusses the need for the insulin therapy, and Patient I agrees to take the insulin while he is in the hospital and staff is around in case he "gets into trouble." After 24 hours, the patient has blood glucose levels less than 150 mg/dL and states he is feeling better than he has in many months. Through education regarding insulin, the connection is made between the increased perception of health and the decrease in blood glucose levels.

Patient I agrees to try insulin at home again. When it is time for his next dose of NPH, the nurse brings in the vial and a syringe to assess his ability to successfully draw up the 10 units of insulin. Observation reveals that the patient is struggling to complete the task competently and has actually drawn up 16 units of insulin opposed to 10 units. When his attention is drawn to the excessive amount of insulin in the syringe, he states, "Those little lines are so hard to see even with my glasses on. I figured the amount is so small it shouldn't hurt me." Patient I also struggles to manipulate the vial and syringe to the extent of the needle bending within the bottle.

Rationale and comments : There are several options available to Patient I to ensure he is receiving the correct amount of insulin. A Magni-Guide may be helpful to increase visualization of the syringe markings. A refrigerator vial stabilization device may also be considered to allow for greater stabilization of the needle when preparing the insulin syringe. The wife's willingness to learn how to draw up insulin into the syringe should be assessed. Once taught, her ability to accurately prepare the insulin syringe should be observed. Finally, the best option may be utilizing an insulin pen, which can increase patient safety.

The treatment options are discussed with Patient I and his wife, and they decide to investigate the use of an insulin pen. The patient calls his insurance company to evaluate the coverage and is happy to hear the insulin pen is covered due to his recent hypoglycemia experience. Patient I and his wife are both taught how to dial the correct amount of insulin units, how to change insulin pen needles, and how to appropriately dispose of needles. Both individuals are able to perform all vital components taught regarding insulin pen usage and safely return home.

INSULIN PUMP THERAPY

Some patients may use a form of insulin delivery known as continuous subcutaneous insulin therapy, or insulin pump therapy. Insulin pumps are small, battery-operated microcomputers that resemble a standard pager device in size and appearance. This therapy is used most often for individuals with type 1 diabetes, although it is an option for some patients with type 2 diabetes. In contrast to multiple daily injections of rapid- and long-acting insulins, the insulin pump delivery system works to mimic normal pancreatic function [22]. This is accomplished by the steady release of precise amounts of insulin from the pump to achieve the basal or background insulin the body requires and optimize metabolic homeostasis. Likewise, when food is consumed, the individual or care provider enters the amount of carbohydrate and the pump calculates the correct dose and recommends a bolus dose. The individual can accept or enter an alternate bolus. Insulin pumps only use rapid-acting insulin to increase the ability of the pump to imitate normal pancreatic functioning [1].

In 2016, the U.S. Food and Drug Administration (FDA) approved the first automated insulin-delivery device for individuals 14 years of age and older with type 1 diabetes. In 2018, the FDA expanded the approval to include individuals 7 to 13 years of age with type 1 diabetes [63]. The device is a hybrid closed-looped system that automatically monitors glucose and provides appropriate basal insulin doses. It measures glucose levels every five minutes and automatically administers or withholds insulin, depending on the level of glucose measured. The device requires little to no input from the user.

A major advantage of insulin pumps is the opportunity for tight blood glucose control. This is possible because insulin delivery becomes very similar to the normal physiologic pattern. Pumps also offer the benefit of a more normal lifestyle, allowing users more flexibility with meal and activity patterns.

Although patients utilizing insulin pump therapy have been proven to achieve better glycemic control, they are not immune to hypoglycemia, and even with the introduction of this technology, hypoglycemia rates have been relatively unchanged for decades. Inappropriate carbohydrate counting or overriding the recommended bolus dose can lead to overdosing and ultimately hypoglycemia. Furthermore, if a meal bolus is programmed and delivered and the meal is interrupted or missed, hypoglycemia may result. As when any form of insulin is injected into the body, the potential of hypoglycemia is increased with planned or unexpected exercise. Lastly, stress can increase the release of adrenocorticotropic hormone and corticotrophin-releasing hormone, resulting in an increase in circulating blood glucose [18]. This stress can be the result of positive or happy events or as a response to negative events. If the pump was programmed for deliveries to meet known stress needs, hypoglycemia may develop when the stressors are removed without adjusting the total insulin delivery [22].

The ADA provides guidelines for the selection of patients appropriate for pump use [64]. Candidates should be highly motivated to take a great deal of responsibility for the care of their diabetes on a day-to-day basis. This includes the ability to count carbohydrate grams, to calculate appropriate bolus dosing, to make adjustments for varying activity patterns, and to monitor blood glucose four to seven times per day.

Healthcare professionals should be aware of these devices and their recommended uses and should be able to access the resources needed to use them. Given the rapid pace of changes in technology, these devices will likely require frequent updates to their software and/or hardware. Periodic education will help keep healthcare professionals informed and updated and able to help keep their patients with diabetes informed as well [6].

Case Study

Patient K is a defense attorney in a busy, prestigious law firm. She has dealt with type 1 diabetes since her diagnosis at the age of 13 years. She was started on an insulin pump in order to level out her blood glucose control and improve her overall health and has been happy with the results. Patient K is invited to play in a softball game prior to the barbeque at the annual neighborhood picnic. She feels it would be a good idea to get a little exercise because she has spent much of the day sitting and relaxing while talking with her friends. In the middle of the game, the patient suddenly becomes weak, diaphoretic, shaky, and confused—clear signs of hypoglycemia.

Rationale and comments : Several factors most likely contributed to Patient K developing hypoglycemia, the most significant being her engagement in exercise (unplanned) prior to eating her meal. In addition, the patient is away from the stress of her job and is relaxing, which is lowering her stress hormones. Together, these conditions are to blame for her hypoglycemic episode.

EXERCISE

Evidence Based Practice Recommendation

Individual glycemic response patterns can differ markedly with exercise; therefore, the Academy of Nutrition and Dietetics recommends that persons with diabetes taking insulin or insulin secretagogues use glucose monitoring and recognition of glucose patterns to make decisions to exercise safely.

https://www.andeal.org/topic.cfm?menu=5305&cat=5595

Last Accessed: February 25, 2026

Level of Evidence/Strength of Recommendation: Consensus, Conditional

Individuals on an insulin therapy regimen should have a clear understanding of the risk of hypoglycemia related to exercise. Strenuous or aerobic exercise raises the blood glucose levels initially, but these levels will decrease as the body re-establishes its stores [65]. Although an initial increase in blood glucose levels will be seen, the potential for hypoglycemia can last up to 72 hours after stopping exercise. This is due to the physiologic reaction of fuel mobilization for energy release. When an individual is exercising at maximal levels, the body's energy level demands increase up to 20-fold in comparison to the resting state. In an attempt to maintain homeostasis and prevent hypoglycemia, several regulatory mechanisms are activated. Initially, skeletal muscles break down their own stores of glycogen, triglycerides, and free fatty acids from adipose tissue. In order to mobilize extramuscular stores, hormonal adjustments are essential. In the early phase of exercise, hepatic glucose production is increased by a reduction of insulin levels and unchanged glucagon levels. In subsequent stages, glucagon and catecholamine levels are elevated. As a result, glucose levels in healthy individuals remain fairly constant during exercise. When individuals with diabetes engage in moderate- or high-intensity exercise on a regular basis, however, the result is a decrease in blood glucose levels and increased insulin sensitivity [65]. Helping patients with diabetes to understand this sophisticated balance of fuel and energy metabolism is vital in the prevention of hypoglycemia [1].

PATIENT ISSUES

Other significant causes of hypoglycemia are patient behaviors and choices. Patient-related risk factors, such as meal timing and accurate administration of medications, are particular concerns when insulin or oral antihyperglycemic agents that increase the production of insulin from the pancreatic beta cells are used [66]. Meal timing is a key component of insulin, sulfonylurea, and nonsulfonylurea insulin secretagogue therapy. Also, vision and manual dexterity are necessary to administer injectable medications and should be assessed in all individuals new to insulin therapy. Likewise, cognitive function is a consideration when caring for persons utilizing any medication, oral or injectable. Rapid-acting oral agents, such as repaglinide and nateglinide, are taken just prior to the first bite of a meal; if short-term memory is an issue, special caution and instructions are required [1]. In many cases, clear and complete patient education may alleviate these factors. However, if cognitive or physical deficits are an issue, involvement of a caregiver and/or the use of adaptive tools may be necessary.

Case Study

Patient G is a White man, 85 years of age, with a long history of type 2 diabetes. The nurse conducts a home health care visit for home assessment and medication evaluation. The patient indicates that his blood glucose levels are consistently in the high 200s, including in the mornings and at night. The nurse reviews the medications remaining in his weekly pill box to assess medication adherence and notes that he has been missing multiple medications throughout the week, including the medication to help control his blood glucose levels. Patient G states that when he realizes he has missed the medication, he is afraid to take it. The nurse informs the patient's physician of the findings, and the patient's regimen is changed to repaglinide 2 mg just prior to each of the three biggest meals. The instructions are given to Patient G, and he states understanding and is able to verbalize when to take the medication.

The nurse returns to Patient G's home three days later to assess his tolerance to the new medication. When the nurse arrives at 9 a.m., the patient is in a state of confusion, diaphoresis, and shakiness. His blood glucose level is 48 mg/dL. The nurse provides adequate treatment, and Patient G is then able to help determine what precipitated the episode of hypoglycemia. The patient reports that he took the repaglinide pill at 7:15 a.m., but he had not consumed breakfast. The nurse works with Patient G to develop a plan to avoid skipping meals. They decide that the patient will make his breakfast each day and elicit the assistance of his daughter to remind him to take the repaglinide when she talks to him each morning. The daughter also agrees to check in after lunch and dinner to assure that the patient is taking the repaglinide as he should at all meals.

6. TREATMENT OF HYPOGLYCEMIA

Treatment of hypoglycemia is fairly straightforward when the cause is known. When symptoms are mild-to-moderate and the patient is able to communicate and swallow, treatment is usually administered via the oral route. In most cases, hypoglycemia may be reversed by adhering to the 15:15 rule [1]. The 15:15 rule is simply defined as utilizing 15 grams of carbohydrate and rechecking the blood glucose in 15 minutes [6]. If the blood glucose level is less than 70 mg/dL, with or without the presence of hypoglycemia symptoms, another 15 grams of carbohydrate should be administered and the blood glucose level should be checked again [66,67]. When the blood glucose level is greater than 70 mg/dL, treatment should be stopped. Examples of foods that provide 15 grams of carbohydrate include three glucose tablets (sold in most pharmacies), one-half can of regular soda, 4 ounces of fruit juice, 2 tablespoons of raisins, 1 tablespoon of sugar, or 8 ounces of non-fat milk [1].

It may take up to 30 minutes for complete resolution of hypoglycemia symptoms following treatment. A common mistake when treating hypoglycemia is continuing the administration of glucose regardless of blood glucose levels because symptoms persist. This can lead to overtreatment and rebound hyperglycemia. When the blood glucose level is greater than 70 mg/dL, the individual should consume a snack consisting of a carbohydrate and a protein to prevent rebound hypoglycemia. This snack could include half of a peanut butter sandwich, crackers and cheese, or half of a ham or turkey sandwich [66].

Episodes of severe hypoglycemia, in which the individual has the potential of becoming comatose, combative, and/or unable to swallow, require more direct and immediate treatment [1]. In cases when a person may be combative but still able to swallow, treatment options include administering a tube of glucose gel or 1 to 2 tablespoons of honey into the cheek to raise blood glucose levels [22]. When the individual is no longer able to cooperate or is unconscious, the options decrease significantly. In cases when the individual is in an acute care facility and has an intravenous access line, the treatment is 50% dextrose. The dose of dextrose is calculated using the formula (100 - blood glucose level) x 0.4. This equation will indicate the amount of 50% dextrose in milliliters to be administered intravenously [1].

Although this treatment is very effective, hypoglycemia does not always occur within the hospital or when intravenous access is available. In these instances, the option for treatment is glucagon [66]. Glucagon is a polypeptide hormone typically secreted by the alpha cells of the pancreas. It increases the blood glucose level by stimulating the liver to change stored glycogen to glucose. Glucagon opposes the action of insulin, and it is used as an injection to reverse hypoglycemia and insulin shock in patients with diabetes. Glucagon also increases the use of fats and excess amino acids for energy production [68]. Glucagon can be given intramuscularly, intravenously, or subcutaneously. For individuals who weigh 20 kg or more, the appropriate dose is 1 mg. For children weighing less than 20 kg, the appropriate dose is 0.5 mg or 20–30 mcg/kg. Treatment can be repeated if unsuccessful but should not exceed a maximum of 1 mg for children [58]. In 2019, the FDA approved the first non-injection glucagon therapy for the treatment of severe hypoglycemia in persons 4 years of age or older [69]. The new product is a nasal powder packaged in a single-use dispenser. Glucagon can be kept at room temperature, and it is suggested that it should be available at all times [1]. Those in close contact with individuals with diabetes (e.g., family, roommates, school personnel, staff, coworkers) should be instructed on the use of glucagon, including where it is kept and when and how to administer it [6].

Treatment of mild, moderate, or severe hypoglycemia in patients who use insulin pumps is similar to the treatment of all patients. However, because insulin pumps administer a rapid-acting insulin analog with a short half-life, removal of the pump may resolve mild-to-moderate hypoglycemia symptoms independent of any other intervention, depending on severity. In cases of severe hypoglycemia, treatment should be provided as described, with the additional need to immediately remove the insulin pump to prevent resistance to hypoglycemia treatment [22].

7. PATIENT EDUCATION

Prevention is the best and most effective intervention for hypoglycemia. Hypoglycemia prevention is a key patient education topic and should be discussed at every interaction with the individual. Education should include information regarding oral medication management, insulin therapy, exercise considerations, SMBG, hypoglycemia awareness, and specific patient-centered issues to maintain safe use of medications in daily life [1,6]. Many healthcare providers believe self-management education is best completed by a certified diabetes educator prepared to do this type of formal education. This is true, but consistent reinforcement is needed and is best done by each healthcare provider in the form of teachable moments while interacting with the patient [70]. Individuals who actively manage their own diabetes care have better outcomes than those who do not. For these reasons, an educational approach that facilitates informed decision making on the part of the patient is widely advocated [71]. It is important to tailor teaching to an individual's specific literacy and comfort level. This will guide the educational interaction. Encompassing a variety of theories and teaching styles is paramount [72]. Patient education is a vital aspect in preventing adverse effects and detrimental outcomes related to medication therapy with diabetes. Each category of medication is associated with specific instructions to prevent hypoglycemic episodes [1].

For patients receiving medication therapy for diabetes, strategies to prevent hypoglycemia include not skipping meals and eating prior to exercise. Additionally, patients should be advised regarding the proper steps if a medication dose is missed. Most medication preparations should be taken as soon as the missed dose is realized, but there are a few exceptions. If the medication is either repaglinide or nateglinide or if it is too close to the time of the next dose, the missed dose should be skipped [58].

Patients should also receive thorough education related to the signs and symptoms of hypoglycemia [6]:

- Dizziness/lightheadedness

- Numbness or tingling around the mouth

- Palpitations

- Confusion

- Shaking

- Sweating

- Irritability/nervousness

- Hunger

- Headache

- Weakness

These signs and symptoms of hypoglycemia should be stressed at each patient education session.

Patient education regarding the treatment of hypoglycemia consists mainly of reinforcement of the 15:15 rule. It is critical that each patient, as well as the support person or caregiver, is aware of the steps to be taken in cases of severe hypoglycemia, when the individual is unable to swallow and has a potential of choking. In these situations, the only treatment available is an intramuscular injection of glucagon [13].

ORAL MEDICATIONS

Fundamental topics for all individuals taking a medication to prevent and/or correct hyperglycemia include [1,58,66]:

- Adherence to the medication regimen

- Adherence to the meal and exercise regimen

- Importance of wearing medical identification at all times

- Physician notification of frequent hypoglycemia or continued, unresolved hyperglycemia

Sulfonylurea medications should be taken with breakfast or the first main meal of the day to maximize effect and safety [58]. Patients taking a sulfonylurea should also space meals no more than four hours apart and avoid situations when meals have the potential of being missed [1]. Patients may carry a rapid-acting glucose source, such as glucose tablets or gel, in order to swiftly treat the onset of hypoglycemia in the initial stages [58]. Safe alcohol consumption practices are also essential when a treatment regimen includes a sulfonylurea agent [66].

As with the sulfonylureas, timing is essential for the prevention of hypoglycemia when utilizing nonsulfonylurea secretagogues (i.e., repaglinide and nateglinide). Patients should be instructed to take the medication no more than 30 minutes prior to the meal; often, the medication is taken with the first bite of the meal [58,66]. If a meal is to be skipped, the patient should also skip the prescribed dose of the medication [58].

Patients prescribed acarbose or miglitol require special consideration. These patients (and/or caregivers) should receive instruction regarding the need to take the medication with the first bite of each main meal [58]. Instruction regarding the action of these alpha-glucosidase inhibitors and the prompt treatment of hypoglycemia with simple sugar sources is imperative. Patients also benefit from carrying glucose tablets or gel at all times [66]. People taking acarbose should treat hypoglycemia with only pure glucose, as acarbose inhibits sucrose breakdown, potentially delaying correction of hypoglycemia if sucrose-containing carbohydrates are used [6].

INSULIN

When an individual is being treated with insulin, patient education needs include the signs and symptoms of hypoglycemia, treatment of hypoglycemia, safe preparation of insulin, and meal planning [66]. Healthcare professionals should assess each patient's ability to adequately see the markings on the small insulin syringe. If this cannot be satisfactorily met, visual aids (e.g., magnifiers) or insulin pens should be considered.

Caregivers and close family members or friends should receive information regarding prevention and treatment of hypoglycemia and providing a safe environment for the individual should hypoglycemia occur [1,6]. Instructions should be provided regarding preparation of glucagon, including how to inject the saline from the prefilled syringe into the glass vial of powdered hormone and appropriate injection sites (e.g., the upper arm, leg, or buttock) [22].

Emphasis on accurate and frequent SMBG and reporting frequent blood glucose levels less than 70 mg/dL to a primary care provider is an essential tool in the education process [73]. Communication between the individual, the certified diabetes educator, and the primary care provider is an optimal approach to incorporate into the education plan [66].

PHYSICAL ACTIVITY

The greatest potential for exercise-related hypoglycemia occurs when a person is receiving insulin therapy, although it may occur in patients taking oral glucose-lowering medications as well [74]. For these patients, education related to exercise should focus on the assessment of pre-exercise blood glucose levels, consumption of additional carbohydrates as needed, and having a carbohydrate source available if symptoms of hypoglycemia develop. It is also important to note that hypoglycemia risk increases as the duration or intensity of the activity increases. If assessment of blood glucose prior to exercise reveals a level less than 100 mg/dL, the individual should consume 25–50 grams of carbohydrate before engaging in physical activity. If the blood glucose level is 100–180 mg/dL, the patient should consume 10–15 grams of carbohydrate [1]. Patients should avoid exercise when their insulin or medication therapy is at peak effect. Lastly, patients should be advised to inject insulin away from muscles that will be the focus of exercise, as when a muscle is used, blood flow and utilization of glucose transport to the skeletal muscle increase [1].

NOCTURNAL HYPOGLYCEMIA

Patients who experience or who are suspected of having nocturnal hypoglycemia should be advised to monitor blood glucose levels prior to going to bed. When the blood glucose is less than 110 mg/dL, the patient should consume a snack that includes a carbohydrate and a protein. The specific signs and symptoms of nocturnal hypoglycemia should be explained, including the need to notify the primary care provider of suspected episodes. If an episode of nocturnal hypoglycemia occurs, the patient will be instructed to measure blood glucose levels at 3 a.m.; these levels are useful when creating a treatment plan [1].

PATIENT BEHAVIORS

Behavioral issues should be an aspect of patient education as well. Meal planning, particularly the need to count carbohydrates and adhere to dietary limitations, should be assessed. A food diary can assist in determining areas of focus for the individual and caregiver when hypoglycemia is occurring and cause is in question [75].

An additional area of educational focus is the issue of safety while driving [76]. The use of appropriate self-care skills and safety precautions should be taught and frequently reinforced in patients who drive. Emphasis should be placed on blood glucose monitoring prior to operation of a vehicle and frequent monitoring (every two hours) while on extended trips. Patients should be advised to refrain from driving when signs and symptoms of hypoglycemia are present [75]. Finally, a rapid-acting glucose source should always be available in the vehicle to treat any signs of hypoglycemia, although tablets should not be stored in the vehicle [76]. As always, wearing medical identification indicating that the patient has diabetes is important [75].

8. CONCLUSION

Hypoglycemia is a serious complication of diabetes and is most commonly experienced by patients who use oral medication or insulin to control the disease. In healthy people, hypoglycemia is prevented by a sophisticated interaction of the fuel metabolism and regulation of the body's counter-regulatory hormones. Causes of homeostatic imbalance include overdose of oral medication therapy, excessive insulin therapy, exercise, and inappropriate patient practices.

Recognition of hypoglycemia and knowledge of the treatment are critical concepts for healthcare providers to incorporate into the education plan of all diabetes patients, especially those who have just initiated medication therapy or have been newly prescribed an insulin regimen. Strategically placed assessment questions allow healthcare providers to illicit critical information regarding symptoms and signs the individual or caregiver may not recognize as hypoglycemia.

Finally, communication is essential to the prevention and understanding of hypoglycemia. In addition to the primary care team (i.e., the individual, support person or caregiver, the primary care provider, and the certified diabetes educator), other members may be added to improve care, including an exercise physiologist, registered dietitian, and pharmacist. All members of the education team should provide consistent information regarding the prevention, recognition, and treatment of hypoglycemia at each patient contact. This approach will provide the best possible level of understanding in order to obtain optimal glycemic control and minimize the adverse effects of hypoglycemia.

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30. de Galan BE, Zoungas S, Chalmers J. Cognitive function and risks of cardiovascular disease and hypoglycemia in patients with type 2 diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Diabetologia. 2009;52:2328-2336.

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32. Katon WJ, Young BA, Russo J, et al. Association of depression with increased risk of severe hypoglycemic episodes in patients with diabetes. Ann Intern Med. 2013;11(3):245-250.

33. Jou J, Johnson PJ. Nondisclosure of complementary and alternative medicine use to primary care physicians: findings from the 2012 National Health Interview Survey. JAMA Intern Med. 2016;176(4):545-546.

34. Foley H, Steel A, Cramer H, et al. Disclosure of complementary medicine use to medical providers: a systematic review and meta-analysis. Sci Rep. 2019;9:1573.

35. Egede LE, Ye X, Zheng D, Silverstein MD. The prevalence and pattern of complementary and alternative medicine use in individuals with diabetes. Diabetes Care. 2003;25(2):324-329.

36. Rhee TJ, Westberg SM, Harris IM. Complementary and alternative medicine in U.S. adults with diabetes: reasons for use and perceived benefits. J Diabetes. 2018;10(4):310-319.

37. Radwan H, Hasan H, Hamadeh R, et al. Complementary and alternative medicine use among patients with type 2 diabetes living in the United Arab Emirates. BMC Complement Med Ther. 2020;20(216)1-12.

38. Sheikhrabori A, Dehghan M, Ghaedi F, Khademi GR. complementary and alternative medicine usage and its determinant factors among diabetic patients: an Iranian case. J Evid Based Complementary Altern Med. 2017;22(3):449-454.

39. Shane-McWhorter L. Botanical dietary supplements and the treatment of diabetes: what is the evidence? Curr Diab Rep. 2005;5(5): 391-398.

40. Sisson E. AADE Quick Guide to Medications. 9th ed. Chicago, IL: American Association of Diabetes Educators; 2019.

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42. Baker WL, Gutierrez-Williams G, White CM, Kluger J, Coleman CI. Effect of cinnamon on glucose control and lipid parameters. Diabetes Care. 2008;31(1):41-43.

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44. Sasa M, Inoue I, Shinoda Y, et al. Activating effect of momordin, extract of bitter melon on the promoter of human PPARdelta.J Atheroscler Thromb. 2009;1696:888-892.

45. Joseph B, Jini D, Antidiabetic effects of Momordica charantia (bitter melon) and its medicinal potency. Asian Pac J Trop Dis. 2013;3(2):93-102.

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Evidence-Based Practice Recommendations Citations

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90285 • Ischemic Stroke

John M. Leonard, MD

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

During the past decades, advances in the prevention, diagnosis, and treatment of cerebrovascular disorders have led to decreases in the prevalence of stroke (primarily ischemic stroke), but the high rates of morbidity and mortality, despite a number of modifiable risk factors, point to the need for enhanced education for both patients and physicians. Enhancing healthcare professionals' knowledge about evidence-based guidelines, as well as about advances in diagnostic tools, is crucial for improving the outcomes for individuals who are at risk for stroke or in whom a stroke has occurred. A better understanding is needed about the options for patients at risk for stroke, as well as for treatment and rehabilitation. This course explores the roles of diagnosis and screening, evaluation of individuals with suspected stroke, immediate treatment of stroke, and the elements of effective rehabilitation programs. Heightened awareness of variations in the prevalence of stroke according to age, sex, and racial/ethnic groups will help clinicians and healthcare educators target individuals in need of enhanced education about the risks of stroke, especially those that are modifiable.

Table of Contents

90285 • Ischemic Stroke

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. OVERVIEW OF CEREBROVASCULAR DISEASE

TYPES OF CEREBROVASCULAR DISORDERS

MORBIDITY AND MORTALITY

MODIFIABLE RISK FACTORS

3. PREVENTION

PRIMARY PREVENTION

PUBLIC HEALTH CAMPAIGNS

PATIENT EDUCATION

PREDICTING RISK

4. EARLY STROKE MANAGEMENT

PREHOSPITAL EVALUATION

DIAGNOSIS IN THE ED

PHYSICAL EXAMINATION AND HISTORY

LABORATORY TESTS

HEAD AND NECK IMAGING STUDIES

5. TREATMENT

STROKE SYSTEMS OF CARE AND COMPREHENSIVE STROKE CENTERS

SUPPORTIVE CARE ISSUES

EVIDENCE-BASED GUIDELINES

6. REHABILITATION

MULTIDISCIPLINARY REHABILITATION TEAM

PATIENT ASSESSMENT

EXERCISE PROGRAM

TRANSITIONS IN CARE AND REHABILITATION CONTINUITY

7. SECONDARY PREVENTION: EVIDENCE-BASED RECOMMENDATIONS

CONTROLLING RISK FACTORS

MANAGING DISEASE

8. CASE STUDY

9. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

90285 • Ischemic Stroke

Education Category. Medical / Surgical

Release Date. 04/01/2026

Expiration Date. 03/31/2029

Course Overview

During the past decades, advances in the prevention, diagnosis, and treatment of cerebrovascular disorders have led to decreases in the prevalence of stroke (primarily ischemic stroke), but the high rates of morbidity and mortality, despite a number of modifiable risk factors, point to the need for enhanced education for both patients and physicians. Enhancing healthcare professionals' knowledge about evidence-based guidelines, as well as about advances in diagnostic tools, is crucial for improving the outcomes for individuals who are at risk for stroke or in whom a stroke has occurred. A better understanding is needed about the options for patients at risk for stroke, as well as for treatment and rehabilitation. This course explores the roles of diagnosis and screening, evaluation of individuals with suspected stroke, immediate treatment of stroke, and the elements of effective rehabilitation programs. Heightened awareness of variations in the prevalence of stroke according to age, sex, and racial/ethnic groups will help clinicians and healthcare educators target individuals in need of enhanced education about the risks of stroke, especially those that are modifiable.

Audience

This course is designed for physicians, nurses, and physician assistants in the primary care setting. Neurologists and other healthcare practitioners will also benefit from this course.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 10 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 10 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 10 ANCC contact hour(s). NetCE designates this continuing education activity for 5 pharmacotherapeutic/pharmacology contact hour(s). NetCE designates this continuing education activity for 12 hours for Alabama nurses. Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 10 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and/or Self-Assessment requirements of the American Board of Surgery's Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anesthesiology’s® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology Program® (MOCA®), known as MOCA 2.0®. Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program® and MOCA® are registered certification marks of the American Board of Anesthesiology®. MOCA 2.0® is a trademark of the American Board of Anesthesiology®. Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 10 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 10 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME's "CME in Support of MOC" program in Section 3 of the Royal College's MOC Program. AACN Synergy CERP Category A. NetCE is authorized by IACET to offer 1 CEU(s) for this program.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Special Approvals

This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

The early identification and management of the risk factors for ischemic stroke can lead to substantial health benefits and reductions in cost. However, research has documented gaps between healthcare professionals' knowledge and practice with respect to prevention, demonstrating that adherence to evidence-based or guideline-endorsed recommendations pertaining to all interventions for primary and secondary prevention are underutilized or ineffective. The purpose of this course is to provide needed information about the roles of diagnosis and screening, timely evaluation of individuals with suspected stroke, immediate treatment of stroke, and the elements of effective rehabilitation programs so that healthcare professionals may implement the necessary interventions appropriately.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe the primary types of cerebrovascular disorders and their causes.

2. Discuss differences in prevalence, morbidity, and mortality according to age, sex, and race/ethnicity.

3. Identify the nonmodifiable and modifiable risk factors for ischemic stroke.

4. Implement primary prevention strategies according to evidence-based guidelines.

5. Discuss the need for education at the community and patient levels.

6. Apply models of predicting risk of ischemic stroke.

7. Select the appropriate tools for screening, diagnosis, and early management of ischemic stroke.

8. Describe the elements of stroke systems of care and a comprehensive stroke center.

9. Discuss evidence-based treatment options for ischemic stroke.

10. Describe the benefits and components of a specialized stroke rehabilitation team.

11. Outline the aspects of patient assessment for stroke rehabilitation.

12. Discuss evidence-based recommendations for secondary prevention of ischemic stroke.

Faculty

John M. Leonard, MD, Professor of Medicine Emeritus, Vanderbilt University School of Medicine, completed his post-graduate clinical training at the Yale and Vanderbilt University Medical Centers before joining the Vanderbilt faculty in 1974. He is a clinician-educator and for many years served as director of residency training and student educational programs for the Vanderbilt University Department of Medicine. Over a career span of 40 years, Dr. Leonard conducted an active practice of general internal medicine and an inpatient consulting practice of infectious diseases.

Faculty Disclosure

Contributing faculty, John M. Leonard, MD, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

John V. Jurica, MD, MPH

Margo A. Halm, RN, PhD, NEA-BC, FAAN

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

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Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Cerebrovascular disease is associated with significant morbidity and mortality in the United States. Stroke occurs in approximately 795,000 individuals each year, of which 610,000 are first-time strokes and 185,000 are recurrent [1]. National surveillance data for the period 2017 to 2021 found that the prevalence rate (per 100,000 population) of stroke was 7.7 (men) and 8.8 (women) in the 60- to 79-year age group, and 13.9/14.0 among all those older than 80 years of age [1]. Stroke is the leading cause of long-term disability in adults; 65% of stroke survivors have some degree of impairment [1,2]. Approximately 3% of men and 2% of women reported that they were disabled because of stroke [3]. The effect of stroke on mortality is illustrated by the fact that cerebrovascular disease is the second leading cause of death in the United States, with an age-adjusted mortality rate of 39.0 per 100,000 population as of 2023 [1,3]. This represents an increase of 7.7% in the mortality rate and a 26.1% increase in actual deaths over the previous decade. It is a substantial healthcare issue, as one of every 19 deaths can be attributed to stroke in the United States [3]. Despite the considerable progress being made in the areas of prevention, management, and rehabilitation, it appears that stroke will increasingly cause death and disability in the coming decades as the population ages [4]. Stroke prevalence in the United States is projected to double from 9.7 million (3.9%) in 2020 to 19.4 million (6.4%) in 2050 [3].

In addition, the financial cost associated with cerebrovascular disease poses a substantial economic burden, with an estimated direct and indirect cost of $414.7 billion between 2021 and 2022 [3]. In 2021 to 2022, the direct and indirect cost of stroke in the United States was $49.1 billion [1]. The estimated direct medical cost of stroke totaled $23.8 billion, including hospital outpatient or office-based professional visit expense, hospital inpatient stays, ED visits, medication costs, and home health care. Additionally, the total direct medical stroke-related costs are projected to rise from $30.5 billion in 2020 to $350.6 billion in 2050 [3].

The two primary types of acute stroke are ischemic and hemorrhagic. Of all strokes, 87% are ischemic, 10% are intracerebral hemorrhages (ICHs), and 3% are subarachnoid hemorrhages (SAHs) [1,3]. There are important modifiable risk factors for ischemic stroke, and predicting risk is an important element in prevention. In predicting risk, consideration should be given not only to comorbidities but also to age, sex, and race/ethnicity, as disparities in stroke prevalence, morbidity, and mortality have been attributed to these patient characteristics [5,6,7,8]. Evidence-based guidelines for primary and secondary prevention have been developed and should be implemented [9,10].

Transient ischemic attack (TIA) is one of the most important risk factors for ischemic stroke. The estimated overall incidence of TIA is 1.19 per 1,000 person-years, and 15% of ischemic strokes are preceded by a TIA [1]. The risk of sustaining a stroke following TIA increases from 2.4% within the first 48 hours to 4.7% at three months [1,11]. Improved understanding of TIAs among both clinicians and patients is needed. A survey of 200 primary care physicians showed that 88% could not correctly identify the typical symptoms and duration of a TIA, and studies have indicated that half of individuals who have a TIA do not report the event to their primary care clinician [1,12].

The early identification and management of the risk factors for ischemic stroke can lead to substantial improvement in health and reductions in cost [13]. For example, the incidence of stroke was reduced by 30% to 40% following improved blood pressure control and the use of antiplatelet therapies [10]. Yet, research has documented gaps between physicians' knowledge and practice with respect to prevention, with data on adherence to evidence-based or guideline-endorsed recommendations demonstrating underuse or ineffective use of all interventions for primary and secondary prevention [11,14,15]. Evidence-based guidelines have also been developed for the early management of stroke and for rehabilitation after stroke and should be followed to provide optimum care [16,17,18].

The focus of this course is ischemic stroke, due to its overwhelming prevalence. Advances have been made in tools for the screening and diagnosis of ischemic stroke, and a better understanding of the options for patients at risk is needed. This course explores the role of the physical examination and history, laboratory studies, and imaging techniques in screening and diagnosis. Also discussed are evidence-based guidelines for the prevention and early management of ischemic stroke, as well as emerging treatment options. Because data have shown that outcome is improved by care provided in comprehensive stroke centers and by early rehabilitation, these topics are addressed as well [17,19,20,21]. The importance of a multidisciplinary rehabilitation team, appropriate patient assessment, and an exercise program is emphasized.

2. OVERVIEW OF CEREBROVASCULAR DISEASE

Although "cerebrovascular disease" is often used interchangeably with the term "stroke," the disease encompasses any neurovascular disorder that exists in the presence or absence of an ictus (e.g., carotid artery stenosis, arteriovenous malformations). Despite advances in understanding the pathophysiology of cerebrovascular diseases, the term "stroke" (also known as cerebrovascular accident or brain attack) is inconsistently defined. Stroke has been classically characterized as an injury to the central nervous system (CNS) by a vascular cause. Because this definition is mainly clinical and not inclusive of advances in science and technology, the American Heart Association (AHA)/American Stroke Association (ASA) convened a writing group to develop an updated definition of stroke. The AHA/ASA recommend that the term "stroke" be broadly used to include a variety of episodic brain injury events, whether symptomatic or asymptomatic (Table 1). The cerebrovascular anatomy at risk for stroke consists of the anterior circulation (cervical and internal carotid artery system) and posterior circulation (vertebrobasilar artery system).

Table 1: AHA/ASA DEFINITION OF STROKE

Injury/Episode

Definition

CNS infarction

Brain, spinal cord, or retinal cell death attributable to ischemia, based on:

- Pathologic, imaging, or other objective evidence of cerebral, spinal cord, or retinal focal ischemic injury in a defined vascular distribution; or

- Clinical evidence of cerebral, spinal cord, or retinal focal ischemic injury based on symptoms persisting ≥24 hours or until death, and other etiologies excluded.

Ischemic stroke

Episode of neurologic dysfunction caused by focal cerebral, spinal, or retinal infarction

Silent CNS infarction

Imaging or neuropathologic evidence of CNS infarction, without history of acute neurologic dysfunction attributable to the lesion

Intracerebral hemorrhage

Focal collection of blood within the brain parenchyma or ventricular system, not caused by trauma

Stroke caused by intracerebral hemorrhage

Rapidly developing clinical signs of neurologic dysfunction attributable to focal collection of blood within brain parenchyma or ventricular system, not caused by trauma

Silent cerebral hemorrhage

Focal collection of chronic blood products within the brain parenchyma, subarachnoid space, or ventricular system on neuroimaging or neuropathologic examination, not caused by trauma and without history of acute neurologic dysfunction attributable to the lesion

Subarachnoid hemorrhage

Bleeding into subarachnoid space

Stroke caused by subarachnoid hemorrhage

Rapidly developing signs of neurologic dysfunction and/or headache because of bleeding into the subarachnoid space, not caused by trauma

Stroke caused by cerebral venous thrombosis

Infarction or hemorrhage in the brain, spinal cord, or retina because of thrombosis of a cerebral venous structure. Symptoms or signs caused by reversible edema without infarction or hemorrhage do not qualify as stroke.

Stroke, not otherwise specified

Episode of acute neurologic dysfunction presumed to be caused by ischemia or hemorrhage, persisting ≥24 hours or until death, but without sufficient evidence to be classified as one of the above

CNS = central nervous system.

Source: Reprinted with permission from Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(7):2064-2089.

TYPES OF CEREBROVASCULAR DISORDERS

The multiple sources, pathophysiologic mechanisms, and sequelae of stroke are reflected in the diverse types of cerebrovascular disorders. The World Health Organization classifies cerebrovascular diseases under "Diseases of the nervous system" in the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), the international standard diagnostic classification for all general epidemiologic purposes and many health management purposes (Table 2) [22]. TIAs and traumatic intracranial hemorrhage are also included in the nervous system disease category in the ICD-11; vascular dementia is not. Its exclusion illustrates the heterogeneity of stroke and its sequelae. Vascular dementia, listed as dementia due to cerebrovascular disease, is categorized under "Mental, behavioral, or neurodevelopmental disorders: Neurocognitive disorders."

Table 2: SELECTED CEREBROVASCULAR DISEASES AS CLASSIFIED BY THE INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS, 11TH REVISION (ICD-11)

ICD Code

Disease

8B00

Intracerebral hemorrhage

8B01

Subarachnoid hemorrhage

8B02

Nontraumatic subdural hemorrhage

8B03

Nontraumatic epidural hemorrhage

8B0Z

Intracranial hemorrhage, unspecified

8B10

Transient ischemic attack

8B11

Cerebral ischemic stroke

8B1Y

Other specified cerebral ischemia

8B1Z

Cerebral ischemia, unspecified

8B20

Stroke, not known if ischemic or hemorrhagic

Source: [22]

As noted, the two primary types of stroke are ischemic and hemorrhagic. In the United States, approximately 87% of strokes are ischemic [1]. An ischemic stroke (impending infarction) denotes interruption of tissue perfusion because of critical vascular occlusion resulting from stenosis, embolism, or sustained spasm of a regional artery [23]. Hemorrhagic stroke occurs from aneurysm rupture or a spontaneous hemorrhage below the arachnoid location of the brain's arteriolar network; the resultant expansion of blood within a confined space results in secondary ischemic and pressure injury to brain tissue. Although ischemic stroke is the main focus of this course, a brief overview of hemorrhagic strokes will help to provide context and comparison of the clinical features of both types of stroke. In addition, TIAs are discussed here, as they are often a precursor to ischemic stroke.

Hemorrhagic Strokes

Hemorrhagic stroke is associated with a higher risk of fatality than ischemic stroke as well as a higher five-year mortality rate [1]. Hemorrhagic strokes are categorized by the location of the hemorrhage, either intracerebral or subarachnoid, with the former being more common.

The majority of hemorrhagic strokes are caused by ICH, and because of this, discussion of hemorrhagic stroke often refers to ICH [1]. ICH is defined as bleeding directly into the brain parenchyma [25,26]. Intraventricular hemorrhage refers to extension of bleeding into the brain ventricles [26,27]. Nontraumatic ICH is categorized as primary (unrelated to congenital or acquired lesions), secondary (caused by a congenital or acquired condition), or spontaneous (unrelated to trauma or surgery) [26]. Hypertension, congenital arterial aneurysm, thrombocytopenia (platelet counts <20,000), and depletion of intravascular clotting factors (e.g., hypothrombinemia) are conditions that elevate the risk of sustaining a hemorrhagic stroke, important because risk can be anticipated and treated.

The clinical features of ICH include sudden, intense headache, vomiting, seizures, depressed consciousness, meningeal irritation, and blood-tainted cerebrospinal fluid. Onset of symptoms may occur within seconds to minutes after the start of an ICH. Individuals with this type of stroke often feel more ill than those with an ischemic stroke.

ICH is the least treatable type of stroke [28]. Functional independence is regained within 6 months in approximately 20% of survivors [29]. The morbidity and mortality depend on the volume and location of the hematoma. The 1-year mortality rate varies according to anatomic location, with the highest mortality rate (65%) associated with ICH in the brain stem; the rate is 57% for lobar hemorrhage, 51% for deep hemorrhage, and 42% for cerebellar hemorrhage [30]. Overall, 46% of patients with ICH survive one year and 29% survive five years [31].

As many as 80% of primary ICHs occur after small vessels are compromised by chronic hypertension [32]. Hypertension is associated with ICH originating in the periventricular deep white matter, deep subcortical structures, pons, and cerebellum [33]. In individuals older than 70 years of age, cerebral amyloid angiopathy, a condition that leads to amyloid protein infiltration into the cortical arterioles, is responsible for approximately 20% of ICHs [34]. Other causes of ICH include anticoagulant and antiplatelet use, drug use (e.g., cocaine, phenylpropanolamine), and other bleeding diathesis [28,35]. Fewer than 15% of all cases of ICH are secondary to congenital vascular abnormalities and malignant brain lesions [26].

Subarachnoid hemorrhages occur less frequently than ICHs. The hallmark of subarachnoid hemorrhage is the immediate onset of a severe headache with signs of meningeal irritation [36]. Individuals may describe this headache as their "worst ever." Nausea, vomiting, neck pain, and photophobia are also classic symptoms, although they are not always present [36]. Neurologic deficits may be acute or may manifest hours to days after the onset of bleeding.

Nontraumatic subarachnoid hemorrhages are subcategorized as aneurysmal or non-aneurysmal [37]. Aneurysmal subarachnoid hemorrhage is associated with higher rates of morbidity and mortality than non-aneurysmal hemorrhage. Among patients who live 3 months after the event, the risk of death is 8.7% within 5 years and 17.9% within 10 years [38]. In contrast, non-aneurysmal subarachnoid hemorrhages are associated with better outcomes and are less likely to cause death [39].

Most nontraumatic subarachnoid hemorrhages involve rupture of an intracranial aneurysm or cerebral arteriovenous malformation. Congenital arteriovenous anomalies are more likely to cause stroke in adolescents and young adults [40]. The incidence of perimesencephalic subarachnoid hemorrhage, a non-aneurysmal type, is increasing. Although the cause remains unknown, increased use of antithrombotic medications may be a factor [41,42].

Guidelines for the management of spontaneous ICH have been published by AHA/ASA [28]. Rapid diagnosis and assessment are crucial, as early deterioration is common in the hours after onset. Prehospital management objectives are maintenance of the airway, cardiovascular support, and rapid transport to the nearest facility prepared to care for patients with acute stroke. Advanced notice to the ED of impending arrival is key to expediting assessment and shortening the time to neuroimaging. Any combination of severe headache, vomiting, systolic blood pressure >220 mm Hg, decreased level of consciousness, and rapid symptom progression suggests ICH, although none are specific and neuroimaging is required to distinguish ICH from ischemic stroke. Computed tomography (CT) is sensitive and usually readily available. Key components of initial evaluation include time of symptom onset, progression of symptoms, vascular risk factors, medications (e.g., anticoagulant medication, illicit drug use), and a focused neurologic examination to assess severity. Laboratory studies should include complete blood count, prothrombin time, partial thromboplastin time, and toxicology screen to detect cocaine and other sympathomimetic drugs associated with ICH. Medical management and follow-up imaging is predicated on initial findings and the underlying vascular abnormalities identified [28].

TIAs

TIAs are sometimes referred to as "ministrokes" because, like ischemic strokes, they are caused by inadequate cerebral blood flow. TIAs are also called warning strokes, as they often precede an ischemic stroke [43]. The superseded definition of a TIA was "a sudden, focal neurologic deficit that lasts for less than 24 hours, is presumed to be of vascular origin, and is confined to an area of the brain or eye perfused by a specific artery" [44]. The 24-hour time limit was an arbitrary remnant of the time interval used in prospective surveys in the early 1970s [45]. Magnetic resonance imaging (MRI) and computed tomography (CT) have demonstrated that one-third of TIAs, including those that last only minutes, cause infarcts [46].

Because TIA and ischemic stroke are less distinct from one another than once believed, a new TIA definition was proposed, revised, and endorsed in 2009. The proposed definition states that TIA is "a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than 1 hour, and without evidence of acute infarction" [44]. This definition was thought to better reflect the ischemic pathogenesis of TIA, promote its early management, and support the use of diagnostic imaging techniques to ensure that the patient does not have infarction [44]. The definition was endorsed by the 2009 AHA/ASA guideline, with the omission of "typically less than 1 hour" (as infarction is not necessarily bound by a set period of time) and reads, "Transient ischemic attack (TIA): a transient episode of neurologic dysfunction caused by focal brain, spinal-cord, or retinal ischemia, without acute infarction" [10,47]. A 2023 AHA scientific statement on diagnosis and management of TIA stipulates no evidence of tissue infarction determined by diffusion-weighted (DW) MRI. Resolution of symptoms combined with MRI demonstrating acute infarction should be diagnosed as an ischemic stroke [402].

TIAs are caused by similar conditions as those leading to ischemic stroke [10]. Among the common causes are embolic platelet thrombi shed from atherosclerotic plaque within large vessels and cardioembolism from mural thrombi related to atrial fibrillation (AF) or valvular heart disease. Other conditions complicated by TIAs include hypercoagulable states, arterial dissection, sympathomimetic drugs (e.g., cocaine), and arteritis (caused by noninfectious necrotizing vasculitis, drugs, irradiation, or local trauma) [53].

Research shows that TIA should be considered a dire event, a herald sign of sustained risk for adverse cardiovascular events in subsequent years. Prompt intervention is necessary for prevention of more potent ischemic stroke. The risk of stroke is 2.4% at 2 days and increases to 4.7% within 90 days after TIA [1]. A large multicenter TIA registry study found that the risk of stroke within one year was 5.1% and the five-year risk 9.5%; the combined risk of stroke, acute coronary syndrome, or death attributable to cardiovascular disease was 6.2% at one year and 12.9% at five years (398). Approximately 15% of ischemic strokes are preceded by a TIA [3]. However, there are several challenges to immediate treatment of TIAs [10]:

- A wide majority of the general population and many healthcare professionals either fail to recognize TIA or underestimate the significance.

- Individuals experiencing a TIA often believe they can postpone or forego professional treatment because clinical symptoms usually resolve quickly and without care.

- Due to the 24-hour arbitrary time limit in the previously accepted definition, healthcare professionals often choose to monitor a patient with a TIA rather than provide immediate treatment.

As with any stroke, the symptoms of TIA depend on the affected vascular territory. For instance, involvement of the carotid artery causes disturbances in the ipsilateral eye or brain [49]. Although the most common focal neurologic signs of TIA are sudden-onset unilateral weakness and numbness or tingling in a limb, a TIA can cause any of the following symptoms [49,50]:

- Numbness of the face, hand, or leg, with or without weakness

- Paralysis

- Slurred speech

- Dizziness

- Double vision

- Hemianopia

- Transient monocular blindness

- Imbalance

- Aphasia

- Confusion

- Head pain

Transient graying or blurring of vision is also common. Occasionally, the line of sight will be shaded. Vertebrobasilar TIAs reflect vestibulocerebellar symptoms such as ataxia, dizziness, vertigo, dysarthria, vision abnormalities (e.g., double vision, hemianopia, bilateral vision loss), and unilateral or bilateral motor and sensory dysfunctions [10]. Clinicians should bear in mind that patients may appear asymptomatic on initial evaluation. This is because TIAs often resolve within 5 minutes [51]. The possibility of TIA should be considered if the patient says, "I don't know why I'm here. Whatever it was, it is all better now" [52].

The risk factors for TIA are similar to those for ischemic stroke and include many modifiable factors, such as hyperhomocysteinemia, hyperlipidemia, smoking, obesity, and diabetes [10]. Risk is substantially reduced by treatment of vascular disorders such as hypertension and AF, two conditions commonly associated with older age. Younger individuals (18 to 45 years of age) who have a TIA or ischemic stroke often have no detectable vascular risk factors [54].

As noted, the risk of ischemic stroke is high in the period following a TIA. A meta-analysis found that approximately 5% of patients who have a TIA will have an ischemic stroke within the next 7 days [11,43]. The risk of stroke within three months after a TIA is approximately 10%; the cumulative risk approaches 25% over the ensuing 5 years [11]. Prompt initiation of secondary prevention strategies for TIA and minor stroke with existing therapies has been shown to reduce the risk of early recurrent stroke by 80% [48]. AHA/ASA guidelines support the concept that, with few exceptions, secondary prevention in patients who present with TIA is the same as that for those with ischemic stroke [10]. A 2020 clinical practice review and 2023 AHA published statement on diagnosis and management of TIA provide updated clinical guidance [399,402]. Selected key principles are as follows:

- Suspected TIA should be evaluated urgently in a TIA clinic or ED where appropriate specialist expertise and imaging are available.

- An initial noncontrast CT of the head, which is part of many stroke/TIA protocols, is useful to evaluate for hemorrhage, mass lesions, and subacute ischemia; however, CT offers limited diagnostic utility for evaluating the patient whose symptoms have resolved. Diffusion-weighted imaging of the head is the preferred imaging modality for patients with suspected TIA and should be performed immediately.

- TIAs typically last for minutes and the likelihood of stroke (infarction) increases with increasing duration of symptoms. DW-MRI demonstrates infarct lesions in about 40% of patients with TIA symptoms, and DW-MRI positivity is associated with a more than sixfold increased risk of recurrent stroke within the next year [402]. If a DW-positive lesion is identified, a diagnosis of ischemic stroke is typically made, followed by hospital admission.

- If possible, immediately after onset of symptoms, the patient should take aspirin 300 mg, followed by 75–100 mg daily; clopidogrel should be added to aspirin during the first 21 days after TIA (at a 300 mg loading dose, followed by 75–100 mg per day).

- Acute phase vascular imaging studies to screen for high-grade cervical carotid and intracranial stenosis, especially in patients older than 50 years of age, is important because it has immediate implications for treatment and stroke prevention.

- Long-term prevention of subsequent stroke includes antiplatelet or anti-coagulant treatment (depending on etiologic findings), attention to modifiable risk factors (e.g., blood pressure, glycemic control, lipid lowering, smoking cessation, lifestyle and diet counseling), and carotid endarterectomy, if appropriate.

Ischemic Strokes

Within minutes of the onset of ischemic stroke, the core of an infarct can begin to form at the least-perfused site. This site is encircled by an area partially altered metabolically and ionically by cytotoxic edema [55]. This area, the ischemic penumbra, is structurally intact and generally salvageable if reperfusion is achieved promptly. Because cerebral function deficits develop rapidly (within minutes to hours) as an ischemic stroke progresses, these brain attacks are a medical emergency. Each minute that passes results in an average loss of 1.9 million neurons and 14 billion synapses; an ischemic brain ages 3.6 years for every hour that passes after the onset of stroke [56]. For this reason, stroke specialists use the mantra, "time is brain." Although irreversible damage occurs, most individuals with stroke have recoverable penumbral tissue for at least three hours following the onset of symptoms [16].

The physical signs, symptoms, and sequelae of ischemic stroke are usually unilateral because of the circulatory anatomy of the brain (Table 3). Anterior circulation is composed of the paired internal carotid arteries and vessels that supply blood to the cerebral hemispheres. Each common carotid artery bifurcates into the internal and external carotid arteries. The ophthalmic artery, posterior communicating artery, and anterior choroidal artery are supplied by the internal carotid artery (Figure 1). Most importantly, the internal carotid artery provides blood to the middle cerebral artery, the largest intracerebral vessel. The middle cerebral artery provides oxygen to the lateral, frontal, parietal, and temporal lobes and the basal ganglia. It also supplies the anterior cerebral artery, which is responsible for the medial part of the frontal and parietal lobes, most of the corpus callosum, the frontobasal cerebral cortex, deep structures, and the anterior diencephalon. The anterior choroidal artery supplies a portion of the thalamus and the posterior limb of the internal capsule.

Table 3: GENERAL REGIONS OF ISCHEMIC STROKE AND CORRESPONDING NEUROLOGIC DEFICITS

Affected Region

Common Signs and Potential Sequelae

Left anterior hemisphere

Aphasia (esp. difficulty reading, writing, calculating)

Right limb weakness and sensory loss Right field visual defect

Right anterior hemisphere

Limb motor weakness or loss

Left field visual neglect

Unable to determine two-point stimuli on left side

Left posterior cerebral artery

Aphasia (esp. difficulty reading, naming objects)

Right visual field defect

Occasionally, right-sided numbness

Right posterior cerebral artery

Left limb sensory loss

Left-sided neglect

Left field visual defect

Vertebrobasilar territory (posterior circulation)

Bilateral vision disturbances and nystagmus

Dysarthria and dysphagia

Ataxia

Dizziness, vomiting, headache

No cortical deficits (e.g., aphasia, cognitive impairments)

Caudate nucleus, thalamus, frontal lobe (anterior circulation)

Sudden abnormal behavior

Thalamus (posterior circulation)

Numbness, decreased sensation on face, arm, leg on same side

Source: [57,58,59]

Figure 1: CORONAL SECTION OF THE CEREBRUM ILLUSTRATING ARTERIAL TERRITORIES

Source : [60] Reprinted from Blumenfeld H. Neuroanatomy Through Clinical Cases. 2nd ed. Boston, MA: Sinauer Associates, Inc.; 2013, with permission from Sinauer Associates, Inc.

Posterior circulation is primarily composed of the vertebrobasilar artery, the posterior cerebral artery, which it supplies, and other branching vessels. The posterior cerebral artery provides blood to the occipital and medial temporal lobes, as well as regions of the midbrain, subthalamic nucleus, basal nucleus, thalamus, mesial inferior temporal lobe, and occipitoparietal cortices. The two main segments of the posterior cerebral artery (P1 and P2) are connected by the posterior communicating artery. The Circle of Willis links the anterior and posterior circulation at the base of the brain.

In general, ischemic strokes are categorized according to etiology: thrombotic and embolic [61]. In addition, they are classified into five subtypes according to a system developed by the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) [62].

Thrombotic Stroke

A thrombotic stroke results from progressive atherosclerosis that impairs cerebral arterial blood flow. The stroke event takes two forms: atherosclerotic plaque formation leads to critical stenosis of an artery supplying blood to a region of the brain, or when a fragment of unstable plaque (embolus) breaks loose and lodges in a branch point downstream. The stenosed or occluded artery may be a large vessel (e.g., carotid artery systems, vertebral arteries, the Circle of Willis) or a small vessel (e.g., branches of the Circle of Willis, the posterior circulation). Approximately 21% to 27% of ischemic strokes arise from atherosclerotic disease of the large vessels [63,64]. The cerebral artery branch points, especially those of the internal carotid artery, are the most vulnerable [65]. Small-vessel disease is associated with 21% to 25% of ischemic strokes [63,64]. Thrombotic strokes caused by small-vessel disease are traditionally associated with lacunar infarcts, small, deep, subcortical lesions of 15 mm or less in diameter resulting from occlusion of a single penetrating artery [62,66]. As many as 20% of older individuals who are otherwise healthy have asymptomatic lacunar infarcts unrelated to an ictal event [67]. These silent infarctions were previously believed to be benign with a good long-term prognosis. However, they now have been linked to increased risks of stroke and death and can lead to debilitating cognitive impairments such as vascular dementia [67,68].

Independent risk factors for lacunar infarcts include hypertension, gender, age, diabetes, smoking, and a history of TIA [67]. Although hypertension is strongly associated with the development of small-vessel occlusion, lacunar infarcts also occur in individuals without hypertension. However, normotensive individuals with lacunar infarcts are typically 85 years of age or older, suggesting that hypertension accelerates the arteriopathy underpinning small-vessel disease. Diabetes is an independent risk factor for lacunar infarcts [69].

Embolic Stroke

An embolic stroke occurs when an embolus (i.e., any circulating clot or particle originating from a distal point) lodges in a cerebral arterial vessel, interrupting blood supply to the brain. Stroke registries indicate that 14% to 30% of ischemic strokes are embolic [70,71,72,73,74]. Arterial emboli may originate from the heart (chamber or diseased valves), from the carotid or intracranial arteries (atheromatous plaque), aortic arch, or peripheral venous system by way of a right-to-left shunt (paradoxical embolus). Emboli may be composed of thrombus, fatty deposits, atherosclerotic plaque fragments, or cellular debris emanating from intravascular infections (e.g., endocarditis) or tumors (e.g., atrial myxoma). Clinical symptoms of the resulting infarct correspond to the location of the embolus, not its type. The region of the middle cerebral artery is most frequently blocked by emboli [75].

AF is the most common cardiogenic cause of embolic stroke, and the proportion of strokes caused by AF increases with increasing patient age. The presence of AF increases the risk of embolic stroke fivefold and doubles the risk of death [76,77]. Atrial fibrillation is associated with blood stasis and thrombus formation within the left atrial appendage. Other cardiogenic sources of brain embolism include valvular thrombi (e.g., rheumatic disease, endocarditis, prosthetic valves), mural thrombi from myocardial infarction (MI) or severe heart failure, and paradoxical embolization across a patent foramen ovale [78,79]. MI is associated with a 2% to 3% incidence of embolic stroke, 70% of which occur in the first week after the event [77,79].

TOAST Classification

The subtype of ischemic stroke influences treatment decisions, prognosis, and risk of recurrent stroke. The TOAST system was designed to facilitate decision making and standardize ischemic stroke research (Table 4) [62]. Most strokes are subclassified as a large-artery atherosclerosis (caused by either a thrombus or an embolus), a cardioembolism, or an occlusion of a small vessel (lacuna) [62]. Approximately 4% of individuals with stroke have coexisting large-vessel and small-vessel disease [61,80]. Other determined causes are rare (approximately 3%), and registries have classified up to 33% of ischemic strokes as being of "undetermined etiology" [81].

Table 4: FIVE SUBTYPES OF ISCHEMIC STROKE AS CLASSIFIED BY THE TRIAL OF ORG 10172 IN ACUTE STROKE TREATMENT (TOAST)

Classification

Major Characteristics

Large-artery atherosclerosis (may be an embolus or thrombus)

Greater than 50% stenosis or occlusion of a major brain artery or branch cortical artery

Cortical, cerebellar, brain stem, or subcortical infarct 15 mm

Cortical or cerebellar dysfunction

Cardioembolism (may be high or medium risk based on evidence of embolism)

Cardiac source of emboli

Cortical, cerebellar, brain stem, or subcortical infarct 15 mm

Cortical or cerebellar dysfunction

Small-vessel (lacuna) occlusion

Patient presents with lacunar syndromea

Subcortical or brain stem infarcts <15 mm may be detected

Other determined cause

May be caused by conditions such as dissection, hypercoagulable states, or sickle cell anemia

May have characteristics of any of the other stroke subtypes

Undetermined etiology

May be any of the following:

Two or more causes identified

Negative evaluation

Incomplete evaluation

aThe five classic lacunar syndromes are pure motor hemiparesis, pure sensory stroke, sensorimotor stroke, ataxic hemiparesis, and clumsy-hand dysarthria.

Source: [62,66,82,83]

MORBIDITY AND MORTALITY

Approximately 16% of men and 14% of women have a stroke by 85 years of age, and stroke is the fifth leading cause of death in the United States, accounting for more than 150,000 deaths in 2019 [1,3,84]. Morbidity associated with stroke is also high, with at least 65% of stroke survivors having some sort of impairment [85]. At three months after a stroke, approximately 20% of survivors depend on long-term care. Between 15% and 30% of stroke survivors are permanently disabled [86]. A six-month follow-up of ischemic stroke survivors (65 years of age and older) demonstrated that [87]:

- 50% had some degree of hemiparesis

- 35% had depressive symptoms

- 30% were unable to walk without some assistance

- 26% were dependent in activities of daily living

- 26% were in a nursing home

- 19% had aphasia

Fortunately, stroke mortality has been declining over the past 50 years. In the United States, stroke has fallen from the third to the fifth leading cause of death, representing a true mortality decline rather than a repositioning of causes of death [3,84]. This decline is a result of reduced incidence of stroke and lower case-fatality rates, concurrent with cardiovascular risk factor control interventions (e.g., hypertension control). Other efforts (e.g., diabetes control, smoking cessation programs) likely have also contributed to the decline in stroke mortality. The effects of telemedicine and stroke systems of care require additional study but appear to be significant. The decline has occurred in both women and men, for all racial/ethnic and age groups, and represents a major improvement in public health and a reduction in years of potential life lost [88].

Disparities in Prevalence and Mortality

Age, gender, and race/ethnicity play major roles in the prevalence of stroke and its associated mortality.

Age

Prolonged damage of the aging cardiovascular system by various risk factors for stroke doubles the risk of ischemic stroke for each decade of life after 55 years of age [9]. Thus, clinicians should be sensitive to their patients' modifiable risk factors, most notably hypertension, starting at an early age [1]. As many as 70% of strokes occur in individuals older than 65 years of age, and the average age at the time of ischemic stroke is 71 years in men and 75 years in women [1]. Stroke patients 85 years of age and older comprise 17% of all stroke patients [1]. Clinicians should be particularly aware of silent cerebral infarctions in older individuals, as these infarctions occur more commonly in this population [89].

Although stroke risk increases with age, strokes can occur at any age; hospital surveillance data from 2014 found that 38% of people hospitalized for stroke were younger than 65 years of age [25]. Approximately 10% to 15% of all strokes occur in adults 18 to 50 years of age, and the underlying pathogenesis and risk factors are more diverse [1,401]. The common types of ischemic stroke in older persons are large vessel atherosclerosis and small vessel occlusions; these two subtypes account for only 10% to 20% of stroke in younger adults. Studies of subtypes have reported a higher prevalence (20% to 47%) of cardioembolism among younger patients with stroke [1,401].

Gender

Women have a higher lifetime risk of stroke than men [90,91,92]. According to estimates from the Framingham Heart Study, among people 55 to 75 years of age, the risk of stroke is 1 in 5 for women and 1 in 6 for men [93]. About 55,000 more women than men have a stroke each year; stroke is the cause of death for about 80,000 women each year [3]. Age-specific stroke incidence rates are substantially lower among women than men, except in those 80 years of age and older, in which the incidence rate in women is approximately equal to or higher than the rate in men [90,91,94,95,96]. Risk factors unique to women or more common in young women include estrogen-containing oral contraceptives, pregnancy, and migraine with aura. The combination of migraine with aura, oral contraceptive use, and cigarette smoking increases stroke ninefold compared with women who do not have any of these three risk factors [401]. The underlying conditions associated with stroke in women with these risk factors include cardioembolism, patent foreman ovale, and prothrombotic states. Pregnancy itself is a prothrombotic state, which in addition to hypertensive disorders of pregnancy increases the risk for ischemic stroke, ICH, and cerebral venous thrombosis. The approximate incidence of stroke is 30 per 100,000 pregnancies, which is three times higher than the incidence of stroke in nonpregnant young adults of comparable age [401]. The complication may occur during the antepartum, peripartum, or postpartum periods.

Among individuals 65 years of age and older, the median survival time after a first stroke is typically longer for women than for men. For both men and women, the median survival decreases with age (Table 5) [97]. However, the possibility of gender disparities in how health care is provided to individuals who present with stroke symptoms is also being evaluated.

Table 5: COMPARISON OF MEDIAN SURVIVAL AFTER A FIRST STROKE ACCORDING TO SEX

Age

Median Survival

Women

Men

55 to 64 years

7.8 years

13.1 years

65 to 74 years

7.7 years

6.2 years

≥75 years

2.3 years

2.1 years

Source: [97]

Studies suggest that, compared with men, women are evaluated less frequently following a stroke and that any evaluation is more likely to be delayed [98,99,100]. This pattern results from women's presentation with nontraditional symptoms or without traditional symptoms and inappropriate worry by both clinician and patient about treatment-related risks (Table 6) [98,99,101,102,103]. Although studies to evaluate differences in strokes between men and women are in early stages, preliminary results indicate that emergency medical service (EMS) personnel and clinicians need an accurate understanding of symptom presentation patterns for men and women. The prevalence of nontraditional symptoms is higher among women than men; nontraditional stroke symptoms include headache, face and limb pain, nausea, and hiccups as well as symptoms typically believed to be unrelated to neurologic deficits (e.g., chest pain, shortness of breath, palpitations) [102].

Table 6: COMPARISON OF PREVALENCE OF SELECT SYMPTOMS IN MEN AND WOMEN

Symptom on Presentation

Prevalence

Men

Women

Overall nontraditional symptoms

19%

28%

Pain

8%

12%

Altered consciousness

12%

17%

Traditional Symptoms

Imbalance

20%

15%

Hemiparesis

24%

19%

Source: [102]

Race/Ethnicity

The decline in stroke mortality has reduced, but not eliminated, the racial/ethnic gap in stroke mortality [88]. Racial/ethnic disparities in the incidence of stroke and its related mortality are substantial, and the factors contributing to the disparities are complex and poorly understood [1,5,6,7,8,104]. The risk of first-time stroke among Black individuals is 1.5 times higher than that for White individuals in the United States, and the incidence of first-ever stroke is increasing among Hispanic Americans compared to White Americans [1]. The Northern Manhattan Study (NOMAS) showed that the age-adjusted incidence of first ischemic stroke per 100,000 individuals was 191 in the Black population, 149 in the Hispanic population, and 88 in the White population [1,104]. Another study showed that the prevalence of stroke among these three groups also varied according to age [6]. In the Black population, the prevalence was 4.8% for individuals 45 to 64 years of age and 10% for individuals 65 years of age and older; the corresponding prevalences were 2.3% and 10% for Hispanic individuals and 2% and 9% for White individuals [6]. Intracranial atherosclerotic strokes were the most common type of strokes among the Black and Hispanic populations [1,104]. Higher rates of hypertension, obesity, and diabetes among Black Americans might account for some of this disparity [400].

According to the AHA 2019 update on statistics for heart disease and stroke, the prevalence of stroke is highest for American Indian/Alaskan Natives and lowest for Asian/Pacific Islanders (Table 7) [1]. Data indicate variation among stroke-related mortality rates as well and show that stroke deaths have increased in minority populations while decreasing in the White population. Projections indicate a 20.5% increase in stroke by 2030, with the greatest increase (29%) in Hispanic men [1].

Table 7: RACIAL/ETHNIC VARIATIONS IN PREVALENCE OF STROKE AND HYPERTENSION

Population

Stroke Prevalence

Hypertension Prevalence

American Indian/Alaskan Native

5.3%

NA

Non-Hispanic Black

4.1%

55.4%

Non-Hispanic White

2.7%

42.8%

Hispanic or Latino

2.3%

41.1%

Asian/Pacific Islander

1.2%

NA

NA = Not available

Source: [1]

Data from 2016 demonstrated an overall rate of 37.3 deaths per 100,000, with a rate of 51.9 for the Black (non-Hispanic) population, 36.1 for the White (non-Hispanic) population, 32.1 for the Hispanic population, 31.0 for the Asian/Pacific Islander population, and 30.7 for the American Indian/Alaskan Native population [1]. Risk factors, such as hypertension, diabetes, and obesity, vary among these populations as well, but increased risks alone cannot completely explain increased prevalence or mortality [9].

MODIFIABLE RISK FACTORS

Several modifiable risk factors for stroke have been well-documented in the literature, and some have been less well-documented (Table 8). The well-documented risk factors include many associated with cardiovascular disease as well, and proper management of these factors can reduce both the risk of a first-time stroke and the development of a cardiovascular condition [7,9]. Clinicians should discuss the potential for stroke associated with risk factors specific to patients and offer strategies to reduce or eliminate them [9]. Four lifestyle factors warrant brief review because of the substantial role the patient has in helping to manage risk: smoking, diet and nutrition, physical inactivity, and obesity and body fat distribution.

Table 8: MODIFIABLE RISK FACTORS FOR STROKE

Well-Documented Factorsa

Less-Documented Factorsb

Hypertension

Atrial fibrillation (AF)

Diet and nutrition

Diabetes

Cigarette smoking

Dyslipidemia

Obesity and body fat distribution

Cardiac conditions other than AF

Asymptomatic carotid stenosis

Sickle cell disease

Physical inactivity

Metabolic syndrome

Inflammation and infection

Migraine

Alcohol abuse

Hypercoagulability

Sleep-disordered breathing

Elevated lipoprotein (a)

Drug abuse

Hyperhomocysteinemia

aListed in descending order of quality of documentation.

bInformation on less-documented risks for stroke can be found in the American Heart Association (AHA) guideline "Primary Prevention of Stroke."

Source: [9]

Diet and Nutrition

Consumption of fruits and vegetables reduces the risk of stroke in a dose-dependent manner. Risk is reduced 6% for each serving of fruits and vegetables per day [105]. Reducing sodium intake and increasing antioxidants, potassium, and calcium also mitigates the risk of stroke [9,106,107]. The AHA/ASA recommend that individuals with stroke residing in long-term care facilities be evaluated for calcium and vitamin D supplementation [21]. The Dietary Approaches to Stop Hypertension (DASH) diet, which is rich in fruits, vegetables, and low-fat dairy products and which limits saturated and total fat intake, has been shown to lower blood pressure and likely reduce the risk of stroke [106,107].

Cigarette Smoking

Overwhelming evidence shows an undeniable association between cigarette smoking and stroke [9,108]. Smoking doubles the risk for ischemic stroke and increases the risk of hemorrhagic stroke 2 to 4 times [109]. The stroke risk for Black Americans who smoke is more than double that for nonsmokers in the same racial/ethnic group. A cohort study found stroke risk was 2.5 times higher for current smokers compared with never smokers [400]. The stroke risk was dose-dependent, according to smoking intensity; the risk increased 2.3 times for individuals who smoked 1 to 19 cigarettes per day and 2.8 times for those who smoked more than 20 cigarettes per day. Recurring exposure to environmental ("secondhand") smoke almost doubles the risk of stroke [110]. Secondhand smoke exposure is a contributing factor in more than 8,000 stroke deaths each year [111]. Using data from the National Health Interview Survey and death certificate data for 2000 through 2004, the Centers for Disease Control and Prevention estimated that smoking resulted in an annual average of 61,616 stroke deaths among men and 97,681 stroke deaths among women [112].

Individuals who smoke should be prescribed smoking cessation medications and be informed about cessation programs, counseling, and nicotine-replacement products. Epidemiologic studies show that, following smoking cessation, stroke risk decreases over time [9]. Individuals who do not smoke should be encouraged not to start.

Obesity and Body Fat Distribution

One study has found that in the body mass index (BMI) range of 25 to 50 kg/m2, each 5 kg/m2 increase in BMI was associated with a 40% increased risk of stroke mortality; in the BMI range of 15 to 25 kg/m2, there was no relationship between BMI and stroke mortality [113]. Another large epidemiologic study showed that the risk almost doubled for overweight and obese men [114]. A meta-analysis of data from 25 studies involving more than 2.2 million people showed an increased risk of ischemic stroke of 22% in overweight individuals and 64% in obese individuals [115]. Studies have not yet addressed if losing weight reduces this risk [9]. However, it is well-documented that weight loss lowers blood pressure and cholesterol and positively affects other risk factors for stroke. Clinicians should encourage overweight patients to begin a weight-loss program that includes a healthful diet and exercise and provide patients with safe weight-loss strategies, such as those recommended by the AHA [9].

Body fat distribution has proven to be a fairly reliable indicator of stroke risk [116,117]. While some studies support abdominal adiposity as a significant risk factor for stroke only in men, other research indicates that a high concentration of abdominal fat is a significant risk factor in both men and women, independent of BMI [9]. On the other hand, gynoid adiposity in women appears to be associated with a lower risk for stroke, even for women with a higher BMI [117]. A high hip-to-waist ratio may be a more important risk factor for vascular disease, including stroke, than BMI score alone [118].

Physical Inactivity

A large and generally consistent body of evidence indicates that routine physical activity prevents stroke [9]. A habitually sedentary lifestyle increases an individual's chance of stroke. Physically active men and women generally have a 25% to 30% lower risk of stroke or death than the least active people [119]. Individuals should be strongly encouraged to engage in aerobic exercise at moderate intensity for 150 minutes or more weekly, at vigorous intensity for 75 minutes or more per week, or a combination of both that fulfills these requirements [9]. It should be noted that only moderate-to-vigorous intensity exercise has been found to reduce the incidence of stroke [104].

3. PREVENTION

PRIMARY PREVENTION

To decrease the incidence of first-time stroke in the United States, primary prevention should focus on individuals at high risk with modifiable risk factors. In areas of the United Kingdom, the incidence of major stroke has been reduced 40% through a reduction in the incidence of risk factors [120]. The AHA has established evidence-based recommendations for primary prevention of stroke and has developed public campaigns and educational materials to help raise awareness of stroke.

Evidence-Based Recommendations

For most individuals with nonmodifiable stroke risks, the probability of stroke can be decreased substantially with rigorous preventive measures and the treatment of modifiable risks [9,16]. The AHA recommends addressing lifestyle risk factors, as discussed, and medically managing several risk factors, including hypertension, diabetes, AF, other cardiac conditions, dyslipidemia, and asymptomatic carotid stenosis [9].

Hypertension

Hypertension is perhaps the most significant risk factor for stroke, and risk increases as blood pressure increases [9]. Sustained elevation in blood pressure has adverse effects on small and large arteries throughout the cerebrovascular system, increasing risk for multiple stroke types (ICH, aneurysmal subarachnoid hemorrhage, and ischemic stroke). Fortunately, the prevalence of hypertension has plateaued over the past decade and remained stable, at 29%, between 2008 and 2017 [121,122]. Control of hypertension (defined as blood pressure less than 140/90 mm Hg) also has improved, with rates of control increasing from 27.3% in 1988–1994 to 50.1% in 2007–2008 [9]. These improvements are likely attributable to heightened awareness and treatment, with awareness among U.S. residents increasing from 69% in 1988–1994 to 81% in 2007–2008 [9]. Still, more than two-thirds of people 65 years of age and older are hypertensive [123].

Treatment of hypertension is effective for primary and secondary prevention of stroke. The AHA and other professional organizations recommend that all adults 18 years of age and older be screened for high blood pressure [124]. The U.S. Preventive Services Task Force (USPSTF) recommends screening for all adults 18 years of age and older and annual screening for adults 40 years of age and older who are at increased risk for high blood pressure. Increased risk is defined as [124]:

- High-normal blood pressure (130–139/85–89 mm Hg)

- Overweight or obese

- Black race

Individuals 18 to 39 years of age with normal blood pressure (<130/85 mm Hg) who do not have other risk factors should be screened every 3 to 5 years. The USPSTF additionally recommends rescreening with properly measured office blood pressure. If the blood pressure is elevated, the diagnosis should be confirmed with ambulatory blood pressure monitoring [124].

The 2017 Guideline for High Blood Pressure in Adults recommends screening every 2 years for adults with a blood pressure less than 120/80 mm Hg and screening every 3 to 6 months for people with systolic blood pressure of 120 to 129 mm Hg or with diastolic blood pressure greater than 80 mm Hg [125]. The AHA/ASA recommends that women be screened for high blood pressure before taking birth control pills, as the combination increases the risk of stroke [126].

Appropriate management of hypertension may also include dietary changes, other lifestyle modifications, and pharmacologic therapy. There is no evidence that any particular class of antihypertensives offers special protection against stroke in all patients; the desired result is more important than the choice of treatment. Treatment should be individualized on the basis of other clinical characteristics and medication tolerance. Among patients with other cardiovascular risk factors, more intensive control (systolic blood pressure <130 mm Hg) reduces risk of stroke more than usual control (<140 mm Hg) (9). Studies have shown that management is possible for the majority of patients, but most will require treatment that includes two or more drugs [9].

Diabetes

Diabetes, if untreated, leads to enhanced atherogenesis and microvascular disease within small arterioles. The risk for stroke is 2 times higher among individuals with diabetes. In 2017, after adjusting for population age differences, hospitalization rates for stroke were more than three times higher among adults 20 years of age and older with diagnosed diabetes compared with those without diagnosed diabetes [127]. Type 2 diabetes is associated with an increased prevalence of atherogenic risk factors, such as hypertension, obesity, and dyslipidemia. The combination of hyperglycemia and hypertension is thought to increase the risk of stroke [9]. The AHA recommends that the target blood pressure for individuals with diabetes be less than 140/90 mm Hg [9]. Pharmacologic therapy with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) has been shown to be safe and effective in this population [9]. In addition, lipid-lowering statins reduce the risk of first-time strokes in patients with diabetes, irrespective of the baseline lipid levels, pre-existing vascular conditions, and glycemic control [128].

Atrial Fibrillation

AF is associated with a fourfold to fivefold increased risk of ischemic stroke, and approximately 60,000 strokes occur among the 2.3 million individuals with AF annually [9]. According to the AHA/ASA, women older than 75 years of age should be screened for AF risk due to its link to greater stroke risk [126]. All patients with AF should be considered for anticoagulant therapy. Whether to use warfarin (a vitamin K antagonist) or a non-vitamin K-dependent, direct-acting anticoagulant depends on underlying predisposition, age, patient comorbidities and concomitant medications, bleeding risk, and stroke risk. High-risk factors for stroke include previous TIA/stroke, mitral stenosis, prosthetic heart valves, and systemic embolism. Moderate-risk factors include age older than 75 years, heart failure, hypertension, and diabetes. AHA guidelines recommend that eligible patients with nonvalvular AF be treated with warfarin or one of the direct non-vitamin-K oral anticoagulants [195]. Patients with AF and mechanical heart valves or mitral stenosis should only receive treatment with warfarin, as the direct non-vitamin K oral agents are contraindicated. The individual's preferences and access to high-quality anticoagulation monitoring should be considered. Warfarin therapy to maintain an international normalized ratio (INR) of 2.0 to 3.0 (target: 2.5) is strongly recommended for high-risk individuals (those with more than a 4% annual risk of stroke) with AF and no significant contraindications to oral anticoagulants [9,129]. Despite the effectiveness of such treatments, anticoagulant therapy continues to remain underprescribed due to overestimation of the associated risks of warfarin (e.g., intracranial, extracranial hemorrhage) and underestimation of stroke risk [129]. Some physicians err on the side of caution and aim for an INR greater than the recommended target, with a corresponding reduction in therapeutic effectiveness.

Other Cardiac Conditions

The management of valvular heart disease, unstable angina, chronic stable angina, acute MI, and other cardiac conditions is a critical factor in stroke prevention. Strategies to prevent postoperative neurologic injury and stroke in patients undergoing surgical revascularization for atherosclerotic heart disease can be found in the American College of Cardiology coronary artery bypass graft surgery guidelines, which are approved by the AHA [9,130]. The AHA states that it is "reasonable" to use warfarin for patients who have had ST-elevation MI and left ventricular dysfunction with extensive regional wall-motion abnormalities [9].

Dyslipidemia

The AHA recommends that statin therapy for individuals with known coronary heart disease or high-risk hypertension (e.g., patients with diabetes), including those with normal low-density lipoprotein (LDL) cholesterol levels [9]. In addition, these individuals should be encouraged at every interaction to exercise, eat a healthful diet, and quit smoking. Niacin, bile acid sequestrants, ezetimibe, or fibric acid derivatives may also be considered for individuals with known coronary heart disease and low levels of high-density lipoprotein cholesterol, such as people in whom target cholesterol levels cannot be achieved with statins or people who cannot tolerate statin therapy; however, their effectiveness in decreasing stroke risk has not been established [9].

Asymptomatic Carotid Stenosis

Evidence Based Practice Recommendation

The U.S. Preventive Services Task Force (USPSTF) recommends against screening for asymptomatic carotid artery stenosis in the general adult population.

https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/carotid-artery-stenosis-screening

Last Accessed: March 31, 2026

Strength of Recommendation/Level of Evidence: D (The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.)

Individuals with asymptomatic carotid artery stenosis should be screened for other modifiable risk factors, and any risk factors identified should be controlled as soon as possible. Antiplatelet therapy with aspirin is recommended, unless contraindicated [9]. Carotid revascularization (endarterectomy or vascular stent) for stroke prevention is an option for asymptomatic patients with >70% stenosis of the internal carotid artery if the risk of perioperative stroke and other adverse outcomes is low (<3%). However, the effectiveness compared with best medical management is not well established [9,10]. Comorbidities and life expectancy should be considered when determining if surgery is appropriate. In addition, thorough discussion with the patient and his or her family/caregivers is a necessity. Topics should include the possibility of surgery-related death, the risks and benefits associated with the procedure, and the patient's preferences. For patients with a high surgical risk, carotid angioplasty/stenting may be considered. However, the periprocedural and overall one-year event rates in some studies have dampened the AHA's enthusiasm for the stenting option [9,10].

Depressive Symptoms

After publication of the AHA guidelines, the findings of a large study showed that depressive symptoms are an independent risk factor for stroke, especially for patients younger than 65 years of age [131]. Clinicians may consider managing depressive symptoms and mood disorders as aggressively as hypertension or diabetes, because mood disorders appear to increase risk for all types of stroke [132].

PUBLIC HEALTH CAMPAIGNS

Although public knowledge regarding the warning signs and risks of stroke has improved, the majority of the general public is still unaware that early treatment can prevent severe disability and death [133,134]. Estimates vary widely, however; the International Stroke Trial found that only 4% of patients with acute ischemic stroke arrive at the emergency department (ED) within 3 hours after the onset of symptoms, and a separate study found that 21% to 25% of individuals with acute ischemic stroke arrive at an ED within the same timeframe [135,136]. Of these individuals, 2% to 4% receive thrombolytic treatment [137,138]. It has been estimated that if all individuals called for emergency help at the onset of symptoms, as many as 29% could realistically receive treatment within 3 hours [137]. In addition, if all patients arrived at the ED within 1 hour after known symptom onset and received optimal treatment, the projected rate of thrombolysis would be 57%.

To improve the rate of early arrival in the ED, public education campaigns designed to help individuals recognize a stroke and seek early treatment often use the "five sudden warning signs" devised by the Brain Attack Coalition, or "FAST," a mnemonic device created by study investigators on the basis of the Cincinnati Prehospital Stroke Scale [139,140]. The AHA and the National Stroke Association and other organizations use FAST as a component of public education campaigns and stroke risk assessment promotion [141]. The mnemonic addresses the symptoms most common to an evolving stroke:

- Face drooping

- Arm weakness

- Speech difficulty

- Time to call 911

Other symptoms that comprise the five sudden warning signs include [140,141]:

- Numbness or weakness of the face, arm, or leg (especially on one side)

- Trouble seeing from one or both eyes

- Severe headache with no known cause

- Dizziness, difficulties with walking, and loss of balance and coordination

- Confusion and trouble speaking or understanding

FAST was designed to focus on fewer common signs of stroke onset (face numbness, arm numbness, and slurred speech) and to include an action component (time) for lay persons who may have trouble recalling the warning signs and the appropriate action. A retrospective study exploring the capacity of the FAST campaign to facilitate the recognition of stroke suggests that it leads to the identification of approximately 89% of individuals who have a stroke or TIA [140]. The most common stroke symptoms were related to the face, arm, and speech/language. The same study found that a modified version of FAST (with removal of the word "numbness") decreased the number of TIAs identified and targeted ischemic stroke more readily than hemorrhagic stroke. Ultimately, it is unknown whether the general public is more likely to remember FAST or the five sudden warning signs.

In 1989, the United States Department of Health and Human Services Public Affairs launched a National Health Observance to help stimulate awareness of the risk factors, prevention, and early treatment of stroke. For more than 25 years, May has been recognized as National Stroke Awareness Month, with special campaigns to heighten awareness of stroke among the general public. Resources to aid community campaigns can be obtained from the American Stroke Association at https://www.stroke.org/en/about-stroke/stroke-symptoms.

PATIENT EDUCATION

Patient education should be presented in several forms and focus on modifiable risk factors, patients' needs, lifestyle, and life stage. Healthcare professionals can be most effective in reducing the risk of stroke when they demonstrate an interest in a patient's lifestyle and psychological status. For instance, if a patient depends on his or her spouse or companion for meals, optimum benefits will result from educating the spouse/companion about healthy diet practices. Clinicians should also consider cultural needs when addressing prevention strategies.

When a patient/caretaker does not speak the same language as the clinician, a professional interpreter should be consulted to ensure accurate communication. A systematic review of the literature has shown that the use of professional interpreters provides better clinical care than the use of informal interpreters, with the former improving the quality of care for patients with limited English language skills to a level equal to that for patients with no language barriers [142]. Use of professional interpreters has been associated with improvements in communication (errors and comprehension), utilization, clinical outcomes, and satisfaction with care [142]. Individuals with limited English language skills have indicated a preference for professional interpreters rather than family members [143].

Whether the education involves stroke prevention, stroke recognition, care after stroke, coping with the effects of stroke, or palliative care, written materials are as important as verbal communication. Several organizations supply general or specialized educational resources, and many also provide patients and family/caregivers with psychosocial, financial, and assisted-living information or aid (Table 9). Clinicians should attempt to obtain materials written in languages appropriate for their patient population and, if appropriate, that target patients in high-risk racial/ethnic populations, especially American Indian/Alaskan native and Black individuals.

Table 9: ORGANIZATIONS PROVIDING PATIENT EDUCATION RESOURCES ON STROKE

American Heart Association

(800) AHA-USA-1 (242-8721)

https://www.heart.org

American Stroke Association (a division of the American Heart Association)

(800) AHA-USA-1 (242-8721)

https://www.stroke.org

Brain Aneurysm Foundation

(888) BRAIN02 (272-4602)

https://bafound.org

Brain Attack Coalition

(301) 496-5751

https://www.ninds.nih.gov/health-information/patient-caregiver-education/brain-attack-coalition

Centers for Disease Control and Prevention

https://www.cdc.gov/stroke

BrightFocus Foundation

(800) 437-2423

https://www.brightfocus.org

Hazel K. Goddess Fund for Stroke Research in Women

http://www.thegoddessfund.org

National Aphasia Association

https://www.aphasia.org

Source: Compiled by Author

PREDICTING RISK

When determining the appropriate degree of risk management, information regarding an individual's risk of first stroke is valuable. The goals of risk assessment tools include [9]:

- Identifying patients who are unaware of their elevated risk

- Assessing the total risk of multiple factors

- Discerning the utility of modifications and treatments

- Projecting a quantitative risk in order to select appropriate treatments or stratification in clinical trials

- Guiding appropriate use of diagnostic tests

The numerous nonmodifiable and modifiable factors that contribute to the risk of stroke have been discussed. Although many of these are independent risk factors, their interactions can affect predictions and management decisions in unexpected ways. No simple, validated stroke risk-assessment tool is currently available [9]. Although risk-assessment tools may have some utility, it is unknown if they improve primary prevention, especially when applied across subgroups according to age, gender, and race/ethnicity [9,144].

Because TIA is a substantial risk factor for a subsequent stroke, clinicians in many EDs are stratifying such patients by degree of risk with use of the ABCD or ABCD2 assessments [145,146]. The ABCD clinical tool is designed to predict 7-day risk of stroke through assessment of age (1 point for patients 60 years of age or older), blood pressure (1 point for a blood pressure greater than 140/90 mm Hg), clinical features (2 points for unilateral weakness with or without speech impairment or 1 point for speech impairment without weakness), and duration (1 point for 10 to 59 minutes, 2 points for greater than 59 minutes) [147]. The "2" designation in ABCD2 was added to represent the presence or absence of diabetes. The effectiveness of these screening tools is lessened by the fact that some individuals do not seek emergency care for a TIA or do not report a TIA to their clinician. However, the ABCD2 assessment has been shown to identify 21% of individuals with a high 2-day risk of having an ischemic stroke [145]. Individuals with high-risk TIA require the same intensity of evaluation and stroke prevention as individuals with ischemic stroke. Scores that predict future stroke risk should be used in conjunction with other diagnostic studies (e.g., imaging) and laboratory tests. The use of ED diagnostic protocols and observation units can reduce length of stay while improving patient treatment and reducing stroke rate [148,149].

4. EARLY STROKE MANAGEMENT

Because the temporal window for effective stroke treatment is short, it is imperative that evaluation and diagnosis are performed promptly and accurately. Use of EMS by persons with stroke is associated with earlier ED arrival, faster ED evaluation, more rapid treatment, and more eligible patients receiving treatment. However, only 60% of all patients with stroke use EMS. In particular, male, Black, and Hispanic patients are less likely to use EMS [150]. The AHA/ASA has established several evidence-based recommendations for the diagnosis and early management of adult-onset ischemic stroke [16]. These recommendations address the evaluation of the individual before he or she arrives at an ED, diagnosis in the ED, the history and physical examination, laboratory tests, carotid ultrasonography, cerebral angiography, and imaging studies.

PREHOSPITAL EVALUATION

The single most important factor influencing the treatment of stroke within 3 hours after the onset of symptoms is the rapid triage and transportation provided by EMS [151]. Public health leaders and medical professionals should design and implement education programs that emphasize the need to rapidly seek emergency care when a stroke is suspected. These programs should be racially/ethnically, age, and sex/gender diverse and should target the public, healthcare providers, and hospital and EMS personnel to increase use of the EMS system, decrease stroke onset to ED arrival times, and increase the timely use of appropriate treatment [16].

Stroke assessment should begin with the EMS dispatcher [16]. When stroke or TIA is suspected, the dispatcher should notify the appropriate EMS provider and coordinate with an appropriate acute stroke treatment facility (Table 10). Regardless of the degree of the neurologic deficits, an individual with suspected stroke or TIA should be dispatched and triaged as if he or she were a serious trauma patient [16]. The goal is rapid transportation to the closest facility that can capably administer intravenous (IV) thrombolysis with alteplase, a recombinant tissue plasminogen activator (rt-PA); if possible, the individual should be taken to a designated stroke center [16,19]. The benefits of IV rt-PA are time-dependent, and treatment should be initiated as quickly as possible, within three hours of stroke onset and after brain imaging (e.g., noncontrast head CT) to screen for hemorrhagic stroke, embolic brain infarction, and tumor [16].

Table 10: "STROKE CHAIN OF SURVIVAL" FROM THE 2013 AMERICAN HEART ASSOCIATION GUIDELINES

Detection: Recognize stroke signs and symptoms

Dispatch: Call 911 and priority emergency medical services dispatch

Delivery: Prompt pre-hospital notification and transport to hospital

Door: Immediate emergency department triage

Data: Emergency department evaluation, prompt laboratory studies, and computed tomography

Decision: Diagnosis and decision about appropriate therapy

Drug/Device: Administration of appropriate drugs or other interventions

Disposition: Timely admission to stroke unit, intensive care unit, or transfer

Source: [152]

Initial EMS evaluation should assess breathing respiration, blood pressure, and positioning the patient to assure maintenance of the airway, Small clinical series shown that the lying-flat position may improve cerebral perfusion in patients with acute ischemic stroke when the intervention is initiated early after stroke onset [16]. EMS personnel should then initiate a prehospital evaluation [16,153]. If the individual exhibits common signs of stroke and/or a stroke is indicated by a validated prehospital examination tool (e.g., Los Angeles Prehospital Stroke Screen, Cincinnati Prehospital Stroke Scale), EMS providers should notify the ED that an individual with suspected stroke is in transport [16,153,154]. Any information about coexisting conditions and, most importantly, time of symptom onset should be provided in advance. A blood glucose level should also be determined, as symptoms of hypoglycemia may mimic those of a stroke [16].

Prehospital evaluation expedites the physician's evaluation of the patient on arrival in the ED. If possible, a witness (preferably a close family member or companion) should be transported with the patient to assist with patient history, symptom onset, and contact information. If no witness was present, a family member should be contacted to go to the hospital and should be informed that he or she may need to provide consent for the patient's treatment. History obtained by EMS providers should include [16]:

- Information about recent events (e.g., stroke, MI, trauma, surgery, bleeding)

- Comorbid diseases (e.g., hypertension, diabetes)

- Use of medications (e.g., anticoagulants, insulin, antihypertensives)

The patient's medication containers should be transported to the ED as well, especially if medications include anticoagulant, antiplatelet, or antihypertensive drugs. Because 60% of individuals with suspected stroke do not use EMS for initial medical care access, ED staff should be alert to signs of stroke among individuals waiting to be seen in the ED [16,150].

DIAGNOSIS IN THE ED

Organization of the ED's stroke team and assessment protocol is paramount to maximize the likelihood of early and successful management [16]. The acute stroke team should include physicians, nurses, and laboratory/radiology personnel. After the patient has been triaged and stabilized, the inaugural ED evaluation (history and physical examination), laboratory studies, and CT imaging should be performed concurrently. The multimodal approach has three goals [16]:

- Rapid and careful identification of ischemic stroke for treatment purposes

- Determination of the underlying cause of the stroke for secondary prevention

- Detection of stroke-mimicking conditions that may require immediate care

Within 1 hour of the patient's arrival, the evaluation (including a neurologic examination) and treatment decision should be completed. The AHA recommends that all patients receive a standardized battery of tests and procedures, with alternative tests performed only if a particular condition is suspected or the patient's history is incomplete (Table 11) [16]. Generally, diagnostic tests should be limited to save time. In addition, all diagnostic tests for stroke should be available 24 hours a day, 7 days a week.

Table 11: IMMEDIATE DIAGNOSTIC STUDIES TO EVALUATE PATIENTS WITH SUSPECTED ISCHEMIC STROKE, AS RECOMMENDED BY THE AMERICAN HEART ASSOCIATION

Population

Diagnostic Test

All patients

Cerebral computed tomography or magnetic resonance imaging (without contrast medium)

Blood glucose

Serum electrolytes/renal function tests

Markers of cardiac ischemia

Complete blood count, including platelet count

Prothrombin time/international normalized ratio (INR)

Activated partial thromboplastin time

Oxygen saturation

Electrocardiography

Selected patients

Hepatic function tests

Toxicology screen

Blood alcohol level

Pregnancy test

Arterial blood gas tests (if hypoxia is suspected)

Chest radiography (if lung disease is suspected)

Lumbar puncture (only if stroke is suspected to be secondary to an infectious disease)

Electroencephalography (if seizures are suspected)

Source: [155] Reprinted from Christensen H, Fogh Christensen A, Boysen G. Abnormalities on ECG and telemetry predict stroke outcome at 3 months. J Neurol Sci. 2005;234:99-103. With permission from Elsevier.

PHYSICAL EXAMINATION AND HISTORY

In addition to time of onset, other crucial historical data that should be obtained include [16]:

- Information about atherosclerotic and cardiac disease risk factors

- Prior and current drug abuse and history of migraine, seizure, infection, trauma, or pregnancy

- Eligibility for treatment of ischemic stroke

If a patient presents with classic signs of stroke and has one or more cardiovascular risk factors, the diagnosis of stroke can be straightforward. However, identifying more unusual cases may be a challenge. If fever and a cardiac murmur are present, the cause of the stroke may be infective endocarditis [156,157]. Giant cell arteritis may be the cause if the patient is 50 years of age or older, has a prominent history of headache, and a strikingly elevated erythrocyte sedimentation rate. The presence of ptosis and miosis contralateral to the deficit may suggest carotid artery dissection [156,157]. If the symptoms were maximal at their onset, a subarachnoid hemorrhage or embolic stroke should be suspected [158]. In up to 40% of patients with subarachnoid hemorrhage, a severe headache (sometimes called a thunderclap or sentinel headache) that may abate within minutes or hours is the only symptom [158]. Head CT should be immediately performed in any patient with a suspected subarachnoid hemorrhage [36].

Following a structured neurologic examination, the general physical examination should include assessment of the head, neck, heart, lungs, abdomen, extremities, and skin [16]. Pulse oximetry and body temperature are also important evaluations. When performing the head and neck examination, the clinician should look for physical signs of trauma or seizure activity (e.g., contusions, tongue lacerations) or heart failure (jugular venous distention). Thrombolytic treatment is inadvisable for a seizure in the absence of acute ischemia detected by imaging [21].

When examining the patient's neck, carotid bruits may be heard. Although a bruit may be indicative of carotid atherosclerosis, confirmatory diagnosis and degree of carotid stenosis requires imaging with Doppler or duplex ultrasound [159]. Because the prevalence of carotid bruit increases with age, its specificity as a clinical marker of stroke risk in asymptomatic individuals 65 years of age or older has been questioned [160]. In a symptomatic patient with acute TIA/stroke event, a focal carotid bruit increases the likelihood of significant (>70%) carotid stenosis, which has implications for secondary stroke prevention. However, the absence of bruit is not reliable for concluding the carotid vessels are normal.

The cardiac examination may demonstrate contributing factors or comorbidities, such as myocardial ischemia, valvular conditions, arrhythmias, or aortic dissection (a rare cause of ischemic stroke). The diagnostic evaluation should include electrocardiography (ECG), because cardiovascular conditions such as AF and MI are prevalent among individuals with stroke [16,155]. The findings of studies have suggested that the value of chest x-ray as part of the diagnostic workup is debatable, and the 2019 AHA/ASA guideline recommends a chest x-ray only if lung disease is suspected [16]. Although cardiac monitoring of patients with stroke has not been evaluated, the AHA/ASA recommend its use for the first 24 hours to monitor for AF and MI, either of which can lead to stroke or be a dangerous coexisting condition [16].

Severe elevation in blood pressure (systolic >210 mm Hg and/or diastolic >120 mm Hg) may signal hypertensive encephalopathy and the possibility of cerebral hemorrhage [123,161]. Examination of the lungs and abdomen may reveal additional clues to pathogenesis of the stroke. The skin and extremities should be examined for signs of systemic conditions, including coagulopathies, platelet disorders, or liver dysfunction [16].

If only historical information and/or physical examination are relied on, up to 19% of stroke mimics are mistaken for stroke. Yet, a patient's history and examination may also identify a condition masquerading as a stroke (Table 12) [16,162]. The use of MRI or CT with laboratory studies enhances the accuracy of diagnosis, but detecting mimics with imaging techniques is a challenge if the patient has a history of stroke [16].

Table 12: COMMON NONCEREBROVASCULAR CONDITIONS THAT MIMIC STROKE

Stroke Mimic

Differential Symptoms

Brain tumor

Gradual progression of symptoms

Drug overdose

Altered mental status without focal findings

Conversion disorder

Neurologic findings in a nonvascular distribution

Inconsistent examination

Other psychiatric disorders

Hypertensive encephalopathy

Headache

Delirium

Significant hypertension

Cortical blindness

Cerebral edema

Seizure

Hypoglycemia

History of diabetes

Low blood glucose level

Decreased level of consciousness

Migraine with aura (complicated migraine)

History of similar events

Preceding aura

Headache

Hemiplegia that outlasts the headache

Seizures/postictal paresis

Paresis

History of seizures

Witnessed seizure activity

Drug toxicity

History of lithium, phenytoin, or carbamazepine use

Source: [162,163]

Another important component of the physical examination is assessment with the National Institutes of Health Stroke Scale (NIHSS). Although initially devised as a research tool to quantify neurologic deficits, this tool is now widely used to measure the severity of a stroke, devise an effective treatment plan that establishes a priority for patient safety, identify the affected vascular region, and predict patient outcome [16,164]. The NIHSS is standardized, reliable, and fast and facilitates communication among healthcare professionals. Any trained healthcare professional can use the scale at the bedside in 5 to 8 minutes. In addition, results are based only on patient evaluation; a history or information from others is not necessary. It is recommended that the scale be used to assess the patient during the ED evaluation and during treatment with recombinant tissue plasminogen activator (rt-PA) or other therapies and that it be repeated often in the first 24 hours. Further information about the NIHSS and a copy of the scale can be obtained from the National Institute of Neurological Disorders and Stroke [165].

LABORATORY TESTS

For all patients with suspected stroke, the battery of diagnostic tests should be carried out concurrently with laboratory tests, including blood glucose level (to rule out hypoglycemia as a stroke mimic), complete blood count (with platelet count), serum electrolyte levels, renal function studies, and cardiac ischemia biomarkers [16]. Prothrombin time and partial thromboplastin time determinations should be included when considering thrombolysis. Generally, waiting for the results of a diagnostic test should not be a reason to delay thrombolytic therapy [16]. The risk of increased neurologic damage and death caused by ischemic stroke outweighs that of a secondary hemorrhage except when a bleeding or blood disorder is suspected, the patient was given warfarin or heparin, or the patient takes anticoagulant drugs.

Electrocardiography and telemetry monitoring are warranted in all patients with ischemic stroke and TIA to screen for AF and silent MI. Studies show that initial assessment detects AF in as many as 7% of patients in this clinical setting; longer cardiac monitoring yields higher detection rates, especially among patients with heart disease [402].

HEAD AND NECK IMAGING STUDIES

All patients with suspected acute stroke should receive emergency brain imaging evaluation on first arrival to a hospital before initiating any specific therapy to treat ischemic stroke. The purpose is to exclude ICH in patients who are potentially eligible for IV fibrinolysis (tPA) or mechanical thrombectomy or both [16]. High diagnostic accuracy of stroke and treatment decisions is optimized by the use of imaging tools such as CT and MRI. Collectively, these neuroimaging options provide detailed information that influences stroke treatment decisions, including infarct age, severity, and distribution; intracranial vascular status; cerebral hemodynamics; estimated reversibility of ischemic damage; and hemorrhage type and distribution [16]. For instance, a widespread distribution of early infarction or edema increases hemorrhagic transformation risk following thrombolytic therapy. CT without contrast medium is readily sensitive to these conditions [16].

For prompt and accurate diagnosis, the use of noncontrast CT (NCCT) or DW-MRI is recommended for initial imaging in a patient with suspected stroke [16,173]. Although NCCT is less expensive, faster, and more widely available, DW-MRI more readily detects small cortical, subcortical, and posterior fossa infarcts and distinguishes chronic ischemia from acute ischemia. MRI is also sensitive to subclinical satellite ischemic lesions that characterize the pathophysiology of the stroke [152,180]. As stated, DW-MRI can detect acute ischemic changes within minutes after the onset of stroke; CT may not detect a zone of ischemic change for some hours after the event [16]. For patients with acute ischemic stroke who are candidates for thrombolysis (0- to 4.5-hour time window), NCCT or MRI of the head is recommended to exclude ICH and determine extent of ischemic changes, while ensuring that patients receive timely IV rt-PA [16]. The AHA recommends that CT imaging be obtained within 25 minutes after the patient's arrival in the ED [152]. If a patient is eligible for rt-PA, treatment should be initiated as quickly as possible without waiting for further imaging [16].

Once a decision regarding thrombolytic therapy has been reached, multimodal CT and MRI are useful for refining the etiologic diagnosis, confirming location and extent of ischemic injury, and selecting patients who may benefit from endovascular therapy within a 6- to 24-hour window. Multimodal brain MRI is the preferred method to evaluate for acute ischemic infarct, should be obtained within 24 hours of symptom onset, and, in most centers, will follow NCCT. In centers with rapid access to MRI in the ED, DW-MRI might be substituted for NCCT as initial imaging procedure in stable patients. The distribution of DW lesions helps identify the stroke pathogenesis (e.g., a single lesion in a deep structure suggests small vessel disease; scattered lesions in multiple territories points to cardioembolism) [402].

Computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and duplex ultrasound or transcranial Doppler are noninvasive imaging modalities that, in selected patients with TIA/stroke, are used for identification of high-grade carotid stenosis and intracranial vascular occlusions amenable to endovascular therapy. Stenosis/occlusion of major vessels carries a high risk for recurrent stroke. CTA has high sensitivity and specificity for detecting intracranial arterial stenoses and embolic occlusions. MRA has the advantage of three-dimensional views, detects vascular patency and can be extended to assess the intracranial vasculature. Imaging strategies for selecting patients under consideration for endovascular therapy fall into three categories [173]. The first is NCCT, followed immediately by digital subtraction angiography (DSA), which enables assessment of vascular patency, demonstrates the collateral pattern, may indicate infarct volume, and has the advantage of minimizing door-to-recanalization time. The second strategy is to obtain a CT angiogram to assess vascular patency, with or without perfusion imaging, in order to better characterize the size of occlusion and zone of ischemic tissue before deciding whether to proceed with an endovascular intervention. The third option is MRI and MRA, possibly with diffusion- and perfusion-weighted imaging where it can be performed quickly and on a constant basis [173]. In selecting candidates for mechanical thrombectomy within 6 to 24 hours after last known well time, AHA/ASA guidelines recommend using either CTA with computed tomographic perfusion (CTP) or MRA with DW-MRI [16].

Cerebral Angiography

Conventional catheter angiography is invasive and requires a nephrotoxic contrast medium [169]. It is particularly valuable for the detection of vasculopathies associated with cerebral complications, including aneurysm, vasculitis, arteriovenous malformation, atherosclerosis, and arterial dissection [10,16]. Digital subtraction angiography (DSA), a type of catheter angiography, remains the standard against which newer technologies for detection of many types of cerebrovascular lesions and diseases are measured [170,171,172,173,174]. Its sensitivity and specificity equal or exceed those of noninvasive techniques; however, because of time considerations and procedural difficulties, it is not recommended in initial evaluation of stroke patients [16].

Unlike catheter angiography, MRA creates a map of blood flow rather than a true image of the vasculature anatomy. Noninvasive time-of-flight MRA is performed without contrast medium, and like phase-contrast (gadolinium) MRA is minimally invasive (catheter insertion required). Although MRA provides a high-resolution image of many vessels, it cannot reliably resolve distal or branch occlusions of the intracranial vasculature [16]. MRA also tends to overestimate the degree and length of high-grade stenosis (compared with DSA) by signaling loss of flow when blood flow is turbulent, in-plane, or slow [175]. MRA is helpful for detecting uncommon causes of ischemic stroke or TIAs (e.g., arterial dissection, venous thrombosis) [172]. The 2019 AHA/ASA guideline recommends the use of MRA with DW-MRI when selecting candidates for mechanical thrombectomy between 6 and 24 hours after last known well time [16]. DW-MRI is sensitive to acute cellular injury in cerebral ischemia and can be used to assess ischemic lesions in the first few hours [177].

CTA also permits noninvasive, rapid screening of intracranial and extracranial vasculature for stenosis and occlusion. Preliminary data suggest that CTA effectively detects large-vessel intracranial occlusions when compared with ultrasound and DSA; however, because it provides a static image of vascular anatomy, it is inferior to DSA for demonstrating flow rates and direction [16,178]. Although CTA is fast and can be adapted to conventional CT, contrast medium is required, and patients are exposed to additional radiation [16]. The 2019 AHA/ASA guideline recommends the use of CTA with CTP or MRA/DW-MRI for selecting candidates for mechanical thrombectomy between 6 and 24 hours after last known well time [16].

Doppler Ultrasonography

Doppler ultrasonography is a noninvasive imaging technique used to measure arterial blood flow and determine the site and degree of stenosis/occlusion of the external carotid and cerebral vasculature. A common use of transcranial Doppler ultrasonography is for primary and secondary stroke prevention in patients presenting with TIA and stroke. It can be used to monitor progress of vascular recovery during the early post-acute thrombolysis treatment phase of stroke care [10,16,166]. Additional uses of transcranial Doppler ultrasonography in patients with stroke include [16,166,167]:

- Detection of intracranial and extracranial vascular disorders

- Assessment of recurrent stroke risk (e.g., microemboli detection)

- Identification of candidates for intensive prophylactic interventions (e.g., carotid endarterectomy, angioplasty/stenting)

- Intraoperative monitoring of carotid endarterectomy

- Detection of right-to-left shunts

- Identification of subclavian steal syndrome

- Measurement of a post-subarachnoid hemorrhage vasospasm

- Assessment of recanalization (spontaneous or thrombolytically induced)

- Prognosis of patients with stroke (performed during post-acute phase)

Despite the usefulness of this technique, its performance is highly operator-dependent [166]. Considerable anatomic and physiologic knowledge of the cerebral vasculature is required, as vessel images are not produced, and skill and experience are prerequisites for data interpretation. Data acquisition and interpretation tend to be time-consuming and may delay treatment [166,168]. While these reasons suggest that vascular imaging is not practical for the diagnosis of ischemic stroke in most cases, it may be useful in some. A recommendation in the 2019 AHA/ASA guidelines states that noninvasive imaging of the cervical carotid arteries should be routinely performed within 24 hours of admission in patients with nondisabling acute ischemic stroke in the carotid territory who are candidates for carotid endarterectomy [16]. Additionally, intracranial vessel imaging is recommended to guide selection of appropriate secondary stroke prevention treatments [16].

Transcranial Doppler (TCD) ultrasonography has been used to detect intracranial vessel abnormalities and to evaluate occlusions and stenoses in intracranial vessels. It is less accurate than CTA or MRA for steno-occlusive disease but can detect microembolic signals that indicate extracranial or cardiac sources of embolism [152]. TCD has been shown to predict and enhance outcomes with IV rt-PA [179].

Because the time between the onset of stroke and treatment should be limited, catheter angiography is not recommended by the AHA for the diagnosis of a suspected stroke [152]. In the case of a stroke, the utility of the imaging tool increases after a diagnosis has been made. As with transcranial Doppler ultrasonography, cerebral angiography is particularly useful for confirming the diagnosis, monitoring the progression of thrombolytic therapy, and assisting with the prognosis, particularly during the first 72 hours after a stroke [152].

5. TREATMENT

Because strokes are heterogeneous, are associated with multiple medical complications, and are time-critical, their effective management depends on organized and comprehensive care. Such treatment is optimally provided in comprehensive stroke centers and stroke systems of care. In 2007, the AHA/ASA published evidence-based guidelines to provide recommendations for treatment. These guidelines were updated in 2013 and again in 2019 [16,152].

STROKE SYSTEMS OF CARE AND COMPREHENSIVE STROKE CENTERS

Comprehensive stroke centers are designed to accommodate the needs of patients with complicated forms of stroke, intracranial hemorrhages, and subarachnoid hemorrhages, as well as patients in need of aggressive intervention measures and intensive care [19]. In general, primary and comprehensive stroke centers have been shown to be associated with better adherence to evidence-based guidelines and with an increased use of IV rt-PA [181]. Nationally, only 2% to 3% of individuals with stroke are treated with rt-PA, but the rate is typically greater than 10% at primary and comprehensive stroke care centers [19,138]. Overall care may also be improved at comprehensive stroke centers [181,182]. A formal certification process for comprehensive stroke centers has been established by the Joint Commission and the ASA. The Joint Commission has been certifying primary stroke centers since 2004, and it began providing certification for comprehensive stroke centers in 2014 [16]. Because patients are more likely to receive thrombolytic therapy at primary and comprehensive stroke centers, many states have enacted policies mandating the direct routing of individuals with suspected stroke (with onset of symptoms less than 3 hours previously) to either of these types of facilities. As of 2015, 1,505 of the 4,640 general hospitals and emergency rooms in the United States have been certified as primary stroke centers [183]. Seventy-four percent of the primary stroke centers have been certified by the Joint Commission and the AHA/ASA, 20% have been certified by state organizations, and 6% have been certified by other organizations. The highest proportion of primary stroke center certifications has occurred in the Northeastern United States [183]. Telemedicine for stroke (also called telestroke) and air transport are being increasingly used to serve individuals in rural areas that lack local stroke expertise [16,182].

Stroke centers are commonly part of a comprehensive support network known as a stroke system of care [16]. The system seeks ways to coordinate the highest quality of stroke prevention, community education, EMS, acute care, and post-acute care. Without a system of care, these components often operate less effectively and in isolation. Implementation of a stroke system of care in underserved regions could substantially improve treatment statistics statewide or nationwide; for example, one study showed that the additional resources at as few as six target hospitals in the western part of North Carolina would increase patient access to stroke care by 61.5% throughout the state [184].

Guidelines for establishing a stroke system of care were developed by an ASA Task Force [20]. Because of the multidisciplinary aspects of a stroke system, Task Force members were experts in areas of stroke prevention, EMS, acute stroke care, rehabilitation, and healthcare policy. Overall, the recommendations promote the communication and collaboration of patients, clinicians, facilities, and agencies. General ASA recommendations for stroke systems of care are [20]:

- Support local/regional educational initiatives designed to increase stroke awareness among the general population, with enriched targeting of populations at increased risk of stroke and poor post-stroke outcomes.

- Design/implement innovative behavioral interventions that address barriers to healthy behaviors and prevention adherence.

- Design/implement public education programs that are repetitive, designed to reach diverse populations, and focused on stroke systems and the need to urgently seek emergency care (by calling 911).

- Develop triage protocols that ensure all patients with known or suspected stroke are rapidly identified and assessed with validated stroke screening instrument.

- All stroke center certification systems should meet or exceed the standards set by nationally certified stroke centers and should work regionally in an integrated way to provide and share best practices.

- Adopt approaches to secondary prevention that address all major modifiable risk factors and are consistent with national guidelines for patients with a history or suspected history of stroke or TIA.

- Standardize postacute care and discharge. Trained stroke nurses, nurse practitioners, social workers, community health workers, and others play a critical role in this process.

- Advance the use of technology and patient-reported outcomes to facilitate improvements in stroke care transitions.

- Enact federal-level policies that standardize the organization of stroke care throughout the continuum.

SUPPORTIVE CARE ISSUES

Several important considerations apply to the management of all patients with stroke in any acute clinical care venue. In the early period after sustaining a stroke, patients are often unable to communicate effectively or move voluntarily to change position in bed. Steps should be taken to assure maintenance of the airway, and attention should be paid to proper positioning (e.g., raising head of the bed) to reduce the risk of aspiration. If there are signs of hypovolemia, IV fluid should be administered to assure normal blood pressure and circulating blood volume, which are necessary to optimize circulation to the region of ischemic injury. Blood pressure is frequently elevated at presentation and for some days afterward. A certain degree of restraint is required for managing hypertension safely in this setting. This is because cerebrovascular autoregulation is impaired following occlusion of a major cerebral artery, and normalizing the blood pressure too quickly may result in reduced blood flow around the infarct penumbra, making the ischemic deficit worse. While it may be prudent to treat hypertension, the goal is gradual improvement without normalization. For safe administration of rt-PA, blood pressure should be <180/<105 mm Hg and maintained so for at least 24 hours [16].

Hypertensive encephalopathy ("malignant hypertension") does require vigorous treatment and is potentially confusing, as patients present with acute neurologic symptoms and severe hypertension. The pathogenesis and clinical signs differ from stroke, though the syndrome may be complicated by ICH. Severe hypertension with mean arterial pressure in excess of 110–120 mm Hg leads to vasogenic cerebral edema. Patients present with headache, global signs of encephalopathy (e.g., vomiting, lethargy, confusion), blurred vision, and papilledema. Blood pressure is usually >220 mm Hg systolic and >120 mm Hg diastolic. Hypertensive encephalopathy is a medical emergency treated with IV antihypertensive agents to prevent further deterioration (e.g., rostro-caudal brain herniation) and death. In those with prior history of hypertension, the goal is to restore blood pressure to previous control levels.

EVIDENCE-BASED GUIDELINES

Thrombolytic therapy with rt-PA is the only treatment approved by the U.S. Food and Drug Administration (FDA) for ischemic stroke [16]. Anticoagulant and antiplatelet agents are also used, but their appropriateness is a source of debate and ongoing research. Intra-arterial rt-PA may be beneficial for select patients; however, the drug is not FDA approved for this use [18]. Mechanical thrombectomy is a consideration as both a primary reperfusion strategy and in conjunction with pharmacologic fibrinolysis [16].

The AHA/ASA recommendations for the treatment of ischemic stroke are based on review of published studies and emphasize the importance of early management [16,18]. Since publication of the 2013 guidelines, substantial new high-quality evidence on the clinical efficacy of endovascular treatments has become available. This new evidence is the basis of the AHA/ASA 2015 focused update to the 2013 guidelines and is included, where appropriate, in the recommendations that follow [18].

Recombinant Tissue Plasminogen Activator (rt-PA) for Thrombolysis

Evidence Based Practice Recommendation

With a goal to improve functional outcomes, the American College of Emergency Physicians recommends that intravenous tPA should be offered and may be given to selected patients with acute ischemic stroke within three hours after symptom onset at institutions where systems are in place to safely administer the medication. The increased risk of symptomatic intracerebral hemorrhage should be considered when deciding whether to administer tPA.

https://www.acep.org/globalassets/new-pdfs/clinical-policies/tpa-for-stroke_new.pdf

Last Accessed: March 31, 2026

Strength of Recommendation: B (Recommendation based on moderate clinical certainty)

The IV administration of alteplase (rt-PA) has been FDA-approved for the treatment of stroke since 1996. Rapid administration of rtPA to appropriate patients remains the mainstay of early treatment of acute ischemic stroke [18]. Treatment with rt-PA is highly effective if administered within 3 hours. The earlier treatment is initiated, the higher the probability of a full recovery. Treatment within 90 minutes has been associated with a higher rate of favorable outcome at 3 months compared with treatment administered within 180 minutes [185]. For patients who meet national and international eligibility guidelines, IV rtPA improves functional outcomes at 3 to 6 months when given within 4.5 hours after ischemic stroke onset and should be administered [18]. However, the therapeutic window may extend to 6 hours [186,187]. Studies to determine the threshold of rt-PA benefits are ongoing. The AHA/ASA recommend that health systems set a goal of increasing their percentage of stroke patients treated within 60 minutes of presenting to hospital (i.e., door-to-needle time of 60 minutes) to at least 80% [152]. Tenectaplase is a newer tissue plasminogen activator investigated for treatment of ischemic stroke; it appears to be as effective as alteplase and may have a better safety profile [16].

The AHA/ASA have changed some of their recommendations regarding rt-PA treatment since their 2013 guidelines (Table 13) [16]. Administration of rt-PA is not recommended for patients who have a systolic blood pressure greater than 185 mm Hg or a diastolic blood pressure greater than 110 mm Hg [16].

Table 13: AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION RECOMMENDATIONS FOR THROMBOLYTIC THERAPY

Class I Recommendations

In patients eligible for IV rt-PA, benefit of therapy is time dependent; treatment should be initiated as quickly as possible (Class I, Level of Evidence A).

Intravenous rt-PA (0.9 mg/kg, maximum dose 90 mg) is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke (Class I, Level of Evidence A). Physicians should review the criteria outlined in the AHA/ASA guidelines to determine the eligibility of patients.

Intravenous rt-PA (0.9 mg/kg, maximum dose 90 mg) is recommended for administration to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke onset (Class I, Level of Evidence B). Physicians should review the criteria outlined in the AHA guidelines to determine the eligibility of patients.

Intravenous rt-PA is recommended for eligible patients with mild but disabling stroke systems who may be treated within 3 hours of onset of stroke symptoms (Class I, Level of Evidence B).

Intravenous rt-PA is reasonable in patients whose blood pressure can be lowered safely (to less than 185/110 mm Hg) with antihypertensive agents, with the physician assessing the stability of the blood pressure before starting intravenous rt-PA. Blood pressure should be maintained at <180/105 mm Hg for at least the first 24 hours (Class I, Level of Evidence B).

In addition to bleeding complications, physicians should be aware of the potential side effect of angioedema that may cause partial airway obstruction (Class I, Level of Evidence B).

Class II Recommendations

Intravenous rt-PA (0.9 mg/kg, maximum dose 90 mg) administered within 4.5 hours of stroke symptom recognition may be beneficial in patients who awake with stroke symptoms or have unclear time of onset 4.5 hours (Class II, Level of Evidence B).

Intravenous rt-PA may be beneficial for adults presenting with acute ischemic stroke with known sickle cell disease (Class IIa, Level of Evidence B).

Intravenous rt-PA may be beneficial in patients with a hyperdense MCA sign (Class IIa, Level of Evidence B).

Intravenous rt-PA administration should not be delayed while waiting for hematologic or coagulation testing, if no abnormal test results are expected (Class IIa, Level of Evidence B).

Administration of IV rt-PA is reasonable in otherwise eligible patients who have previously had a small number (1 to 10) of CMBs demonstrated on MRI (Class IIa, Level of Evidence B).

In otherwise eligible patients who have previously had a high burden of CMBs (10) demonstrated on MRI, treatment with IV rt-PA may be associated with an increased risk of sICH, and the benefits of treatment are uncertain. Treatment may be reasonable if there is the potential for substantial benefit (Class IIb, Level of Evidence B).

The risk of antithrombotic therapy (other than intravenous aspirin) within the first 24 hours after treatment with IV rt-PA (with or without mechanical thrombectomy) is uncertain. Use might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV rt-PA is known to provide substantial benefit or withholding such treatment is known to cause substantial risk (Class IIb, Level of Evidence B).

It may be reasonable to choose tenecteplase (single IV bolus of 0.25 mg/kg, maximum 25 mg) over IV rt-PA in patients without contraindications for IV fibrinolysis who also are eligible to undergo mechanical thrombectomy (Class IIb, Level of Evidence B).

Tenecteplase (0.4 mg/kg single IV bolus) might be considered as an alternative to IV rt-PA in patients with minor neurologic impairment and no major intracranial occlusion (Class IIb, Level of Evidence B).

Intravenous rt-PA may be reasonable for patients who can be treated within 3 to 4.5 hours of stroke symptom of onset (Class IIb, Level of Evidence B).

The usefulness of IV administration of the glycoprotein IIb/IIIa inhibitors tirofiban and eptifibatide coadministered with intravenous rt-PA is not well established (Class IIb, Level of Evidence B).

Class III Recommendations

Intravenous rt-PA is not recommended for patients who could be treated within 3 hours of stroke symptom onset (Class III, Level of Evidence B). This applies to otherwise eligible patients with mild nondisabling stroke symptoms (NIHSS score 0–5).

Do not administer abciximab concurrently with IV rt-PA (Class III, Level of Evidence B).

Do not administer IV aspirin within 90 minutes of initiation of IV rt-PA (Class III, Level of Evidence B).

Intravenous rt-PA is not indicated for nonvascular conditions (Class III, Level of Evidence B). Clinicians should be aware that hypoglycemia and hyperglycemia may mimic acute stroke and should determine blood glucose levels prior to initiation of IV rt-PA.

Do not administer IV rt-PA to patients who have received a full treatment dose of LMWH within the previous 24 hours (Class III, Level of Evidence B).

Intravenous rt-PA is not recommended for patients who could be treated within 3 to 4.5 hours of stroke symptom onset (Class III, Level of Evidence C). Applies to otherwise eligible patients with mild nondisabling stroke symptoms (NIHSS score 0–5).

Do not delay treatment with IV rt-PA to monitor improvement (Class III, Level of Evidence C).

MCA=middle cerebral artery; CMB=cerebral microbleed; MRI=magnetic resonance imaging; sICH=symptomatic intracerebral hemorrhage.

Source: [16]

Between 31% and 50% of patients treated with rt-PA have a 4-point or greater improvement on the NIHSS by 3 months after the stroke [152]. These clinical improvements do not recede for at least 1 year after the stroke. In general, the best response to rt-PA has been found for patients who are younger than 75 years of age, with a baseline NIHSS score of less than 20, and no history of diabetes or pre-existing disability [152].

The most common serious medical complication of rt-PA is secondary brain hemorrhage, which occurs in 6% of patients [188]. Yet, the risk does not outweigh the benefits of rt-PA. Three months following rt-PA therapy, approximately 30% of patients are neurologically normal or near normal; 30% have mild-to-moderate neurologic deficits; 20% have moderate-to-severe deficits; and 20% have died [189]. Other dangerous complications of rt-PA, although rare, are angioedema, anaphylaxis, systemic hemorrhage, and, if rt-PA is administered soon after an acute MI, myocardial rupture [16,190].

Anticoagulants

The AHA/ASA Task Force reviewed and discussed several studies addressing the use of heparin or low-molecular-weight heparin (LMWH) as an adjunct to a thrombolytic agent in the treatment of stroke [16]. In general, the Task Force concluded that early administration of heparin or LMWH is inadvisable partly due to the increased risk of bleeding complications, especially the hemorrhagic transformation of ischemic strokes. Additionally, early administration has not been shown to prevent recurrent stroke, lessen the risk of neurologic worsening, or improve patient outcome [16].

Antiplatelet Therapy

Although no new data regarding antiplatelet treatment have emerged since the 2003 version of the AHA/ASA guideline for ischemic stroke management, the AHA/ASA recommendations for antiplatelet therapy have changed (Table 14) [16]. Data combined from two large clinical trials suggest that administration of aspirin (325 mg) within 24 to 48 hours after the onset of stroke slightly reduces mortality and morbidity by preventing early recurrent stroke in some patients [191,192]. The findings of these trials do not suggest the use of aspirin within 24 hours of thrombolytic administration or as a substitute for thrombolytic therapy. A 2014 Cochrane review confirmed the results of these trials [193]. A review that summarized the results of nine randomized controlled trials also confirmed these findings and demonstrated increased odds of complete recovery [194]. In patients presenting with minor (NIHSS ≤3) noncardioembolic stroke who are not treated with rt-PA, dual antiplatelet therapy (aspirin and clopidogrel) started within 24 hours after symptom onset and continued for 21 days is effective in reducing risk of recurrent stroke for a period up to 90 days [16].

Table 14: AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION RECOMMENDATIONS REGARDING ANTIPLATELET TREATMENT FOR ISCHEMIC STROKE

Class I Recommendations

The oral administration of aspirin (initial dose is 325 mg) within 24 to 48 hours after stroke onset is recommended for treatment of most patients (Class I, Level of Evidence A). For patients treated with IV rt-PA, aspirin administration is generally delayed 24 hours.

In patients presenting with minor noncardioembolic ischemic stroke (NIHSS score ≤3) who did not receive IV rt-PA, treatment with dual antiplatelet therapy (aspirin/clopidogrel) started within 24 hours after symptom onset and continued for 21 days is effective in reducing recurrent ischemic stroke for a period of up to 90 days from symptom onset (Class I, Level of Evidence A).

Class II Recommendations

The efficacy of intravenous tirofiban and eptifibatide is not well established (Class IIb, Level of Evidence B). Further trials are necessary to clarify the safety and efficacy of this intervention.

Class III Recommendations

Ticagrelor is not recommended over aspirin for treatment of patients with minor stroke (Class III, Level of Evidence B). Ticagrelor may be a reasonable alternative in stroke patients with a contraindication to aspirin.

The administration of abciximab as medical treatment for acute ischemic stroke is potentially harmful and should not be performed (Class III, Level of Evidence B).

Aspirin is not recommended as a substitute for other acute interventions for treatment of stroke, including the intravenous administration of rt-PA (Class III, Level of Evidence B).

Source: [16]

Evidence Based Practice Recommendation

In patients with acute ischemic stroke or transient ischemic attack, the American Heart Association/American Stroke Association recommends early (within 48 hours) aspirin therapy at a dose of >60–325 mg.

https://www.ahajournals.org/doi/10.1161/STR.0000000000000211

Last Accessed: March 31, 2026

Strength of Recommendation/Level of Evidence: 1A (Strong recommendation, high-quality evidence)

Ticagrelor is a reversible, short-acting P2Y12 agonist. The Acute Stroke or Transient Ischemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes (SOCRATES) trial tested the efficacy of ticagrelor (18-mg loading dose, then 90 mg twice daily) to aspirin in 13,199 patients with acute ischemic stroke or high-risk TIA [196]. The primary outcome (i.e., time to stroke occurrence, MI, or death within 90 days) occurred in 6.7% of patients treated with ticagrelor versus 7.5% treated with aspirin. Ischemic stroke occurred in 5.8% in the ticagrelor arm versus 6.7% in the aspirin arm. There were no differences in major bleeding, intracranial hemorrhage, or fatal bleeding. A subgroup analysis of the SOCRATES trial found that ticagrelor was effective at preventing the primary outcome in patients with a background history of aspirin use [197]. Ticagrelor versus placebo was the subject of the THALES (Acute Stroke or Transient Ischemic Attack Treated with Ticagrelor and ASA for Prevention of Stroke and Death) trial, which was completed in December 2019. As of 2026, the results have not yet been published [198].

Several trials have examined the efficacy of clopidogrel plus low-dose aspirin [199,200,201,202,203,204]. While the data from two of these trials suggest a benefit from dual antiplatelet therapy (i.e., clopidogrel/aspirin), the results of the other trials suggest a lack of benefit and possibly harm in the longer term. The combination dipyridamole plus aspirin for ischemic stroke management has been studied in several trials involving more than 17,000 patients [205,206,207,208,209,210]. The combination was found to be an acceptable antiplatelet therapy for patients with ischemic stroke or TIA and probably superior to aspirin alone. However, twice-daily dosing and headache cause many patients to discontinue the regimen [207,208,209,210].

The efficacy of IV glycoprotein IIb/IIIa receptor blockers (GP IIb/IIIa inhibitors), such as abciximab, in combination with other interventions or alone is under investigation. Preliminary results from the Abciximab in Emergent Stroke Treatment Trial (AbESTT) indicate that IV GP IIb/IIIa inhibitors may accelerate spontaneous recanalization, improve microvascular patency, and offer an adequate safety profile [211,212]. However, a systematic review of GP IIb/IIIa inhibitors as well as results of the AbESTT-II (a phase III trial of abciximab) did not demonstrate either safety or efficacy of the drug for treatment of acute ischemic stroke and found an increased rate of symptomatic or fatal intracranial hemorrhage, with no reduction in death or disability in survivors [213,214]. The 2019 AHA/ASA guideline contains both revised and new recommendations regarding the use of IV GP IIb/IIIa inhibitors, including abciximab (Table 14) [16].

Angioplasty and Stenting

Although emergent angioplasty and stenting are high-risk procedures, progressing strokes, which occur when patients' moderate neurologic deficits deteriorate significantly within 72 hours after onset, are associated with very poor outcomes and high mortality rates [215]. Therefore, some case studies suggest that emergency angioplasty followed by immediate or delayed stenting is appropriate for patients with a progressing stroke caused by carotid artery occlusion or stenosis, respectively [216,217]. However, the safety and efficacy of emergency carotid artery stenting are not established, and the procedure remains controversial [218,219].

Angioplasty and stenting may be appropriate for patients with acute stroke secondary to carotid artery dissection [220,221]. In one study, emergency angioplasty and stenting of the internal carotid artery performed in conjunction with intra-arterial thrombolysis was associated with more favorable outcomes than pharmacologic treatment alone in patients with acute carotid artery occlusion and secondary artery-to-artery embolism to the middle cerebral artery [222]. In a larger study by the same group of investigators, treatment with urokinase followed by angioplasty and stenting increased recanalization [223]. Another study found that angioplasty and stenting of the proximal occlusion and stent-based thrombectomy of the intracranial occlusion may be feasible, effective, and safe in selected patients with acute internal carotid artery occlusion and concomitant major vessel embolic stroke [221].

The AHA/ASA assert that the use of angioplasty and intra-arterial thrombolytics in the emergency management of stroke should be limited to comprehensive stroke centers, which have the resources and physician expertise to perform them safely, and in the setting of clinical trials [18].

In addition to use in emergent angioplasty and stenting, mechanical thrombectomy is both a primary reperfusion strategy and an adjunct to pharmacologic fibrinolysis for achieving recanalization in patients with acute ischemic stroke [16]. Mechanical treatments include the use of catheters during angiography to directly deliver either a clot-disrupting or retrieval device to an artery-occluding thromboembolus [224].

The primary advantage of mechanical devices is their ability to remove a clot in a matter of minutes, compared with pharmacologic thrombolytics (even those delivered intra-arterially) that may take as long as two hours to dissolve the clot [225,226]. A second advantage is that newer devices (e.g., retrievable stents) have shown higher recanalization rates and better outcomes than those seen with older devices (e.g., the Merci Retriever) [224]. The primary disadvantage of endovascular therapy is the delay in initiation of treatment because of the time required to mobilize the interventional team and, in many cases, the need to transfer the patient to another hospital [227,228]. In the absence of sufficient trial data, it had been uncertain whether endovascular therapy, with or without the previous use of IV rt-PA, would be more effective than IV rt-PA alone [229]. However, newer trials (i.e., MR CLEAN, EXTEND-IA, ESCAPE, and SWIFT-PRIME) have demonstrated the efficacy of endovascular therapy using the newer, retrievable stents [230,231,232].

In addition to reviewing the results of these four trials, the AHA/ASA also reviewed the results of the REVASCAT trial [18,233]. Of the five stent retriever trials, MR CLEAN, ESCAPE, and SWIFT-PRIME permitted use of salvage intra-arterial fibrinolytic drugs, whereas EXTEND-IA and REVASCAT did not [18]. Every or nearly every patient in the trials first received IV rt-PA. All five studies enrolled participants 18 years of age and older. Four of the trials used NIHSS scores (>2, >5, and 8–29) as eligibility criteria, and the fifth trial enrolled patients with a similar distribution of NIHSS scores. Four of the five trials used a prestroke function eligibility criterion. All five trials required baseline nonenhanced CT or MRI and used different strategies of an imaging-based selection criterion in addition to nonenhanced CT or MRI. A large majority of patients in the trials had ICA or proximal MCA (M1) occlusion. All five trials allowed the inclusion of patients with proximal cervical carotid stenosis, and all but one trial (SWIFT-PRIME) allowed the inclusion of patients with complete atherosclerotic cervical carotid occlusion. General anesthesia and conscious sedation were the two most frequently used anesthetic approaches for patients with acute ischemic stroke receiving endovascular therapy. None of the trials established the usefulness of mechanical thrombectomy devices other than stent retrievers [18].

The AHA/ASA analysis of and conclusions about these five stent retriever trials form the basis of their 2015 focused update to the guidelines on the management of patients with acute ischemic stroke (Table 15) [18].

Table 15: AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION RECOMMENDATIONS REGARDING ENDOVASCULAR INTERVENTIONS FOR ISCHEMIC STROKE

Class I Recommendations

Eligible patients should receive intravenous rt-PA even if endovascular treatments are being considered (Class I, Level of Evidence A).

Patients should receive endovascular therapy with a stent receiver if they meet all the following criteria (Class I, Level of Evidence A):

- Prestroke mRS score 0 to 1

- Acute ischemic stroke receiving intravenous rt-PA within 4.5 hours of onset according to guidelines from medical societies

- Causative occlusion of the internal carotid artery or proximal MCA (M1)

- Age ≥18 years

- NIHSS score of≥6

- ASPECTS of≥6

- Treatment can be initiated (groin puncture) within 6 hours of symptom onset

As with intravenous rt-PA, reduced time from symptom onset to reperfusion with endovascular therapies is highly associated with better clinical outcomes. To ensure benefit, reperfusion to TICI grade 2b/3 should be achieved as early as possible and within 6 hours of stroke onset (Class I, Level of Evidence B).

Use of stent retrievers is indicated in preference to the MERCI device (Class I, Level of Evidence A).

The technical goal of the thrombectomy procedure should be a TICI 2b/3 angiographic result to maximize the probability of a good functional clinical outcome (Class I, Level of Evidence A).

Initial treatment with intra-arterial fibrinolysis is beneficial for carefully selected patients with major ischemic strokes of less than 6 hours' duration caused by occlusions of the MCA (Class I, Level of Evidence B). However, these data derive from clinical trials that no longer reflect current practice, including use of fibrinolytic drugs that are not available. A clinically beneficial dose of intra-arterial rt-PA is not established, and rt-PA does not have FDA approval for intra-arterial use. As a consequence, endovascular therapy with stent retrievers is recommended over intra-arterial fibrinolysis of first-line therapy (Class I, Level of Evidence E).

Class II Recommendations

When treatment is initiated beyond 6 hours from symptom onset, the effectiveness of endovascular therapy is uncertain for patients with acute ischemic stroke who have causative occlusion of the internal carotid artery or proximal MCA (Class IIb, Level of Evidence C). Additional randomized trial data are needed.

In carefully selected patients with anterior circulation occlusion who have contraindications to intravenous rt-PA, endovascular therapy with stent retrievers completed within 6 hours of stroke onset is reasonable (Class IIa, Level of Evidence C). There are inadequate data at this time to determine the clinical efficacy of endovascular therapy with stent retrievers for patients whose contraindications are time-based or nontime based (e.g., prior stroke, serious head trauma, hemorrhagic coagulopathy, or receiving anticoagulant medications).

Although the benefits are uncertain, use of endovascular therapy with stent retrievers may be reasonable for carefully selected patients with acute ischemic stroke in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries (Class IIb, Level of Evidence C).

Although the benefits are not established in this age group, endovascular therapy with stent retrievers may be reasonable for some patients <18 years of age with acute ischemic stroke who have demonstrated large vessel occlusion in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset (Class IIb, Level of Evidence C).

Although the benefits are uncertain, use of endovascular therapy with stent retrievers may be reasonable for patients with acute ischemic stroke in whom treatment can be initiated within 6 hours of symptom onset and who have prestrike mRS score of 1, ASPECTS <6, or NIHSS score <6 and causative occlusion of the internal carotid artery or proximal MCA (M1) (Class IIb, Level of Evidence B).

The use of mechanical thrombectomy devices other than stent retrievers may be reasonable in some circumstances (Class IIb, Level of Evidence B).

The use of a proximal balloon guide catheter or a large bore distal access catheter rather than a cervical guide catheter alone in conjunction with stent retrievers may be beneficial (Class IIa, Level of Evidence C). Future studies should examine which systems provide the highest recanalization rates with the lowest risk for nontarget embolization.

Use of salvage technical adjuncts, including intra-arterial fibrinolysis, may be reasonable to achieve these angiographic results, if completed within 6 hours of symptom onset (Class IIb, Level of Evidence B).

Angioplasty and stenting of proximal cervical atherosclerotic stenosis or complete occlusion at the time of thrombectomy may be considered, but the usefulness is unknown (Class IIb, Level of Evidence C). Future randomized studies are needed.

Intra-arterial fibrinolysis initiated within 6 hours of stroke onset in carefully selected patients who have contraindications to the use of intravenous rt-PA might be considered, but the consequences are unknown (Class IIb, Level of Evidence C).

It might be reasonable to favor conscious sedation over general anesthesia during endovascular therapy for acute ischemic stroke. However, the ultimate selection of anesthetic technique during endovascular therapy for acute ischemic stroke should be individualized based on patient risk factors, tolerance of the procedure, and other clinical characteristics. Randomized trial data are needed (Class IIb, Level of Evidence C).

Class III Recommendations

Observing patients after intravenous rt-PA to assess for clinical response before pursuing endovascular therapy is not required to achieve beneficial outcomes and is not recommended (Class III, Level of Evidence B).

Source: [18]

Carotid Endarterectomy

In the setting of acute ischemic stroke, justification for emergent (within the first 24 hours) or early revascularization with carotid endarterectomy (CEA) is based on reports of increased risk of recurrent stroke in patients undergoing medical therapy while awaiting revascularization. Some studies have found that CEA is most beneficial when performed within 2 weeks of the last cerebrovascular symptom and that the benefits decline rapidly after 3 weeks [194,234]. However, the risk associated with emergency CEA is believed to be high, for several reasons, particularly in patients with an unstable neurologic status [235]. First, embolic and hemodynamic injuries can occur [236]. Second, detection of an arterial lesion and mobilization of an operating room staff is time-intensive. Lastly, hyperperfusion, which occurs in 0.3% to 1.2% of patients who have CEA, can lead to brain edema and hemorrhagic transformation [236]. Other complications may also develop.

For some patients, however, the benefit of CEA may outweigh the risk. For instance, patients with acute ischemic stroke who have already had previous CEA may be successfully treated with surgical revascularization. Some studies indicate that early CEA may also be appropriate for patients with small, nondisabling stroke in whom the goal is to reduce ongoing thromboembolism or flow-limiting ischemia [235,237,238,239,240,241]. Results of other small studies have suggested that administration of an anticoagulant and delaying surgery until after the patient is stabilized is a better option [242]. Due to the limited and conflicting data, high perceived risk, and unestablished usefulness, the AHA/ASA have a Class II, Level of Evidence B recommendation regarding the use of carotid endarterectomy for treatment of acute ischemic stroke [16].

6. REHABILITATION

More than two-thirds of patients who survive stroke receive rehabilitation services after hospitalization, yet only a minority receive thrombolytic therapy and many have residual functional deficits, despite the development of designated stroke centers and improvements in stroke recognition and care delivery [21]. Effective stroke rehabilitation is likely to continue to be an essential component of the continuum of stroke care for the foreseeable future. Thus, in 2016 the AHA/ASA published a guideline for stroke rehabilitation and recovery [21]. This guideline spans the entire course of rehabilitation, from the early actions taken in the acute care hospital through the patient's reintegration into the community. The guideline uses the framework (rating scheme) established by the AHA concerning classes and levels of evidence [21].

The likelihood of functional independence and survival is enhanced by organized multidisciplinary rehabilitation; five more patients for every 100 treated are able to live independently following structured rehabilitation [243]. Early initiation of rehabilitation is a particularly strong predictor of improved outcome [21,244].

Rehabilitation in an inpatient stroke unit has been associated with better outcomes than rehabilitation in a general healthcare facility, with improved quality of life, survival, and functional status at five years [17,21,245,246,247,248,249]. Yet the decision to refer a stroke patient to a particular setting after discharge involves a complex set of demographic, clinical, and nonclinical factors that are also inevitably related to patient outcomes [21]. Variations in inpatient stroke rehabilitation outcomes have been found among racial/ethnic populations [21,250,251,252,253,254]. Black individuals have less functional improvement at discharge compared with White individuals and are more likely to be discharged to home despite worse functional independence measure (FIM) scores [255]. Asian individuals have functional improvements similar to those for White individuals but have less improvement at 3 months after discharge [255]. These disparities point to the need for focused attention on appropriate rehabilitation services for minority populations.

Dedicated, multidisciplinary stroke centers are more likely to provide specific interventions for stroke rehabilitation that promote functional recovery and reduce disability. Arm-robot and mirror therapy have been shown to reduce motor defects and enhance arm function; the use of electro-mechanical gait training increases the number of patients able to regain the ability to walk; treadmill training with partial body-weight support improve walking speed and walking endurance in ambulatory patients [57].

MULTIDISCIPLINARY REHABILITATION TEAM

Because the effects of stroke are multifaceted and unique to each patient, multidisciplinary and organized services play an important role in patient recovery [21,246]. Post-acute stroke care settings include specialized inpatient rehabilitation hospitals, stroke rehabilitation units in acute care hospitals, outpatient therapy clinics, long-term care facilities, and patients' homes. The findings of a systematic review showed that, of these settings, an inpatient specialized stroke unit is best for providing care due to the presence of skilled nursing services, physician care, and variety of therapies [256]. However, the rehabilitation needs of some patients with mild or no disabilities may be addressed effectively in an outpatient facility (e.g., all-day care at a hospital) or in their homes [21,257]. For select patients, early discharge to a community setting for ongoing rehabilitation may provide outcomes similar to those achieved in an inpatient rehabilitation unit. This "early supported discharge" model links inpatient care with community-based rehabilitation services and allows some patients to return home sooner [21]. In some cases, recovery may occur without the need for rehabilitation services.

For inpatient and outpatient rehabilitative intervention, the multidisciplinary teams typically consist of several or all of the following: physicians, physical therapists, occupational therapists, kinesiotherapists, speech and language pathologists, social workers, recreational therapists, and nurses [21]. Nursing care for patients in the post-acute phase is particularly intensive. Patients who are triaged to inpatient facilities receive great benefit from 24-hour care by nurses who specialize in stroke care [257,258].

Depending on the patient's and family's/caregivers' specific needs, a clinical psychologist, psychiatrist, dietitian, and other healthcare professionals may join a patient's stroke rehabilitation team [21,258]. However, a team's exact composition is less important in maximizing a patient's outcome than is early intervention and the use of a coordinated, interdisciplinary approach. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential [21].

The AHA/ASA recommendations for the organization of post-stroke rehabilitation care and interventions specific to the inpatient hospital setting are summarized in Table 16 and Table 17[21].

Table 16: AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION RECOMMENDATIONS FOR THE ORGANIZATION OF POST-STROKE REHABILITATION CARE (LEVELS OF CARE)

Class I Recommendations

Organized, coordinated, interprofessional care is recommended for stroke patients who are candidates for postacute rehabilitation (Class I, Level of Evidence A).

Stroke survivors who qualify for and have access to inpatient rehabilitation facility (IRF) care should receive treatment in an IRF in preference to a skilled nursing facility (SNF) (Class I, Level of Evidence B).

Organized community-based and coordinated interprofessional rehabilitation care is recommended in the outpatient or home-based settings (Class I, Level of Evidence C).

Class II Recommendations

Early supported discharge services may be reasonable for people with mild-to-moderate disability (Class IIb, Level of Evidence B).

Source: [21]

Table 17: AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION RECOMMENDATIONS FOR REHABILITATION IN THE INPATIENT HOSPITAL SETTING

Class I Recommendations

Early rehabilitation for hospitalized stroke patients should be provided in environments with organized, interprofessional stroke care (Class I, Level of Evidence A).

Stroke survivors should receive rehabilitation at an intensity commensurate with anticipated benefit and tolerance (Class I, Level of Evidence B).

Class III Recommendations

High-dose, very early mobilization within 24 hours of stroke onset can reduce the odds of a favorable outcome at 3 months and is not recommended (Class III, Level of Evidence A).

Source: [21]

Stroke is an acute and harrowing event, and the emotions and deficits that follow are usually overwhelming to the patient and the patient's family. The multidisciplinary rehabilitation team should therefore develop a treatment strategy to help individual patients based on a consensus model that incorporates family members and caregivers. Securing the family's/caregivers' active involvement early in the rehabilitation process optimizes the patient's chances for recovery and community reintegration [21,259]. After the rehabilitation team has formulated a plan of action for the patient, a team liaison should present its recommendations to the patient and family/caregivers through open discussions [260]. Providing patients and families/caregivers with both interactive and written materials is equally important [260]. Information to be presented should include:

- Preferred setting and environment based on the patient's projected recovery

- Treatment options, including suggested rehabilitation programs, estimated length of stay, frequency of therapy, and discharge criteria

- Information regarding the patient's prognosis and the anticipated recovery process

Once rehabilitation has commenced, involving the patient's family/caregivers in the rehabilitation sessions and training them to assist the patient with functional activities may aid patient recuperation [21,261]. During rehabilitation, at least one or two informal meetings per week should be held with family/caregivers to reassess their concerns about the process [262].

Social and Family Caregiver Support

As stated, the stroke survivor's family members and caregivers are integral to the post-stroke treatment plan [21]. However, 12% to 55% of caregivers suffer from emotional distress, most commonly depression [21,263,264]. Untreated depression is associated with a lower quality of life for both the caregiver and the stroke survivor [21,265]. A growing body of research is focused on treatment strategies to benefit both the caregiver and the stroke survivor and on educational programs that target issues such as supportive problem solving, physical care needs, financial and domestic assistance, respite, reassurance, and counseling [21,266,267,268,269,270].

PATIENT ASSESSMENT

For individuals who have had a stroke and are medically stable, rehabilitation assessment, prevention of medical complications, and secondary prevention become the focal points [10,16,21]. To begin, the rehabilitation team's systematic evaluation of the patient addresses various issues, including the need for rehabilitation services; the risk of complications; physical functioning, cognition, and communication; and psychosocial conditions [21]. Next, the team works with the patient and family to implement a rehabilitation plan that includes a detailed exercise program and general as well as tailored strategies for secondary prevention [10]. Throughout, the team should strive to foster a climate of familial support [21].

Need for Rehabilitation Services

When a patient is medically stabilized, a rehabilitation physician is consulted to assess the patient's rehabilitative needs and recommend the proper rehabilitation setting (Table 18) [17]. Additionally, the patient's complete medical history is provided to the rehabilitation physician. If indicated, other rehabilitation specialists may perform specialized or more intensive assessments. Overall, rehabilitation assessments should be [21]:

- Multidisciplinary, to account for the heterogeneous effects of stroke.

- Well-coordinated and prompt, so patients can begin a rehabilitation program as soon as possible.

- Well-documented, to provide the patient's rehabilitation team with accurate and detailed information.

- Conducted using formal standardized, validated measures.

Table 18: AREAS OF SPECIAL INTEREST FOR PURPOSES OF REHABILITATION ASSESSMENT

Risk factors for stroke recurrence

Medical comorbidities

Swallowing

Skin assessment and risk for pressure injuries

Bowel and bladder function

Risk of deep vein thrombosis

Pain

Mobility, with respect to the patient's needs for assistance in movement

Safety awareness

Motor function

Cognition and communication status

Psychological status

History of previous antiplatelet or anticoagulation use, especially at the time of the stroke

Psychosocial status

Source: [17]

The NIHSS is a strong prognosticator of functional outcome, rendering it a valuable tool for determining rehabilitation needs [271,272]. It is the most widely used global assessment of impairment in the United States. It is a good predictor of short- and long-term morbidity and mortality and has been found to be sensitive to change in numerous studies [21]. Multiple assessments with the scale provide the rehabilitation team with a sense of the patient's recovery trajectory as he or she enters the rehabilitation stage.

The NIHSS provides detailed information in addition to an overall stroke severity score. A score of less than 5 indicates minor or no functional disability, whereas a score of more than 16 suggests severe disability and an increased probability of death [273]. With the advent of stroke treatment, patients with a score of 5 to 15 are likely to benefit from rehabilitation without the need for a nursing facility [274]. Patients with a score of more than 15 may improve with rehabilitation; however, these patients will likely require long-term care. More than one-half of survivors with a baseline score greater than 20 are initially sent to some form of rehabilitation facility rather than directly discharged to a nursing facility or home [274].

Because the type of stroke affects the usefulness of the NIHSS, its results should be qualified by medical history, examination, and brain imaging data [275]. Specifically, the scale is better suited for predicting functional outcomes at 3 and 6 months after stroke for patients with subcortical lesions than for patients with cortical lesions [21,276,277]. Additionally, the reliability of the scale in predicting depressive symptoms and cognitive dysfunctions depends on the hemisphere affected [21,277]. Because the NIHSS does not include evaluation of weakness of the distal part of the upper extremity, which is common in patients with stroke, a finger extension evaluation should be conducted in addition to the scale [278,279]. The presence of finger extension or partial shoulder abduction within 72 hours after stroke onset can help predict the patient's functional recovery at six months [280,281].

Although new measurement tools are being developed, they are difficult to evaluate with the traditional criteria (e.g., validity, reliability) normally used in evidence-based reviews [21]. The AHA/ASA recommendations for the assessment of rehabilitation needs (Table 19) are based on traditional measurement models, such as the FIM [21].

Table 19: AMERICAN HEART ASSOCIATION/AMERICAN STROKE ASSOCIATION RECOMMENDATIONS FOR DISABILITY ASSESSMENT AND REHABILITATION NEEDS

Class I Recommendations

It is recommended that all individuals with stroke be provided a formal assessment of their ADLs and IADLs, communication abilities, and functional mobility before discharge from acute care hospitalization and the findings be incorporated into the care transition and the discharge planning process (Class I, Level of Evidence B).

It is recommended that all individuals with stroke discharged to independent community living from postacute rehabilitation or SNFs receive ADL and IADL assessment directly related to their discharge living setting (Class I, Level of Evidence B).

A functional assessment by a clinician with expertise in rehabilitation is recommended for patients with an acute stroke with residual functional deficits (Class I, Level of Evidence C).

Determination of postacute rehabilitation needs should be based on assessments of residual neurologic deficits; activity limitations; cognitive, communicative, and Psychological status; swallowing ability; determination of previous functional ability and medical comorbidities; level of family/caregiver support; capacity of family/caregiver to meet the care needs of the stroke survivor; likelihood of returning to community living; and ability to participate in rehabilitation (Class I, Level of Evidence C).

Class II Recommendations

It is reasonable that individuals with stroke discharged from acute and postacute hospitals/centers receive formal follow-up on their ADL and IADL status, communication abilities, and functional mobility within 30 days of discharge (Class IIa, Level of Evidence B).

The routine administration of standardized measures can be useful to document the severity of stroke and resulting disability, starting in the acute phase and progressing over the course of recovery and rehabilitation (Class IIa, Level of Evidence C).

A standardized measure of balance and gait speed (for those who can walk) may be considered for planning postacute rehabilitation care and for safety counseling with the patient and family (Class IIb, Level of Evidence B).

ADLs = activities of daily living, IADLs = instrumental activities of daily living (tasks involving more complex domestic, community, and leisure activities), SNF = skilled nursing facility.

Source: [21]

Soon after patient assessment, family/caregivers should be educated about and referred to community resources [21,282]. If it is recommended that the patient be discharged from an acute care facility to a nursing facility or the patient's home, relevant contact and background information for nursing home facilities, assisted-living services, social support groups, and stroke-related organizations should be provided to facilitate familial decision-making. Viable options should be presented to the family, especially information about long-term care placement if a severely disabled patient is not a candidate for rehabilitation [21]. If the family/caregivers will be taking care of the patient at a private residence (with or without professional assistance), it is essential to foster discussions about the needs of the patient, challenges the patient and family/caregivers may face, and the benefits of social support programs for the patient and family/caregivers. Whenever possible, written materials should be provided, and they should be in the primary language of the family. Among the important topics to discuss and provide education about include [21]:

- Secondary prevention and medication administration specifics

- Nutrition and hydration

- Symptoms of complications

- Specifics regarding assistance with activities of daily living (e.g., transfers, positioning, bathing, toileting, dressing, and grooming)

- Swallowing difficulties

- Feeding tube use

- Bladder catheter care

- Signs of mood disorders

- Strategies to improve cognitive skills and communication

- Exercises (range of motion)

Education about and referral to appropriate community resources can help to support the needs and priorities of the patient and the family or caregiver [21]. A systematic review and meta-analysis demonstrated that functional outcomes (i.e., motor, cognitive, and psychosocial function) can be improved or, at a minimum, maintained in stroke survivors when community interventions are available [21,283,284].

The patient's psychosocial status will influence his or her willingness and approach to participating in a rehabilitation program. A psychosocial assessment enables the rehabilitation team to incorporate family/caregivers more effectively into the rehabilitation process [285]. In addition, how the team manages the patient's care may be contingent on the patient's life circumstances and personality profile. Some patients and their caregivers fail to discuss psychosocial issues with their providers [21,264]. Cultural differences may also play a part in a patient's willingness to discuss these issues [21]. Areas of emphasis for the psychosocial assessment should include:

- Medical history

- Coping style

- Therapeutic style and recovery expectations

- Demographic information

- Response to treatment

- Substance use and abuse

- Psychiatric/psychological evaluation

- Emotional and mental status and history

- Education and employment

- Spiritual and cultural beliefs

- Family/caregiver relationship

- Preferred activities

When designing and implementing the patient's treatment plan, the rehabilitation team should also take into account the residual effects of any difficulties the patient may have had before the stroke, such as drug or alcohol addiction; stress from recent life events, such as divorce, a loved one's death, or retirement; or clinical depression [21]. Individual patients will vary in how well they respond to challenging and demanding therapeutic approaches. After a patient's unique needs and circumstances are determined, relevant specialists will be incorporated into the team. All members of the rehabilitation team should be sensitive to the patient's psychosocial needs.

Risk of Complications

Medical complications related to illness, being bedridden, or lack of proper care/attention can prolong hospitalization, impede rehabilitation, increase disability, or result in death. Living in an inappropriate post-stroke environment also substantially increases a patient's risk for complications. Complications may develop in as many as 85% of hospitalized patients who have had a stroke [286]. Thus, medical examinations before and during a patient's rehabilitation program should assess the most common risks of complications: skin breakdown, deep vein thrombosis (DVT), swallowing dysfunction, bowel and bladder incontinence, falls, and pain [21].

Skin Breakdown and Contractures

Pressure injuries are a commonly encountered complication in hospital and long-term care facilities, occurring in approximately 10% and 25% of patients in those settings, respectively [286]. According to the National Pressure Injury Advisory Panel, a pressure injury is a "localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear" [287,288]. Although pressure injuries typically occur proximal to osseous prominences (e.g., the sacrum, hips, ankles), skin breakdown at the ears is also common in certain settings [289,290]. Most pressure injuries are associated with deep tissue injury [291]. Regular assessment of skin and the use of objective risk scales (e.g., the Braden scale) may help prevent skin injury and should be followed by regular skin inspection with documentation [21,292]. Risk factors for pressure injuries include [286]:

- Immobility

- Poor hygiene

- Urinary incontinence and other sources of moisture

- Diabetes and other causes of poor circulation

- Peripheral vascular disease

- Lower body mass index

- Localized infection or trauma

- Edema

- Poor hydration and/or nutrition

Conditions secondary to pressure injuries include pain, localized infection, cellulitis, osteomyelitis, sepsis, and even death [293,294]. However, not all pressure injuries, even those that are severe, will elicit a pain sensation [295].

These injuries can be prevented or minimized with several measures, including proper positioning, turning, and transferring techniques; good hygiene; proper nutrition and hydration; and the use of barrier sprays, special mattresses, and protective dressings [21,292]. Good pain management may be necessary to perform correct positioning and frequent turning. Patients should be monitored daily for skin breakdown [21]. Any sign of a pressure injury warrants daily treatment [21].

Following stroke with hemiparesis, contracture on the affected side will develop in approximately 60% of patients within the first year, with wrist contractures occurring most commonly in patients who do not recover functional hand use [21,296,297]. Contractures are painful and can make self-care difficult. Many clinicians recommend daily stretching of the affected limb(s); families and patients should be taught proper stretching technique [21]. The effectiveness of resting hand splints is not well established [21]. Contractures of the ankle/foot can affect gait quality and patient safety. Ankle-foot orthosis and the nighttime use of a resting ankle splint may be beneficial in preventing ankle contracture [21].

Deep Vein Thrombosis

DVT affects only 2% of patients with stroke; yet, its prevention is critical [286]. The American Academy of Family Physicians recommends that DVT risk be calculated with use of the Well's DVT prediction model, and the results of this model will dictate subsequent DVT testing (Table 20) [298,299]. For patients with symptoms in both legs, the more symptomatic leg should be tested. A score of 3 or more on the Well's test indicates a high clinical probability of DVT; the probability is intermediate for a score of 1 or 2.

Table 20: WELL'S PREDICTION RULE FOR DIAGNOSING DEEP VENOUS THROMBOSIS: CLINICAL EVALUATION TABLE FOR PREDICTING PRETEST PROBABILITY OF DEEP VEIN THROMBOSIS

Clinical Characteristic

Score

Active cancer (treatment ongoing, within previous 6 months, or palliative)

1

Paralysis, paresis, or recent plaster immobilization of the lower extremities

1

Recently bedridden >3 days or major surgery in previous 12 weeks requiring general or regional anesthesia

1

Localized tenderness along the distribution of the deep venous system

1

Entire leg swollen

1

Calf swelling 3 cm larger than asymptomatic side (measured 10 cm below tibial tuberosity)

1

Pitting edema confined to the symptomatic leg

1

Collateral superficial veins (nonvaricose)

1

Alternative diagnosis at least as likely as venous thrombosis

-2

Source: [299]

The D-dimer test alone is not recommended to rule out DVT in patients who have had a stroke. Patients with intermediate-to-high risk for DVT should be screened with use of ultrasonography. This imaging modality may not detect DVT in the calf, however, and repeat ultrasonography or venography should be used when DVT in the calf is suspected. Contrast venography was previously the most definitive test for the diagnosis of DVT, but today, Doppler ultrasound is the diagnostic study of choice [299].

Measures such as early mobilization and anticoagulation therapy are recommended to decrease the incidence of DVT after stroke. A patient's risk can be substantially reduced by 50-foot walks daily (with assistance, if necessary), administration of subcutaneous, low-dose unfractionated heparin (5,000 units twice a day, unless contraindicated), and the use of graduated compression stockings (GCS) as an adjunct to medication [300]. GCS and intermittent pneumatic compression may be considered for prevention of post-stroke DVT, but their routine prophylactic use requires further study. The benefit of treatment should be weighed against the increased risk of skin complications [21,301,302].

Swallowing Dysfunction

Based on instrumental testing results, dysphagia may develop in 42% to 78% of patients within three days after stroke [21,303]. This disorder is strongly linked to the development of malnutrition and pneumonia if not identified early and managed properly [21,303,304]. The AHA/ASA guidelines include a Class I recommendation for early dysphagia screening in patients with acute stroke [21]. Patients with dysphagia often have problems with aspiration, which can cause serious consequences if the stroke has suppressed cough sensations [21]. Although cerebral and cortical strokes can cause dysphagia, swallowing is most severely compromised by brain stem strokes [303].

The speech and language pathologist on the rehabilitation team should perform a brief swallow assessment on all patients with stroke before oral intake of food and fluids [21,305]. A dysfunctional swallow should be further examined using a complete bedside swallow examination. If bedside swallow screenings indicate an affected swallow, or if the patient has a high risk for aspiration and/or dysphagia, performing a videofluoroscopy swallowing study or fiberoptic endoscopic examination is recommended [21,305,306]. The grade of dysphagia correlates with dysarthria, aphasia, low functional independence, and level of cognitive functioning [306]. The speech and language pathologist may best identify the specific physiologic problem and recommend the necessary management and interventions for treatment. A Cochrane review assessing the effectiveness of a variety of interventions (e.g., acupuncture, neuromuscular electrical stimulation, physical stimulation) on functional outcome found that behavioral interventions and acupuncture reduced dysphagia, and pharyngeal electrical stimulation reduced pharyngeal transit time. However, the authors concluded that data are insufficient to determine the effect of these and other interventions (e.g., nutritional/fluid supplementation) on functional outcome and death. [304]. Authors of another review found that acupuncture may be effective for treatment of post-stroke dysphagia, but concluded that the reported benefits should be verified with further studies [307].

Bladder and Bowel Dysfunction

Upon admission to community-based facilities, approximately 50% of stroke survivors have urinary incontinence and 30% have fecal incontinence [308,309]. Almost all patients with fecal incontinence (98%) suffer from urinary incontinence. Urinary and fecal incontinence can lead to patient discomfort, skin breakdown, and sepsis. Fecal incontinence, in particular, reduces patient and family morale.

Large infarcts, aphasia, cognitive impairment, functional disability, lesions in the frontal cortex or frontoparietal lobes, and advanced age are associated with post-stroke urinary dysfunction [310]. Medications such as diuretics, alpha-adrenoreceptor blockers, and anticholinergic drugs can cause or exacerbate this complication [311,312]. Hyper-reflexia and hyporeflexia are the most common mechanisms of urinary incontinence in stroke survivors [313]. Detrusor sphincter dyssynergia, a cause of incomplete bladder voiding, is uncommon because its pathogenesis involves lesions between the brain stem and spine [312]. When assessing bladder function in patients with acute stroke, it is important to evaluate urinary retention with use of a bladder scanner or an in-and-out catheterization; urinary frequency, volume, and control; and the presence of dysuria. Patients who have urinary incontinence may benefit from bladder-training regimens and scheduled voiding [311,314].

Fecal incontinence can be due to neurogenic impairments or leakage around a fecal impaction (overflow incontinence) [315]. If the underlying cause of fecal incontinence is neurogenic, the signs and symptoms would likely include reduced rectal sensation and tone, inability to voluntarily contract the rectal sphincter, and stool in the rectal vault [315]. A diagnosis of constipation with overflow incontinence is more likely if the patient has rectal sensation and tone.

Risk factors for impaction and constipation include immobility, inactivity, dehydration, some medications, mood disorders, and cognitive deficits [316,317]. Multivariate analysis has shown that advanced age and diabetes are risk factors for fecal incontinence [317]. Patients with persistent constipation or fecal incontinence may benefit from bowel-management programs and psychosocial support [318]. Because of the risk of skin breakdown, the social stigma, and the burden of care associated with bowel and bladder incontinence, management is an essential component of the rehabilitation process [21].

Falls

Within 12 weeks after a stroke, approximately 25% of patients will fall [286]. Up to 70% of individuals with a stroke fall during the first six months after discharge from the hospital or rehabilitation facility [21,319]. Individuals with stroke are also at risk of repeated falls that include injury [21,320]. One study found that most falls occur at home in the first 3 months following post-stroke risk assessment [320]. Falls are a common complication for several reasons, including [315,321,322]:

- Unfamiliar environment and physical state

- Pain, fatigue, poor balance, and muscle weakness

- Incontinence

- Frequent positioning, turning, and transferring, especially in rehabilitative settings

- Cognitive impairments, mood disorders (including depressive symptoms), visual impairments, spatial neglect, and any other condition that can decrease a patient's safety awareness

The Berg Balance Scale may be the most appropriate screen for patients who are likely to fall [21,323,324]. This scale tests 14 specific functional movements of daily living of increasing difficulty [325]. The 56-point maximum score indicates adequate balance and low risk of a fall. A score of less than 45 is associated with a proclivity for falling [323,325]. The score at 2 months post-stroke is useful for informing a patient's risk of falls, but it does not account for the multifactorial nature of the problem and should not preclude risk management provided in conjunction with exercise interventions, such as rehabilitation that targets gait coordination, to improve mobility [320,326]. If the patient is able to walk, the Stops Walking When Talking test may further help to identify the risk for a fall [323]. With this test, the examiner initiates a conversation with the patient while walking; if the patient stops walking to respond, the risk of a fall is increased [327]. St. Thomas' Risk Assessment Tool in Falling Elderly Inpatients (known as STRATIFY), a tool used commonly in the rehabilitation setting, has been shown to be a poor predictor of the risk for fall when screening patients with stroke [328].

In addition to the physical consequences associated with falls, there are also psychological and social consequences. Impairments in balance, gait, motor control, perception, and vision contribute to a heightened fear of falling in the stroke survivor, with 30% to 80% reporting various levels of fear associated with falling and mobility [21]. This fear can cascade into reduced levels of physical activity and deconditioning, resulting in greater physical decline, loss of ability to perform activities of daily living, loss of independence, social isolation, and depression. Education in fall prevention and balance training are essential components of the rehabilitation process [21].

Pain

Pain is one of the most frequently experienced complications. Almost one-half of all stroke survivors experience chronic pain, 65% of whom have shoulder pain [286]. Whether chronic or periodic, pain can delay functional recovery by masking motor function improvement, diminishing a patient's motivation or willingness to perform rehabilitative tasks, or limiting the patient's movement or requiring the use of a cane or wheelchair for ambulation [17]. Pain most often results from joint immobilization and the fixation of tendons and ligaments in one position [85]. In some patients, however, stroke-induced sensorimotor pathway damage leads to the sensation of pain in an affected extremity or side of the body. The most common pain syndrome of this type is central post-stroke pain, which affects 8% of patients, or at least 56,000 stroke patients in the United States each year [21,329,330]. Four percent of patients with central post-stroke pain experience it as shoulder pain. Central post-stroke pain can be difficult to manage, even with medications. Only amitriptyline and lamotrigine have been shown to be effective in placebo-controlled studies [331].

Evidence Based Practice Recommendation

The evidence from randomized controlled trials so far does not confirm or refute that electrical stimulation around the shoulder after stroke influences reports of pain, but there do appear to be benefits for passive humeral lateral rotation.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001698/full

Last Accessed: March 31, 2026

Level of Evidence: Meta-Analysis

The AHA/ASA recommend patient and family education (i.e., range of motion, positioning) about shoulder pain and care following stroke [21]. A clinical assessment of the pain that includes musculoskeletal evaluation, evaluation of spasticity, identification of any subluxation, and testing for regional sensory changes is also recommended. Ultrasound may be considered for diagnosis of shoulder soft tissue injury [21]. Botulinum toxin injection or a trial or neuromodulating pain medications may be useful to reduce severe hypertonicity in hemiplegic shoulder muscles. Positioning and the use of supportive devices may help reduce pain [21].

Use of diagnostic criteria for central post-stroke pain can be helpful [21]. Additionally, initial medical examinations should thoroughly document suspected etiology of any pain, its location and characteristics (e.g., burning, tingling, stabbing, dull), its duration and intensity, and what aggravates or relieves the pain. Any pain that interferes with the rehabilitation process should be identified and treated accordingly. There is limited evidence on the efficacy of proposed treatments for central post-stroke pain. Combined pharmacotherapy (e.g., amitriptyline, lamotrigine) and therapeutic exercise may be reasonable. Few nonpharmacologic options exist [21].

Functional Outcome

Approximately 45% of stroke survivors have residual neurologic deficits that impair mobility, which is one of the most devastating sequelae of stroke [21,87]. At 6 months, about half of ischemic stroke survivors who are 65 years of age or older have hemiparesis, nearly one-third require assistance with walking, and more than one-quarter need assistance with activities of daily living [87]. Although functional outcome primarily depends on the patient's post-stroke neurologic damage and compensatory capacity, the multidisciplinary rehabilitation team plays a major role in recovery [246]. The team's coordinated and customized efforts can help many stroke survivors adopt an active and social lifestyle. To tailor services to a patient's needs, the team should assess his or her functional abilities during the immediate post-acute stroke phase before hospital discharge. Assessment relies on a physical examination and a systematic battery of tests that measure a patient's ability to complete activities of daily living and that screens for cognitive/communication skills as well as visual/spatial neglect disorders [21]. Knowledge of the patient's preferred activities is also helpful.

Several functions/activities are typically measured to assess comprehensive functional status initially and during the rehabilitation process (Table 21). Although many measurement tools can be used to objectively record a patient's comprehensive functional acuity, the most widely used and trusted instrument in the stroke rehabilitation setting is the FIM [332,333]. Throughout the rehabilitation process, FIM-supported systematic screening can help the rehabilitation team to [21,332]:

- Identify functional, cognitive, and visual/spatial deficits not previously detected

- Set realistic functional goals and document progression toward these goals

- Deduce discharge or extended care plans

- Ensure patients' safety as they perform functional tasks and teach proper mechanics to reduce their risk of injury with continued performance

Table 21: ACTIVITIES MEASURED TO ASSESS COMPREHENSIVE FUNCTIONAL STATUS INITIALLY AND DURING THE REHABILITATION PROCESS

Activities of daily living

Aerobic capacity and endurance

Balance

Bladder and bowel management

Circulatory response to position changes and other functional tasks

Communication and social cognition

Gait

Joint integrity and mobility

Locomotion

Mobility

Motor function (agility, coordination, dexterity)

Muscle performance (activation, endurance, power, strength)

Pain response to functional tasks

Posture

Range of motion

Reflex integrity

Self-care ability

Sexual activity

Upper extremity activity/function

Use of assistive and adaptive devices

Visual and spatial neglect

Source: [21,332]

As stated, loss of mobility is a devastating post-stroke outcome and restoration of gait-related activities (e.g., rising to stand, sitting down, climbing stairs) is often one of the primary goals of rehabilitation. Additionally, many patients will require assistive devices, adaptive equipment, and other items to maximize independent functioning after stroke [21].

In general, major rehabilitation goals are for patients to regain safe ambulation in the home and community and to regain the ability to perform activities of daily living with minimal or no assistance. Thus, patients should be reassessed for daily tasks that are appropriate to their expected level of dependency [21]. If a return to independent community or home living is possible, domestic functioning should be evaluated [17,334]. Skills needed to stay home alone include preparing a meal, using safety precautions, properly taking medications, and obtaining emergency services. Patients who wish to resume driving should be assessed thoroughly for driving-related physical, cognitive, and behavioral functions [21]. Driving is an instrumental activity of daily living for many individuals due to its impact on their ability to participate in activities outside the home. Between one- and two-thirds of post-stroke survivors resume driving after one year, but because it is a highly complex activity requiring skills in cognition, perception, and emotional and motor control, the ability to drive is often affected by stroke. The AHA/ASA recommend that [21]:

- Individuals who prove ready to return to driving, as demonstrated by successful performance on fitness-to-drive tests, should have an on-the-road test administered by an authorized person and should be referred to a driver rehabilitation program for training if the test is failed.

- It is reasonable to assess individuals for cognitive, perception, physical, and motor abilities to determine readiness to return to driving. This may be achieved with a driving simulation.

Cognition and Communication

Healthy cognition and communication are essential to an individual's sense of well-being. Unfortunately, stroke has an adverse effect on cognitive and communicative abilities.

Cognition

Calculation, executive functioning (the integration of multiple and complex processes), and visual perception/construction are the cognitive arenas most often affected during the first several weeks after a stroke [335,336]. Up to 88% of patients with a cerebellar stroke have cognitive deficits, such as impairments in abstract thought, attention, control, memory, planning, and speech [337]. In many cases, patients with stroke-associated right brain damage have anosognosia, a condition in which patients are rendered unaware of their contralateral sensory and motor neurologic deficits (hemiplegia, hemianesthesia, and hemianopia) [338]. Although many survivors regain some or all cognitive skills soon following a stroke, up to 38% remain cognitively impaired at 3 months [339]. Recovery rates may be as high as 80% within 6 months for stroke survivors, with visual perception and visual memory showing the most improvement and language and abstract reasoning showing the least [340,341]. At 1 and 3 years after a stroke, cognitive impairment is one of the factors most strongly linked with poor physical and mental health status [342]. Cognitive status is an important determinant of post-stroke success. The AHA/ASA recommend that all stroke patients be screened for cognitive deficits before being discharged to home [21].

Stroke-induced damage to the brain's cognition centers is second only to Alzheimer disease as the leading cause of dementia. Stroke-associated dementia manifests with the following symptoms [343]:

- Memory loss, especially short-term memory

- Attention deficits and difficulty following instructions

- Difficulty planning/organizing tasks or solving problems

- Confusion

- Poor judgment

- Behavioral changes, including inappropriate emotions and extreme mood fluctuations

- Mood disturbances and depression

Evidence Based Practice Recommendation

The National Guideline Centre recommends that patients should be screened for cognitive deficits after stroke. Where a cognitive deficit is identified, carry out a detailed assessment using valid, reliable, and responsive tools before designing a treatment program.

https://www.nice.org.uk/guidance/ng236

Last Accessed: March 31, 2026

Level of Evidence: Expert Opinion/Consensus Statement

Areas of cognitive and arousal ability that should be assessed before and during rehabilitation are learning and memory, attention, visual/spatial neglect and impairments, executive functioning, and apraxia (loss of the ability to execute skilled movements despite having the desire and the physical ability to perform them) [21]. In addition to its use in assessing functional ability, the FIM is effective as an initial screen of cognitive and functional communication deficits [344]. Because stroke-related cognition deficits are independently associated with left hemispheric stroke, visual field defect, and urinary incontinence, the presence of any of these conditions should heighten awareness of the possibility of the presence of the others [339].

Visual and spatial dysfunctions may be particularly difficult to identify during the initial post-stroke examination because multiple neuroanatomic systems can be affected to varying degrees. When a standard medical examination does not include the brief, systematic screening for visual and spatial neglects, more than 60% of these dysfunctions remain undiagnosed. However, the use of the FIM may increase their early identification [344]. Patients with neglect deficits are unknowingly inattentive to specific body parts and/or spaces in the external environment. For instance, patients may brush half of their teeth or only eat food on half of their tray. Unilateral neglect is present in almost 50% of patients with right hemispheric stroke [345]. Patients with unilateral neglect are also unaware of limbs contralateral to the site of the brain lesion(s). Neglect disorders are strongly associated with poor functional outcomes and safety issues. Patients with neglect are prone to falls and injuries as well as burns to the affected limbs [322]. Addressing visual and spatial deficits as early as possible in the rehabilitation process using multiple functional adaptation techniques (e.g., visual scanning, external cues) and patient/caregiver education may decrease a patient's risk for injury [21].

Communication

As with cognitive difficulties, communication problems strain relationships between stroke survivors and their social system, impede rehabilitation, and lead to poor quality of life. Common communication-related stroke sequelae are aphasia, dysarthria, and apraxia (a speech disorder in which there is incoordination of muscles required for speech). Patients with communication deficits may also have dysphagia. How these disorders are manifested as well as their severity depends on the location and degree of the stroke. Interventions for apraxia of speech should be individually tailored and may include behavioral techniques and strategies that target [21]:

- Physiologic support for speech, including respiration, phonation, articulation, and resonance

- Global aspects of speech production (e.g., loudness, rate, prosody)

Augmentative and alternative communication devices and modalities should be used to supplement speech [21].

Aphasia affects one-third of stroke survivors and is one of the most common stroke-associated communication deficits [21,346].

The three types of aphasia are expressive, receptive, and global (Table 22) [347]. Patients with expressive aphasia have difficulties using words and sentences, whereas patients with receptive aphasia struggle to understand what others are communicating to them. Global aphasia is a combination of these two types. Aphasia is typically related to lesions on the left side of the brain, as the language center is located within this hemisphere in most individuals [348]. In many cases, aphasia (mild aphasia in particular) can be an elusive diagnosis because patients may [347]:

- Be able to carry on normal conversations in many settings

- Have trouble understanding only when sentences are long or complex

- Have trouble finding the words to express an idea or may say, "the word is right on the tip of my tongue"

Table 22: CHARACTERISTICS OF EXPRESSIVE AND RECEPTIVE APHASIA

Patients with expressive aphasia may:

Use single words or short phrases

Omit smaller words like "the," "of," or "and" (the patient's message may sound like a telegram)

Say words out of sequence

Switch sounds or first letters of words (e.g., dishwasher becomes a "wish dasher")

Invent words

Create meaningless sentences by fluently stringing nonsense words and real words together

Patients with receptive aphasia may:

Require a significant amount of extra time to understand verbal communication, especially if the speech is fast

Have difficulty following radio or television news

Interpret figurative speech (e.g., "It's raining cats and dogs.") literally

Patients frequently have global aphasia, with various combinations of expressive and receptive difficulties.

Source: [347]

A variety of treatment approaches for aphasia have been developed, but no conclusions can yet be made about the effectiveness of one treatment over another [21].

An additional challenge in assessment is that members of the rehabilitation team typically do not have a clear sense of the patient's communication skills before the stroke. Lastly, reading and writing skills are usually more affected than oral communication.

Well-trained, organized rehabilitation teams can use alternative methods of communicating to mitigate the effects of cognitive and communication disorders. Ideally, these problems should be recognized and managed early. However, arriving at a diagnosis can be challenging. The speech and language pathologist on the rehabilitation team is best suited to evaluate the patient for cognitive/communication disorders. In some cases, problems are initially undetected or develop after the evaluation. Training the rehabilitation team to recognize symptoms of cognitive and communication deficits early (especially those that are subtle) and report findings to the speech and language pathologist can serve as a "safety net" for patients [21]. For proper diagnosis, the speech and language pathologist should also seek the help of the patient's family to gain an understanding of the patient's cognition and communication history.

Through interviews, conversation, structured observations and other formal tests, the speech and language pathologist can evaluate the individual's cognition and communication skills, including speech, expression, social communication, and reading/writing (Table 23) [21,349].

Table 23: MEASURES EVALUATED TO ASSESS COGNITION AND COMMUNICATION SKILLS

Category

Skills to Evaluate

Speech

Fluency, vocal quality, clarity, loudness

Strength and coordination of muscles needed for speaking

Understanding

Use of semantics and syntax

Understanding and answering of different types of questions

Understanding facts and inferences within extended speech

Ability to follow instructions that increase progressively in length and complexity

Language sample of an extended story, written and spoken

Expression

Chaining a sequence of events together

Describe the "plot" in an action picture

Message coherency

Word recall

Use of complete sentences, telegraphic sentences or phrases, or single words

Social communication

Ability to interpret jokes and sarcasm, as well as absurdities in stories or pictures

Ability to initiate conversation, take turns speaking and listening during a discussion, and express thoughts clearly

Ability to clarify or restate a message that is initially misunderstood by a conversation partner

Reading and writing

Reading and writing of letters, words, phrases, sentences, and paragraphs

Other

Swallowing (as needed)

Ability to use an augmentative or alternative communication aid, if necessary

Source: [349]

If necessary, the speech and language pathologist can formulate remediation strategies to accelerate recovery of the affected communication skills, development of compensatory techniques, or use of residual skills [21,349]. In many cases, patients with stroke-induced attention deficits, visual neglect, memory deficits, executive function deficits, and problem-solving difficulties can be retrained or taught compensation techniques [350]. Strategies to enhance communication with the patient should be taught to the rehabilitation team as well as the family/caregivers [21]. Any interventions should be individually tailored and designed to target the overt communication deficit as well as any deficits that accompany or underlie the communication deficit, including attention, memory, and executive functions. The use of drugs to improve cognitive impairments is not well established [21].

Psychological Status

Following a stroke, it is understandable that patients and their families experience intense emotions. In many cases, the staff's kindness and helpfulness, familial support, and the passage of time allow patients and their families to deal with the grief and other feelings precipitated by the stroke without medication or psychological therapy. However, approximately 33% of patients experience post-stroke depression, and other mood disorders also manifest in stroke survivors [1,351,352]. In general, psychological conditions can have a significant impact on the success of rehabilitation. Thus, all patients should be thoroughly evaluated for psychological disorders as early as possible and on an ongoing basis [21].

Detecting post-stroke depression can be particularly challenging, as symptoms often appear to be typical post-stroke symptoms or are subtle. Patients may experience fatigue, sleeping difficulties, loss of appetite, tearfulness, and feelings of hopelessness. They may refuse to participate in therapy [21]. Additionally, cognitive deficits may prevent the patient from recognizing or having the ability to communicate depressive symptoms. Patients with an acquired flat affect may "sound sad" or indifferent to their situation without having post-stroke depression. Although several screening tools for depression in the older population are available (Table 24), a single, universally accepted evaluation tool for post-stroke depression has not been developed. Because little research in this area is available and the condition is underdiagnosed by nonpsychiatric physicians, the diagnosis of post-stroke depression should be based on information from multiple sources, including medical evaluation, patient self-report, observation of patient behavior, patient history, and staff reports of changes in behavior and motivation.

Table 24: SCREENING TOOLS FOR DEPRESSION

Evaluation Instrument

Time Required

Benefits

Disadvantages

Beck Depression Inventory (BDI)

10 minutes

Widely used

Easily administered

Norms available

Good for somatic symptoms

Less useful in elderly and in patients with aphasia or neglect

High rate of false-positive results

Somatic items may not be due to depression

Center for Epidemiologic Studies Depression (CES-D) Scale

<15 minutes

Easily administered

Useful in older individuals

Effective for screening in stroke population

Not appropriate for patients with aphasia

Geriatric Depression Scale (GDS)

10 minutes

Easy to use with older or cognitively impaired individuals, as well as with individuals with visual or physical problems or low motivation

High rates of false-negative results in minor depression

Hamilton Depression Scale

<30 minutes

Observer rated

Frequently used for patients who have had a stroke

Multiple versions compromise interobserver reliability

Folstein Mini-Mental State Examination

10 minutes

Widely used for screening

Several functions with summed score

May misclassify patients with aphasia

Patient Health Questionnaire-2 (PHQ-2)

15 minutes

Widely used for screening

Easily administered

Poor specificity in detecting major depression

Source: [353,354,355]

The accompaniment of post-stroke depression with other psychological disorders is not uncommon [21]. Therefore, the medical evaluation should also screen for other categories of psychiatric symptoms [21]. Generalized anxiety disorder, which affects 20% of survivors, often coexists with post-stroke depression [356]. Generalized anxiety disorder delays the recovery of the ability to carry out activities of daily living and negatively affects social functioning [21]. Additionally, up to 15% of stroke survivors have pseudobulbar affect, characterized by uncontrollable laughing/crying [21].

Both post-stroke depression and pseudobulbar affect respond well to selective serotonin reuptake inhibitors [357]. Although these drugs carry some risk, they are safe in most patients who have had a stroke. However, these medications should not be administered prophylactically [358,359]. Although studies are limited, the use of cognitive-behavioral therapy techniques and brief supportive therapy in conjunction with medication may be beneficial to those with post-stroke depression and other neuropsychiatric sequelae of stroke [21].

EXERCISE PROGRAM

Physical inactivity that typically occurs following a stroke can exacerbate muscle weakness (through atrophy and changes in muscle fibers), fatigue, cardiovascular and metabolic deconditioning, and poor balance [360,361]. These complications have been shown to slow physical and social recovery and hinder brain activation over time [362]. Comprehensive fitness training may offset these effects (Table 25) [360,363,364]. Moreover, exercise programs can benefit a stroke survivor by reducing recurrent stroke and cardiovascular risks; reducing the risk and severity of post-stroke osteoporosis, preventing injuries and falls; increasing fitness, strength, flexibility, and functional activities; and promoting socialization [21,360,365]. However, exercise is not without risks. Training programs should be tailored to the patient's capabilities and conditions to promote safety and reduce musculoskeletal injuries [366,367]. For some patients, stroke severity and coexisting conditions may render exercise inadvisable. For instance, silent coronary artery disease, especially in sedentary patients, increases the chance of exercise-induced cardiac death. Because up to 75% of stroke survivors have cardiac comorbidities, the AHA suggests that the medical evaluation for an exercise program should include a graded exercise test with ECG monitoring [360]. Thorough screening, customized exercise program design, monitoring, and patient education should be performed during rehabilitation to maximize benefits and safety.

Table 25: SUMMARY OF EXERCISE PROGRAM RECOMMENDATIONS FOR STROKE SURVIVORS

Mode of Exercise

Major Goals

Intensity, Frequency, Durationa

Hospitalization and early convalescence

Low-level walking, self-care activities

Intermittent sitting, standing

Seated activities

Range of motion activities and motor challenges

Increase independence in activities of daily living

Increase walking speed/efficiency

Improve tolerance for prolonged physical activity

Reduce risk of cardiovascular disease

Reduce motor impairment; improve cognition

Prevent deconditioning, pneumonia, orthostatic intolerance, and depression

Approximately 10 to 20 beats per minute increases in resting heart rate; rating of perceived exertion (RPE) ≤11 (6–20 scale)

Frequency, duration as tolerated, using interval or work-rest approach

Inpatient/outpatient exercise therapy or "rehabilitation"

Large-muscle activities (e.g., walking, graded walking, stationary cycle/arm ergometry, functional activities seated exercises), if appropriate

Increase walking speed, efficiency

Improve functional capacity and independence in activities of daily living

Reduce motor impairment

Improve cognition

Improve vascular health and induce other cardioprotective benefits

40% to 70% peak oxygen uptake; 40% to 70% heart rate reserve; 55% to 80% maximal heart rate; RPE 11–14 (6–20 scale)

3 to 5 days/week 20 to 60 min/session (or multiple 10-min sessions)

Complement with pedometers to increase lifestyle physical activity

Strength/endurance (e.g., circuit training, weight machines, free weights, isometric exercise)

Increase independence in activities of daily living

Increase muscle strength and endurance

Reduce cardiac demands during lifting/carrying objects by increasing muscular strength

1–3 sets of 10–15 repetitions of 8–10 exercises involving the major muscle groups

2 to 3 days/week, with resistance gradually increased over time as tolerance permits

Flexibility/stretching

Increase range of motion (ROM) of involved extremities

Prevent contractures

Decrease risk of injury

Increase activities of daily living

2 to 3 days/week (Before or after aerobic or strength training)

Hold each stretch for 10 to 30 seconds

Neuromuscular (coordination and balance activities)

Improve level of safety during activities of daily living

Improve balance, skill reacquisition, quality of life, mobility

Decrease fear of falling

Use as complement to aerobic, muscular strength/endurance training, and stretching activities

2 to 3 days/week (Consider performing on same day as strength activities)

aRecommended intensity, frequency, and duration of exercise depend on each individual patient's level of fitness.

Intermittent training sessions may be indicated during the initial weeks of rehabilitation.

Source: [360] Reprinted from Billinger SA, et al. Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(8):2532-2553. With permission from Lippincott Williams & Wilkins.©American Heart Association.

As with any rehabilitation program, the degree of a patient's cognitive and communicative deficits may impact an exercise program's success. The Neurobehavioral Cognitive Status Examination is a brief screening tool that provides a rapid and sensitive measure of the patient's cognitive function. However, this and other brief mental status scales cannot adequately assess executive skills and other higher-level cognitive functions [21]. Personalized, tailored counseling interventions have demonstrated mixed results in improving adherence to an exercise program, whereas physical activity counseling has resulted in greater physical activity at 9 and 52 weeks post-stroke [360]. The crucial elements of a successful physical activity counseling intervention have not been identified definitively [360]. Barriers that may need to be addressed include lack of familial support, depression, fatigue, social integration, and cultural issues [360].

The consequences of inactivity may be most noticeable in patients with hemiparesis or other gait deficits. More than 50% of stroke survivors require rehabilitation to regain a functional level of ambulation [368]. Effects of neural damage underlying gait impairment, spasticity, and poor muscle performance are significantly compounded by muscle weakness, a lack of fatigue resistance, and the increased energy demands of rehabilitation [360]. Patients with mild-to-moderate conditions can benefit from treadmill training with partial body weight support [360]. As the patient walks on a treadmill, his or her body weight is supported by harnesses to facilitate walking at a comfortable speed. This training augments conventional gait rehabilitation therapies by increasing gait speed, muscle performance, and fatigue resistance; however, its effect on long-term walking outcomes requires further study [368,369].

Incorporation of progressive resistance training increases the generalizability of the fitness program and may improve the ability to carry out activities of daily living [370]. Although there are no accepted guidelines, the AHA suggests more repetitions with reduced loads (10 to 15 repetitions rather than 8 to 12), similar to programs recommended for patients recovering from MI [360]. Additionally, at least one set of at least 8 to 10 exercises should involve the major muscle groups (arms, shoulders, chest, abdomen, back, hips, and legs).

As technology continues to advance, rehabilitation programs may become enhanced with new ways to engage stroke survivors in exercise [21]. A study of virtual reality training sessions was shown to improve arm and hand movement skills in two patients with chronic hemiparesis [371]. The approach was also able to provide individualized, progressive practice based on the patient's level of movement ability and rate of improvement [371]. Other studies have found virtual reality rehabilitation to be an equally effective and potentially motivating alternative and/or supplement to conventional training in post-stroke care [372,373].

Nerve stimulation therapy has also been proposed as a means to improve motor deficits and physical activity capacity. In 2021, the FDA approved a vagus nerve stimulation system intended to treat moderate-to-severe upper extremity motor deficits associated with chronic ischemic stroke [397]. The device may be incorporated into a comprehensive rehabilitation program for these patients.

TRANSITIONS IN CARE AND REHABILITATION CONTINUITY

The transition from inpatient care to home after a stroke can be difficult for both patients and caregivers. Ongoing rehabilitation, profound or permanent disability, or discharge to a long-term care facility affects not only the transition in care but also the continuity of that care. To ensure medical and rehabilitation continuity for the patient through the rehabilitation process and into the home or community, the AHA/ASA recommend individualized discharge planning in the transition from hospital to home that includes comprehensive assessment of activities of daily living, instrumental activities of daily living, and mobility assessments and discussion of sexual issues (e.g., safety, changes in libido), recreational and leisure activities, and return to work ability and timeline, where appropriate [21]. Patients for whom the discharge living setting is evaluated should be considered candidates for community- or home-based rehabilitation when feasible. Providers should consider alternative methods of communication and support (e.g., telephone, visits, telehealth, online support), particularly for patients who reside in rural settings [21].

Rehabilitation services provided in the community can improve cardiovascular health, decrease the risk of cardiovascular events, and increase short-term survival rates for stroke survivors [21]. Among the benefits associated with community- and home-based rehabilitation programs are reduced costs, decreased length of stay in hospitals or institutional settings, increased opportunities for involvement by patient and family/caregiver, and less stress for family/caregiver. Patient satisfaction also is generally higher.

7. SECONDARY PREVENTION: EVIDENCE-BASED RECOMMENDATIONS

In the United States, approximately 23% of stroke incidences are recurrent [1]. Due to the high risk of recurrent stroke and its consequences, secondary ischemic stroke prevention tends to follow a risk-stratified model of disease management [374]. Treatment of at-risk patients' conditions is typically aggressive, as inadequate management can have serious implications.

A patient's risk for a recurrent stroke is highest during the first year; 14% of survivors have a recurrent stroke within one year after the initial cerebrovascular event, suggesting that secondary prevention is time-critical and should be initiated during the rehabilitation process [375]. After the first year, the chance of recurrent stroke decreases to 4% per year [374]. Because TIA is a precursor to stroke, secondary prevention applies to this category as well. AHA/ASA guidelines, updated 2021, are for prevention of stroke in patients with stroke and TIA [10]. The guidelines focus on four areas: diagnostic evaluation for secondary prevention, risk factor management, treatment in relation to etiology, and systems of care for secondary ischemic stroke prevention. Key take-home points and selected guideline recommendations are discussed in the following sections.

CONTROLLING RISK FACTORS

A major component of secondary prevention is the treatment of modifiable risk factors and, in select patients, correcting the underlying etiology of the stroke. Most strokes can be prevented by controlling blood pressure, following a healthy diet, regular physical activity, and smoking cessation. Global population-based studies have found that five factors—blood pressure, diet, physical activity, smoking, and abdominal obesity—account for 82% to 90% of risk for ischemic and hemorrhagic stroke worldwide [10]. Management of vascular risk factors also requires effective treatment of hypertension, diabetes, hyperlipidemia, and substance misuse. Patient education regarding healthy diet, regular physical activity, and avoidance of sedentary behavior is important. Multidisciplinary teams and goals tailored to the individual patient are often required for optimal results [10].

Hypertension

The results of meta-analyses have indicated that lowering blood pressure reduces the risk of stroke 30% to 40% [376,377]. The findings of longitudinal studies suggest that treatment with antihypertensive medications in hypertensive and normotensive patients reduces the incidence of recurrent strokes, MI, and other vascular events [378]. In particular, diuretics or diuretics combined with ACE inhibitors (e.g., ramipril, perindopril) most significantly reduce the risk of recurrent ischemic stroke [10,378]. However, lifestyle modifications that include weight loss; increased intake of fruits, vegetables, and low-fat dairy products; habitual aerobic physical activity; and limited alcohol consumption are crucial components of controlling blood pressure [123]. Although most studies address the prevention of additional ischemic strokes, hypertension management has also been shown to reduce the risk of recurrent hemorrhagic stroke and is included in guideline recommendations published by the AHA/ASA [10,378]. In the context of secondary stroke prevention, the target blood pressure is <130 mm Hg systolic, <80 mm Hg diastolic.

AHA Recommendations

- Initiation of antihypertensive medication can be beneficial in patients with no history of hypertension who experience ischemic stroke or TIA and have an average office blood pressure of >130/80 mm Hg, reducing risk of recurrent stroke, ICH, and other vascular events.

- Resumption of blood pressure therapy is indicated for previously treated patients with known hypertension for both prevention of recurrent stroke and prevention of other vascular events in those who have had an ischemic stroke or TIA and are beyond the first several days. An office blood pressure goal of <130/80 mm Hg is recommended for most patients to reduce the risk of recurrent stroke and vascular events.

- The choice of specific antihypertensive agent should be individualized on the basis of pharmacologic properties, mechanism of action, and consideration of the patient's comorbidities (e.g., extracranial cerebrovascular occlusive disease, renal impairment, cardiac disease, diabetes).

- Lifestyle modifications are an integral part of a patient's antihypertensive therapy.

Diabetes

Diabetes is a well-documented independent risk factor for recurrent stroke [379,380]. Aggressive control of hypertension in diabetic patients, with a lower target of 130/80 mm Hg, has been shown to reduce the risk of stroke as well as other cardiovascular events [123]. Including ACE inhibitors in the treatment regimen of patients with diabetes effectively lowers blood pressure, slows the progression of renal disease, and reduces albuminuria [10,381].

AHA Recommendations

- After a TIA or ischemic stroke, all patients should probably be screened for diabetes with testing of fasting plasma glucose, glycated hemoglobin (HbA1c), or an oral glucose tolerance test. Choice of test and timing should be guided by clinical judgment and recognition that acute illness may temporarily perturb measures of plasma glucose. In general, HbA1c may be more accurate than other screening tests in the immediate postevent period.

- Use of existing guidelines for glycemic control and blood pressure targets for patients with diabetes is recommended for patients who have had a stroke or TIA.

Cigarette Smoking

Smoking doubles the risk of stroke [382]. Its cessation eliminates the elevated risk after 5 years and reduces the overall risk of stroke-related hospitalization [10,382,383]. Exposure to secondhand smoke also appears to increase the risk of stroke [10,384]. The most effective combination of therapies for smoking cessation is nicotine replacement, social support, and counseling [10,385].

AHA Recommendations

- All patients with TIA or stroke who smoke should be strongly urged to quit and to avoid passive smoke. Counseling with or without nicotine replacement/drug therapy is recommended to assist in smoking cessation.

- In patients with ischemic stroke or TIA, avoidance of environmental (passive) tobacco smoke is recommended.

Alcohol Consumption

The results of a meta-analysis suggest that the risk of stroke is increased 69% for individuals who have more than five drinks (with one drink defined as 12 ounces of beer, 4 ounces of wine, or 1.5 ounces of liquor) per day compared with nondrinkers [386].

AHA Recommendations

- Patients with ischemic stroke or TIA who drink more than two alcoholic drinks per day for men or more than one drink per day for women should be counseled to eliminate or reduce their alcohol consumption to lessen risk factors that increase the likelihood of recurrent stroke.

- In patients who have substance use disorder, specialized services are recommended to help manage this dependency.

Physical Activity

Habitual exercise clearly prevents stroke [365]. In addition, a sedentary lifestyle impedes functional recovery and places patients at a higher risk for stroke recurrence.

AHA Recommendations

- After successful screening and completion of formal stroke rehabilitation, an individu-ally tailored exercise program is indicated to enhance cardiorespiratory fitness and reduce risk of stroke recurrence.

- In patients with stroke or TIA who are capable of physical activity, engaging in at least moderate-intensity aerobic physical exercise for 10 to 30 minutes three or four times per week or vigorous-intensity exercise for at least 20 minutes two times per week is recommended to lower the risk of recurrent stroke. Moderate-intensity exercise is sufficient to break a sweat or noticeably raise heart rate (e.g., walking briskly); vigorous-intensity exercise includes activities such as jogging.

- Patients who are able and willing to initiate increased physical activity should be encouraged to engage in an exercise class that includes counseling to change physical activity behavior.

- Supervision by a healthcare professional (e.g., physical therapist) on initiation of an exercise regimen is beneficial for individuals with disability after ischemic stroke.

MANAGING DISEASE

Pharmacologic antithrombotic therapy with either an antiplatelet or anticoagulant agent is recommended for nearly all patients who do not have contraindications. Dual antiplatelet therapy is recommended only for short-term use in specific patients (early-arrival minor stroke and high-risk TIA, or severe symptomatic intracranial stenosis) [10].

For patients who have large-artery atherosclerosis, the specific underlying condition should be managed. Similarly, identification and treatment of cardioembolic stroke source (e.g., AF, cardiomyopathy and left ventricular thrombus, valvular heart disease, patent foramen ovale) is recommended. Patients with ischemic stroke and a high-risk source of cardioembolism generally benefit from anticoagulant therapy.

In patients with paradoxical embolus and patent foramen ovale, clinical studies support percutaneous closure of the defect for secondary stroke prevention in patients meeting the following criteria: age 18 to 60 years, nonlacunar stroke, no other identifiable cause, and high-risk patent foramen ovale features [10].

Extracranial Carotid Artery Disease

Extracranial carotid stenosis is an important and treatable cause of stroke. Patients with severe stenosis ipsilateral to a disabling stroke or TIA who are candidates for intervention should be treated early after presentation. The choice between carotid endarterectomy and carotid artery stenting should be determined by specific patient comorbidities and vascular anatomy [10].

AHA Recommendations

- Carotid endarterectomy (CEA) is recommended for all patients who had a recent TIA or an ischemic stroke within the past 6 months and ipsilateral severe (70% to 99%) carotid artery stenosis if the morbidity/mortality risk is less than 6%.

- CEA is recommended for certain patients (based on age, gender, and comorbidities) who had a recent TIA or an ischemic stroke within the past 6 months and ipsilateral severe (50% to 69%) carotid artery stenosis if the morbidity/mortality risk is less than 6%. CEA is not recommended when the degree of stenosis is <50%.

- When CEA is indicated for patients with TIA or stroke, surgery within 2 weeks is reasonable rather than delaying surgery if there are no contraindications to early revascularization.

- Carotid artery stenting (CAS) is indicated as an alternative to CEA for symptomatic patients at average or low risk of compli-cations associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is found to be reduced by more than 70% on noninvasive imaging or more than 50% on catheter angiography or noninvasive imaging with corroboration and the anticipated rate of periprocedural stroke or death is less than 6%.

- It is reasonable to consider patient age in choosing between CAS and CEA. For patients older than 70 years of age, CEA may be associated with improved outcome compared with CAS, particularly when arterial anatomy is unfavorable for endovascular intervention. For younger patients, CAS is equivalent to CEA in terms of risk for periprocedural complications (e.g., stroke, MI, death) and long-term risk for ipsilateral stroke.

- CAS may be considered for patients with symptomatic severe stenosis (greater than 70%) if the stenosis is difficult to access surgically, medical conditions are present that greatly increase the risk for surgery, or other specific circumstances exist (such as radiation-induced stenosis or restenosis after CEA). In this setting, CAS is reasonable when performed by operators with established periprocedural stroke and mortality rates of less than 6%, similar to those observed in trials of CEA and CAS.

- For patients with recurrent or progressive ischemic symptoms ipsilateral to a stenosis or occlusion of a distal carotid artery, or occlusion of a midcervical carotid artery after institution of optimal medical therapy, the usefulness of extracranial to intracranial bypass is considered investigational.

- Optimal medical therapy, which should include antiplatelet therapy, statin therapy, and risk factor modification, is recommended for all patients with carotid artery stenosis and a TIA or stroke.

Intracranial Large Artery Atherosclerosis

The rate of stroke recurrence for patients with symptomatic intracranial atherosclerosis is approximately 9% [10]. The findings of retrospective studies have suggested that the greatest rate of recurrence is found among patients with this condition who do not have a response to antithrombotic therapy [387]. Although the results of some studies have indicated that angioplasty or stenting should be considered for such patients, the usefulness of these surgical interventions is unknown and considered investigational [10]. AHA/ASA recommends that patients with severe intracranial stenosis in the territory of stroke or TIA should not receive angioplasty and stenting as the first-line therapy for stroke prevention; aggressive medical management and short-term dual antiplatelet therapy are preferred [10].

AHA Recommendations

With regard to patients with stroke or TIA due to 50% to 99% stenosis of a major intracranial artery:

- Aspirin 325 mg per day is recommended in preference to warfarin.

- The addition of clopidogrel 75 mg per day (or ticagrelor 90 mg twice per day) to aspirin for up to 90 days is reasonable to further reduce recurrent stroke risk.

- Long-term maintenance of blood pressure <140 mm Hg systolic, high-intensity statin therapy, and at least moderate-intensity physical activity are recommended.

- Angioplasty and/or stent placement is not recommended, given the low rate of stroke with medical management and the inherent periprocedural risk of endovascular treatment.

- Extracranial-intracranial bypass surgery is not recommended.

With regard to patients with stroke or TIA due to 70% to 99% stenosis of a major intracranial artery, the addition of clopidogrel 75 mg/day to aspirin for 90 days might be reasonable.

Atrial Fibrillation

The anticoagulant warfarin has a narrow therapeutic margin and numerous food and drug interactions, and these factors (which necessitate frequent INR testing and dose adjustment), combined with the associated significant bleeding risks, have led to the underutilization of this drug despite having been shown to prevent recurrent stroke substantially in patients with ischemic stroke or TIA and AF and despite the adoption of performance measures and guidelines advocating its use in these patients [10,24,388,389]. Easy-to-use alternative therapies are required and include dabigatran, rivaroxaban, and apixaban [390,391,392]. Significant adverse effects (i.e., serious, sometimes fatal bleeding, acute coronary events) have been associated with some of these agents, making their use inappropriate for some patients [393,394]. However, a 2011 focused update on dabigatran published by the American College of Cardiology, the AHA, and the Heart Rhythm Society recommends this agent as a useful alternative to warfarin for select patients [395].

Between 35% to 45% of patients with stroke and AF have coexisting conditions that may have caused the stroke [396]. In many cases, both the AF and the other condition (usually stenosis) will require treatment [10].

AHA Recommendations

- For patients who have experienced an acute ischemic stroke or TIA with no other apparent cause, prolonged rhythm monitoring (for approximately 30 days) for AF is reasonable within 6 months of the index event.

- For patients with ischemic stroke or TIA and nonvalvular paroxysmal (intermittent), persistent, or permanent AF, an oral anticoagulant (e.g., apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin) is recommended to reduce the risk of stroke.

- In patients who do not have severe mitral stenosis or a mechanical heart valve, apixaban, dabigatran, edoxaban, or rivaroxaban is recommended in preference to warfarin.

- The selection of an antithrombotic agent should be individualized based on risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including renal function and time in INR therapeutic range if the patient has been taking warfarin.

- The combination of oral anticoagulation (i.e., warfarin or one of the newer agents) with antiplatelet therapy is not recommended for all patients after ischemic stroke or TIA but is reasonable in patients with clinically apparent CAD, particularly an acute coronary syndrome or stent placement.

- For patients unable to take oral anticoagulants, aspirin alone (75 mg to 100 mg per day) is recommended. The combination of clopidogrel plus aspirin, compared with aspirin therapy alone, might be reasonable.

- Following stroke, for patients at low risk for hemorrhagic conversion in the setting of AF, it is reasonable to initiate oral anticoagulation within 2 to 14 days after the onset of the index event. In the presence of high risk for hemorrhagic conversion (i.e., large infarct, hemorrhagic transformation, uncontrolled hypertension, hemorrhage tendency), it is reasonable to delay initiation of oral anticoagulation beyond 14 days.

- For patients with AF at high risk for stroke (i.e., stroke or TIA within 3 months; Cardiac failure, Hypertension, Age, Diabetes, Stroke system [CHADS2] score of 5 or 6; mechanical or rheumatic valve disease) who require temporary interruption of oral anticoagulation, bridging therapy with a LMWH administered subcutaneously is reasonable.

Noncardioembolic Strokes and TIA

The use of certain antiplatelet therapies rather than oral anticoagulation for noncardioembolic ischemic strokes and TIAs has been shown to reduce the overall risk of recurrent stroke and decrease the incidence of fatal recurrent strokes [10]. Clopidogrel is appropriate for patients who are allergic to aspirin or for patients in whom dipyridamole-associated headaches occur.

AHA Recommendation

Aspirin (50 mg to 325 mg per day) monotherapy, the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily, or clopidogrel 75 mg monotherapy are all acceptable options for initial therapy. The selection of an antiplatelet agent should be individualized on the basis of patient risk factor profiles, cost, tolerance, and other clinical characteristics.

8. CASE STUDY

Patient M is an active woman, 70 years of age, who lost consciousness and collapsed at home. Her daughter, who was visiting her at the time, did not witness the collapse but found her mother on the floor, awake, confused, and slightly short of breath. The daughter estimated that she called EMS within 5 minutes after the collapse, and EMS responded within 15 minutes. EMS evaluated Patient M, drew blood for a glucose level, and determined that she may have had a stroke. They notified the nearest designated comprehensive stroke center that they would be arriving with the patient in approximately 20 minutes. Patient M's daughter accompanied her.

The triage and transportation of an individual with suspected stroke should be similar to that for an individual with serious trauma, and treatment is recommended within 3 hours after the onset of stroke. Because of the limited time available for assessment and diagnosis before optimal treatment, the EMS dispatcher should notify EMS personnel immediately and coordinate transport of the individual to the closest emergency facility, preferably one that is a designated primary (or comprehensive) stroke care center.

On presentation in the emergency department, Patient M is immediately triaged. Because Patient M is still somewhat confused, her daughter is asked to provide information on the patient's history. The daughter reports that her mother had had an episode of sudden-onset numbness and tingling in the right limb, with slight confusion and slurred speech, 3 days previously. The episode lasted only 5 minutes, and Patient M had not called her primary care physician. Additional information provided by the daughter indicates that Patient M has been treated for hypertension for 10 years but notes that she is often not compliant with her antihypertensive medicine, a diuretic. The patient has never smoked, drinks occasionally, and is of normal weight.

Patient M has two significant risk factors for stroke; one is a long history of hypertension. More than two-thirds of individuals older than 65 years of age are hypertensive, and it is important for individuals with hypertension to have regular blood pressure screening and to maintain a blood pressure of less than 140/90 mm Hg. Antihypertension therapy has been found to reduce the incidence of stroke by 30% to 40%. Patient M's noncompliance with her antihypertension medicine likely includes her among the 65% of known hypertensive individuals in whom blood pressure is not controlled.

Patient M's previous episode of numbness, confusion, and slurred speech appears to be evidence of a TIA, another substantial risk factor for stroke. Research has shown that approximately 5% of patients will have an ischemic stroke within 7 days after a TIA. In addition, the risk of stroke within 7 days is doubled for patients with TIAs who did not seek treatment. As is the case for many individuals who have a TIA, Patient M did not seek medical attention because the clinical symptoms resolved quickly. However, research findings indicate that urgent treatment should be provided for TIAs, as early treatment for TIA and minor stroke has been shown to reduce the risk of early recurrent stroke by 80%.

On physical examination, Patient M's blood pressure is 150/95 mm Hg. She has pain in her left arm and a slight headache. There is a focal carotid bruit on the right. She is assessed with use of the NIHSS and found to have 1/5 weakness in the left upper and lower extremities and left visual/spatial neglect. The results of laboratory tests, including a complete blood count, prothrombin time, serum electrolyte levels, cardiac biomarkers, and renal function studies, are all within normal limits. CT of the head obtained about 45 minutes into her ED evaluation (1.5 to 2 hours since last well) indicates an occlusion in a branch of the right internal carotid artery with 50% narrowing due to atherosclerosis. An area of ischemia/infarction is visible in the right anterior cerebral hemisphere. There is no evidence of subarachnoid hemorrhage. Approximately 2.5 to 3 hours after Patient M collapsed at home, she is treated with IV rt-PA at a dose of 0.9 mg/kg. Twenty-four hours later, aspirin antiplatelet therapy is started at an initial dose of 325 mg, and a maintenance dose of 75 mg per day.

Many of the patient's symptoms, including her loss of consciousness, shortness of breath, pain, and headache, are nontraditional symptoms of stroke. Studies have demonstrated that nontraditional symptoms are more prevalent among women, often leading to a delay in the evaluation for stroke. EMS personnel and clinicians should be aware of the potential for nontraditional symptoms in women and carry out a diagnostic evaluation addressing a suspicion of stroke.

Patient M is eligible for thrombolytic therapy with rt-PA according to evidence-based guidelines developed by the AHA/ASA: her blood pressure is lower than 185/110 mm Hg, the onset of symptoms is less than 3 hours prior to the start of treatment, and the laboratory values are within normal limits. Antiplatelet therapy with aspirin 325 mg daily (versus anticoagulant therapy with warfarin) is recommended for treatment of patients with stroke or TIA due to intracranial atherosclerosis with 50% to 99% occlusion. Antiplatelet therapy is not recommended as an adjunctive therapy within 24 hours of thrombolytic therapy.

When Patient M's condition is stabilized, her primary care physician and consultant neurologist provide a referral for stroke rehabilitation, and a multidisciplinary rehabilitation team is formed to assess her rehabilitative needs, recommend the proper rehabilitation setting, and develop a treatment strategy tailored to her specific needs that includes daily antiplatelet therapy. Patient M is again assessed with the NIHSS, and the score is 12. The patient's cognitive and communication skills are intact on evaluation with the FIM, with the exception of the previously documented left visual/spatial neglect. The assessment also includes evaluation of the patient's risk for complications. Because of her spatial neglect, she is screened with the Berg Balance Scale and the Stops Walking When Talking test. The score on the Berg Balance Scale is 43, and Patient M does stop walking to engage in conversation. Psychosocial assessment includes screening with the Center for Epidemiologic Studies Depression (CES-D) Scale, as well as review of the medical history and conversations with the patient and her children; no signs of depression are present.

Patient M's score of 12 on the NIHSS falls within the range (6 to 15) that indicates she is likely to benefit from rehabilitation. Evaluating a stroke survivor's risk of complications is an important component of the overall assessment, and among the most common complications are falls, deep vein thrombosis, pressure injuries, swallowing dysfunction, bladder and bowel dysfunction, and depressive symptoms. In assessing the risk of complications, the Berg Balance Scale appears to be the most appropriate screen for patients who are likely to fall, and a score of less than 45 is associated with a likelihood of falling. The risk of a fall is also increased when a patient stops walking to talk, as Patient M did, during the Stops Talking When Walking test.

Screening for signs of depression is also essential, as depression affects approximately 33% of stroke survivors. Signs of depression are subtle and may be vague. Several screening tools are available, but there is no universally accepted tool for use in the post-stroke setting. The CES-D was chosen in this case because it is easy to administer, is useful in older individuals, and has been found to be effective for screening in the stroke population, except for individuals who have aphasia. The diagnosis of depression in stroke survivors should be based on sources in addition to a formal screening tool, such as a medical evaluation, patient self-report, observation of patient behavior, patient history, and staff reports of changes in behavior and motivation.

The rehabilitation team discusses the results of the assessment with Patient M's daughter and son, both of whom live about 45 minutes away from the patient. Together, the team and the family members explore options to determine the best approach to rehabilitation. A decision is made to transfer Patient M to an inpatient stroke unit, and a rehabilitation program is developed. The nurse on the team discusses the program with Patient M and her children and explains the course of rehabilitation and the expectations. Rehabilitation will focus on an exercise program consisting of aerobic exercise, strength training, stretching, and coordination and balance activities.

Early initiation of rehabilitation is a particularly strong predictor of improved outcome, and rehabilitation in a stroke unit has been associated with improved quality of life, survival, and functional status at 5 years compared with a general healthcare facility. No studies have demonstrated the superiority of one rehabilitation setting over another, and the inpatient setting was chosen primarily to ensure consistent care, given how far away Patient M's children live, and the limited support she otherwise has for healthcare needs. Decisions about the setting and program for rehabilitation should be shared with family members, and family and other caregivers should be provided with educational resources about the rehabilitation process.

The exercise program developed for Patient M is designed to help her regain the ability to independently carry out activities of daily living safely and to regain a functional level of ambulation. The benefits of an exercise program include increasing fitness, strength, and flexibility; improving function; preventing injuries and falls; and reducing the risk of recurrent stroke.

Patient M gradually resumes the ability to function independently, and after more than 2 weeks in the stroke rehabilitation unit, the score on the NIHSS has improved to 5. Before she is discharged to her home, the rehabilitation team provides instructions for exercises to continue at home and recommends moderate physical activity as a secondary prevention measure. The team also educates Patient M about the importance of maintaining a normal blood pressure through use of her antihypertension medication and lifestyle modifications. At a follow-up visit with her primary care clinician at 3 months, Patient M's blood pressure is 135/80 mm Hg, and she reports that she has been compliant with her antihypertension medicine and antiplatelet therapy and is functioning well at home.

9. CONCLUSION

Ischemic stroke remains a significant contributor to morbidity and mortality in the United States. Stroke is associated with several modifiable risk factors including hypertension, smoking, physical inactivity, and obesity. Clinicians should encourage their patients to adopt healthy lifestyle habits, especially those at highest risk. In addition, primary prevention of stroke involves effective control of many medical conditions, such as hypertension, diabetes, dyslipidemia, and AF.

Early diagnosis and appropriate immediate treatment are key to recovery of neurologic function and survival after stroke, making it imperative for both healthcare professionals and the general public to recognize the symptoms of stroke and TIAs, a substantial risk factor for stroke. Clinicians, as well as EMS staff and ED staff, should be skilled in identifying possible stroke-related symptoms, especially noting that women are more apt to have nontraditional symptoms of both TIAs and stroke. Efforts to educate the public about the importance of seeking medical care for TIAs and about the warning signs of stroke are also essential.

Evidence-based guidelines are available for the primary and secondary prevention of ischemic stroke, as well as for early management and rehabilitation. Adherence to these guidelines has been shown to reduce the incidence of stroke and to decrease morbidity and mortality resulting from stroke. Thrombolytic therapy with rt-PA is the cornerstone of treatment for ischemic stroke, and the AHA now recommends beginning antiplatelet therapy with aspirin 24 to 48 hours after the onset of stroke. Other antiplatelet agents, as well as anticoagulant therapy, are not recommended on the basis of the evidence to date.

Outcomes after stroke are improved when care is provided in a comprehensive stroke center and when rehabilitative care is provided by a multidisciplinary team. Effective rehabilitation begins with a systematic evaluation of the patient to determine the need for specific rehabilitation services, the risk of complications, the patient's physical functioning and level of cognition and communication, and the patient's psychosocial status. This evaluation allows for the development of a rehabilitation program that addresses an individual patient's specific needs, with tailored strategies for secondary prevention. When all available resources are utilized, prevention and appropriate treatment of stroke will result.

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356. Leppävuori A, Pohjasvaara T, Vataja R, Kaste M, Erkinjuntti T. Generalized anxiety disorders three to four months after ischemic stroke. Cerebrovasc Dis. 2003;16(3):257-264.

357. Rosen HJ, Cummings J. A real reason for patients with pseudobulbar affect to smile. Ann Neurol. 2007;61(2):92-96.

358. Ramasubbu R. Cerebrovascular effects of selective serotonin reuptake inhibitors: a systematic review. J Clin Psychiatry. 2004;65(12):1642-1653.

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361. Michael KM, Allen JK, Macko RF. Reduced ambulatory activity after stroke: the role of balance, gait, and cardiovascular fitness. Arch Phys Med Rehabil. 2005;86(8):1552-1556.

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363. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 5th ed. Champaign, IL: Human Kinetics Publishers; 2013.

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365. Thompson PD, Buchner D, Piña IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107(24):3109-3116.

366. Morris JH, Macgillivray S, Macfarlane S. Interventions to promote long-term participation in physical activity after stroke: a systematic review of the literature. Arch Phys Med Rehabil. 2014;95(5):956-967.

367. Coupar F, Pollock A, Legg LA, Sackley C, van Vliet P. Home-based therapy programmes for upper limb functional recovery following stroke. Cochrane Database Syst Rev. 2012;5:CD006755.

368. Schwartz I, Meiner Z. The influence of locomotor treatment using robotic body-weight-supported treadmill training on rehabilitation outcome of patients suffering neurological disorders. Harefuah. 2013;152(3):166-171.

369. Macko RF, Smith GV, Dobrovolny CL, Sorkin JD, Goldberg AP, Silver KH. Treadmill training improves fitness reserve in chronic stroke patients. Arch Phys Med Rehabil. 2001;82(7):879-884.

370. Yang YR, Wang RY, Lin KH, Chu MY, Chan RC. Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clin Rehabil. 2006;20(10):860-870.

371. Stewart JC, Yeh SC, Jung Y, et al. Intervention to enhance skilled arm and hand movements after stroke: a feasibility study using a new virtual reality system. J Neuroeng Rehabil. 2007;4:21.

372. Brunner I, Skouen JS, Hofstad H, et al. Virtual reality training for upper extremity in subacute stroke (VIRTUES): a multicenter RCT. Neurology. 2017;89(24):2413-2421.

373. Schuster-Amft C, Eng K, Suica Z, et al. Effect of a four-week virtual reality-based training versus conventional therapy on upper limb motor function after stroke: a multicenter parallel group randomized trial. PLoS One. 2018;13(10):e00204455.

374. Jamieson DG. Secondary prevention of ischemic stroke: evolution from a stepwise to a risk stratification approach to care. Dis Manag. 2007;10(5):273-284.

375. Hankey GJ. Long-term outcome after ischaemic stroke/transient ischaemic attack. Cerebrovasc Dis. 2003;16(Suppl 1):14-19.

376. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000;342(3):145-153.

377. Lawes CM, Bennett DA, Feigin VL, Rodgers A. Blood pressure and stroke: an overview of published reviews. Stroke. 2004;35(4):1024-1033.

378. Rashid P, Leonardi-Bee J, Bath P. Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review. Stroke. 2003;34(11):2741-2748.

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97210 • Managing Disruptive Patients

Shirley Aycock, DNP, RN

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

Healthcare professionals will encounter disruptive or hard to manage patients during their career. Examples of these disruptive encounters include workplace violence, nonadherence to medical treatments, and manipulation of caregivers. This course explores how healthcare professionals can avoid potentially violent situations and work with disruptive patients by being prepared and recognizing the signs and risk factors for these occurrences. De-escalation skills, diagnosis, preventative measures, training, and planning are all presented in this course to help healthcare professionals respond to disruptive patients and ensure a healthy environment for everyone.

Table of Contents

97210 • Managing Disruptive Patients

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. FACTORS THAT MAY INCREASE THE RISK OF VIOLENCE

INCIDENCE OF VIOLENCE IN HEALTHCARE SETTINGS

3. PREVENTION OF WORKPLACE VIOLENCE

4. PREVENTION AND EARLY DETECTION

EARLY WARNING SIGNS

5. PRELIMINARY ACTIONS

WHEN VIOLENCE ERUPTS

RESTRAINTS

INTERVENTIONS FOR POTENTIALLY AGGRESSIVE BEHAVIORS

HOLISTIC CONSIDERATIONS

CASE STUDY 1

6. NONCOMPLIANCE

INCIDENCE

HEALTH BELIEF MODEL

LEGAL AND ETHICAL ISSUES

SPECIAL CASES

RISK FACTORS

7. NONADHERENCE

INTERVENTIONS

HOLISTIC CONSIDERATIONS

TECHNOLOGY

CASE STUDY 2

8. MANIPULATIVE BEHAVIORS

A DEVELOPMENTAL VIEW OF MANIPULATIVE BEHAVIORS

ADAPTIVE VERSUS MALADAPTIVE MANIPULATION

IDENTIFYING MANIPULATIVE BEHAVIORS

INTERVENTIONS FOR MANIPULATIVE BEHAVIORS

CASE STUDY 3

9. GLOSSARY OF TERMS

10. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

97210 • Managing Disruptive Patients

Education Category. Ethics - Human Rights

Release Date. 01/06/2025

Expiration Date. 01/05/2028

Course Overview

Healthcare professionals will encounter disruptive or hard to manage patients during their career. Examples of these disruptive encounters include workplace violence, nonadherence to medical treatments, and manipulation of caregivers. This course explores how healthcare professionals can avoid potentially violent situations and work with disruptive patients by being prepared and recognizing the signs and risk factors for these occurrences. De-escalation skills, diagnosis, preventative measures, training, and planning are all presented in this course to help healthcare professionals respond to disruptive patients and ensure a healthy environment for everyone.

Audience

This course is designed for all healthcare professionals who may encounter disruptive patients.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 9 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 9 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 9 ANCC contact hour(s). NetCE designates this continuing education activity for 10.8 hours for Alabama nurses. NetCE designates this continuing education activity for 3 NBCC clock hour(s). Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 9 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. NetCE designates this activity for 9 ACPE credit(s). ACPE Universal Activity Number: JA4008164-0000-25-011-H99-P. Social workers participating in this intermediate to advanced course will receive 9 Non-Clinical continuing education clock hours. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and/or Self-Assessment requirements of the American Board of Surgery's Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. This activity has been approved for the American Board of Anesthesiology’s® (ABA) requirements for Part II: Lifelong Learning and Self-Assessment of the American Board of Anesthesiology’s (ABA) redesigned Maintenance of Certification in Anesthesiology Program® (MOCA®), known as MOCA 2.0®. Please consult the ABA website, www.theABA.org, for a list of all MOCA 2.0 requirements. Maintenance of Certification in Anesthesiology Program® and MOCA® are registered certification marks of the American Board of Anesthesiology®. MOCA 2.0® is a trademark of the American Board of Anesthesiology®. Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 9 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 9 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME's "CME in Support of MOC" program in Section 3 of the Royal College's MOC Program. NetCE designates this continuing education activity for 9 credit(s). AACN Synergy CERP Category A. NetCE is authorized by IACET to offer 0.9 CEU(s) for this program.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

The purpose of this course is to provide healthcare professionals with the knowledge and skills necessary to identify patients at risk for disruptive behavior and to avoid potentially violent situations.

Learning Objectives

Upon completion of this course, you should be able to:

1. Interpret the early warning signs of workplace violence in patients who are aggressive.

2. Apply appropriate interventions for managing patients who are assaultive or have the potential to engage in workplace violence.

3. Differentiate risk factors associated with nonadherence.

4. Analyze interventions that may be used when caring for patients who are nonadherent.

5. Distinguish ways in which manipulative behavior can be identified.

6. Analyze the appropriate interventions for patients who demonstrate manipulative behaviors.

Faculty

Shirley Aycock, DNP, RN, is a registered nurse who has spent the majority of her nursing career serving in a variety of leadership roles. Her leadership roles range from clinical operations within acute care facilitates to serving as Adjunct Nursing Faculty at several Universities including LeTourneau University and University of Texas at Arlington, College of Nursing and Health Innovation. She received her Bachelor of Science in Nursing degree from University of Texas at Arlington, a Master of Science in Nursing Administration from University of Texas at Tyler, and a Doctorate of Nursing Practice from Rush University in Chicago, Illinois.

Faculty Disclosure

Contributing faculty, Shirley Aycock, DNP, RN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Candace Pierce, DNP, RN, CNE, COI

Leyna Antonucci, PT, DPT

Abimbola Farinde, PharmD, PhD

Scott Deatherage, PhD

Verlyn Evans, EdD, CCC/SLP

John Makopoulos, MD

Jessica Restivo, MS, OTR/L, NTMTC

Kimberly Byrd, EdD, LMSW

Nicholas Bertoni, MD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

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It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Hospitalization can sometimes be frightening, disorientating, and may even cause a patient to resort to behaviors that include hostility, noncompliance, and manipulation. Psychiatric healthcare professional personnel are trained in the management of aggressive behavior and crises. However, healthcare professionals working in a general hospital setting may not have been given specific instructions in handling such situations. In acute care settings, security staff frequently manage the occasional behavioral incident associated with patient aggression.

Healthcare institutions must take necessary precautions to protect healthcare professional personnel from workplace violence. The Occupational Safety and Health Act of 1970 requires that employers ensure each employee has a place of employment that is free from recognized hazards that are causing, or are likely to cause, death or serious physical harm [1].

Healthcare professionals may experience disruption with patients who are noncompliant or nonadherent with treatment. The concept of noncompliance, or nonadherence, is a subject of debate in healthcare. At the heart of the issue is the right of the patient to choose a treatment course that is different from the recommendations of the healthcare team. Discovering the cause of nonadherence is a necessary first step. If it can be determined, then patient education or problem solving by the healthcare professional may assist in future adherence. Helping patients truly understand the risks of not following the treatment regimen can go a long way toward achieving better adherence.

Another way patients may demonstrate disruptive behavior in a hospital setting is through manipulation. The term manipulate means to influence the behavior or emotions of others, often at their expense, for one's own purposes. The stress of hospitalization may cause a patient to resort to manipulation to meet needs that are absent in a hospital setting. Patients who demonstrate manipulative behaviors are typically trying to gain power over the healthcare professional to get what they need/want. This behavior can evoke a negative response towards the patient from healthcare professionals and other clinicians.

2. FACTORS THAT MAY INCREASE THE RISK OF VIOLENCE

Workplace violence ranges from offensive or threatening language to homicide. Incidents of violence are episodes or outbursts that involve hitting, choking, or assaulting another person; damaging property; throwing cups; smashing glassware; and so forth. One of the difficulties with providing a safe environment is that sickness and potential life-threatening factors cause stress in patients, their family members, and personnel in healthcare workplaces. Such stress can aggravate factors that lead to violence, which is reportedly on the increase [2].

Research demonstrates that among healthcare personnel, nurses are the most likely victims of workplace violence [3]. According to the World Health Organization, up to 38% of healthcare workers have experienced some form of physical violence within their career. Many more are threatened or exposed to verbal aggressions often perpetrated by patients and visitors. The risk factors for violence vary with each healthcare facility, depending on location, size, and type of care. According to Lim et al., risk factors for workplace violence in healthcare settings include attitudes and behaviors of patients, family members, friends, or visitors who are often under intense emotional charge and expectations [4]. Work factors that increase the risk of violence include shortage of staff, inexperienced or anxious staff, poor coping mechanisms, and lack of training. System or environmental factors include overcrowded areas, long waiting hours, and inflexible visiting hours. Factors that may influence the risk for violence in healthcare settings are listed in Table 1.

Table 1: FACTORS THAT MAY INCREASE THE RISK OF VIOLENCE IN HEALTHCARE SETTINGS

Patients and Visitors

Staff

Environment

Patients who are acutely agitated, violent, or volatile

Lack of training in recognition, early intervention, and management of escalating, hostile, and assaultive behavior or patients who are potentially volatile

Poor or inadequate security measures

Patients with a history of violence or certain psychotic diagnoses

Low staffing levels during times of specific increased activity, such as mealtimes, visiting hours, and shift changes

Poorly lit corridors, rooms, parking lots, and other areas

Patients who are on criminal holds by police and the criminal justice system

Solo work, particularly in remote locations

Highly accessible worksites with little or no privacy

Patients with a history of trauma

Interventions demanding close physical contact, such as examinations, treatments, or transporting patients

Unrestricted movement of the public in clinics and hospitals

Patients who abuse drugs or alcohol, are under the influence of these substances, or are withdrawing from substances

Shift work, including commuting to and from work at night

Long waits in emergency or clinic areas that are overcrowded and uncomfortable

Distraught family members

Demanding workloads

Availability of drugs or money at hospitals, clinics, and pharmacies, making them likely targets for robbery

Presence of gang members

The use of temporary and inexperienced staff; working alone

Prevalence of handguns and other weapons; home visiting, with its associated isolation

Source: [3,4,5]

Workplace violence is destructive and has a profoundly negative impact on healthcare professionals. Healthcare professionals may experience physical injuries, psychological trauma, anxiety, or even death. Feelings such as anger, depression, fear, self-blame, and powerlessness might take over the healthcare professional's life. This can affect the institution by causing loss of job satisfaction, low worker morale, increased job stress, and an increased staff turnover rate [1,6].

Members of the healthcare professional staff need guidelines for dealing with workplace aggression, just as they do for a fire or dangerous situations. These guidelines should be based on a team approach with security staff since both groups have their own unique perspectives and skills to offer. Healthcare professionals who work in long-term care facilities should have training in the management of patients who are potentially aggressive; both the frequency of incidents and the delicate nature of some patients' conditions increase the likelihood of violent incidents. The areas of a hospital where violence is most likely to occur are the emergency department, intensive care units, psychiatric services, and geriatric units [7]. Ideally, all healthcare professionals should receive education on how to handle violence in their workplace.

INCIDENCE OF VIOLENCE IN HEALTHCARE SETTINGS

Hospital workers are at high risk for experiencing violence in the workplace [3]. According to a 2022 study by the U.S. Bureau of Labor Statistics, incidence of nonfatal assaults on healthcare workers was 8.5 assaults per 100 full time employees. This rate was much higher than the rate of nonfatal assaults in private sector industries, which was 1.7 per 100 full-time employees. Healthcare workers are five times more likely to experience workplace violence than individuals in other professions. It continues to be a critical issue for all hospital workers. Individual states have enacted legislation to help curb this problem. Through these efforts, many emergency departments have added secure entry systems and, as much as possible under current budget restrictions, additional security personnel.

3. PREVENTION OF WORKPLACE VIOLENCE

Healthcare professionals in all healthcare settings should expect training in dealing with patient aggression. Being prepared for situations that may escalate allows healthcare professionals and other staff to defuse potentially violent situations before injuries occur. Areas where patients are most likely to become violent require lower staff-to-patient ratios to decrease incidents of violence. Suggested prevention strategies include (i) substitution by transferring a client or patient with a history of violent behavior to a more suitable secure facility or area; (ii) engineering control measures that include installing barrier protection, metal detectors and security alarm systems, and allocating conducive patients or visitors areas and clear exit routes; (iii) administrative and workplace practice controls that include implementing workplace violence response and zero-tolerance policies, ability to resolve a conflict situation, establishing a mandatory timely reporting system, ensuring employees are not working alone, and a flowchart for assessing and response in emergency situations; (iv) post-incident procedures and services that include trauma-crisis counselling, critical-incident stress debriefing, and employee assistance programs; (v) safety and health training in order to ensure that all staff members are aware of potential hazards and how to protect themselves and their co-workers through established policies and procedures [4,8].

Patients are not the only individuals responsible for workplace violence. Family, other visitors, staff, and vendors are all potential aggressors. Healthcare professionals educated in de-escalation techniques may be able to help any of these individuals calm down rather than create a violent episode. Everyone benefits when an emotionally charged situation does not end in violence of any sort.

In the United States, home health care is the fastest growing industry, with a projected growth of 33% by 2030. A cross-sectional survey conducted by Small et al. found that home health care workers (HHCWs) are at increased risk for workplace violence (WV) [9]. Results from previous survey research indicated the percent of home health care workers who reported exposure to any form of WV ranged from 2.5% to 65.1%. Non-physical aggression was most pervasive, with the highest percentage reported by HHCWs being 65.1% during a study that asked about their personal experiences of emotional abuse (e.g., name calling) committed by a client or someone else in the home. HHCWs reported concerns regarding safety as it relates to weapons in the home, neighborhood crime, and working evening shifts. For HHCWs, prevention should begin with risk assessments that include a patient history of violence and safety concerns in the patient's home and surrounding neighborhood. Home health agencies should have adequate training for addressing workplace violence along with policies and procedures that address the growing problem of violence in healthcare [9].

4. PREVENTION AND EARLY DETECTION

Healthcare professionals need to be aware of how they deal with patient anger. For example, becoming angry in response to anger will not be therapeutic and will create a situation in which the healthcare professional is unable to defuse a patient's aggression. Such behavior will more likely intensify the patient's emotions. Overly controlling behavior may lead to a power struggle with the patient. Simply withdrawing from an angry patient will almost always be ineffective. If the patient's angry feelings are escalating, the patient is communicating loss of control and needs help regaining composure [5].

Healthcare professionals should not overlook personal feelings of anxiety during an interaction with a patient. If their intuition gives them a message that a patient may become dangerous or that the situation may be getting out of hand, healthcare professionals should do the following:

- Seek help early.

- Use healthcare professional skills to establish and maintain a trusting relationship with the patient.

- Conduct a thorough psychosocial and mental status assessment.

- Be a good monitor of a potential crisis.

- Pay attention to "gut" reactions.

- Inform the patient that violent or aggressive behavior is not acceptable.

- Use calming statements to lower the patient's anxiety and decrease the likelihood of aggression.

- Encourage the patient to talk things through rather than acting out.

- Ask very simple, short-answer questions and not broad questions in these situations.

- Anticipate potential problems. Have a plan for obtaining help from security and/or other staff members, as well as an escape route out of the patient's room.

- Know each patient's history and current problems. Consider obtaining an order for medication to calm a patient who has a history of aggressive behavior (if this appears in the patient's history or if the patient's behavior suggests loss of control and emotional escalation).

- Be alert to patients whose primary or secondary diagnoses are associated with a high degree of potential for violent occurrences (e.g., patients experiencing delirium or dementia, and patients with certain substance use disorders).

Healthcare professionals should request a psychiatric consultation for any patient who demonstrates violent behavior. A thorough assessment is crucial in making a correct diagnosis so that appropriate treatment may be initiated [5].

EARLY WARNING SIGNS

Considering the source and target of the patient's anger, as well as the likelihood of escalation, is important. Patients who are potentially violent are often demanding, argumentative, hostile, and perhaps challenging and blatantly threatening in all their interactions. This behavior may be directed toward staff members, other patients, or the patient's family and friends, depending on the situation. Authority figures are often the recipients of verbal and other abuse, although anyone who is "in the way" may be the target of patients who cannot control themselves.

A history of previous violence is the highest predictor of future violence. Patients who are at risk for violence often have a history of recent acts of aggression or violence and might exhibit the following behaviors [3]:

- Becoming extremely loud, shouting, and making menacing verbal or physical threats.

- Becoming physically tense and appearing rigid and tight.

- Clenching their teeth and hands or wringing their hands.

- Becoming quite agitated, anxious, and restless; pacing around if mobile; seeming quite jittery.

- Exhibiting a labile mood but mostly anger.

5. PRELIMINARY ACTIONS

The healthcare professional staff should carefully manage patients who are agitated and seem to be at risk for violence. The following steps are important for healthcare professionals to remember in these situations [1,3]:

- Maintain a demeanor that helps defuse anger. Present a calm, caring attitude.

- Give patients who exhibit irritability choices and options, but make sure they are valid, true choices and options.

- Do not be demanding and argumentative; perhaps some rules or procedures can be waived temporarily. Patients who are angry and potentially violent generally feel helpless and powerless. They need help with their self-control.

- To avoid power struggles with these patients, do not confront them. This approach will help de-escalate the patients' behavior and the situation.

- Open and consistent communication should be ongoing among staff members and between the patient and the staff. Talk to the patient. Try to find out what is precipitating this crisis.

- Do not match the threats. Do not give orders. Acknowledge the person's feelings (e.g., "I know you are frustrated"). Ask the patient what they would like done (e.g., "How can the staff help?", "How can I help?").

- Decrease the stimuli for the patient. The loud and unfamiliar noises of the hospital may be particularly stressful and bright lights may be bothersome.

- Avoid any behavior that may be interpreted as aggressive (e.g., moving rapidly, getting too close, touching, or speaking loudly). Physical touch can be a trigger. Patients may misinterpret the contact and feel threatened with bodily harm, and they may feel the need to defend themselves. Delay procedures that may escalate a patient's potentially violent behavior.

- Before the situation gets out of control, check the environment. Look for potentially dangerous objects and remove them if possible. Items such as glasses, scissors, food utensils, and other breakable or sharp objects can be used as weapons.

- Avoid being alone and vulnerable with a patient who is potentially violent or being trapped in a room away from the exit; stay between the patient and the door. Team up with another member of the staff when encountering such a patient; there can be safety in numbers.

- Alert other members of the healthcare professional staff of a potential problem. Do not call on new and inexperienced staff members. Additional personnel should be available to help with a crisis.

WHEN VIOLENCE ERUPTS

If the risk for violence escalates and a patient is behaving in a threatening manner, the healthcare professional staff must act quickly. This may mean administering medication against the patient's will. In such situations, following the textbook protocols may not be possible. The best rule of thumb is to follow hospital policy and state laws, protect the patient, and provide for the safety of all present. Careful and timely evaluation of the situation means containing any violence using the least restrictive means possible. Rigid adherence to precise procedure may not result in the desired outcome.

When patients, families, or visitors are experiencing a crisis, a person's ability to think rationally may be diminished. This can lead to unpredictable behavior. Urbanek and Graham suggest when staff are being threatened, they should [10]:

- Stay calm and communicate in an even tone and manner.

- Attempt verbal de-escalation strategies to calm the person in crisis.

- Keep a safe distance away from the person to avoid being physically assaulted.

If things begin to escalate further, staff should remove themselves from the situation as quickly as possible and seek further assistance from other staff, the internal response team, Public Safety, or even police if necessary.

Do not attempt a hands-on approach with a person who is an active threat, unless required by your role and trained to do so.

Healthcare professionals should always seek assistance in an emergency. They should get help from the security staff, other available healthcare professionals, or any other facility personnel. A patient who has a weapon should be disarmed by persons who are trained to do so. If the patient cannot be disarmed easily, the safety of healthcare personnel and that of others in the area must be considered. Shields and barriers may protect against knives but not against a patient with a loaded gun. Other patients and visitors should be moved to safe and secure areas, and local police should be engaged in such a situation.

If the patient is unarmed, anti-anxiety or anti-psychotic medication, physical restraints, or possibly both may be needed. This is often the decision that needs to be made by appropriate medical staff, quickly and with assurance, based on existing protocols and appropriate training. Erring on the side of caution is the best choice because the safety of all in the area is a priority. At the same time, the lowest level of effective restraint is desirable. Knowledge of the hospital's policies, state laws and regulations, the patient, and appropriate and available interventions is necessary for successful resolution of a violent episode.

RESTRAINTS

Evidence Based Practice Recommendation

The American Medical Association asserts that, except in emergencies, patients should be restrained only on a physician's explicit order. Patients should never be restrained punitively, for convenience, or as an alternate to reasonable staffing.

https://code-medical-ethics.ama-assn.org/ethics-opinions/use-restraints

Last Accessed: June 19, 2026

Level of Evidence: Expert Opinion/Consensus Statement

Each healthcare institution has, or should have, some guidelines for the use of chemical or physical restraints in potentially violent situations, and all healthcare professionals should be aware of the procedures used in their institution.

Chemical Restraints

The medication protocol generally consists of giving a patient who cannot be "talked down" an initial, low dose of a high-potency anti-psychotic (such as haloperidol) or a short-acting anti-anxiety medication (such as a benzodiazepine). Oral medications may be offered first, but if escalation is rapid, an intramuscular medication may be required. The patient is observed at 15-minute intervals or possibly on a continuous basis. In some instances, medication may be given as often as every half hour until the violent episode is in check or the maximum dose is reached.

The healthcare professional's responsibilities involved in handling a violent episode by medicating a patient with a potent pharmacologic agent include the following:

- Checking for or obtaining a healthcare practitioner's order to administer medication.

- Preparing the medication: capsules, tablets, or liquid; intramuscular injection, intravenous drip, or butterfly infusion.

- Assessing the patient's vital signs before giving the drugs if this can be done safely.

- Informing the patient of the procedure that will follow and providing reassurance and support if needed.

- After the medication has been admin-istered, observing the patient, assessing for a decrease in signs and symptoms of aggression, and noting any untoward side effects of medication given.

- Periodically checking the patient's vital signs.

- Documenting the incident and the medications given by recording the information in the patient's medical record or as the institution directs.

Mechanical Restraints

As with protocols for using medications, each healthcare institution should have a procedure to follow for mechanically restraining a patient. Without an order for an involuntary commitment, however, the patient cannot be held against their will [5].

When a patient in a general hospital setting is at high risk for harm, the number of staff members needed to restrain the patient depends on the patient's size, strength, and potential for violence [11]. The general recommendation is that one staff member needs to be available to hold each extremity and an additional staff member must be available to apply the restraints; if six staff members are available, one person can support the patient's head.

The patient is held by the arms and legs and walked, carried, or placed in as comfortable a position as possible (usually in a hospital bed with the side rails up) and put in wrist and ankle restraints. These restraints may be cotton, gauze, cloth, or leather, depending on the patient's size and strength.

Ideally, one person (one of the registered healthcare professionals) should be in charge of a group of five or six staff members. If no one is in charge, the possibility of miscommunication can produce a disjointed effort. Consequently, the patient may escape and be harmed or do harm. The confusion that ensues when no one is in charge invariably adds to the patient's sense of being out of control and thus escalates the situation. The decision as to which staff member will be in charge should be made before any action is taken. A "show of force" of five or six staff members may be enough to defuse the situation.

The best approach toward the patient is a uniform one. All staff members should move or walk toward the patient together. Sometimes, this simple show of force subdues a patient. Before the approach is undertaken, to avoid confusion, the team leader should assign which staff member will hold which extremity. Staff members should try to be calm themselves. They should not speak loudly; instead, they should be firm and speak slowly, clearly, and precisely. A soft voice may have a quieting effect on the patient.

The healthcare professional responsibilities involved in handling a violent episode by mechanically restraining a patient include the following [5]:

- Staff should monitor the patient frequently, according to the facility's protocol.

- At least every two hours, the restraints should be untied and the patient's position should be changed. However, the patient may not need to be restrained this long.

- Staff should not negotiate with the patient.

- Staff should not confuse the patient with options.

- Staff should remember that this patient is out of control.

- Staff can say something like the following: "We feel you are not in good control of yourself right now. We will help you calm down."

The room should be checked for potentially dangerous objects. Healthcare professionals should remove any watches, eyeglasses, jewelry, shoes, belts, and other items that could be a hazard. No place is free of danger. Patients have broken light bulbs and cut themselves with the shards or used pajama waist cords to hang themselves. Healthcare professionals should be cautious and aware. Healthcare professionals should look around the area from the patient's eye level so they can see what the patient sees.

The safety of the patient and the staff should always be considered. The goal is to demonstrate no tolerance for the violence and to present the intervention as not punitive but an attempt to help the patient regain some self-control over violent behavior. Patients should be shown respect and allowed to maintain their dignity. The staff should know the patient's name and use it.

Healthcare professionals should use calming statements or phrases and always explain step-by-step to the patient what is happening. They should be firm and provide information on why the staff is acting the way they are. For example, if giving an injection, the healthcare professional should, for instance, tell the patient that the injection is intended to relax and calm the patient. While putting on restraints, the healthcare professional should acknowledge that they may not be comfortable but that they will be removed as soon as possible. Providing these brief explanations will take away the unknown and, ideally, help the patient accept the interventions a little more calmly.

INTERVENTIONS FOR POTENTIALLY AGGRESSIVE BEHAVIORS

The role of the healthcare professional in the management of a patient's aggressive behaviors will be found within the protocol, policy, or procedure manual of each institution, as well as in the scope of practice or mental health act of the state [12]. Healthcare professionals need to remain nonconfrontational. A calm, quiet approach that acknowledges the patient's anxiety and probable dislike of the situation will provide the best possibility of de-escalating the patient's aggression. By acknowledging the patient's feelings and providing the patient with an opportunity to talk, the healthcare professional establishes rapport and offers an opening for the patient to vent verbally rather than resorting to violence. Becoming aware of the potential of a violent episode before the situation escalates is a skill healthcare professionals should master. When a situation has arisen that requires intervention, healthcare professionals must carefully document all that happened, including any precipitating factors, attempted interventions, and the length of time it took to resolve the situation. Within this framework, the healthcare professional interventions in Table 2 may apply.

Table 2: INDEPENDENT HEALTHCARE PROFESSIONAL INTERVENTIONS AND THEIR RATIONALE FOR PATIENTS WHO EXHIBIT AGGRESSIVE BEHAVIORS

Independent Healthcare Professional Interventions

Rationale

Use good interpersonal skills. Be nonconfrontational.

Establishing rapport can help decrease the likelihood of aggression.

Assess for potentially violent occurrences.

Maintaining alertness to possibilities of violence allows the healthcare professional to be prepared.

Acknowledge the patient's feelings (e.g., "You seem angry"). Listen actively.

Providing an opening for verbal discussion can decrease possible violent episodes.

Anticipate a potential problem.

It is important to stay aware of environmental cues for escalating violence.

If a patient's anger is escalating, communicate verbally with then in a soft but firm voice.

Attempt to foster a therapeutic relationship by conveying empathy, acknowledging the patient's feelings.

Encourage patients to express anger verbally rather than by "acting out" their feelings.

Dealing with anger in this way will create a safe environment and help the patient learn more effective coping skills.

Be respectful of a patient's personal space.

Allowing a patient plenty of room sometimes keeps anger at a lower level.

Teach stress reduction techniques (e.g., deep breathing).

Providing alternative outlets for anger is good patient education.

Continuously observe patients who are potentially dangerous to themselves or to others.

Evaluation is part of the healthcare professional process.

Assess the patient's coping skills and ability.

Crisis intervention techniques may work to prevent violent eruption.

Help the patient maintain control by offering choices, talking, or walking.

Physical activity can sometimes defuse angry outbursts.

Initiate or collaborate on a plan that includes a team approach to restraining a patient.

Prepare ahead of time for potential violence.

Alert others of the potential problem. Do not approach an aggressive patient alone.

Use of a team to demonstrate a show of force is often all that is needed to defuse a potentially violent situation.

Monitor the situation for the safety of others and the staff.

Ask those who can to leave the area if violence is erupting.

Source: [5]

HOLISTIC CONSIDERATIONS

Healthcare is one of the professions where the incidence of workplace violence is particularly concerning to governing agencies such as the Joint Commission, OSHA, and, within the Centers for Disease Control and Prevention, NIOSH [1,3,13].

Healthcare professionals need to educate themselves on how to identify institutional policies that might put them at higher risk for workplace violence. They should learn how to recognize warning signs and behaviors and how to develop a workplace violence-prevention program. The Centers for Disease Control and Prevention offer a free online course, Workplace Violence Prevention for Nurses [14]. Developing an awareness of changes in the environment involves paying attention, intentionally. As both witnesses to and recipients of workplace violence, healthcare professionals can campaign this cause at their facility to increase the care and safety of all staff. The healthcare profession does not tolerate violence of any kind, from any source [15].

The best way to deal with any patient's violent behaviors is to defuse the agitation during the early stages of escalation. Healthcare professionals need to watch for early warning signs and try to avoid dangerous outbursts. When this fails, their own safety and that of other patients and staff members, as well as that of the patient, must be considered.

CASE STUDY 1

Erik Nilsson is admitted to a large general hospital for a surgical procedure scheduled for early the next morning. He is 68 years old, and English is his second language. Although he can understand some words and phrases, his ability to speak in English is extremely limited. Erik is accompanied to the hospital by his daughter, Astrid, who can translate for Erik during the admission process. She tells Jackie, the healthcare professional conducting the interview, that her father lives with her and her family. Astrid says that she does not think he is especially worried about his surgery but did add that lately she has noticed that her father exhibited mood swings.

That evening, Erik speaks in an agitated manner, in Swedish, to another patient. Jackie, his evening healthcare professional, goes to Erik's bedside to calm him down and see what is wrong. He is gesturing and muttering to himself, quite loudly at times. Jackie notifies the physician on call. When the physician examines Erik, he still appears agitated but somewhat calmer. The attending practitioner orders a sedative and informs Jackie that he will check with her again in an hour. Erik falls asleep in a short while. The rest of the evening shift progresses unremarkably.

Jackie wakes Erik at about 6:00 a.m. and administers his preoperative medications. Erik is taken to surgery at 7:00 a.m. The surgery goes well, with no complications. Erik has an uneventful recovery and is returned to his unit at 2:00 p.m. His daughter and son-in-law are waiting to see him. Although he appears somewhat sleepy, Erik is mumbling to himself and gesturing with his hands. Neither his daughter nor his son-in-law can understand what he is saying. They try to visit with him briefly but finally leave, telling him to get some rest and they will return later.

Erik dozes off, but when he awakes, the unusual behaviors seem to increase. Erik's voice becomes louder. He then begins to appear very tense, grimacing and clenching his fists. When Jackie approaches him, he seems angry with her, and she is confused as to why. The nurse reports her concerns to her unit manager: "I'm not sure what's going on with Erik, but I feel somewhat frightened of him."

Jackie and the nurse manager decide that they both will go to Erik's room together to conduct a postoperative assessment. As they approach Erik's bedside, he begins shouting, trying to pull out his intravenous line and catheter, and attempting to leap out of the bed. He picks up a water bottle that was on his over-the-bed tray and throws it at the unit manager. It hits her on the arm, stunning her but not hurting her.

Staff arrive on the scene ready to assist in restraining Erik. In the meantime, a Swedish-language interpreter has come to the unit. After the interpreter is introduced, Erik seems to calm down considerably.

The on-call healthcare practitioner responsible for Erik's care arrives and, after reviewing the situation, orders medication to calm Erik. The interpreter tells Erik, in his own language, about the medication and why he is receiving it. Erik responds favorably to this and accepts the medication. A staff member is assigned to remain at Erik's bedside until he falls asleep. Soft restraints are made available at the bedside in case they are needed.

After this incident is under control, the unit manager, Jackie, and the other staff involved go to a conference room to review the episode. A plan is made to confer with the family about Erik's reported "mood swings," request a psychiatric evaluation, use Swedish-speaking personnel when available, and maintain close observation of the patient. Jackie asks the team why Erik behaved in this way.

The nurse manager may also tell Jackie, "Often patients will react aggressively but the staff has no sure way of knowing why this happens. It could be that the 'mood swings' mentioned by the daughter are connected to Erik's current behavior. It might be the unknowns of the hospital process or of what the findings from his surgery will indicate. The fact that Erik does not speak English well may increase what might be normal anxiety to a frightening level."

6. NONCOMPLIANCE

There is some debate among healthcare professionals regarding the concept of noncompliance [12,16]. Healthcare professionals have argued that a diagnosis of noncompliance labels the patient negatively, arguing that it places the emphasis on the patient's behavior instead of on a mutual process with the healthcare professional and other healthcare providers. At the heart of this argument is the issue of the right of the patient to choose a treatment course that is different from the recommendations of the healthcare team.

Treatment adherence is usually associated with optimal health. The most obvious result of nonadherence is that the disorder may not be relieved or cured. For example, when patients with glaucoma fail to take their prescribed medications, optic nerve damage and blindness may be the result. For patients with an erratic heart rhythm, failure to comply with suggested treatment can lead to cardiac arrest. Stroke may be the outcome when people with high blood pressure ignore prescribed treatment. Failing to take prescribed doses of an antibiotic can cause an infection to flare up and may contribute to the emergence of drug-resistant bacteria. These failures to follow healthcare suggestions are not only frustrating but are also costly because of the undesired patient outcomes.

Evidence Based Practice Recommendation

The Center for Practical Bioethics recommends that the provider is obligated to provide information to the patient about the potential consequences of his or her lack of cooperation with treatment.

https://www.practicalbioethics.org/wp-content/uploads/2021/10/Ethical-Care-in-Difficult-Relationships.pdf

Last Accessed: June 19, 2026

Level of Evidence: Expert Opinion/Consensus Statement

Sometimes, patients who need to take medication regularly are the ones who are the most worried about addiction. In some cases, the family is also worried that their loved one will become addicted. In many cases, prescribed drugs are reducing symptoms, not curing the disease. Many psychiatric medications reduce symptoms, but, from the patient's perspective, the side effects seem to be worse than the symptoms. When patients begin to feel better, they stop taking their medication. After a period of time without the medication, the symptoms return, and the patients must start the cycle all over again. Education of patients and their families is critical in helping them understand why they are taking their medications, the expected side effects, when there is reason to be concerned about developing tolerance or dependence, and that continuing the medication is what will make them continue to feel better. A similar situation exists in the frequent nonadherence with antibiotic treatments. Although patients are told to take the entire prescription, they often stop once they feel better. Again, education is the key to patients' adherence to treatment. Verbal instruction followed by giving the patient a written pamphlet is often necessary to achieve adherence.

INCIDENCE

Although it is almost impossible to correctly determine statistics related to nonadherence, estimates have been made. It is estimated that the financial burden on healthcare systems in the United States is $528 billion per year [17]. In addition, it is estimated that around 20% to 30% of new prescriptions do not get filled. There is evidence that the presence of comorbid conditions, such as depression, anxiety, and drug or alcohol misuse, can negatively impact adherence [16].

Medication nonadherence leads to poor health outcomes, increased health costs, and increased health risks for individuals and populations. Misuse and overuse of antibiotics have contributed to the emergence of antibiotic-resistant strains of bacteria [18]. Population health is affected by medication nonadherence; an example of this is persons with tuberculosis who did not adhere to treatment protocols, creating the antibiotic-resistant tuberculosis strain now evident [19].

Patients fail to take medications as prescribed approximately 30% to 50% of the time, which often leads to hospitalization and emergency room visits [17]. One of the recommended means of improving adherence is to involve the patient in the development of the treatment plan [17].

Patients with mental health disorders are frequently nonadherent with medications. Some psychiatric medications do have intrusive side effects that may seem to the patient more difficult to bear than the illness itself. Patients who are nonadherent with medications may also be nonadherent with interventions such as rehabilitation, relaxation, counseling therapy, quitting smoking, or losing weight.

HEALTH BELIEF MODEL

Many attempts have been made to create a conceptual model of adherence that will enable healthcare providers to predict and understand patients' behavior. The Health Belief Model offers some understanding of the phenomenon of adherence. In a systematic review, Al-Ani et al. found that individuals' beliefs about their susceptibility, perceived benefits, and sense of self-efficacy are strongly linked to their adoption and use of preventative measures for common treatable diseases [20]. The significance of this model is that it suggests that patients' choices depend on their beliefs, not necessarily on the medical evaluation of the situation.

The Health Belief Model proposes that changes in beliefs about the severity of and susceptibility to a health outcome and its consequences are associated with the motivation to take action. Once an individual feels threatened, a decision is made from among alternative actions based on a cost-benefit analysis. This model also emphasizes the concept of self-efficacy. Patients must feel capable of mastering their environment and behavior to risk trying to make behavioral changes. If they do not feel capable, assistance may be offered by healthcare providers through skill practice and positive reinforcement so that the patients come to see that they are capable of change.

The model postulates that people choose healthcare actions when they are faced with a threat to their health. The actions they choose depend on their perceptions of the situation. They decide how much of their personal goals they might be risking and compare it with how severe the threat is to their health. Then a further determination is made as to whether the costs to their lifestyle are worth the potential benefits. Unfortunately, a lot of this "balance sheet" is based on personal viewpoints and not on medical facts. Even when patients decide on a course of action that is adherent, they struggle with long-term habits that must be overcome. Lifelong habits are difficult to change, and the ease of continuing a previous pattern of behavior works against making healthy lifestyle changes [21]. For many patients, nonadherence may be the perception that the illness is less of a problem than the treatment. Some changes are much more difficult than others as well.

LEGAL AND ETHICAL ISSUES

Healthcare professionals face increasingly complex situations in which the patient's wishes may deviate from the treatment recommendations. Some ethical guidelines can help healthcare professionals choose a response to a patient who is nonadherent. In addition, to practice within the law, healthcare professionals must be aware of legal guidelines. This area of healthcare is changing quickly. Healthcare professionals need to be clear about their obligations to patients and be knowledgeable about patients' rights.

Rights of the Patient

Inviolability is the fundamental right of every individual to be left alone. The U.S. Constitution and Bill of Rights are based on this principle. The individual has authority over what happens to their body. In practice, however, the situation is not always so clear. In some instances, individual rights may interfere with the rights of others. In addition, fluctuations in public sentiment may affect the decisions made by practitioners and institutions.

Ethicists differ in their perceptions about the dilemmas that healthcare professionals face. The concept of personal freedom becomes unclear when the perspective is one of social responsibility. Some ethicists believe that people can have both individual autonomy and responsibilities to one another.

The issue of mandatory testing for communicable diseases illustrates the dilemma of conflicting principles. Inviolability would guarantee the individual the right to refuse such testing. The principle of social responsibility would support mandatory testing because the individual has the obligation to participate to protect others.

Legal Concerns

One legal issue that affects a Healthcare Professional when discussing patient adherence to treatment is the issue of competence. A patient is considered competent if they are able to participate in making decisions, which means the patient has the ability to comprehend information, understand choices, and communicate their decision verbally or nonverbally to the healthcare team. For example, patients must be able to understand the nature of their illness and the available treatment alternatives. Equally important is an understanding of the consequences of any decision the patient might make about these alternatives.

Patients are presumed to be competent. This assumption means that the burden of proving incompetence belongs to parties other than the patient. Unless otherwise indicated, patients are assumed to be making competent choices about their healthcare.

At times, however, patients may be caught in a frustrating contradiction between the issues of adherence and competence. A patient may refuse a treatment recommendation. Healthcare professionals may label the patient incompetent because of the refusal. In this situation, a cognitively capable patient has made an informed decision. However, because the patient has made the decision, which opposes that of the treatment team, healthcare professionals view the patient as incompetent.

SPECIAL CASES

Rights of Women Who Are Pregnant

Pregnancy offers a unique slant to the issue of patients' rights. For some people, the fact that the fetus is affected by the mother's behavior alters the mother's right to personal freedom. The legal system has increasingly over-ridden the right of the pregnant mother to disregard medical advice. The legal basis for these decisions is weak. However, societal support for protecting the unborn fetus can result in a disregard for the rights of the pregnant woman. The ongoing debate over the rights of the unborn fetus versus the rights of the mother evokes intense emotions on both sides of the issue.

Withholding Nutrition

There is little consensus on the ethics of withholding or withdrawing nutrition from patients. When a patient chooses to refuse nutrition, it is often difficult for healthcare providers to honor this wish. Healthcare professionals may be concerned about participating in behavior that will lead to hunger or thirst in the patient. The American Nurses Association maintains the position that the decision to withhold artificial nutrition and hydration should be made by the patient or the patient's surrogate after consultation with the healthcare team [22].

In some ethical deliberations, a distinction is made between allowing a patient to die and killing a patient. The difference lies with the intent of the actions. Nutrition may be withheld on the premise that, if given, it will prolong life and thus prolong suffering. This is different from starving a patient with the intent to kill them. Others argue that the finality of the act of withholding nutrition makes the act untenable.

It is imperative that every healthcare professional be familiar with the legalities surrounding the patients' right to refuse treatment. They should find out if there are advance directives that have addressed this issue. In addition, careful thought concerning the healthcare professional's ethical position on these issues is necessary. The answers are not always clear in the increasingly complex environment of healthcare today. Although it may be difficult for healthcare professionals to act on patients' wishes that are contrary to their own beliefs, they are usually mandated to do so by the policies of the institution where they work. Although they may be free to operate on their own principles and beliefs, they should be fully aware that by doing so their job might be in jeopardy in some situations.

The Patient Who Signs Out Against Medical Advice

Leaving the hospital against medical advice (aka AMA) may be an extreme example of nonadherence. It is rarely a spontaneous act. There are often warning signals or repeated conflictual interactions with staff members before the patient actually signs out of the hospital.

Healthcare professionals and physicians react strongly when a patient leaves against medical advice. Healthcare providers may attempt to cajole or coerce the patient into staying, since there are often concerns about the patient's safety and the providers' obligations to the patient. Healthcare professionals may also feel a personal failure when a patient's choice is to leave against medical advice.

Patients should be free to leave against medical advice as long as they are competent and not endangering their lives. It is not appropriate to medicate a patient who is nonpsychotic and threatening to leave against medical advice. Using drugs as chemical restraints in this manner is battery from a legal standpoint.

RISK FACTORS

Nonadherence has meaning in the patient's life. The healthcare professional must be able to assess the patient's situation carefully in order to understand this meaning. In this way, the healthcare professional can uncover and deal with obstacles to adherence. Patients' individual characteristics and living conditions will influence the likelihood of their being compliant or noncompliant. For example, if the patient's home has no running water, then maintaining cleanliness will be more problematic for them than it will be for someone living with modern plumbing. Knowledge of risk factors can help healthcare professionals be more aware of the possibility that patients may have difficulties following their treatment plans. This knowledge is most helpful when it is used to prevent possible problems with compliance.

Psychological and Cognitive Risk Factors

The most important psychological risk factors include the following:

- Cognitive abilities

- Mental status

- Denial and anxiety

- Addictions

- Depression

- Past experiences

Psychological and cognitive factors influence adherence to treatment. To be able to comply, patients must understand the information presented to them. Teaching should be brief and focused. Complex information should be broken into smaller and more understandable parts whenever possible. It is helpful to simplify teaching material as much as possible. Use of written materials that reflect a fourth or fifth grade reading level is appropriate so that the patient's level of health literacy is not overestimated.

Patients with cognitive deficits may not be able to learn. Patients must have an adequate attention span to be capable of concentrating and learning new behaviors. If the patient has little focus or scope of attention, the healthcare professional should attempt to consult with a family member or other support person and determine who should receive healthcare information because the patient is not capable of understanding it.

Similarly, patients with changes in mental status may be unable to integrate new learning material effectively. Their judgment may be significantly impaired. A thorough mental status examination is needed if there is any indication that a patient's mental status is compromised.

Some patients may be in denial, a defense mechanism used to guard against uncomfortable feelings. They may be too frightened by their illness to be able to accept it. This can cause them to feel their treatment recommendations are unnecessary. They need time to adjust and an opportunity to discuss these difficult feelings.

Denial is a normal part of grieving and sometimes occurs in people when they find out they have a terminal illness. Illness and hospitalization involve losses for people regardless of the prognosis, and denial may be part of any patient's presentation. Sometimes giving patients time to adjust to their new status is sufficient and they will be ready to accept and, ideally, adhere to their new treatment needs.

Anxiety reduces the ability to process information or to make decisions. An anxious patient might exhibit several different emotions and behaviors, including anger, complaining, demanding, withdrawing, or even crying. When a patient's anxiety is reduced, it will help the patient in adhering to the treatment regimen. Many patients are fearful of the unknown. Education often allays these fears.

Dependence on medications and illegal substances affects adherence because these drugs may be the priority in the individual's life. If the treatment regimen interferes in any way with the behaviors surrounding the need to maintain the drug to avoid withdrawal, the patient will not be adherent until the substance use disorder is treated. The classic example of this is the patient with an alcohol use disorder who has cirrhosis. The recommended treatment is abstinence from alcohol, but few patients who misuse alcohol can accomplish this without professional intervention.

A person who suffers from a depressive disorder will not take in information or make decisions as well as one who is not depressed. Individuals who are depressed are more likely than others to be nonadherent to treatment plans. They commonly have low self-esteem and feelings of hopelessness that can interfere with their ability to follow a regimen to better their health. To a large degree, they lack the energy to comply. Although depression is the most common mental health problem in the United States and one of the easiest to treat, it is the least treated; thus, patients who are depressed are often overlooked. Patients with depression often have other physical inflammatory illnesses such as heart disease, diabetes, or chronic obstructive pulmonary disease.

Finally, patients enter the healthcare system with ideas and beliefs that affect the course of their current hospitalization. Previous experiences that were negative can affect a patient's expectations. If a patient enters the system expecting the worst, chances are good that healthcare recommendations will not be viewed in a positive light. Healthcare professionals can influence these patients to take a more positive outlook by building trust and meeting their expectations as much as possible. When healthcare professionals cannot meet these expectations, it can be helpful for them to explain why.

Age

The estimated rate of nonadherence for older adult patients is 50%. They are more at risk for nonadherence than other adult patients. Because of their unique needs, older adult patients present a challenge in adherence. Their hearing, vision, and cognitive functioning are likely to be impaired in some way. These impairments, as well as years of ingrained habits, make changes in behavior more difficult.

Most patients 60 years of age or older require vision correction of some sort. These impairments make self-administration of medications particularly difficult. Almost one third of all people aged 65 to 79 years have significant hearing impairment. In older adult patients, recall is best when material is given verbally. Information must be delivered slowly and audibly. Reinforcing verbal instruction with written materials is essential and teach-back will assess understanding. Print materials with large-type fonts and pictures are most effective.

Depression is common in older adult patients. It often goes undetected and untreated. Depression lessens the ability of older adult patients to adapt to changes in lifestyle. Seemingly simple tasks such as picking up a pill become difficult. Plans for self-management must take this loss of dexterity into account.

Older adults often find that their social support systems are shrinking. Friends and relatives may be ill, dying, or making changes in living arrangements. This resulting isolation can affect adherence.

The number of medications prescribed for older adult patients can be a problem. At least one-fourth of older adult patients recently discharged from hospitals have six or more prescriptions that require self-administration. Medication costs must be considered, as well as the ability to obtain the medications if transportation and mobility are issues [16].

It is easy to see why the nonadherence rates for older adult patients are high. This population is also less likely to be assertive about their needs with healthcare providers. Older adult patients constitute a major part of general care patients today. Healthcare professionals need to be sensitive to the unique needs of this age group.

Social and Economic Risk Factors

The social spheres that most affect a patient's health behaviors are:

- Family and significant others

- Relationships with healthcare providers

- Cultural or ethnic groups

- Religious community or beliefs

- Economic status

Patients are more likely to adhere with their treatment plans if their family or significant others are supportive of it and encourage them to follow it. They are also more likely to be adherent if they have a positive relationship with their healthcare team, are included in the decision-making process, and are acknowledged for being adherent.

A patient's cultural or religious beliefs and practices may prohibit adherence with a treatment regimen. In some religions, use of certain types of medical interventions is regarded as a lack of faith in God, and those interventions are therefore prohibited. Some cultures have lay healers, and the patient may wish to combine the healer's cures with medical treatment. Many cultures view healing as a family affair; therefore, the family will always need to be present and involved in the patient's care. Healthcare professionals must try to understand and appreciate the importance of these practices to help patients be adherent.

A significant concern related to nonadherence is limited income. Patients may have hospitalization coverage but lack sufficient funds to follow through on recommendations after discharge. A patient who must choose between feeding their family and buying blood pressure medicine has no choice at all. This is particularly true for older adult patients who are frequently on fixed, limited incomes. Choices between food and medication are not easy ones, and healthcare professionals can help access as much assistance as is available to older adult patients. It is helpful to examine older adult patients' finances with them and plan realistic healthcare choices together.

Environmental Risk Factors

The healthcare setting can influence patient adherence. The most common factors are comfort issues and ease of access, including transportation. The needs of patients who are physically impaired must be considered carefully. For example, an older adult who has been directed to return to the clinic after a surgical admission may not keep this appointment. The patient may not have transportation, the parking may be remote and require walking a long distance between the parking lot and office, or the stairs may be too much to handle. If there is little to motivate patients' return, then when they are feeling well, environmental obstacles will result in nonadherence.

Determining risk factors early in treatment enables healthcare professionals to intervene effectively. Healthcare professionals are in the best position to use their skills to develop a care plan with the patient that maximizes adherence. In the same way, knowledge of risk factors affecting compliance can enhance discharge planning and make it more effective.

Situational factors are best dealt with through anticipatory planning. A conversation with the patient about the possibility of these events occurring and how to deal with them can ensure their adherence. A patient on a restricted diet, for example, is asked to consider eating at home until they are familiar with the diet. The patient is also given ideas about what to order in a restaurant that would be allowed on this diet. The patient may feel uncomfortable explaining their diet to friends. Role playing can be helpful in these situations.

7. NONADHERENCE

Healthcare professionals' willingness to examine their attitudes and feelings toward the patient is of primary importance in working with patients who are nonadherent. The identity of a healthcare professional is closely tied to the concepts of helping, caring, and service. When a patient appears to reject a healthcare professional's expertise in promoting wellness, the healthcare professional must deal with many intense and conflicting emotions.

Many healthcare professionals state that they would prefer to spend their time with motivated patients who want to get well rather than with patients who do not comply with their treatment plan. They express anger that the patients are "wasting" a bed, precious resources, or the healthcare professionals' time. It is important to understand that many patients who are nonadherent are not deliberately working against the treatment team.

Sometimes anger can lead to withdrawal of services. A healthcare professional may avoid going into the patient's room or omit teaching the patient because "the patient isn't going to do it anyway." The healthcare professional should deal with these feelings in another way because it is obviously not helpful to punish the patient with these behaviors. Discussing the patient's case with the healthcare team and getting suggestions for new approaches to handling the patient can be helpful. Discussions may need to focus on the degree to which care is patient-centered, so that patients feel they are active, respected partners in healthcare decisions. Patients will resist interventions if they feel that their needs are not being heard or respected. When they do resist and appear to be nonadherent, this may be a signal to the healthcare team that an internal assessment of the system's approaches to patient care should be conducted (Figure 1).

Figure 1: CYCLE OF NONADHERENCE BETWEEN PATIENTS AND HEALTHCARE PROFESSIONAL

Depending on the reasons for nonadherence, the patient may be quite happy to be left alone or to be overly dependent on the healthcare professional. More likely, however, the patient will feel that their real healthcare needs are going undetected. This behavior may become a cycle.

Healthcare Professional Strategies to Stop This Cycle

- Becoming aware of feelings

- Performing a healthcare professional assessment

- Using care planning as a mutual process

Source: Author

At times, healthcare professionals may feel unable to "allow" a patient to be nonadherent. This situation might occur when the healthcare professional has some commonality with the patient, such as being the same age as the patient or having a parent who died of the disease the patient has. Healthcare professionals who feel powerless in the face of a patient's nonadherence may push the patient to adhere while assuming decision-making responsibilities that belong to the patient.

INTERVENTIONS

Healthcare professionals can be key players in enhancing adherence on the part of their patients. By establishing rapport and creating trust, they present themselves to their patients as informed and knowledgeable persons who can answer questions and offer ways to adhere to plans of care. Healthcare professionals can reassure patients that it is not always easy to change long-term behaviors and gently reinforce why some changes may be necessary. Providing their patients with education as to the reason for certain treatment regimens is something healthcare professionals are well equipped to do. Often patients are more likely to follow through on their treatment requirements when they fully understand the reason and importance of what they are doing.

Patients benefit from the help of family and friends; healthcare professionals can assist their patients in obtaining support from these individuals. If there is a particular part of the treatment that goes against the patient's belief system in some way, the healthcare professional can help explain this to the healthcare team and together they (including the patient) can try to come up with an alternative intervention. Healthcare professionals implement their role as a patient advocate when they assist in these situations.

In addition to being professionals with a job to do, healthcare professionals are also individuals with their own belief systems. When patients are nonadherent, healthcare professionals can take it personally and react poorly in the situation. It is helpful for healthcare professionals to examine their reactions and why the patient may be acting in this way.Table 3 provides some suggested healthcare professional interventions along with their rationale for working with patients who are nonadherent.

Table 3: INDEPENDENT HEALTHCARE PROFESSIONAL INTERVENTIONS FOR PATIENTS WHO ARE NONADHERENT AND THEIR RATIONALE

Independent Healthcare Professional Interventions

Rationale

Develop awareness of feelings toward patients who are nonadherent with their treatment regimens.

If unaware of personal feelings toward patients who are nonadherent, there is the possibility to be unaware of feelings of anger and/or powerlessness toward patients. This may a withdrawal from the patients and thus their needs will go unmet.

Develop a trusting relationship with patients.

Trust is basic to a therapeutic relationship. The quality of the healthcare professional-patient relationship has been shown to be a powerful predictor of adherence.

Assess patients' mental status.

Several studies have shown that clinical depression is a risk factor for nonadherence.

Explain clearly why the treatment is necessary and what to expect (e.g., delayed benefits, general side effects). Ask the patients to identify benefits of treatment and how likely they think it is that there will be consequences of the current illness or health problem (perceived susceptibility and perceived severity).

A complicated or demanding treatment plan is an ordeal for even the most motivated patients. Patients need to understand why the plan is necessary; otherwise, they have little incentive to follow through with it.

Include the patients in setting goals and planning care.

Ask the patients to identify potential barriers to adherence (e.g., social, economic, or environmental factors).

The mutuality of expectations of patients and healthcare professionals makes it more likely that patients will be adherent with the treatment plan. Encourage patients to ask questions and express their concerns regarding their illness and the advantages and disadvantages of a treatment regimen.

Addressing issues and strategizing with the patients as to how best to deal with these issues will help with adherence and help to reinforce the importance of the treatment plan.

Teaching should be aimed at the patients' learning level.

To be able to adhere, patients must understand the information presented to them:

Teaching should be brief and focused.

Complex information should be broken into smaller, more understandable parts whenever possible.

Teaching material should be simplified as much as possible. Aim for a reading level of fourth or fifth grade with few words with more than three syllables.

Encourage patients to report problems with their treatment regimen, such as any unwanted or unexpected side effects, before adjusting or stopping it.

Patients often have valid reasons for not following a treatment plan. The better the understanding of patients' concerns about their treatment regimen, the more likely its importance will be explained.

Encourage patients to request the support and help of family or friends.

If family members or other caregivers are not providing direct care to patients, and if patients are having difficulty following through on taking medications or other therapies, family members may be helpful in reminding patients to take their medications.

Communicate concerns about the patients' nonadherence with other members of the healthcare team. Revisit the facility's philosophy about patient-centered care.

The healthcare team may detect and help solve nonadherence problems, including health system problems as well as patient issues.

Source: [16,23]

HOLISTIC CONSIDERATIONS

Patients do have the right to choose their own treatment and make their own decisions unless their choices will harm themselves or others. However, healthcare professionals and other clinicians may have a better knowledge base about treatment options. The healthcare professionals' role is to educate patients so that they can make an informed choice and not to assume patients do not know what is best for themselves. Walker outlined four basic philosophical orientations for clinician-patient relationships related to adherence [24].

Paternalism

The paternalism model is based on the expertise of the clinician, coupled with a grounding in beneficence (the doctor or healthcare professional knows what is best for the patient). This framework often conflicts with the concept of patient autonomy. This model is most acceptable in emergency situations and to value-neutral, technical decisions. There has been a shift in healthcare in recent decades toward more patient-centered, autonomous decision making.

The Radical Individualism Model

The patient has absolute autonomy and absolute rights over decisions regarding their body. The patient can assess alternatives, and healthcare staff members are obligated to adhere with these wishes.

The Consumer Model

This relationship model is market-based. Healthcare is seen as a commodity with the patient as a consumer. This relationship model tends to undermine the caregiver ethos by encouraging emotional disengagement.

Shared Decision-Making Model

Also known as the reciprocal model or negotiated contract model, the shared decision-making model lies between the extremes of paternalism and radical individualism. It is rooted in the concept of shared humanity in all participants. It emphasizes the relationship to the patient, not the disease.

Holistic healthcare professionals, understanding the experience from their perspective, work with the patient. They recognize that the burden of responsibility for the ultimate decision and change belongs with the patient. The healthcare professional's duty is to educate and empower the patient.

TECHNOLOGY

Some technology-based interventions, such as reminder apps on a cell phone or digital patient education are becoming more common, but do they really work? Some clinical trials have been examining the effectiveness of smart phone reminders and education for mental health patients. One meta-analysis examined numerous clinical trials, and the adherence and improvement in behavior was not consistently improved [25]. Mental health patients often drop out of programs or trials, and low levels of adherence are seen as common for this population. Healthcare professionals can only continue to offer education and support for the patient and their family.

CASE STUDY 2

Michael Longfellow is a 60-year-old male patient who was admitted to the hospital after he fell and broke his hip. He had been helpless at home for several hours after the fall because his wife was away from the house. When she returned and found him, he was immediately brought to the hospital by ambulance. On the day of admission, surgical repair was performed.

After surgery, Michael was disoriented for several days. He was confused, belligerent, and had visual hallucinations. Medication for agitation was required some of the time. Michael's blood pressure and pulse rate were high. Eventually, his mental status cleared and the remainder of the postoperative period went smoothly. Michael's incision began healing and his vital signs became stable.

Pain management, however, remained a problem for Michael; it was difficult to develop a pain management regimen that enabled Michael to experience pain relief. He was unwilling to practice coughing or deep breathing as recommended because of reported pain. It was a constant struggle to assist him with ambulation exercises, although he had been informed of the dangers from immobility many times. He developed pneumonia and his hospitalization continued.

His wife and adult children rarely visited and were unwilling to talk with staff members. Michael reported that he had not worked for years and relied on his wife for much of his care and support. He gave vague reasons for this situation, stating that he had been laid off and that there were never any jobs in his field of employment.

The healthcare professional staff began to be concerned as time passed and Michael did not appear to be assuming responsibility for his recovery. He, on the other hand, was eager to return home and pressured his physician to let him go prematurely. The staff called a patient care conference to discuss the discharge plans for Michael.

During the conference, several of the healthcare professionals on the evening shift expressed concern that Michael would not be well taken care of if he were to return home at this time. They had met his wife because she visited in the evening after work. They described her as "cold" and "mean." They were sure that she would provide no assistance to Michael, who would be forced to fend for himself at home.

The night healthcare professionals described ongoing episodes of insomnia that the patient had experienced since his admission. One of the healthcare professionals had found Michael attempting to smoke in his room. She stated that he drank cup after cup of coffee whenever he could. She thought that he was simply a patient who was nonadherent with his treatment plan and should be discharged as soon as possible with home care assistance.

One of the healthcare professionals mentioned the possibility that Michael might have an alcohol use disorder. She cited his delirious episode after admission, his low pain tolerance, and the dysfunction in the family as possible indicators that he might have a substance use problem. The physician added that the hypertensive episode after surgery and the insomnia supported that assessment.

The social worker remembered that Michael's wife had bitterly discussed with her Michael's lack of employment and his previous falls. The social worker admitted that she had focused on the wife's hostility instead of on the possibility of an alcohol use disorder. She added that the behavioral habits of smoking and excessive coffee drinking have been linked in the literature to problem drinking.

It was agreed that the social worker would meet again with Michael's wife and discuss the possibility that Michael has an alcohol use disorder. With the information from that interview identifying Michael with a pattern of problem drinking, it was easier to approach Michael about his problem and he was, in fact, assessed and referred for treatment of an alcohol use disorder.

Reflection Questions

- What are the staff's issues regarding Michael's nonadherence to his treatment plan?

- What are some approaches that the healthcare professionals can use when caring for patients who are nonadherent?

Discussion

The evening staff healthcare professionals who described the patient's wife as cold and mean were clearly angry. If they had examined their feelings closely, they might have discovered that they were angry with the patient for his unwillingness to participate in recovery. It is often easier to be angry at a healthy, and distant, family member than to be angry with the patient. It can be difficult for healthcare professionals to accept their anger toward a patient who is ill and with whom they interact on a daily basis. It seems like the night healthcare professionals felt little compassion for this patient. They were most likely dealing with feelings of powerlessness. Michael was a patient who ignored the rules and the healthcare advice offered to him. Powerlessness is difficult for anyone to experience and is most often masked by anger and rejection. When staff learn how to use techniques of brief assessment and intervention with patients who have alcohol problems and see their role in patient-centered care more clearly, they will feel less powerless.

Most of the issues of nonadherence in this case study may be attributable to the patient's unrecognized alcohol use disorder. Michael was unwilling to adhere to treatment recommendations because of his as-yet-untreated alcohol use disorder. His wanting to leave the hospital may be, in large part, motivated by his desire to have easier access to alcohol. If he had been discharged to home without treatment of this problem, his chances of a successful recovery would have been low. In addition, his alcohol use would have placed him at risk for more falls and other physical problems.

In this example, the staff needed to learn to look beyond Michael's nonadherent behavior and find out what was really occurring. He was certainly not following the treatment plan, but it was not simply negativity. There was an unidentified problem beneath the surface that needed resolution before Michael could address his nonadherence.

Family issues in this case study should not be overlooked. The wife and adult children should be included in discussions, with some focus on their own possible health issues, needs, and feelings as well. Further assessment and referral may be appropriate for the entire family. Because adherence to the treatment plan will be critical for a successful outcome for Michael, paying attention to family issues interfering with adherence is important.

Much of the time, the healthcare team is asking the patient to make significant changes in a lifelong pattern of behavior. This is not easy for anyone. Creating attainable short-term goals for which the patient can experience success is helpful in ultimately reaching long-term goals. The healthcare professional provides thorough and appropriate education and training on any aspect of the patient's care plan to enhance cooperation with the recommended treatments and interventions. Use of the Internet or smart phone resources can help remind and educate the patient. Teaching family and friends to be alert for signs of changes in behavior is part of a holistic approach. Establishing a strong sense of rapport is essential to teaching being effective.

It is also useful to discuss with the patient why adherence is difficult for them. Finding the root of the problem and addressing it directly can help with optimizing the patient's ability to carry out the plan of care and achieve the desired health benefits. For example, the patient may not remember to take a prescribed medication because it is effectively working and there are no symptoms triggering the need to keep taking the drug. The healthcare professional can assist the patient with finding other reminders as to when the medication should be taken. Many people have cell phones equipped with alarm features, so teaching the patient how to use this alarm function may be a constructive way to gain adherence to medication use.

Healthcare professionals who acknowledge their own problems make it less likely that those problems will interfere with helping the patient. Healthcare professionals, just like patients, may find it difficult to follow many health-related behaviors. Adherence on the healthcare professionals' part helps patients see congruence in what is practiced by others and what is asked of them. However, examining their feelings is not always the easiest thing for healthcare professionals to do. Because patients present with many different issues, it is likely that situations will arise when the patients' problems match ones that healthcare professionals, themselves, are experiencing. Self-awareness is critical for successful interactions in these situations. Healthcare professionals are not perfect, and they may have unsolved problems and issues, but knowing what they are is important.

There is also the recognition that patients do have the right to nonadherence. Sometimes the patient is making choices for reasons the healthcare professional has not considered. It is essential to examine why the patient stopped (or never started) the treatment as prescribed. There is also a time when patients will have to live with the consequences of their own actions. The self-aware healthcare professional knows that there are limits to what teaching and explaining can do to change the health behaviors of others.

8. MANIPULATIVE BEHAVIORS

Illness poses a severe threat to a person's security, self-esteem, and autonomy. It results in a loss of self-control and a fear of becoming helpless and dependent. The healthcare system may also place patients in child-like positions. The resulting anxiety may prompt a regression to manipulation as a coping mechanism, even in patients who do not typically demonstrate manipulative behaviors.

A DEVELOPMENTAL VIEW OF MANIPULATIVE BEHAVIORS

Before healthcare professionals can intervene effectively, they must understand not only what manipulation is and how they respond to it but also where it begins. How does manipulation become entrenched as a need-gratifying mechanism?

The use of manipulation as an adaptive, need-gratifying mechanism starts early in life. It is defined as an automatic behavioral pattern that infants use to get their basic needs met. They manipulate without any regard for the needs of others. In newborns, who are utterly dependent on others, the use of manipulation is acceptable and, in fact, vital. It is a matter of survival.

As children grow and develop, they test a variety of adaptive maneuvers to manipulate the environment to gratify their needs. If a child's unacceptable behaviors are met with clear and consistent limits delivered by primary caretakers with unconditional love and acceptance (of the child if not of the behavior), then the child will gradually develop a sense of self-esteem and self-control. Slowly, children learn to replace manipulation with more independent, adaptive behaviors.

If, on the other hand, a child's first limit-testing manipulative efforts are met with inconsistent limits or with no limits at all, with conditional love, and with lack of acceptance of the child, then the child will not learn how to fulfill their needs and how to gain love and acceptance from others [12].

ADAPTIVE VERSUS MALADAPTIVE MANIPULATION

Manipulation, learned early in life, is a process that occurs consciously or unconsciously in virtually all interpersonal interactions. When manipulation is used in an adaptive sense, it is just one of many behaviors that a person can call on to ensure that their needs are fulfilled. It is neither the only need-gratifying behavior nor the dominant one. For manipulation to be considered maladaptive, it depends on the:

- Extent to which it is used as a dominant need-gratifying mechanism

- Degree to which a person is aware of using it

- Degree to which the person is self-oriented and not oriented to others

- Degree to which others are treated as objects

- Effect on others, such as the person who has been manipulated feeling angry but not necessarily being certain as to why

Unquestionably, the word manipulator has taken on a derogatory or pejorative connotation. However, the fact is that everyone manipulates at times as a way of ensuring that needs are met. It is important to understand that isolated instances of manipulation do not make a person a manipulator. It is when manipulation as a need-gratifying mechanism becomes an adult behavioral pattern that it is viewed negatively. When it is adopted as the primary means of decreasing anxiety without the opportunity of learning or experiencing personal growth, then it is problematic.

For the same reasons younger patients are prone to manipulation, anxiety, lack of control in their environment, low self-esteem, and feelings of insecurity, the elderly are also likely to use such behavior to meet their needs. Although healthcare professionals working with geriatric patients may understand why it is happening, it is no less frustrating to manage. It is important for the healthcare professional to provide information to this population about reasonable expectations and then make every effort to meet those expectations. If something has been promised that cannot happen, the healthcare professional should explain to the patient why this change must be made. Open and honest communication is important in establishing trust and modeling straightforward behavior. One healthcare professional notes that consistent therapeutic communication and remaining accountable decreases the likelihood of allegations of neglect or abuse [26].

IDENTIFYING MANIPULATIVE BEHAVIORS

Healthcare professionals may overuse the term manipulative. After a difficult day or after caring for a string of patients with particularly taxing behaviors, a healthcare professional may be prone to assign the label manipulator to the patient who makes that one final demand that sends the healthcare professional over the edge or to the patient who is just a little too insistent in their self-advocacy. Patients who use manipulation have many requests that begin to seem unreasonable. Asking for a fresh beverage is understandable but asking for another within an hour and then needing more ice, then a pain pill, and then wanting to have a pillow fluffed becomes too much [27]. Healthcare professionals who work in correctional or psychiatric settings often experience this manipulation as a stressor [28]. If the term manipulative is to have clinical meaning, its characteristics must be understood.

Manipulation Is Not Always Easy to Recognize

Patients who use manipulation are often charming, entertaining, and intelligent. They rarely see themselves as having a problem and are unlikely to seek help on their own. In fact, many individuals who demonstrate manipulative behaviors are loathe to change, even when confronted, because these behaviors get their needs met [5]. When the harmful effect on others is pointed out, these patients may feign guilt or remorse because they are aware that these are the socially acceptable responses. They will not actually feel those feelings, however. Patients with dominant manipulative traits do not have a superego (concerned with moral behavior) strong enough for pangs of conscience to be genuine.

The reaction of healthcare professionals faced with such situations is, understandably, negative. It is sometimes possible to detect manipulation by virtue of a negative reaction to a patient's interaction or request. Sensing that something does not ring true can assist the healthcare professional to suspect manipulative behavior. Universally, healthcare professionals, like most of the population, want to avoid interaction with patients who regularly use manipulation.

Assessment Tools

There are a variety of measurement tools available to attempt to decipher personality traits. Exploring manipulative behavior is of interest to many, especially because of its apparent connection with delinquent and/or criminal behavior later in life. Bergstrom and Farrington investigated whether the use of one or more scales could be predictive of psychopathology in adulthood [29]. The data were supportive of a connection between high scores on callous-unemotional traits combined with high scores on daring-impulsive ones, pointing to a higher risk in childhood and outcomes as adults that were below normal.

Cycle of Manipulation

A person has needs to be met but cannot trust the environment to meet them consistently. The ensuing anxiety causes the person to fall back on the earliest need-gratifying mechanism—adaptive maneuvering and manipulation to ensure that their needs are met. If the manipulative behavior is effective, then the anxiety temporarily decreases. The person's needs have been met. However, the pattern of manipulation has been reinforced.

When the same person gets a negative response, they may become angry and frustrated, and anxiety skyrockets. The person again tries desperately to manipulate the environment in an effort to regain control. The pattern is set, especially when the manipulative behaviors work.

Lacking basic trust, the person is caught in an endless cycle of having to resort to manipulative behaviors to ensure that their needs are met. In the process, however, individuals are likely to alienate those around them and generate mistrust from other people. The issue of this loss of trust is key to understanding the pathology of manipulation. The patient who uses manipulation in a maladaptive way has little concern for the wants and needs of other people. Because individuals who use manipulation do not trust their own feelings, they cannot trust others. This lack of trust leads to a sense of loss of control, and the individual tries to regain a sense of self-mastery by controlling others.

Provider-Patient Cycle of Manipulation

The patient who exhibits manipulative behaviors is uncannily adept at seeking out the unique weaknesses and vulnerabilities of others and using those weaknesses and vulnerabilities to gain control. Their manipulative behavior can be active or passive.

Active manipulation may involve any of the following behaviors:

- Making demands: "I want my medication at 9 o'clock, not 8 o'clock. I don't care about your rules!"

- Violating rules and routines: "Oops! I forgot I was supposed to be measuring my urine. Guess I'll need to stay another day so you can get a complete sample."

- Making threats: "If you don't get that guy and his obnoxious family out of my room this minute, I'm going to tear up this place – and you along with it!"

Manipulative behaviors can also be passive and more subtle:

- Eliciting pity: "Can't you understand how hard it's been for me lately? My husband is leaving me for another woman, my two kids are out every night until 1:00 a.m., and my son wrecked a brand-new car last weekend. Wouldn't you drink too?"

- Ingratiating and flattering: "You're the only one on this unit who can possibly understand me. I don't even know why you're working here – you're so much smarter than the rest of them. And prettier too."

- Evoking guilt feelings: "Well, if you had come in here to talk to me at 2:15, when you said you would, I wouldn't have gotten so depressed, and I wouldn't have had to cut my wrist."

- Abusing compassion: "You said you understood how hard it was for me to be in this hospital, so I was sure you'd understand why I needed to sneak out this morning. I'm back now, so take it easy. Why do you have to search me? You said you trusted me!"

- Attempting to exchange roles and become the helper's helper: "I heard you tell one of the healthcare professionals that you're having trouble with your son. I can't believe he doesn't appreciate having a mother like you. I'm about his age, I'll bet. Tell me what he's doing. Maybe I can help."

- Pitting staff members against each other: "I couldn't get that other healthcare professional to understand why she should persuade the doctor to discharge me tomorrow. She said not to discuss it with you because you're too new to understand the rules yet. But I know you understand my situation. Will you explain it to my doctor? And pick a time when she's not around to interfere."

- Questioning competence or authority: "My doctor said that I could have another sleeping pill if the first one didn't work. Can't you even read a chart? Well, you're not in charge around here anyway. We'll see what happens to your job when the unit manager comes in tomorrow."

- In each of the foregoing examples, patients seized on a particular need of the healthcare professional (the need to be professionally competent; to maintain a safe, consistent environment; to be viewed as empathic and understanding) and geared their behavior to exploit the healthcare professional's weaknesses or therapeutic vulnerability.

When healthcare professionals realize they have been successfully manipulated, their likely response is a range of negative feelings and behaviors, including anger, frustration, indifference, and withdrawal. Although patients with manipulative behaviors will enjoy these responses as signs of their power, they will also feel an inward sense of increasing anxiety because once again they have successfully managed to manipulate someone. Can no one be trusted? Will no one ever be able to see through them and give them what is truly needed – a sense of realistic limits and a genuine feeling of self-control? The vicious cycle of manipulation can play out repeatedly between healthcare professional and patient when manipulative behaviors are not accurately identified, and healthcare professional interventions are not put in place to halt the cycle. It is essential that firm, realistic limits be set and then followed with all patients. The limits should be communicated clearly and openly, with an appropriate rationale. Although there should be consequences for nonadherence, they should not be punitive but should be set to reflect the best interests of the patients.Table 4 summarizes steps that are helpful in setting limits for patients who act in a manipulative manner.

Table 4: TEN STEPS TO SETTING LIMITS WITH PATIENTS WHO EXHIBIT MANIPULATIVE BEHAVIORS

1. Define clear expectations.

2. Communicate expectations positively and firmly.

3. Limit only those behaviors that clearly impinge on the well-being of the patient or others.

4. Make sure that the limits are in the patient’s best interests and are not punitive.

5. Offer a brief rationale for the limit but do not engage in a debate about its fairness or justification.

6. Define the consequences of exceeding the limit, and make sure that they are consequences that can be fulfilled.

7. Hold all discussions related to limit setting on a one-to-one basis, in private. (This limits the opportunity for the patient to involve an “audience” in determining whether the limit is “fair.”)

8. Make sure that all staff members understand the limit and its consequences as they were communicated to the patient.

9. Stand firm in the face of the inevitable testing of the limit.

10. Provide positive reinforcement every time the patient is able to meet the limit.

Source: [12,30]

If healthcare professionals are to stop the cycle, self-awareness is vital. If they have difficulty with their own self-esteem, they will be vulnerable to manipulative behavior. The key is for healthcare professionals to be aware of their needs so they will know when they are being exploited. They also need to be aware of their own responses, such as feelings of anger, the need to withdraw, frustration, or loss of objectivity, as indicators that they are being manipulated. Only then can they be effective in helping patients find more adaptive ways of getting their needs met.

INTERVENTIONS FOR MANIPULATIVE BEHAVIORS

Patients who use manipulation as a means to have their needs met present a challenge for healthcare professionals. Patients may be unable and unwilling to recognize their maladaptive manipulative coping mechanism. Even when the healthcare professional points it out, the patient may not be willing to change. As noted previously, manipulation is inherently rewarding. However, manipulation also has a way of alienating others and making it impossible for the patient to form meaningful relationships. The healthcare professional who can help patients recognize the effects of their manipulative behavior and find alternative need-gratifying mechanisms will do much to improve their patients' quality of life. Role-modeling straightforward behavior is an effective way to encourage patients to lessen their manipulative behaviors.

Gaining the patient's trust, although difficult, and sometimes not possible, is something the healthcare professional should work toward. Trust-building behavior includes being on time for treatments or other appointments with the patient, never promising something that cannot be delivered, and remembering things the patient has related. In addition, healthcare professionals must accept that patients may say hurtful things and not take them personally; patients who use manipulation make such remarks to everyone. Self-confidence on the part of the healthcare professional is important because patients who use manipulative behaviors will try their best to gain power by undermining the healthcare professional's knowledge, skill, and competence.

Consistency will help gain rapport with patients using manipulation. All staff members must agree on a plan and follow through with it. Individually, healthcare professionals must remain consistent day to day in their expectations and responses. See Table 5 for healthcare professional interventions that may be useful in caring for patients who use manipulative behaviors.

Table 5: HEALTHCARE PROFESSIONAL INTERVENTIONS AND RATIONALE FOR MANAGING PATIENTS' MANIPULATIVE BEHAVIORS

Independent Healthcare Professional Interventions

Rationale

Establish a trusting relationship.

Establishing a trusting relationship is as difficult as it is vital.

Deception is a way of life for the patient who uses manipulation, but every healthcare professional intervention is based on the foundation of a trusting healthcare professional-patient relationship.

It may be the first trusting relationship that the patient has ever had in their life. Allow time for trust to develop.

Help patients recognize their manipulation and potential causes of their behavior.

Patients cannot be helped to find more adaptive ways of living if they do not recognize their current behavior as a problem and take responsibility for the circumstances in which they find themselves.

Provide a consistent environment.

Inconsistent caretaking is at the root of the development of maladaptive manipulation as a coping mechanism in early childhood.

The goal of manipulation is to somehow make the environment safe and secure.

Knowing what to expect decreases the patient's anxiety and helps them learn to trust others and the environment.

In addition, consistency reduces the patient's opportunity to divide the staff by manipulating them.

Formulate short- and long-term goals to ensure that every member of the staff carries out the care plan as consistently as possible.

Consistency is vital to ensuring that the patient cannot manipulate by "splitting" the staff – all team members should provide input in setting goals.

Short-term goals include the following:

Recognize and verbalize feelings of anxiety, frustration, or powerlessness.

Recognize instances of manipulative behavior.

Gain insight into the effect of manipulative behavior on others.

Distinguish between wants and needs and learn to delay immediate gratification of both.

Verbalize acceptance of responsibility for own actions.

Limit manipulative behavior and determine and practice alternative methods of gratifying needs.

Long-term goals include assisting the patient to achieve the following:

Determine and express needs in a clear, direct manner that does no harm to others.

Demonstrate responsibility for their own actions.

Recognize and refuse to respond to manipulation.

Refusing to support the manipulative behavior tells patients who are manipulative that you, the healthcare professional, cannot be used as an object. They will have to find another way to get the healthcare professional to meet their needs.

Do not accept the behavior but accept the patient.

Patients who manipulate are in desperate need of acceptance and positive regard. The healthcare professional should recognize the patient's behavior as manipulative rather than label the patient as a "manipulator."

Help the patient to understand the impact of their behavior on others.

Do not assume that empathy comes naturally to patients who manipulate. Help them develop an awareness of their impact on others by being honest about how it feels to be manipulated.

Set limits that are reasonable, clear, firm, and consistent.

Although patients will most likely rail against limits, they will be enormously relieved by them. Limits will provide the external control patients need until they can develop internal control.

Provide positive reinforcement every time the patient is able to communicate needs directly, take responsibility for their own actions, or accept limits.

The patient needs to recognize not only unacceptable behavior but also acceptable behavior. Reinforcement of positive behavior is likely to elicit more of the same.

Source: [12,16]

Holistic Considerations for Interventions

Manipulation tactics can include flattery, interest, or praising one healthcare professional while degrading another healthcare professional. This attempt at control is usually the means to an end; there is some goal in mind for power, entertainment, or privileges. Manipulation is so prevalent in some settings that healthcare professionals have developed theories and strategies to better manage the difficulties associated with these patients' behaviors [28].

Intentionally developing social maturity, which includes the emotional strength and ego to recognize and deflect manipulation, is an important goal for healthcare professionals. Healthcare professionals' benefit from learning to recognize intrinsic rewards such as knowing they have made a difference and helped someone else transcend to a higher level of functioning. For patients who use manipulation, healthcare professionals must clearly set the healthcare professional-patient relationship with appropriate professional boundaries and maintain those boundaries [28].

Patients often use a combination of charm and manipulation to disturb the flow of care on a healthcare professional unit. These patients can be difficult. One moment one healthcare professional will be the only healthcare professional who can care for the patient and then the patient will refuse to see that healthcare professional [28]. Reflection on each experience with a fellow team member can be helpful for healthcare professionals. Meeting frequently to ensure all staff members (even non-healthcare professional staff) are applying the same rules to patients who manipulate is recommended. It is critical to understand that the underlying aspect of this personality trait is stable and enduring. It is difficult to change a pattern of behavior, but consistency and a caring and professional approach must be maintained to begin to make a change.

The management of "difficult" patients leads to frustration, stress, and burnout for healthcare professionals. The team needs to work cohesively and reflectively and offer support to all team members. Training to work with patients who use manipulation will reduce burnout and increase job satisfaction, while continuing to provide care to all those who need it. Mentoring healthcare professional colleagues is highly recommended for situations involving patients with manipulative behaviors.

CASE STUDY 3

David Andrews, a single, 32-year-old man, has been admitted to the general surgery unit for a hernia repair. His healthcare professional, Bonnie Blake, introduces herself and welcomes him to the hospital. Bonnie is a recently divorced 28-year-old and has been a healthcare provider for about 6 months. She explains to David that she will need to ask a series of questions, some of which he may already have answered, but that she would like to hear his answers herself. David says he will be very happy to answer questions asked by such a cute healthcare provider. He tells Bonnie that he hopes she is his healthcare provider the whole time he is in the hospital and will meet his "every need, if you get what I mean!"

Discussion : How should Bonnie interpret David's last remark? It is hard to be sure of how to interpret the remark at this point. It is possible that this comment can be taken as harassment, but it is still too early to make a definitive judgement.

Bonnie begins her assessment by asking David ordinary questions such as his name, address, date of birth, and marital status. Each time he answers, David adds a short comment such as, "Yes, I already answered that one" or "Seems like you people could pass along information better; are you people all incompetent?"

Discussion : The best response to David's comments at this point is: "I do understand your frustration, there aren't too many more items." It is important to acknowledge that the process is cumbersome without taking sides or "scolding" the patient.

When asked the question about marital status, David replies, "I'm single, who wants to know?" and gives Bonnie a wink. He then asks her what her marital status is.

Discussion : The best response to David's comments at this point is: "That is not the purpose of this interview." Providers should be straightforward without being rude or flirty or creating a bargaining situation.

Bonnie is becoming increasingly uncomfortable and decides she needs to take a short break from this interaction. She tells David she needs to check on something and will be back as soon as she can. As she leaves the room, David calls out, "You hurry back, you sweet thing, I'll miss you while you are gone!"

Bonnie finds her supervisor and tells her that she is very uncomfortable with David. She asks if she can be reassigned to a different patient and let Joe, another provider on the unit, take over for her with David. The supervisor tells Bonnie that it would be better if she learned to manage patients with manipulative behaviors and that, for now, the assignments remain as they are. The supervisor does spend a bit more time with Bonnie and asks her what, specifically, is making the interview so uncomfortable and what she thinks would be the best thing to do about her discomfort.

On hearing her supervisor tell her that she will continue as David's healthcare provider, Bonnie's first reaction is to plead her case and ask her supervisor to reconsider.

Discussion : The supervisor's best response at this point is: "Tell me more about your feelings of discomfort." This will help Bonnie to focus on the feelings she is having about the situation and hopefully what is at the root of her discomfort.

Bonnie returns to the assessment room to continue the interview.

Discussion : The best way to resume the interview once Bonnie has returned to the assessment room is: "Sorry for the delay. Let's start where we left off." At least to begin with, it would be best for Bonnie to start with a clean slate and not address David's previous behavior. If it continues, then Bonnie will need to say something, but it would be best to first wait and see how things progress from the new starting point.

Reflection Questions

Why is Bonnie feeling so uncomfortable?

More than likely, Bonnie is uncomfortable because David is behaving inappropriately, and she is unsure what to do about it. Although David is cooperating by answering the questions, he is making remarks that undermine Bonnie's confidence in her ability to provide competent care. He is putting their relationship on a personal, rather than professional, level, and is treating her as a potential date, not his healthcare provider. As a new provider, it is normal that Bonnie does not yet have complete confidence in her abilities. On top of that, as a recently divorced woman, she possibly has doubts about her desirability as a woman. Because his behavior is inappropriate for the setting, Bonnie cannot be sure what David means by his flirtatious remarks; does he actually find her attractive or is he teasing her? With the ambiguity and Bonnie's lack of experience, it is not unusual that she would become anxious in her interaction with David.

Why is David behaving the way he is?

David may be nervous about having to be admitted to the hospital. The behavior he is exhibiting might demonstrate an attempt to gain control of an unfamiliar situation. He is manipulating his healthcare professional in such a way that gives him the upper hand, in his opinion at any rate. Or David might simply be used to this sort of interaction under any circumstance. Whatever his reasons for this manipulative behavior, David will have difficulty getting his needs met in this manner. Instead of gaining the support and help he needs, he alienates people and causes them to avoid him.

Did Bonnie make a good decision to "take a break?"

Given the fact that Bonnie is becoming extremely anxious and feels like she is losing control of the interview, taking a break is not an inappropriate decision. Although there are other ways to deal with the situation, Bonnie has found a way to interrupt the seemingly downward turn that the interaction was taking.

Did the supervisor make the right decision in having Bonnie continue to work with David?

At least for the present, the supervisor seems to be making the right decision. Bonnie will encounter all sorts of people in her career as a healthcare professional and will not have the luxury of changing assignments every time she is uncomfortable with one of them. She needs to develop the skills to work effectively with all types of behaviors exhibited by patients. Given his manipulative behaviors, the patient has made her uncomfortable, but her supervisor sees this as a good learning experience and offers support by talking over the difficulties Bonnie is encountering.

9. GLOSSARY OF TERMS

Adherence: The term adherence describes the degree to which a person's behavior corresponds with the agreed recommendations from a healthcare provider. Adherence acknowledges that the patient is part of the decision-making process. To promote adherence, hospitalization must become an experience in which patients maintain control over most of what happens to them. Healthcare providers are finding new ways to alleviate the dilemmas that patients face when hospitalized. An example is the patient-controlled analgesia pump for self-administration of pain medication. Use of this device reduces the patient's dependence on the healthcare professional for comfort and, in many cases, reduces anxiety about pain control.

Compliance: The term compliance is used to describe the degree to which patients follow their healthcare providers' recommendations. It implies a patient-healthcare provider hierarchy, or a power differential in the relationship, in which the patient is relegated to a subordinate role. Some healthcare professionals believe this has a negative influence on patient compliance with the healthcare provider's recommendations.

Noncompliance: The North American Nursing Diagnosis Association (NANDA) definition of noncompliance is when the actions of the patient do not follow the health-promoting or therapeutic plan agreed on with the healthcare team [31]. A plan of action for involvement and agreement with the management plan is needed.

10. CONCLUSION

Healthcare professionals should never underestimate the potential for violence; assaults by patients—young or old, male or female—can occur for many reasons. This course explored how healthcare professionals will encounter difficult or hard to manage patients during their career, including workplace violence, non-adherence to medical treatments, and manipulation of caregivers and the treatments and skills needed. This course demonstrated how healthcare professionals can avoid potentially violent situations and work with difficult patients by being prepared and recognizing the signs and risk factors for these occurrences. It also explores how healthcare professionals must deal with their own feelings toward difficult patients while treating them. De-escalation skills, diagnosis, preventative measures, training, and planning are all presented in this course to help healthcare professionals respond to difficult patients and ensure a healthy and safe environment.

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Evidence-Based Practice Recommendations Citations

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