Der Einfluss von psychosozialen Faktoren auf die Prähospitalzeit beim akuten Schlaganfall

Hintergrund: Die Zeit zwischen dem Eintreten der Beschwerden und der Ankunft in der Klinik schwankt bei Schlaganfallpatienten sehr. Daher ist nicht in allen Fällen eine optimale Versorgung der Patienten gewährleistet. Zur Verkürzung der Prähospitalzeit zeigten Aufklärungskampagnen bezüglich der Symptome des Krankheitsbildes bisher leider keinen ausreichenden Effekt. Patienten warten immer noch viel zu lang bis zur Inanspruchnahme medizinischer Hilfe. Die Entscheidungszeit der Patienten stellt dabei den bedeutsamsten Anteil an der Prähospitalzeit dar. Ziel: Ziel dieser Studie ist es einflussnehmende klinische und psychologische Faktoren auf die Zeit bis zur Alarmierung des Rettungsdienstes und die Prähospitalzeit bei Auftreten von Symptomen des Schlaganfalls zu identifizieren. Methoden: Bei der vorliegenden Studie handelt es sich um eine deskriptive Querschnittsstudie. Es wurden insgesamt 566 Patienten mit Schlaganfall mittels eines standardisierten Interviews, innerhalb 72 Stunden nach Klinikaufnahme, befragt. Ergebnisse: Die Zeit zwischen Symptombeginn und der Entscheidung Hilfe zu suchen (Entscheidungszeit) lag im Median bei 61,0 Minuten und die Prähospitalzeit bei 164,0 Minuten. Die Analysen der Daten ergaben mehrere signifikante Einflussfaktoren. Wählten die Patienten einen privaten Transport in das Krankenhaus war dies mit einer Verlängerung von 8,3 Stunden assoziiert. In der statistischen Analyse ergab dieser Faktor eine Odds Ratio von 5,392 für eine Verzögerung der Prähospitalzeit von über 164,0 Minuten. Sprachstörungen, ein plötzlicher Symptombeginn und durchgehende Beschwerden verkürzten die Entscheidungs- und Prähospitalzeit signifikant. Ein erhebliches Risiko für eine verlängerte Entscheidungszeit war es wenn der Symptombeginn eher schleichend war (OR 2,44). Weiterhin verlängerten ein prämorbid vorliegendes geringes allgemeines Wohlbefinden und das Vorliegen einer Depression die Entscheidungs- und Prähospitalzeit. Die Odds Ratio lag bei Depressivität bei 3,143 und erhöhte das Risiko auf eine Entscheidungszeit von über 61,0 Minuten signifikant. Fazit: Wesentliche Einflussfaktoren auf die Entscheidungs- und Prähospitalzeiten beim akuten Schlaganfall konnten durch diese Studie weiter identifiziert werden. Auch konnte die Relevanz von psychologischen Faktoren, neben den Kenntnissen des Krankheitsbildes, aufgezeigt werden, welche in zukünftigen Aufklärungskampagnen berücksichtigt werden sollten.Background: The time between symptom onset and hospital arrival in patients with an acute stroke differs a lot. Therefore, appropriate treatment is not guaranteed at all times. Multiple attempts to reduce prehospital delay through public awareness campaigns did not show a sufficient effect. Until this day patients still wait far too long until they seek treatment regarding their stroke symptoms. The time until the decision to seek treatment seems to be the most significant part in the prehospital delay. Aim: Purpose of this study is to identify clinical and psychological factors which have an impact on the patient’s treatment seeking behavior and the prehospital delay. Methods: The present study is a descriptive cross-sectional study. We interviewed 566 patients with an acute stroke, within 72 hours after hospital arrival, using a standardizes Interview. Results: The median time between symptom onset and the decision to seek treatment revealed to be 61,0 minutes and the prehospital time to be 164,0 minutes. Further analyses showed multiple significant factors with an impact on the treatment seeking behavior and the prehospital time. The prehospital time delayed 8,3 hours if patients choose a private transport to the hospital. Statistical analyses showed an odds ratio of 5,392 for this factor to be delayed longer than 164,0 minutes. Impaired speech, a sudden symptom onset and constant symptoms shortened the treatment seeking- and the prehospital time. A gradual symptom onset showed to be a significant risk factor for a delayed treatment seeking (OR 2,44). A minor well-being or a depression premorbid to the stroke resulted in a delayed treatment seeking and prehospital time. The odds ratio was 3,143 if patients showed signs of a depression, which increased the risk of a decision time longer that 61,0 minutes significantly. Conclusion: Essential factors with an impact on the treatment seeking behavior and the prehospital time of patients with an acute stroke could be further identified in this study. Besides the knowledge of the clinical pattern, important psychological factors could be discovered which should be considered in future public awareness campaigns

Perceived performance of activities of daily living by stroke patients: key in decision to call EMS and outcomes

BackgroundUntil recently, public education campaigns aimed at improving help-seeking behavior by acute stroke patients have achieved only limited or even no effects. Better understanding of psychological factors determining help-seeking behavior may be relevant in the design of more effective future campaigns.MethodsIn this prospective, cross-sectional study, we interviewed 669 acute stroke patients within 72 h after hospital admission. The primary endpoint was the effect of psychological factors on the decision to call emergency medical services (EMS). Secondary endpoints were the effects of such factors on treatment rates and clinical improvement (difference between modified Rankin scale (MRS) scores at admission and at discharge).ResultsOnly 48.7% of the study population called the EMS. Multivariate logistic and linear regression analyses revealed that perception of unimpaired performance of activities of daily living (ADL) was the only psychological factor that predicted EMS use and outcomes. Thus, patients who perceived only minor impairment in performing ADL were less likely to use EMS (odds ratio, 0.54 [95% confidence interval, 0.38–0.76]; p = 0.001), had lower treatment rates, and had less improvement in MRS scores (b = 0.40, p = 0.004). Additional serial mediation analyses involving ischemic stroke patients showed that perception of low impairment in ADL decreased the likelihood of EMS notification, thereby increasing prehospital delays, leading to reduced thrombolysis rates and, finally, to reduced clinical improvement.ConclusionPerception of unimpaired performance of ADL is a crucial barrier to appropriate help-seeking behavior after acute stroke, leading to undertreatment and less improvement in clinical symptoms. Thus, beyond improving the public’s knowledge of stroke symptoms, future public education campaigns should focus on the need for calling the EMS in case of stroke symptoms even if daily activities do not seem to be severely impaired

Perceived performance of activities of daily living by stroke patients: key in decision to call EMS and outcomes

Background: Until recently, public education campaigns aimed at improving helpseeking behavior by acute stroke patients have achieved only limited or even no effects. Better understanding of psychological factors determining help-seeking behavior may be relevant in the design of more effective future campaigns. Methods: In this prospective, cross-sectional study, we interviewed 669 acute stroke patients within 72  h after hospital admission. The primary endpoint was the effect of psychological factors on the decision to call emergency medical services (EMS). Secondary endpoints were the effects of such factors on treatment rates and clinical improvement (difference between modified Rankin scale (MRS) scores at admission and at discharge). Results: Only 48.7% of the study population called the EMS. Multivariate logistic and linear regression analyses revealed that perception of unimpaired performance of activities of daily living (ADL) was the only psychological factor that predicted EMS use and outcomes. Thus, patients who perceived only minor impairment in performing ADL were less likely to use EMS (odds ratio, 0.54 [95% confidence interval, 0.38–0.76]; p  =  0.001), had lower treatment rates, and had less improvement in MRS scores (b  =  0.40, p  =  0.004). Additional serial mediation analyses involving ischemic stroke patients showed that perception of low impairment in ADL decreased the likelihood of EMS notification, thereby increasing prehospital delays, leading to reduced thrombolysis rates and, finally, to reduced clinical improvement. Conclusion: Perception of unimpaired performance of ADL is a crucial barrier to appropriate help-seeking behavior after acute stroke, leading to undertreatment and less improvement in clinical symptoms. Thus, beyond improving the public’s knowledge of stroke symptoms, future public education campaigns should focus on the need for calling the EMS in case of stroke symptoms even if daily activities do not seem to be severely impaired

Research diagnostic criteria for Alzheimer’s disease: findings from the LipiDiDiet randomized controlled trial

Background: To explore the utility of the International Working Group (IWG)-1 criteria in recruitment for Alzheimer’s disease (AD) clinical trials, we applied the more recently proposed research diagnostic criteria to individuals enrolled in a randomized controlled prevention trial (RCT) and assessed their disease progression. Methods: The multinational LipiDiDiet RCT targeted 311 individuals with IWG-1 defined prodromal AD. Based on centrally analyzed baseline biomarkers, participants were classified according to the IWG-2 and National Institute on Aging–Alzheimer’s Association (NIA-AA) 2011 and 2018 criteria. Linear mixed models were used to investigate the 2-year change in cognitive and functional performance (Neuropsychological Test Battery NTB Z scores, Clinical Dementia Rating-Sum of Boxes CDR-SB) (criteria × time interactions; baseline score, randomization group, sex, Mini-Mental State Examination (MMSE), and age also included in the models). Cox models adjusted for randomization group, MMSE, sex, age, and study site were used to investigate the risk of progression to dementia over 2 years. Results: In total, 88%, 86%, and 69% of participants had abnormal cerebrospinal fluid (CSF) β-amyloid, total tau, and phosphorylated tau, respectively; 64% had an A+T+N+ profile (CSF available for N = 107). Cognitive-functional decline appeared to be more pronounced in the IWG-2 prodromal AD, NIA-AA 2011 high and intermediate AD likelihood, and NIA-AA 2018 AD groups, but few significant differences were observed between the groups within each set of criteria. Hazard ratio (95% CI) for dementia was 4.6 (1.6–13.7) for IWG-2 prodromal AD (reference group no prodromal AD), 7.4 (1.0–54.7) for NIA-AA 2011 high AD likelihood (reference group suspected non-AD pathology SNAP), and 9.4 (1.2–72.7) for NIA-AA 2018 AD (reference group non-Alzheimer’s pathologic change). Compared with the NIA-AA 2011 high AD likelihood group (abnormal β-amyloid and neuronal injury markers), disease progression was similar in the intermediate AD likelihood group (medial temporal lobe atrophy; no CSF available). Conclusions: Despite being less restrictive than the other criteria, the IWG-1 criteria reliably identified individuals with AD pathology. More pragmatic and easily applicable selection criteria might be preferred due to feasibility in certain situations, e.g., in multidomain prevention trials that do not specifically target β-amyloid/tau pathologies. Trial registration: Netherlands Trial Register, NL1620. Registered on 9 March 2009