Don't assume your patient's stroke history is correct
Next time you ask an older adult about a history of stroke, consider that the response might not be accurate. Older adults might deny a history of stroke, when in fact they have had one.
Researchers obtained magnetic resonance imaging scans (MRIs) for 717 Medicare recipients 65 and older, and they asked these patients whether they had ever had symptoms of or been told by a physician they had a stroke.1 Although only 85 reported a history of stroke, evidence of a stroke was visible in 225 of the MRIs. Patients were more likely to give a false negative report if they had lower-functioning memory, cognitive or language ability; hypertension; or history of myocardial infarction.
Take the aging process into consideration when triaging elderly patients, advises Tia Moore, RN, CEN, clinical nurse educator for the ED at University of California — San Diego Medical Center. "The brain loses the ability to recall information, and also loses the ability to retain specifics about some events," Moore says. "Also, some elderly patients may feel that 'if I deny it is occurring, then it really isn't there.'" To establish a factual history, Moore says you should:
• Link the reason for taking a specific medication with a clinical diagnosis.
An example is an elderly patient on donepezil and hydrochlorothiazide who denies any history of hypertension and says she hasn't been diagnosed with early stage Alzheimer's.
"At times, the elderly patient can get a little verbally aggressive when questioned as to the rationale for specific medications, because it forces them to admit their own physical ailments," says Moore. "Use open-ended questions that force the patient to answer you. It will demonstrate the level of understanding the patient has as to the ailment and treatment, as well as open a window to demonstrate if they are in denial of the problem."
• Look for nonverbal clues.
"When a person purposefully denies an event, this can cause the patient to have modest eye contact and make them restless in the chair," says Moore. Also, if there are bruises of different stages or skin tears in various forms of healing, this could have resulted from episodes of syncope due to a transient ischemic attack or mild stroke, she adds.
• Ask about recent events.
"This can be useful at times to determine if the short-term memory is intact," says Moore. Show the patient a pen, book, and a piece of paper. Three to five minutes later, show them the identical objects and see if they can recall what they are.
"Rewording the same question also can be helpful in eliciting information from the patient," says Moore. "Ask a question like, 'Does this hurt when I touch your arm here?' Then a few minutes later, ask, 'Does your arm hurt at all?'"
[The form used by ED nurses at University of California -- San Diego Medical Center to obtain and track information on the initial phase of a patient with stroke symptoms is included.]
Reference
- Reitz C, Schupf N, Luchsinger JA, et al. Validity of self-reported stroke in elderly African Americans, Caribbean Hispanics, and whites. Arch Neurol 2009; 66:834-840.
Source
For more information on obtaining stroke history from ED patients, contact:
- Tia Moore, RN, CEN, Clinical Nurse Educator, Emergency Department, University of California — San Diego Medical Center. E-mail: [email protected].
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