The importance of cognitive and behavioural support on the hyper acute stroke pathway during winter pressures/covid-19

Background and Aims: Cognitive and behavioural assessments are routinely performed on the hyperacute stroke unit (HASU). These may not provide a comprehensive patient profile. On an acute neurorehabilitation step-down unit for COVID-19/winter pressures, we assessed cognition and behavioural needs using stroke specific tools, functional tasks and detailed collateral information. Setting: 6-bedded acute neurorehabilitation step down unit developed for COVID-19/winter pressures, St. Pancras Hospital, London, UK. January 4th-April 1st 2021. We accepted patients triaged by an MDT neuro-navigation HASU team. We used standardised stroke specific screening tools: Oxford Cognitive score (OCS), detailed collateral and more comprehensive functional tasks. We assessed delirium, mood, anxiety and behavioural needs, eg, enhanced observations, impaired safety awareness, impaired attention affecting rehabilation, poor carry over, impulsivity, and need for Deprivation of Liberty Safeguards (DoLS). Results: 80 patients accepted;mean age 72.3years (SD 17.3);41% >80years. 30 (27%) had cognitive impairment identified pre-transfer, increasing to 52 (75%) on comprehensive assessment post-transfer. 35 (45%) had complex behavioural needs necessitating specialist nursing. 20 (25%) required DoLS;18(23%) had documented delirium on transfer. 34 (43%) had depression and anxiety. Anxiety 13(16%);depression 8(10%), combined 13 (16%). 36(45%) could benefit from formal psychology input. Average length of stay for those with psychology needs was greater than those without (16.1 v 12.6 days). Conclusions: Three quarters of patients had significant cognitive impairment;One quarter had delirium;nearly half required additional nursing for behavioural needs. This risk may be under-estimated in the hyperacute phase of the stroke pathway.