1. Clinical Pearls for Stroke Prevention in Geriatric
Population
Stroke Prevention Clinic

2. Objectives
• Stroke Prevention clinic scopes and services
• Introduce the signs of stroke: newest FAST tool from Heart
and Stroke Foundation
• The importance of secondary prevention after a TIA
• Risk factors and management of stroke in geriatric population
• Basic Antithrombotics principles and nursing implications
• Common Post stroke positioning, mobility, and safety

3. Ontario Stroke Networks
• Ontario’s 11 regional stroke
networks support the 14 LHINs
• Each stroke network is a
collaborative partnership of health
care organizations and providers
• Central LHIN Stroke Prevention
Network:
1 Regional Stroke Center
5 Stroke Prevention Clinic
MH
SPC
Humber
SPC
NYG
SPC
MSH
SPC
SRHC
SPC
Mackenzie
Health
Regional Stroke
Center

5. 2008 Best Practice Recommendations for
Stroke Care
Stroke prevention clinics
Provide a comprehensive interdisciplinary approach to
prevention of first or recurrent stroke, conduct detailed
assessments by a range of healthcare disciplines, facilitate
timely access to appropriate diagnostics and interventions, and
provide education to patients and families. They also promote
continuity of care between acute care facilities, the patient and
their primary care providers”.

6. Stroke Prevention Clinic Model
Life style modifications and self-management:
Link clients back to local Cardiovascular Rehab services

8. Comparison of Stroke Signs
(CIHI, 2011)
FAST TOOL

9. Risk of Stroke Within 90 Days of a TIA

10. Stroke Risk Factors
Non-modifiable Factors
• Age over 60
• Gender
• Ethnic
• Family history of Stroke
• Family history of coronary artery
disease
Modifiable Factors
• Hypertension
• Dyslipidemia
• Diabetes
• Heart disease (ischemic, a-fib)
• Carotid stenosis
• Smoking
• Obese
• Inactivity
• Excessive alcohol use
• Sleep apnea: ↑HTN, ↑diabetes, ↑heart diseases,
↑carotid thickness, ↑depression
• Stress

11. Risk Management in Stroke Prevention
• Blood pressure in geriatric population ≤150/90
• Hemoglobin A1C <6.0% for non-diabetic
• Hemoglobin A1C<7.0% for diabetic
• LDL 50% reduction or below 2
• Antiplatelet therapy
• Treat atrial fibrillation
• Treat sleep apnea with CPAP
• Smoking cessation
• Chronic disease management: Diabetes Education Center, Geriatric services, etc
• Cardiac rehabilitation program and weight management
• Other services: SLP, PT, OT, CCAC, vascular surgeon referral, etc

12. Oral Antithrombotic Therapy in Ischemic Stroke
Patients
Oral
Antithrombotic
Antiplatelet
Oral
Anticoagulants
Vitamin K
antagonists
DOACs
ASA
Aggrenox
Plavix

13. Useful facts about Direct-acting Oral anticoagulants
• Generally more favorable benefit/risk profile vs. warfarin, with
sharply reduced intracranial bleeding
• Lack of antidote
• Concomitant aspirin use increases bleeding
• Don’t work for all
• anticoagulation indications (e.g. prosthetic cardiac valves)
• Each has different dosing and special issues
• INRs / prothrombin times are not useful to monitor
• Elderly patients do well on DOACs

15. Nursing implications
• Short half-life require timely medication administration and
medication adherence
• Missed Dose → ↑thrombotic event: administer the dose as soon as
possible on the same day.
• Grapefruit juice may also increase plasma concentrations of
XARELTO and should be avoided (FDA, 2009)
• Meal consumption increase Xarelto’s bioavailability for larger dose:
15 mg and 20 mg tablets should be taken with the evening meal
• Avoid administration of Xarelto via a method that could deposit drug
directly into the proximal small intestine (e.g., feeding tube) which
can result in reduced absorption and related drug exposure.
• Monitor signs and symptoms of bleeding, especially in clients with
antiplatelets /NASIDs

16. References
• CIHI. (2011). Warning signs and symptoms of stroke. Retrieved from
http://www.cihi.ca/cihi-ext-portal/internet/en/document/types+of+care/hospital+care/acute+care/RELEASE_12JU
• Food and Drug Administration (2009). Review of Xarelto. Retrieved from
http://www.accessdata.fda.gov/drugsatfda_docs/nda/2011/022406Orig1s000ClinPharmR.p
df
• Gottschalk, R. (2014). Sleep apnea and stroke. Retrieved from
http://www.heartandstroke.on.ca/atf/cf/%7B33C6FA68-B56B-4760-ABC6-D85B2D02EE71%7D/GOTTSCHAL
Hart, R. G. (2014). New oral anticoagulants for atrial fibrillation: 4 things that primary professional
should know. Retrieved from http://www.heartandstroke.on.ca/atf/cf/%7B33C6FA68-B56B-4760-
ABC6-D85B2D02EE71%7D/GOTTSCHALK-Sleep-Apnea-and-Stroke-F1-05.pdf
• Hear and Stroke Foundation. (2014). Stroke signs. Retrieved from
http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483937/k.ED98/Stroke__Stroke_Warning_Si
gns.htm?gclid=CjwKEAjw9bKpBRD-geiF8OHz4EcSJACO4O7Tgi3l5qeh9QC4vOc-
mg0nXUR1UQe2OBS-7KbXECjOMRoC_Vfw_wcB
• Food and Drug Administration ( 2011). Xarelto (Rivaroxabab) tablet label. Retrieved from
http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/202439s001lbl.pdf