Again, the requirement for social workers will depend on the make-up of society. In societies with no social support systems a social worker will be of little use! In the UK and many European countries, there is an often complex collection of services for the person with stroke. This can range from a home help who can do the shopping and clean the house, to a full package of domiciliary care to get someone out of bed, washed, dressed, and toileted, the reverse at night, and all meals (called the dawn and dusk visits plus meals). This all costs money, and social workers are essential to help navigate through the myriad of services and regulations. They are especially important if the patient is unlikely to recover well enough to return home and alternative arrangements are required, such as a nursing home or supported accommodation.
Psychologists can have an important role in stroke units. Their expertise may be useful in assessing mood and depression, helping people through difficult adjustment periods, managing difficult behaviour and other distress, and providing cognitive therapy. Cognitive therapy is a behavioural technique which is used to help stroke patients recover, and includes areas such as concentration, attention, orientation to time and day, and memory. At present, there is a limited evidence base for such techniques, but improvements in cognitive scales and measures have been shown by interventions delivered by clinical psychologists and, in keeping with the theme of brain plasticity, it is highly likely that this type of training technique will help people recover from stroke. However, there are some provisos. Research has struggled to find treatments that make a difference in overall activities or disability level, people need to be able to tolerate the treatments (and many people with stroke will not because of dementia, drowsiness, or fatigue), and clinical psychologists are few and far between in most stroke services. It is very possible that other members of the stroke team can take on some of these roles, but this will depend on the complexity of the technique used.
Dieticians should play a role in a stroke unit. Some people are so dysphagic that they have to be tube-fed, and such feeding requires an appropriate liquid feed, commenced at the appropriate rate and monitored carefully. If patients are tube-fed after a period of starvation, there is a ‘refeeding syndrome’ that may be dangerous, and appropriate precautions must be taken to avoid this. In the recovery period after stroke, people should be advised to adopt a healthy diet, low in salt and saturated fats, with plenty of fresh fruit and vegetables, and dieticians can help counsel patients and their families.
Pharmacists have a crucial role to play in many hospital services, especially the stroke service. The use of medication is such a complex area that it is renowned for causing a large number of hospital errors. Any help in reducing these errors is welcome. Medication use has become very important in stroke medicine, as numerous RCTs have established the use of a variety of different treatments not only to treat the stroke itself, but also to ward off another stroke (Chapter 8). In addition, many patients with stroke have swallowing difficulties, and sometimes medication may be given by the intravenous route, or rectally by suppository, or crushed down a feeding tube, and pharmacists can advise on these matters.
The family and/or the patient’s carer have a crucial role to play after a stroke. Their support will usually be of great comfort for the patient, and when the stroke has caused major problems, their help in the recovery process is a key part of good stroke unit care. This can include getting the family to reinforce particular training sessions, and training family members to manage the patient with a view to discharge (e.g. teaching techniques to transfer the patient from bed to wheelchair, or getting the patient into a car safely). Families also need information about stroke in general and about the progress of the patient.