Although it has been two years since I brought my mother to live in my home, I have wondered why the hospital never suggested a rehab hospital for her care. Mom is now 93, will be 94 in May. Back in 2011 Mom had a series of mild strokes, I had her neighbor check on her and she didn't know who he was. He said that Mom was trying to sit up on her bed but kept slumping over. She also did not know who he was even though he has been picking up groceries for her for several years. He called the ambulance and they took her to a hospital that was closest.
When I arrived she did not know me either. The staff ran many tests, she saw many doctors, and the Neuro said that she had had small strokes, she had Dementia and could not live by herself anymore. She was in the hospital for 3 days. I remember check-out time, . Mom was soooo sleepy, she kept putting her head down and falling asleep. She kept saying that she just wanted to rest. I didnt know what to do so I let Mom fall asleep. The head nurse wanted us to vacate the room and bed so another patient could move in. She helped me wheel Mom out to the car to take her home. They did set up home care, Occupational Therapy and other things that I don't remember, but my husband drove 200 miles to her house with U haul truck and we moved her down to our house. I realize that Mom didn't have any after stroke care. Her new doctor in my area was just a small clinic, and they did not offer anything.
After her move, we signed her up for a new health plan. the one she had was not offered in my area. I guess Im just wondering if there was a better way to handle this situation.

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Mom had a minor stroke Jan 7th. The ER simply released her. Her primary did not see a need for PT or OT. Depends on the stroke.
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Um. It's a bit late, isn't it?!

I'm interested in your question and your thoughts about it, though. I am in a similar position in that my mother, then 88, had two small but unmistakeable strokes two years ago...

- and before I forget to mention it, whatever else you do stay right on top of your mother's anti-clotting medication. It's the single most useful thing you can do for her now.

… and it was at that time that the sharp division between my own and my SIL's views on my mother's care needs was formed. My SIL is a (now retired) dietitian and was gung-ho for intensive rehab - physical therapy every day, occupational therapy, residential setting, the works. Thinking that my mother was dying - the sleepiness, the apathy - I took an opposing view, got her home as fast as I possibly could, and made her as comfortable as I could. The major changes we made were anti-clotting medication and an SSRI to alleviate her depression; and other than that I let her sleep if she wanted to, eat and drink as much as I could persuade her to, and be at peace.

Well. It took ages - months, perhaps as much as three months - but she gradually began to get back not quite to normal, but more or less herself. Meanwhile we went to a falls prevention clinic to improve her balance; she then fell anyway and broke her wrist so we had further involvement from PTs for that; but overall she eventually regained a reasonable quality of life. Would she have done so more quickly if she'd had more intensive work done? I don't think so. I think we'd just have made her miserable, without speeding up the process.

Nearly two years passed, and my mother then had a major stroke just before Christmas. Among many useful things, her excellent geriatrician (who is also a neurologist specialising in stroke) explained to me how brain recovery works after an infarction, and why the complication of vascular dementia makes recovery much more difficult. He was going into detail because he did not believe that my mother would benefit from rehabilitation and wanted me to understand why: an elderly, diseased brain does not have the plasticity, the ability to form new pathways around a damaged area, to make significant recovery a realistic prospect. He then referred her for rehab anyway! - and they've given it a fair shot, and there are tiny improvements, but I've accepted that she will remain severely disabled from now on and that what we're looking for is to maximise her comfort and quality of life all the same.

I don't think there can be a standard treatment, apart from medical measures to reduce the risk of further stroke: so much depends on the underlying condition of the individual and what exactly the stroke has done to her brain. Recovery is lengthy even in young people; it must be a mistake to expect too much of a very elderly lady. Be guided by her symptoms and her mood, encourage her patiently, cross your fingers and celebrate any improvements.
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Usually the Case Manager at the hospital will offer a person or their medical POA a choice of rehab facility or rehab at home. Would your Mom had been able to choose on her own? Maybe she picked home rehab. Or maybe it was a case where the rehab facilities didn't have any open beds for her.

From what you have written, it sounds like there are no rehab facilities or home therapy in the area where you live. You might need to take your Mom to the closest large city to get the rehab that she will need. Have her new doctor write out a prescription for such after care.
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