Life After A Stroke

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THERE are many questions that come to the minds of stroke victims and their caregivers. Some people view a stroke negatively, whilst others take up the challenge of recovery and restoration of function as much as is possible.
Importantly, the stroke victim’s attitude has a substantial influence on recovery.

The care of stroke patients requires a multidisciplinary approach. The ideal is for all stroke patients to be managed in a stroke unit, which is a dedicated unit in the hospital that only manages strokes. Such a unit would be staffed by neurologists, geriatricians, general physicians with an interest in stroke, trained nurses, physiotherapists, occupational therapists and speech therapists. It would also include neurosurgeons, social workers and dietitians.

The specially trained staff of the unit provides co-coordinated multidisciplinary 24-hour care throughout the year. There is ample evidence that stroke patients managed in such units have significantly lower death, dependency and institutionalisation rates. In addition, their length of hospital stay is lower when compared to management in general medical wards.

The benefits of a stroke unit include early acute treatment, reduced infection rates, reduced systemic complications and effective rehabilitation. The benefits are independent of the patients’ age, gender, extent of the stroke and the presence of other medical conditions.

The functioning of a stroke unit is enhanced by an efficient referral and rehabilitation network that includes the family doctor.

Cognitive matters

Every human brain has processes and functions which it uses to process information from the environment. These cognitive functions include thinking, memory, concentration, communication skills, spatial awareness and praxis, which is the ability to carry out skilled physical activities.

After a diagnosis of stroke has been made, the doctor and other healthcare professionals will make an assessment of the patient’s cognitive functions, especially the degree to which it has been affected by the stroke.

The assessments, which may take a few days to be completed, enable the formulation of treatment and rehabilitation plans that are specific for the individual patient.

Most cognitive functions affected by the stroke will return with the passage of time, especially with compliance to the treatment and rehabilitation plans. However, full recovery may not occur in some patients.

Many stroke patients have problems with understanding, speech, reading and writing, a condition called aphasia. This results from damage to the part of the brain that controls language, or the muscles involved in speech may be affected.

In such situations, the patient’s recovery of cognitive functions will require interactions with other healthcare professionals, e.g. a speech therapist to assist in the recovery of communication skills.

Various other methodologies are used to assist the patient who has lost some particular cognitive function, e.g. memory aids or diaries for daily tasks.

Recovering physical functioning

Many stroke patients have weakness or paralysis of one side of the body. Many also have difficulties with balance and co-ordination of the body’s movements.
There is often marked tiredness in the initial weeks after the stroke. There may also be problems getting to sleep, thereby aggravating the tiredness.

As soon as a patient’s medical condition permits, he or she should be attended to by a physiotherapist who will formulate a treatment and rehabilitation plan after making an assessment of the degree of physical disability. The primary goal of rehabilitation is to achieve an improvement in the patient’s functional status.

There are various phases in a rehabilitation plan. It starts with evaluation, which is followed by setting of objectives, delivery of management, task reacquisition and environmental modification.

The initial objectives are to improve balance and then to regain muscle strength and control. The exercises are of a short duration initially, which then increases with the recovery of motor function, e.g. the patient may have to pick up an object initially, and later, stand up and walk.

It is vital to follow the instructions and advice of the physiotherapist, although progress may be perceived as difficult and slow initially. The extent of recovery of motor functions is often influenced by the extent of compliance with the rehabilitation plan.

The involvement of a family member or caregiver is always encouraged because the physiotherapist can teach the patient and the caregiver the exercises that can be carried out at home.

The duration of physiotherapy varies and can last for months, or sometimes, years. The decision as to when to stop physiotherapy should only be made after a full discussion with the doctor and physiotherapist.

Bladder and bowel function may be affected if the part of the brain which controls these functions is damaged by the stroke. This can lead to urinary and/or bowel incontinence.

Most patients recover these functions within a fortnight or so. If the problem persists, help could be sought from nurses, and supplemented by aids like incontinence pads.

There are occasions when a stroke leads in damage to the parts of the brain that receive, process and interpret information from the eye(s). This results in various visual problems like double vision, and partial or total blindness in one eye. The management of these problems would require the expertise of an eye specialist (ophthalmologist).

Some patients give up on sex after a stroke. It is important to know that sex does not increase the risk of another stroke. Although there is no guarantee that another stroke will not recur, there is no reason why it should occur while having sex.

Other ways of having sex can be found even if there is severe disability. If there are any problems, a discussion with the doctor will be helpful. This is especially so as sex drive (libido) is reduced by certain medicines.

Some stroke patients enquire about driving. This depends on residual disabilities and the type of vehicle in question. An assessment by a specialist or family doctor will be helpful. The patient’s medical status and the safety of other road users will have to be taken into consideration.

Psychologically speaking

The majority of psychological disorders after a stroke are depression, in which there are feelings of hopelessness and withdrawal from social life, and anxiety disorder, in which there is intense and often uncontrollable fear and anxiety.
These psychological disorders impact upon family and sexual relationships. They are common but will usually disappear with the passage of time. Doctors and other healthcare professionals will provide advice and assistance in addressing the psychological aspects of stroke. They will usually carry out regular reviews of the patient’s psychological functioning.

If the psychological disorders are severe or persistent for a long period of time, a referral will be made to a psychiatrist, who will use various modalities to manage the patient. This includes medicines, counselling and cognitive behavioural therapy.

Looking towards the future

After a stroke, many patients and their caregivers are interested in what the future holds (prognosis) .

The prognosis of stroke depends on the type, size and location of the pathology. A Malaysian study in 2003 reported that mortality is higher in haemorrhagic stroke (27.3%) compared to ischaemic stroke (11%). However, there is better neurological and functional recovery in haemorrhagic stroke.

Strokes that involve the brainstem or are large have a poorer prognosis. The lowest mortality rates are in small focal strokes.

Deaths in the initial month after a stroke are often due to direct effects of the brain damage. Subsequent mortality is usually due to the complications of immobilisation, i.e. bronchopneumonia, deep vein thrombosis, recurrent stroke and coronary heart disease.

In general, a third will recover almost completely and should be able to lead a normal life. Another third will have substantial disability which is variable, eg requiring assistance with bathing (which is mild) and assistance with getting in and out of bed (which is severe). Another third will be severely affected and will die within a year, with the majority of deaths occurring in the initial weeks after the stroke.

Recent studies have reported that mortality rates after a first-ever stroke (all types) were 10% at one week, 20% at one month, 30% at one year, 60% at five years and 76% at 10 years.

The risks of recurrent stroke are 4% in the first month and 12% in the first year. The risks decrease subsequently to about 4-5% per year so that 30% will have suffered a recurrent stroke five years after the first stroke.

The incidence of deaths following a stroke has decreased in the past few decades in both sexes. This has been due to the introduction of stroke units and better prevention in those with risk factors.

(Written by Dr Milton Lum is a member of the board of Medical Defence Malaysia.)