World Stroke Day 2018 OCTOBER 29 : Support for Life After Stroke #UpAgainAfterStroke -Prof.Dr.M.A.Aleem M.D.D.M (Neuro) TRICHY TAMILNADU INDIA

World Stroke Day 2018 : Support for Life After Stroke

-Prof.Dr.M.A.Aleem  M.D.D.M (Neuro)

Emeritus Professor Neurology
The Tamilnadu Dr.M.G.R. Medical University

Past President
Tamilnadu Pondycherry Association of Neurologists

Former Vice-Principal  
KAPV Govt. Medical College and MGM Govt. Hospital.

Fromer HOD and Professor of Neurology Senior Neurology civil surgeon KAPVGMC and
MGM Govt. Hospital

Consultant Neurologist
ABC Hospital

Trichy 620018
Tamilnadu
India

drmaaleem@hotmail.com
Phone 9443159940

Introduction

Around 80 million people living in the world today have experienced a stroke and over 50m survivors live with some form of permanent disability as a result. While for many, life after stroke won’t be quite the same, with the right care and support living a meaningful life is still possible. As millions of stroke survivors show us every day, it is possible to get Up Again After Stroke.

While the impact of stroke will be different for everyone. On World Stroke Day on 29th October 2018 we want to focus the world’s attention on what unites stroke survivors and caregivers, namely their resilience and capacity to build on the things that stroke can’t take away; their determination to keep going on the recovery journey.

In 2018, the theme of the campaign is ‘support’ and the focus of our campaign is raising awareness of key issues and needs of stroke survivors and caregivers, in order to achieve the best possible quality of life after stroke. 

Despite advances in modern medicine, medications, and medical technology, stroke diseases impose a substantial mortality and morbidity risk to the individual with increased economic burden to the society. Globally, stroke is the second leading cause of death after ischemic heart disease, with approximately 6.7 million stroke deaths every year.

In India

Stroke is the second most common cause of death after coronary artery diseases globally. It is also the most prevalent cause of chronic adult disability. However, while stroke threatens humankind all across the globe, developing countries like India account for more than four-fifths of all strokes. The stroke incidence rate in India is much higher than in other developing countries with approximately 1.8 million Indians out of a population of 1.2 billion suffering from stroke every year.

Early detection is very crucial because in stroke, 32,000 brain cells are damaged every second the disease goes untreated.
Previous hospital-based data from India observed a high proportion of young stroke (first-ever stroke onset below 40 years of age), ranging between 15 and 30%.

 Stroke is not limited to the elderly only.

In India, common risk factors for stroke such as hypertension, diabetes, smoking, and dyslipidemia are prevalent and insufficiently controlled due to low awareness levels of the disease. Another major challenge is that treatment for stroke is still evolving in India. Until recently, physicians have been using intravenous tPA, a clot-busting drug to open blocked blood vessels, as the first line of defense. Five global clinical trials have shown that the addition of stent retriever therapy to IV-tPA improves functional disability in patients and is now recommended as a first-line treatment for acute ischemic strokes.

Many people affected by stroke are unable to access treatment and rehabilitation due to lack of awareness. People generally tend to ignore the symptoms of stroke. However, early detection is very crucial because in stroke, 32,000 brain cells are damaged every second the disease goes untreated. But ignorance about stroke symptoms, poor infrastructure, and hesitancy about hospital admission even when infrastructure and access are available often leads to delay.

Stroke is treatable and its impact can be significantly reduced. The addition of stent retriever technology has reduced disability, improved neurological outcomes and increased the rate of return to functional independence in patients suffering stroke.

While stroke is a major public health concern worldwide, the burden on India has been increasing at an alarming rate over the past few decades. The startling statistics show that there is an urgency with which the phenomenon of stroke needs to be addressed in India for reducing the huge stroke burden that the country is facing. Without more effective public education of all demographic groups, the full potential of acute prevention will not be realized.

As the population rapidly ages, the burden of stroke is expected to increase significantly, posing challenges to limited healthcare resources.

There have been many advances in management of stroke.  However, stroke is still one of the leading causes of disabilities and mortality worldwide with significant socioeconomic burden. This article summarizes the consequences of stroke in the elderly, predictors of stroke rehabilitation outcomes, role of rehabilitation in neuronal recovery, importance of stroke rehabilitation.

Stroke Consequences 

The incidence of stroke increases with age, in both men and women with approximately 50% of all strokes occurring in people over age 75 and 30% over age 85 . Stroke is among the top leading causes of disability and reduced quality of life . Elderly patients are at higher risk of mortality, poorer functional outcomes, prolonged length of hospital stay, and institutionalization .

Mobility Problems

Motor impairment is the most common deficit after stroke, which either happens as a direct consequence of the lack of signal transmission from cerebral cortex or as a slowly accumulating process of the cerebral injuries or muscle atrophy due to learned disuse.  The risk of falling and fall-related injuries were higher in stroke elders . Risk factors associated with increased fall risks in stroke survivors include poor general health, time from first stroke, psychiatric problems, urinary incontinence, pain, motor impairment, and a history of recurrent falls . Risk factors associated with fall-related injuries are female gender, poor general health, past injury from fall, psychiatric problems, urinary incontinence, impaired hearing, pain, motor impairment, and presence of multiple strokes . Motor function deficits, increased fall risks, and fall-related injuries can significantly affect the patients’ mobility, and their daily living activities which limit their participation in social events and other professional activities.

Higher Function Problems

Poststroke cognitive impairment is common and can affect up to one-third of stroke survivors . However, subtle cognitive impairment may not appear apparent, especially when the stroke survivor seems to have recovered functionally in other aspects . In most cases, these deficits are persistent and usually have progressively worsened . Poststroke cognitive impairment is also more common in those with recurrent strokes . It often coexists with other neuropsychological problems including language disorders, fatigue, depression, and apathy . The mechanisms of poststroke cognitive impairment could be either directly due to cerebral vascular injury or indirectly due to an associated asymptomatic Alzheimer pathology or white matter changes from small vessel disease . Factors independently associated with dementia in stroke survivors include atrial fibrillation, previous stroke, myocardial infarction, hypertension, diabetes mellitus, and previous transient ischemic attack . The combined motor and cognitive impairments significantly increase risks of long term functional disability and increase healthcare cost as reflected by an increase in hospital readmission rates and mortality rates .

Urination and Defecation problems

Bladder and bowel dysfunction are common and cause significant distress to stroke survivors. Poststroke urinary incontinence or retention has been shown to affect about 30% of stroke survivors . Urinary incontinence is an important marker of stroke severity and has been linked with functional dependency, increased risk of institutionalization, and mortality . Risk factors for poststroke urinary retention include cognitive impairment, diabetes mellitus, aphasia, poor functional status on admission, and urinary tract infection . Common gastrointestinal symptoms after stroke include dysphagia, heartburn, abdominal pain, fecal incontinence, bleeding gastrointestinal tract, and constipation . Among these, constipation is the most common bowel dysfunction with the incidence ranging from 29% to 79% in stroke survivors and more prevalent in hemorrhagic stroke patients . Although fecal incontinence is less common with a prevalence of 11% at 1 year after stroke, it is associated with increased risk of nursing home admission and 1-year mortality rate .

Infection

Infection is a serious complication after a stroke despite optimal management. The reported prevalence of poststroke infection ranges from 5% to 65%, depending on the study population, study design, and the definition of infection . Mortality rate is higher in stroke patients with any type of infection, particularly higher in patients with pneumonia and patients with urinary tract infection . Among the survivors, stroke-associated infection is also an independent risk factor for poor outcome at discharge and at 1 year . The association between poststroke infection and poor outcome is likely related to a delay in rehabilitation due to prolonged hospital stay and immobilization as well as general frailty . More importantly, evidence from experimental studies suggests that infection also promotes antigen presentation and autoimmunity against the brain which worsens the outcome .

After Stroke

Following a stroke, patients may have impaired mobility which predisposes them to pressure sores and deep vein thrombosis (DVT). Pressure ulcer results from an imbalance between external mechanical forces acting on skin and soft tissue and the internal susceptibility of skin and its underlying soft tissue to injury. Pressure ulcer is associated with increased poststroke mortality in both genders and patients aged 60 years or older . Stroke patients also have an increased risk of developing deep DVT and pulmonary embolism due to immobility and raised prothrombotic activity . The major risk factors of poststroke DVT include advanced age, male gender, congestive heart failure, malignancy, and fluid and electrolyte disorders .

Pain

Pain is a frequent but often neglected complication of stroke . It can happen immediately, weeks, or months after a stroke event and can span a spectrum from irritating headache to debilitating limb pain secondary to complex regional pain syndrome, spasticity or joint subluxation, and /or contractures . Pain, together with depression and fatigue, is associated with increased risk of cognitive impairment, functional dependence, and reduced quality of life in stroke survivors . Reported risk factors for the development of poststroke pain include female gender, older age at stroke onset, history of alcohol use and depression, anatomical location of stroke and presence of clinical features such as spasticity, reduced upper extremity movement, and sensory deficits .

Stroke Rehabilitation

Due to the medical complications after stroke, many patients are markedly functionally disabled when they are discharged from acute care. Functional recovery is based on the restitution of brain tissue and on the relearning of and compensation for lost functions . Therefore, understanding and identification of predictors of good rehabilitation outcomes in addition to institution of early rehabilitation are essential in the recovery phase after an acute stroke event.

Age has been well established as a strong predictor of functional outcome and discharge destination in stroke patients in multiple studies across the world in both young and elderly stroke survivors . A large community-based cohort study in Denmark reported more than 58% of the very elderly (85 years old and above) were discharged to nursing homes or died during hospital stay poststroke .

Cognitive impairment which occurs either as a prestroke condition or a poststroke is often significantly correlated with reduced functional gains and poor rehabilitation outcomes in elderly patients. 

The cognitive impairment (preexisting or new) together with age was the most important predictor of institutionalization 3 years after stroke . Pre stroke dementia has been shown to increase risk of 6-month and delayed poststroke mortality . However, elderly stroke patients with cognitive impairments could still benefit from rehabilitation.

 

Hence, cognitive impairment should be screened for and has to be taken into consideration when rehabilitation goals are formulated and rehabilitation program ought to be individualized according to the stroke survivor’s learning ability .

Activities of Daily Living (ADL)

 dependency on admission, significantly predicts functional dependency outcome in stroke survivors . Elderly stroke patients with poorer preadmission functional status also have longer length of stay and are less likely discharged to an independent or assisted living situation .

 Aphasia arising from stroke was associated with worse outcomes in both the acute and chronic stroke periods with poorer functional recovery and increased length of rehabilitation and mortality risk .

Urinary incontinence is predictive of poor stroke outcome . Mortality at 6 months has been shown to increase in stroke patients with initial urinary incontinence . 64% of incontinent poststroke patients were discharged to nursing homes compared to 18% for continent poststroke patients . The link between urinary incontinence and poor outcomes could be related to incontinence associated with severe hemiparesis, larger stroke lesions, stroke lesion location, and a disruption of the neuromicturition pathways .

Rehabilitation process after Stroke

Rehabilitation aims to enhance and augment natural mechanisms of recovery. At the time of ischemic injury, immediate mechanisms of repair are initiated, which include resolution of poststroke edema, vicriation of function, and reversal of diaschisis. Vicariation refers to neighboring tissues taking over a function lost by the stroke-affected tissue . Diaschisis is based on the mechanism of reduction in metabolism and blood flow of intact brain regions which are distant away from the ischemic core but are still functionally and structurally connected with the ischemic core. It is thought that at least some of the improvement observed after a stroke could be due to the reversal of diaschisis .Such processes lead to “unmasking” of latent networks which can be as rapid as several hours within ischemic injury .

Evidence suggests that, within days of stroke, the injured brain has the ability for limited neuronal regeneration by angiogenesis and is coupled with neurogenesis. The ability to self-repair has been shown to happen in aged brains . The repair processes are initially intense and then slow down. Most of the spontaneous stroke recovery occurs in the first 3-6 months after the acute neurological event . Generally, patients make 70% of their recovery in the first 3 months after a stroke . Despite variations in therapy, such observations of proportional recovery have remained consistent which means that a minimum amount of spontaneous activity and therapy is enough for proportional recovery to happen . An exception to this proportional recovery rule includes damage to the corticospinal tract which results in poorer recovery from impairment .

In order to achieve a greater proportion of recovery, a much higher intensity of therapy has to be considered . Greater intensity of stroke rehabilitation has been associated with improved outcomes . Skill learning and active participation help to promote plasticity and network activation in stroke recovery . Motor retraining not only enables somatotopic reorganization to happen in perilesional areas and in distant areas connected to the infarct site but also negate the inhibitory effects of myelin associated proteins and ephrins which suppress axonal sprouting . An “enriched environment” in addition to motor retraining has been shown to facilitate motor recovery and neural plasticity in animal studies due to the numerous associated cellular and molecular effects . Rehabilitation facilities are ideal enriched environments as they are often situated in stimulating and specialized centers managed by a multidisciplinary team of medical professionals.

 Specialized stroke rehabilitation units have been shown to improve functional outcomes, decrease mortality and reduce length of hosp stay in moderate to severe stroke patients . Combining an enriched environment with skill retraining, stroke rehabilitation units are made up of a multidisciplinary team of medical professionals who offer realistic goal setting and engage in multimodal disability and impairment assessment, medical management, and functional training. 

The rehabilitation team addresses the many challenges stroke patients could face such as sensorimotor and balance impairments, dysphagia, cognitive-communication impairments, mood disorders, visual and hearing impairments, and hemispatial neglect. Regular multidisciplinary meetings are conducted to discuss the rehabilitation goals, rehabilitation intervention, functional improvement, discharge planning, and arrangement of outpatient rehabilitation. These structured meetings have been shown to improve functional outcomes . Such collaborative teamwork involves communication among the team members, working towards a common goal and accepting responsibility as a group for the final outcome of the patients . Recommended realistic goals are also planned together with the patients and their caregivers to prepare them for a smooth transition to outpatient rehabilitation and discharge destination with the eventual aim to achieve maximum independence as possible .

The hours of therapy vary across different inpatient rehabilitation settings. Generally, most guidelines advocate minimum 45 minutes of each relevant therapy for at least 5 days a week .I Immediate rehabilitation can improves functional outcomes, independence, and mortality compared to a subacute rehabilitation, given the interprofessional team of providers, advanced treatment strategies, and the requirement that patients participate in therapy at least three hours daily  . Patient’s ability to tolerate such level of intensity has to be taken into account when considered for an acute intensive inpatient rehabilitation placement. When the stroke patient is admitted to inpatient rehabilitation, the rehabilitation team would assee patient and determine an individualized rehabilitation program of suitable intensity and duration to suit the needs for favorable stroke recovery .

It is generally recommended to commence stroke rehabilitation as soon as patients are medically stable, to maximize their functional gains and to take advantage of the period of early stroke recovery . However, caution and individualized clinical judgement are indicated especially in older patients and patients with intracerebral hemorrhage .

Very early, more frequent, and increased dose of mobilization intervention reduced the odds of a favorable outcome at 3 months after stroke when compared with usual care  .

Earlier access to rehabilitation seems to favor better functional outcomes, shorten length of hospital stay, and increase likelihood of discharge to home .

Due to residual functional disability and associated medical complications, poststroke elderly survivors and their caregivers often experience significant physical, mental, and social challenges adischarged home. In most cases, caregivers are usually poorly understood and ill-prepared for their roles and responsibilities they must face at home As elderly stroke survivors require substantial care demands at home, their caregivers often feel overwhelmed and exhausted, which eventually lead to depression and deterioration of physical health .

Conclusion

The following support as being most important to recovery sfter Stroke

Be provided with hope for the best possible recovery I can make now and into the future

Receive psychological and emotional support in a form that best meets my needs

Be included in all aspects of society regardless of any disability I may have

Receive support (financial or otherwise) to ensure I am cared for in the longer term

Be supported to return to work and/or other activities I may choose to participate in after my stroke

Get access to formal and informal advocacy to assist me with access to the services I need

Be connected to other stroke survivors and caregivers so I may gain and provide support in my recovery from stroke

In conclusion, stroke in elderly patients poses a major public health concern, due to its strong association with multiple medical complications, poorer functional outcomes, and substantial healthcare cost. For stroke survivors and their families, a good and comprehensive rehabilitation program is the key to recovery and to enable them to reach their highest level of independence as possible. The success of a stroke rehabilitation unit depends on the effective utilization of its resources and seamless coordination between different healthcare professionals as well as the ongoing support from the caregivers and other community services. Provision of evidence-based and culturally relevant stroke rehabilitation will help to effectively manage limited local healthcare resources and improve quality of life in our aging population.