28 March 2019
Living after a Stroke
A third of patients achieve a satisfactory recovery following a stroke, one-third retain severe sequelae and one-third of strokes are fatal. Of the fatalities, one-third occur during hospital admission and the remainder in the following months.
The initial severity of the stroke, which is related to the size of the blocked artery and the area of the brain damaged, is the main factor in determining the extent of post-stroke sequelae (after-effects).
Another primary factor is the patient’s age; elderly patients have a limited capacity for recovery and frequently have other diseases which can complicate their progress after a stroke. Nevertheless, biological age is more important than chronological, in other words, a healthy condition prior to the stroke favours better recovery regardless of the patient’s age.
People who have suffered a stroke may experience some complications and after-effects (sequelae):
Weakness, lack of coordination or uncontrolled movement. It's a secondary disability that tend to improve, but even with rehabilitation therapy, complete recovery cannot be guaranteed.
More likely to suffer falls. It is important to exercise and strengthen muscles, and also improve balance. Features in the home that imply an increased risk of falls should be identified and modified; for example, remove rugs, use bath or shower chairs, fit handles and wear nonslip shoes.
Visual disturbances. Sometimes patients lose half their visual field, a condition called hemianopsia. With a little training can be compensated for by turning the head to look towards the damaged side.
Language disorders. A speech therapist will assess and rehabilitate, where possible, any post-stroke speech disorders.
Spasticity. Is another common problem comprising a permanent contraction of certain muscles. This can lead to stiffness, pain, spasms and hinder certain
Disorder senility. Manifesting with symptoms of pins and needles, uncomfortable sensations or numbness to touch.
Superficial pain. Known as central pain syndrome, that produces a burning or stinging sensation which worsens when touched, in contact with water or upon moving. Some antidepressants and anticonvulsants are effective at controlling this type of pain. Stroke patients who subsequently suffered paralysis in one arm may feel pain in that shoulder. Episodes of pain can be treated with simple painkillers but if the pain persists patients should be.
Another possible sequela is dysphagia (difficulty swallowing). Patients with dysphagia can benefit from a modified diet, a change in its texture or, if necessary, safer feeding techniques should be used.
Urinary incontinence. It tends to be a temporary effect, although it may endure in patients with significant sequelae. If the problem persists when the patient is discharged from hospital, healthcare professionals should be consulted about incontinence treatment and management.
Mood disorders during convalescence, rehabilitation and even after recovery. Depression, apathy, irritability or emotional lability (uncontrollable swings from crying to laughing, or crying and/or laughing for no apparent reason) are potential sequelae of a stroke. Healthcare professionals should be consulted whenever a stroke patient presents any signs of a mood disorder.
Cognitive impairment (e.g., a decline in memory, attention span and orientation, or difficulty planning and organising tasks). Although this decline can improve over time, if it affects the patient’s recovery they will probably need to be referred to a specialist.
In many cases patients are unable to make a full recovery, especially following a severe stroke. The aim of rehabilitation is to help patients adapt to their new situation, stimulate recovery of their self-esteem and improve their independence.
Rehabilitation usually starts in the early stages, during the initial hospital stay, once the indication for complete bed rest has been ruled out. The majority of improvement in moderate to severe lesions occurs in the first three months after the stroke.
Recovery then proceeds more slowly until at least six months and in some patients slight improvement may continue for up to one year. Not all patients make a full recovery. The duration and type (physiotherapy, occupational therapy, speech therapy or others) of rehabilitation will depend on the age and objectives of each patient.
Stroke prevention is in the hands of the patient: 80% depends on their lifestyle and 20% on the prescribed medication.
Healthy diet. It is important to eat a varied diet, with lots of fruit and vegetables, low in saturated fats and cholesterol, and with plenty of fibre. Salt intake should be limited to control blood pressure. Studies have shown that a Mediterranean diet, especially the consumption of virgin olive oil and nuts with meals, is effective at reducing the risk of stroke.
Recent studies have confirmed that diet plays a very important role in producing a generally healthy vascular system and in stroke prevention. A Mediterranean diet contains the main components of a healthy diet, as it features a high intake of cereals, fruits, vegetables, rice, pasta, fish, and olive oil, and a reduced intake of high-fat meat and dairy products, sugar and alcohol (preferably red wine or beer).
The PREDIMED study compared the effects of taking large amounts of olive oil or nut supplements with another study group who only followed recommendations for a healthy diet. The study was terminated prematurely because patients in the latter group experienced more vascular complications, such as myocardial infarction and particularly stroke, than those in the two groups receiving olive oil or nuts. This study represents the highest degree of scientific proof attainable from medical research and therefore the consumption of olive oil and nuts can be recommended as a means to prevent vascular diseases such as stroke.
Avoid obesity and practice physical exercise. Where possible, recommendations are for 30 minutes of moderate-intensity exercise five days per week. Good activities include walking at a light pace, jogging or cycling.
It is essential to stop smoking.
Drugs and toxic agents. Consumption of illegal drugs, such as cocaine or amphetamines, amongst others, can lead to a stroke and therefore should be avoided. Light alcohol consumption, particularly wine, can help decrease the risk of stroke. This is because alcohol increases HDL cholesterol levels, the type of cholesterol that reduces cardiovascular risk (also known as “good cholesterol”). Either way, this is not a recommendation for patients who did not already drink alcohol to start consuming, while those who drank alcohol previously should moderate their intake (two glasses of wine per day for men and one for women). Higher levels of alcohol consumption would increase the risk of stroke and other diseases.
Drugs. Prevention treatment is not always the same for each patient, as it must be adapted to the underlying disease responsible for the stroke. There are two large groups of medicines used to reduce the chance of producing a blood clot:
- Antiplatelet agents. These medicines inhibit platelet function; platelets are blood cells involved in the formation of plaques on artery walls and blood clots. The most commonly used antiplatelet agent is acetylsalicylic acid, better known as Aspirin®.
- Anticoagulants. Anticoagulants form the second group and work by inhibiting substances known as coagulation factors. The most widely used anticoagulant in Spain is Sintrom®. It must be monitored regularly to determine if coagulation is well controlled and to discover the correct dose for each patient. In recent years, three anticoagulants have been marketed which provide the same function as Sintrom® but they are administered in fixed doses and without the need to monitor the anticoagulant effect.
- Drugs to control high blood pressure, diabetes and hypercholesterolemia. Sometimes specific medicines are also required to maintain blood pressure (below at least 14/9), blood sugar (glycaemia) and cholesterol levels within normal values.
At least 2% of the Spanish population take anticoagulants. These medicines impede coagulation and are primarily used to prevent a heart-related stroke which is usually due to atrial fibrillation.
This is an arrhythmia affecting the normal function of the atria (two of the heart’s chambers) and potentially causing the formation of blood clots that may travel through the circulatory system until they block one of the body’s arteries, for example in the brain, causing what is known as an embolism.
Most patients who are diagnosed with this arrhythmia, especially if they have already suffered a stroke, are indicated anticoagulants because they significantly reduce the risk of stroke. The most commonly used anticoagulant agents are acenocoumarol (Sintrom®) and warfarin. These medicines require regular laboratory tests to control the extent of their anticoagulant effect as they do not produce the same response in everybody and thus a unique, fixed dose cannot be recommended for all. New agents have been introduced in recent years, such as dabigatran, rivaroxaban, apixaban, which have a different mechanism of action and can be administered at a fixed dosage without the need for coagulation monitoring.
Studies which formed the basis for the commercialisation of these new products demonstrate that they match traditional anticoagulants for effectiveness and equal or better their safety regarding the risk of haemorrhages.
Hence these new anticoagulants are being prescribed in the same situations as acenocoumarol and warfarin. However, as they are much more expensive, most healthcare systems recommend their use in cases where they may imply an advantage, for example, in patients who have presented brain haemorrhage complications and so the use of traditional anticoagulants would be risky.