Daughter's concerns over dad's stroke recovery
Dr Tanvir Jamil discusses the issues
Dr Tanvir Jamil discusses the issues
Edward, a 75-year-old smoker, was admitted to hospital after a stroke four weeks ago. Since his discharge he has made steady progress with his mobility but still has a significant hemiparesis. His daughter asks about his prognosis and wonders if there is anything else that can be done.
As GPs we all have patients with strokes. Can you give me an epidemiological snapshot?
- Incidence : two per 1,000 per annum.
- Approximately 60,000 deaths per year from stroke.
- Risk of recurrence after a cardiovascular event in the first year – 13%; reduces to 5% in later years.
- Average GP sees four new strokes per year plus 12 to15 patients on his list who have survived a stroke.
Anatomically, where do the majority of strokes occur?
Around 75% occur in the area supplied by the internal carotid artery (which forms the anterior and middle cerebral arteries); 15% are in the area supplied by the vertebrobasilar artery.
A typical carotid stroke picture will involve:
- facial paresis
- dysphasia and dysarthria
- homonymous hemianopia
- conjugate gaze to the side of the lesion
A typical vertebrobasilar picture is:
- homonymous hemanopia
- blindness – both eyes
- diplopia and nystagmus
- gait disturbance
- hemi or bilateral motor paresis and sensory loss
Is there any way to distinguish clinically between an infarction and haemorrhage as a cause for stroke?
Patients with a cerebral infarct are often older and may already have a history of atherosclerosis, atrial fibrillation or transient ischemic attacks (TIAs). Consciousness will be relatively unaffected but they may complain of a moderate headache. The stroke may be 'stuttering'. Clinical examination may reveal carotid bruits, clinical evidence of internal carotid occlusion (facial pulses and retinal sign) but a normal cerebrospinal fluid (CSF).
Patients with a cerebral haemorrhage tend to develop a sudden stroke with severe headache, vomiting and early onset of coma. There is often a progression of their deficit, such as loss of consciousness. Patients may already be suffering from recognised risk factors (such as hypertension). Lumbar puncture will reveal blood in the CSF.
Do all patients with stroke need hospital admission?
In general, yes. However, if the patient refuses or the symptoms are very mild then care and follow-up such as referral to a stroke clinic can be carried out in the community. On the other side of the spectrum, if the stroke is very severe and death is imminent then admission may not be necessary. However, do talk to the relatives – if they are not happy with this decision or if there is any doubt at all about the diagnosis or prognosis, admit the patient.
What can I tell Edward's daughter about his prognosis?
Patients with a stroke have a 30% chance of dying in the first month after the event. Half of these deaths will be from the effects of the stroke and half from complications such as pneumonia or pulmonary embolism.
Fewer than 50% of stroke patients end up fully independent. Some 30% need help with daily tasks and 25% are entirely dependent on a carer. After six months, 50% to 80% will be able to walk independently. About 25% of all stroke patients suffer from depression – the onset of depression does not correlate with the site of the stroke or amount of cerebral damage.
What are the main factors to deal with in secondary prevention?
- Hypertension – the target blood pressure in non-diabetics is 140/85mmHg and in diabetics it is 130/80mmHg
- Lifestyle: patients should follow a low-fat diet, stop smoking and start exercising
- Lipid lowering
- Aspirin – following a stroke the risk of further events can be reduced by a quarter in patients who have had an infarct. It should not be used in patients with haemorrhagic stroke. Clopidogrel can be used in patients who cannot take aspirin
- Patients with atrial fibrillation having a stroke should be started on warfarin (INR 2-3)
What other problems do I need to be aware of?
Look for signs of depression, which is twice as likely in stroke victims compared with the rest of the elderly population. Patients often tend to dwell on things they cannot do instead of being positive about things they can. Treatment with SSRIs often works well.
Patients can suffer from pain and spasm in their muscles – especially on the affected side. Some patients may suffer from limb swelling and contractures. A regular dose of simple analgesia or anti-inflammatories may help as well as early community physiotherapy.
Lack of balance and falls are common as patients' ability to correct a simple stumble is usually impaired for many months. Early physiotherapy may again help.
Watch for bed sores and ask about incontinence – advice from the district nursing team will be very useful for the patient and carers. Referral for speech therapy may help problems with dysarthria or dysphasia. The occupational therapist can help with aids and adaptations to the home.
What about driving?
The patient or carer should inform the DVLA if a stroke has occurred. The patient should not drive for at least a month after the stroke. If the patient is left with epilepsy or significant motor or visual problems, driving should not be resumed until the patient has been cleared by the DVLA. The DVLA may arrange an independent medical examination and/or driving test.
What help can I give carers?
Most of the carers are the partners of patients and so elderly themselves. Look for signs of depression – figures indicate that 12% of stroke carers are depressed but this goes up to 40% if that carer is the spouse. Ask about low moods, bouts of crying and feelings of despair and hopelessness and treat as necessary with antidepressants.
Other useful areas to cover with the family include financial advice (attendance allowance and disability living allowance) and respite admission.
The Stroke Association has useful information about the condition itself and where patients and carers can access additional help and support (Stroke Association).
Dr Tanvir Jamil is a partner and trainer in Burnham, Buckinghamshire