Stroke Management in Older Adults: Prevention, Identification and first-aid support
Prepared by: LP Iuliu Hațieganu University of Medicine and Pharmacy - (UMFCJ), Romania1. General description
Stroke is the fourth leading cause of death in the United States and causes more serious long-term disabilities than any other disease. Risk increases with age. Therefore, older adults are the most exposed population1. About 75 percent of strokes occur in people 65 or older. It is an increasing problem the older we get. It has been estimated that the chance of having a stroke doubles every decade after 552. Stroke afflicts about 800,000 people a year and is estimated to occur at the rate of one American every 40 seconds. About three-fourths of the annual strokes are first-time strokes and the other quarter are recurrent. Therefore, most strokes are first-time episodes.
Stroke prevention, but especially early identification of stroke signs and first-aid support are paramount in decreasing ill-health and mortality consecutive to stroke.
The current module will present:
- The problematic of stroke in older adults: prevalence, main causes, and negative health impact
- Stroke prevention in older adults
- Stroke signs identification and first-aid support (F.A.S.T. response)
- Stroke recovery
- The use of modern technology in stroke prevention, identification, first aid and recovery
Objectives of the training:
- Raise awareness of health & care workers regarding the importance of prevention, rapid identification & management of stroke in older adults
- Increase the knowledge level of health & care workers regarding methods for stroke risk assessment, stroke signs identification, rapid response and management.
- Increase skills level of health & care workers regarding methods (including modern technology instruments such as mobile apps) for stroke rapid identification and management interventions.
By the end of the module, the participants will be able to:
- Understand the negative impact of stroke in older adults population in terms of ill-heath and mortality
- Understand the importance of assessment of stroke risk
- Understand the importance of stroke identification signs and acting F.A.S.T.
- Be able to conduct (with or without assistance/collaboration) stroke risk assessment
- Be able to conduct (with or without assistance/collaboration) stroke recognition/diagnosis based on F.A.S.T. test
- Be knowledgeable in using modern technology applications (such as mobile apps) for prevention, risk assessment, early recognition and stroke management.
The main barriers to get connected and effectively use internet services are lack of knowledge & skills, affordability, accessibility, and lack of awareness.
2. Target group description and characteristics
The main target group for this module comprises health & care workers from inpatient and outpatient older adults care settings such as community day centres, retirement facilities etc.
A second target group is individual care takers, either family members or employed personnel, involved in home nursing or home care services.
A third target group is older adults that should be aware about the importance of adequate nutrition and PA to avoid frailty and maintain independence and mobility for as long as possible.
3. Duration - 6 hours
4. Format - online training
5. Module structure
The module will comprise 3 sub-modules lessons, as follows:
- Sub-module / Lesson 1: The burden of stroke in older adults, causes and prevention; stroke risk assessment.
- Sub-module / Lesson 2: Stroke management: early recognition, early and late management.
- Sub-module / Lesson 3: Recovery after stroke.
Asynchronous online learning – based on lectures prepared and uploaded on the platform in advance, reading materials, quizzes and other support materials
CONTENTS OF THE TRAINING PROGRAMME
Lesson 1: The burden of stroke in older adults, causes and prevention; stroke risk assessment
Lesson 2: Stroke management: early recognition, early and late management.
Lesson 3: Recovery after stroke
Lesson 1: The burden of stroke in older adults, causes and prevention
The burden of stroke in older adults
A stroke is a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off.Stroke is the fourth leading cause of death in the United States and causes more serious long-term disabilities than any other disease. Risk increases with age. Therefore, older adults are the most exposed population1. About 75 percent of strokes occur in people 65 or older. It is an increasing problem the older we get. It has been estimated that the chance of having a stroke doubles every decade after 552. Stroke afflicts about 800,000 people a year and is estimated to occur at the rate of one American every 40 seconds. About three-fourths of the annual strokes are first-time strokes and the other quarter are recurrent. Therefore, most strokes are first-time episodes.
In Europe, in the year 2017, there were 1.12 million incident strokes in the European Union, 9.53 million stroke survivors, 0.46 million deaths, and 7.06 million disability-adjusted life years lost because of stroke. By 2047, we estimated an additional 40 000 incident strokes (+3%) and 2.58 million prevalent cases (+27%)3.
Historically, stroke predominantly affects older population. However, more recent studies revealed a decrease in the mean age of stroke affected population. The mean age at stroke significantly decreased from 71.2 years in 1993/1994 to 69.2 years in 2005 (p < 0.0001). The proportion of all strokes under age 55 increased from 12.9% in 1993/1994 to 18.6% in 20054.
Even more recent figures, from 2018, show that 38% of people from the United Kingdom suffering strokes are middle aged (40-69) – up from 33% a decade ago. The average age for a woman suffering a stroke has dropped from 75 to 73 and for men it has dropped from 71 to 685.
These trends toward increasing stroke incidence at younger ages are of great public health significance because strokes in younger patients carry the potential for greater lifetime burden of disability and because some potential contributors identified for this trend are modifiable.
Stroke causes
There are two main causes of stroke: a blocked artery (ischemic stroke) or leaking or bursting of a blood vessel (haemorrhagic stroke). Some people may have only a temporary disruption of blood flow to the brain, known as a transient ischemic attack (TIA), that doesn't cause lasting symptoms. Ischemic stroke
This is the most common type of stroke. It happens when the brain's blood vessels become narrowed or blocked, causing severely reduced blood flow (ischemia). Blocked or narrowed blood vessels are caused by fatty deposits that build up in blood vessels or by blood clots or other debris that travel through the bloodstream, most often from the heart, and lodge in the blood vessels in the brain.
Some initial research shows that COVID-19 infection may increase the risk of ischemic stroke, but more studies are needed.
Haemorrhagic stroke
Haemorrhagic stroke occurs when a blood vessel in the brain leaks or ruptures. Brain haemorrhages can result from many conditions that affect the blood vessels. Factors related to haemorrhagic stroke include:
- Uncontrolled high blood pressure
- Overtreatment with blood thinners (anticoagulants)
- Bulges at weak spots in your blood vessel walls (aneurysms)
- Trauma (such as a car accident)
- Protein deposits in blood vessel walls that lead to weakness in the vessel wall (cerebral amyloid angiopathy)
- Ischemic stroke leading to haemorrhage
Stroke prevention
The best ways to help prevent a stroke is to eat a healthy diet, exercise regularly, and avoid smoking and drinking too much alcohol.These lifestyle changes can reduce your risk of problems like:
- arteries becoming clogged with fatty substances (atherosclerosis)
- high blood pressure
- high cholesterol levels
An unhealthy diet can increase your chances of having a stroke because it may lead to an increase in your blood pressure and cholesterol levels.
A low-fat, high-fibre diet is usually recommended, including plenty of fresh fruit and vegetables (5 A Day) and wholegrains.
Combining a healthy diet with regular exercise is the best way to maintain a healthy weight.
Regular exercise can also help lower your cholesterol and keep your blood pressure healthy.
For most people, at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week is recommended.
If you're recovering from a stroke, you should discuss possible exercise plans with the members of your rehabilitation team.
Smoking significantly increases your risk of having a stroke. This is because it narrows your arteries and makes your blood more likely to clot. You can reduce your risk of having a stroke by stopping smoking.
Not smoking will also improve your general health and reduce your risk of developing other serious conditions, such as lung cancer and heart disease.
Excessive alcohol consumption can lead to high blood pressure and trigger an irregular heartbeat (atrial fibrillation), both of which can increase your risk of having a stroke.
Because alcoholic drinks are high in calories, they also cause weight gain. Heavy drinking multiplies the risk of stroke by more than 3 times. If you choose to drink alcohol and have fully recovered, you should aim not to exceed the recommended limits:
• men and women are advised not to regularly drink more than 14 units a week
• spread your drinking over 3 days or more if you drink as much as 14 units a week
If you have not fully recovered from your stroke, you may find you have become particularly sensitive to alcohol and even the recommended safe limits may be too much for you6.
Stroke risk assessment7
Figure 1. Stroke risk assessment questionnaire.
Did you score higher in the “higher risk” column or are you unsure of your risk? Talk to your healthcare provider about how you can reduce your risk.
The above instrument can be easy translated into an electronic format and annexed in the electronic medical file or used in different remote or underserved settings, to assess the risk of stroke in older adults populations.
A simple online instrument that can be used to assess the risk of risk of heart disease or stroke can be found at: https://www.cvriskcalculator.com/. The risk calculator is based on the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. Before going to the Website be sure to have a record of recent blood pressure and blood lipid results.
Figure 2. The 10-year risk of heart disease or stroke calculator
If your risk is greater than 10 percent, you need to discuss primary stroke prevention with your doctor.
Lesson 2: Stroke management: early recognition, early and late management
Acting F.A.S.T. can help stroke patients get the treatments they desperately need. The stroke treatments that work best are available only if the stroke is recognized and diagnosed within 3 hours of the first symptoms. Stroke patients may not be eligible for these if they don’t arrive at the hospital in time.
F—Face: Ask the person to smile. Does one side of the face droop?
A—Arms: Ask the person to raise both arms. Does one arm drift downward?
S—Speech: Ask the person to repeat a simple phrase. Is the speech slurred or strange?
T—Time: If you see any of these signs, call the emergency service (112) right away.
Figure 3. Waring signs and symptoms of stroke – FAST8
Note the time when any symptoms first appear. This information helps health care providers determine the best treatment for each person. Do not drive to the hospital or let someone else drive you. Call an ambulance so that medical personnel can begin life-saving treatment on the way to the emergency room.
Signs of Stroke in Men and Women
- Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.
- Sudden confusion, trouble speaking, or difficulty understanding speech.
- Sudden trouble seeing in one or both eyes.
- Sudden trouble walking, dizziness, loss of balance, or lack of coordination.
- Sudden severe headache with no known cause.
tPA improves the chances of recovering from a stroke. Studies show that patients with ischemic strokes who receive tPA are more likely to recover fully or have less disability than patients who do not receive the drug.2,3 Patients treated with tPA are also less likely to need long-term care in a nursing home.4 Unfortunately, many stroke victims don’t get to the hospital in time for tPA treatment. This is why it’s so important to recognize the signs and symptoms of stroke right away and call 9-1-1.
Medicine, surgery, or other procedures may be needed to stop the bleeding and save brain tissue. For example:
Endovascular procedures
Endovascular procedures may be used to treat certain haemorrhagic strokes. The doctor inserts a long tube through a major artery in the leg or arm and then guides the tube to the site of the weak spot or break in a blood vessel. The tube is then used to install a device, such as a coil, to repair the damage or prevent bleeding.
Surgical treatment
Haemorrhagic strokes may be treated with surgery. If the bleeding is caused by a ruptured aneurysm, a metal clip may be put in place to stop the blood loss.
If you have had a stroke, you are at high risk for another stroke:
• 1 of 4 stroke survivors has another stroke within 5 years.
• The risk of stroke within 90 days of a TIA may be as high as 17%, with the greatest risk during the first week.
That’s why it’s important to treat the underlying causes of stroke, including heart disease, high blood pressure, atrial fibrillation (fast, irregular heartbeat), high cholesterol, and diabetes. Your doctor may give you medications or tell you to change your diet, exercise, or adopt other healthy lifestyle habits. Surgery may also be helpful in some cases9.
Mobile apps for stroke
Figure 4. Screen captures from Doctot Stroke App main screen
Doctot Stroke app is addressed at health professionals that work in the fields of care related to stroke and/or older adults.
Figure 4 above presents the Doctot Stroke app panels that present the tools that can be used for the assessment of stroke risk, for different causes of stroke and by using different validated scales.
Also, as shown in Figure 5 below, the stroke severity can also be assessed; validated tools have been translated into the online app and comprise all the necessary instruments, including a timer, in order to properly perform the indicated tests.
Results can be saved for each patient and consulted at a later point or distributed to other health & care professionals.
Figure 5. Screen captures from Doctot Stroke mobile app - NIH stroke scale
Lesson 3: Recovery after stroke
Recovering From Stroke
Rehabilitation after a stroke begins in the hospital, often within a day or two after the stroke. Rehab helps ease the transition from hospital to home and can help prevent another stroke.Recovery time after a stroke is different for everyone—it can take weeks, months, or even years. Some people recover fully, but others have long-term or lifelong disabilities.
What to Expect After a stroke?
If you have had a stroke, you can make great progress in regaining your independence. However, some problems may continue:• Paralysis (inability to move some parts of the body), weakness, or both on one side of the body.
• Trouble with thinking, awareness, attention, learning, judgment, and memory.
• Problems understanding or forming speech.
• Trouble controlling or expressing emotions.
• Numbness or strange sensations.
• Pain in the hands and feet that worsens with movement and temperature changes.
• Trouble with chewing and swallowing.
• Problems with bladder and bowel control.
• Depression.
Stroke Rehabilitation10
Rehab can include working with speech, physical, and occupational therapists.Speech therapy helps people who have problems producing or understanding speech.
Physical therapy uses exercises to help you relearn movement and coordination skills you may have lost because of the stroke.
Occupational therapy focuses on improving daily activities, such as eating, drinking, dressing, bathing, reading, and writing.
Therapy and medicine may help with depression or other mental health conditions following a stroke. Joining a patient support group may help you adjust to life after a stroke. Talk with your health care team about local support groups, or check with an area medical centre.
Support from family and friends can also help relieve fear and anxiety following a stroke. Let your loved ones know how you feel and what they can do to help you.
Preventing Another Stroke
If you have had a stroke, you are at high risk for another stroke:One in four strokes each year are recurrent.
The chance of stroke within 90 days of a TIA may be as high as 17%, with the greatest risk during the first week.
That’s why it’s important to treat the causes of stroke, including heart disease, high blood pressure, atrial fibrillation (fast, irregular heartbeat), high cholesterol, and diabetes. Your doctor may prescribe you medicine or tell you to change your diet, exercise, or adopt other healthy lifestyle habits. Surgery may also be helpful in some cases.
Special measures in the older adults population
Age is one of the non-modifiable risk factors for stroke, and there is therefore a correlation between the increasing incidence of stroke and the growing number of older people within the population, which poses predictable challenges for health and social care systems. In addition, people aged over 80 have an increased risk of frailty and multiple co-morbidities and are also more likely to have a severe stroke, which makes their management more complex. The third challenge associated with this increased prevalence of stroke in the older population is that the very old are often excluded from clinical trials, and therefore there is little evidence of whether treatments are as effective as they are for those under 80 years of age.Prevention and effective treatment of complications are therefore crucial for reducing mortality after stroke. This is particularly important in older stroke patients, as they are at greater risk of developing complications such as:
- Dysphagia – difficulty swallowing
- Venous thromboembolism
- Decubital ulcers
- Incontinence
- Urinary retention
- Falls
- Delirium
QUIZ - Progress tracking / achievements
References:
1. https://www.nia.nih.gov/health/stroke
2. https://muschealth.org/medical-services/geriatrics-and-aging/healthy-aging/stroke#:~:text=About%2075%20percent%20of%20strokes,one%20American%20every%2040%20seconds
3. https://www.ahajournals.org/doi/10.1161/STROKEAHA.120.029606#:~:text=In%202017%2C%20there%20were%201.12,prevalent%20cases%20(%2B27%25)
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475622/
5. https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2018/february/average-age-of-stroke-victims-is-getting-younger-according-to-new-figures-released-today-by-phe#:~:text=The%20figures%20show%20that%2038,dropped%20from%2071%20to%2068
6. https://www.nhs.uk/conditions/stroke/prevention/#:~:text=The%20best%20way%20to%20help,high%20blood%20pressure
7. https://www.stroke.org/-/media/Stroke-Files/About-Stroke/Stroke-Risk-Factors/Stroke-Risk-Quiz-English.pdf
8. https://www.medicinenet.com/11_signs_and_symptoms_of_stroke/article.htm
9. https://www.cdc.gov/stroke/signs_symptoms.htm
10. https://www.cdc.gov/stroke/recovery.htm