Today is National Stroke day :

Reducing risk factors can prevent stroke

By Carol Aloysius

Are you at risk of developing a stroke? The sharp rise in the number of stroke patients in Sri Lanka and abroad has raised serious concern among health authorities worldwide.

Stroke is one of the most debilitating diseases that can afflict a person. Although it is not contagious and therefore, non infectious, stroke affects both the patient and care giver. For the patient it means leading a life of disabilities which prevents him from fulfilling his fullest potential. For the care-giver it involves a punishing 24- hour job of patient care since many of them, depending on the severity of the stroke, are unable to even wash themselves, go to the toilet, dress, brush their teeth, or feed themselves without assistance. Feeding and changing their clothes if they are bed bound, are no longer simple chores since care givers need to follow certain rules to prevent further complications for the patient.

Stroke impacts on the family as well. Although most of the treatment is usually free for patients admitted to stroke units in state hospitals, many other expenses are incurred by the family, who face severe economic difficulties especially if the victim is a bread winner.

To find out more about stroke, how it can be prevented and available treatment, the Sunday Observer spoke to Consultant Nephrologist, Sri Jayewardenepura Hospital, Dr HARSHA GUNESEKERA for his views.

Excerpts…

Q. Stroke is one of the leading causes of illness and death worldwide and in Sri Lanka. Compared to the incidence about a decade ago, is there a significant increase? If so why?

A. Stroke is the 3rd leading cause of death and the leading cause of disability worldwide. In Sri Lanka, stroke has taken the 2nd or the 3rd place for hospital deaths.

However, national statistics on stroke incidence are not available to date in Sri Lanka.

Two community based studies done in Colombo and Gampaha districts show that around one percent of the population develop stroke annually.

There is a definite increasing trend in the stroke incidence and mortality in developing countries like Sri Lanka, unlike in developed countries.

Q. Why?

A. In developed countries, the incidence of stroke is declining, largely due to efforts to lower blood pressure and reduce smoking. However, the overall rate of stroke remains high.

Q. What are the main reasons for this rise? Stress? Modern lifestyles?

A. The three major causes for this in the developing countries like ours include change in lifestyle associated with urbanisation, increase in the ageing population and poor socio-economic status which hinders successful strategies for prevention and treatment of stroke.

Q. Are they similar to the factors that have led to a rise in other non communicable diseases (NCDs)?

A. There is considerable overlap among the risk factors for stroke and other NCDs (heart disease, cancer etc.), and they are more or less same for Heart disease and Stroke. There are five major risk factors for stroke: They are: 1) smoking 2) high blood pressure, 3) diabetes, 4) atrial fibrillation (irregular heart rhythm which predisposes to stroke) and 5) Carotid artery disease (narrowing of the major arteries which feed the brain).

Q. Can they be prevented or modified?

A. All these five major risk factors are modifiable, which means that if you correct them (for example quitting smoking, treating high blood pressure, diabetes and irregular heart beat etc.) you can prevent a stroke.

Q. What are the modifiable factors?

A. They include the following: obesity, physical inactivity, high blood cholesterol levels, some heart diseases, use of contraceptive pill and post-menopausal hormone replacement, diseases which predisposes to abnormal blood clotting, excessive alcohol consumption, and narcotic drug use.

Q. And the non modifiable factors?

A. They include advanced age, male gender, and family history of stroke, Asian and afro-Caribbean ethnicity and low birth weight.

Q. Is stroke the cause of heart attacks or vice versa?

A. Stroke is not a cause of heart attacks but due to the similarity of causative risk factors, a person with a stroke has a higher risk of developing a heart attack. On the contrary, heart attacks can give rise to stroke, especially in the early stages due to the development of blood clots within the diseased heart.

Q. Can stroke be prevented?

A. Even with most modern treatment facilities, only a third of patients gain complete recovery from stroke. Therefore, it’s best to prevent a stroke before it develops.

This can be done at two levels, namely, “primordial prevention” and “primary prevention”. In primordial prevention, lifestyle modifications are practised early to prevent development of Stroke Risk Factors stated above. Primary prevention is for people with established risk factors, who have not yet suffered a stroke where treatment with medication in addition to lifestyle modifications is started to prevent a stroke.

The third form of prevention called “Secondary prevention” is for patients who have suffered a Stroke or a TIA where anti-platelet (“blood-thinning”) treatment is started in addition to the measures used in primary prevention. It’s best to adopt the two former methods of prevention and anyone can assess his or her stroke risk using a simple scorecard (see the colored chart).

Q. When a person gets a stroke how soon should he or she be taken to hospital to prevent complications?

A. Most of us are aware that a person with symptoms of a heart attack should be taken to the nearest hospital immediately. The practice should be exactly the same after a stroke. Heart attacks occur due to blockage of a blood vessel feeding the heart muscle. Similarly, over 85 percent of strokes occur due to blockage of a blood vessel feeding the brain (the rest due to ruptured blood vessel causing a brain bleed). Stroke is a “brain attack”. A person with symptoms of a suspected stroke should be taken to the nearest hospital immediately. There are two main reasons for this. Firstly, to perform a CT scan to rule out or confirm a brain bleed and secondly to initiate treatment without delay.

Q. What are the early symptoms? How do you recognise them if a family member develops them at home?

A. As the name implies, symptoms of stroke “strikes” you suddenly. There is a wide range of symptoms depending on the area of the brain affected. The common ones are: 1) numbness or weakness of one side of the body or one limb alone, 2) disturbance of speech, 3) impaired vision in one eye or double vision, 4) impaired balance and co-ordination and 5) impaired swallowing and bladder control. Sometimes headache, vomiting and impaired level of consciousness can occur especially in the case of a brain bleed.

Q. Is there an easy way for one to remember these rules?

A. Yes. The Stroke Organisations have put forward a simple test called FAST - Face, Arm, Speech, Time which is explained in the diagram. If any of the three checks are positive, the patient should be taken to the nearest hospital immediately. Around a quarter of patients with stroke may experience a Transient Ischaemic Attack (TIA or mini stroke). Here the symptoms of stroke last only for a few minutes and then rapidly resolve. This condition should be given serious consideration and treatment initiated as it may be the only warning one may get before developing a major stroke.

Q. What is the first line of treatment?

A. Doctors will first assess the patient to confirm a stroke and determine the risk factors, then do investigations including a CT scan. Initial treatment involves monitoring and controlling the blood pressure (which should not be too high or too low in the early stages after a stroke), blood glucose level, oxygen level, and if needed measures to reduce brain swelling.

Once a brain bleed is ruled out, blood thinning (anti-platelet) treatment is initiated. Patients will also be given cholesterol lowering drugs. If the patient is brought to the hospital and a brain bleed is ruled out within three hours, clot buster treatment is given in a few hospitals where it’s available.

All patients with stroke should also be assessed and treated for possible complications such as infections (of the lungs and the urinary passage), DVT (clots in the leg veins), pressure ulcers and depression. Stroke patients should be managed with the aim of preventing these complications which would otherwise adversely affect recovery from stroke.

Q. Thereafter what is the next step towards rehabilitating victims?

A. Rehabilitation of a stroke victim requires multidisciplinary support and is best undertaken in the setting of a stroke unit.

A Stroke Unit is a hospital unit (may be separate or part of a ward) that cares for stroke patients exclusively or almost exclusively, with specially trained staff and a multidisciplinary approach to treatment and care. The multidisciplinary team consists of doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, psychologists/counsellors and a social worker. It has been proven that treatment in a Stroke unit improves chances of survival and reduces both disability and length of hospital stay.

Q. After a stroke, are there any dietary guidelines?

A. Dietary guidelines are not specific for stroke victims but should be followed by all to prevent a first or a recurrent stroke and other NCDs. The diet should be rich in fruits and vegetables and low-fat dairy products and reduced saturated and total fat, sugar and salt. Cessation of smoking and limitation of alcohol intake are essential.

Q. What about exercise? Can a stroke victim cycle, swim, walk, climb stairs, carry weights/ play tennis?

A. Guidelines for exercise recommend increased moderate aerobic physical activity for 150 minutes a week (i.e. 30 minutes a day for five days).

There is no limitation of the type of aerobic physical activity as long as the patient can cope with it safely (especially with the aim of avoiding falls).

Q. Is there a limit to such exercises? Do they have to be under medical supervision?

A. Supervision and guidance by a physiotherapist or carer may be needed in the initial period. In the presence of heart or lung disease, close medical supervision may be required.

Q. Once a stroke victim, are you always a stroke victim? How long does recovery take, on average?

A. Not necessarily. On average after a stroke, one- third of patients fully recover or will be left with only minor disability. Another third will be significantly disabled for life. One third of patients will die, either directly as result of the stroke or due to one of its complications.

Duration of recovery is variable and depends on the severity of stroke, age of the patient, presence of complications and the setting of post-Stroke care.

The majority of patients who do recover usually regain physical functions and activities of daily living over a period of approximately 2 - 4 weeks. Stroke victims carry a higher risk of developing a second stroke, irrespective of their level of recovery. Approximately one quarter of strokes occur in patients who have already suffered a stroke.

Therefore, patients should strictly adhere to the advice given on lifestyle modifications and the treatment prescribed to prevent another stroke.

Q. In some countries there are stroke units where patients get everything they need from treatment to rehabilitation and counselling. Does the National Hospital have this facility and also any private hospital? Tell us more about the functions of this unit.

A. The first stroke unit in Sri Lanka was established at the Institute of Neurology of the National Hospital in 1998 by Consultant Neurologist Dr Jagath Wijesekera, who was also the Founder President of the National Stroke Association.

Thereafter stroke units have been established in several provincial hospitals largely due to the advocacy of the National Stroke Association and its past presidents together with the initiative taken by the Ministry of Health. Some private hospitals too have stroke units.

Focusing on others' success can make us selfish

It is believed that the success of humans as a species depends to a large extent on our ability to cooperate in groups.

Much more so than any other ape (or mammal for that matter), people are able to work together and coordinate their actions to produce mutual benefits. But what do we base our decisions on when we know whatever we do will affect those around us?

New research involving Dr Lucas Molleman, an expert in decision making and human cooperation in the School of Economics at The University of Nottingham, suggests that successful cooperation in groups depends on how people gather information about their peers, and how they base their cooperative decisions on it. The broader implication of this research is that the type of information we use to make our decisions can affect our social decision making.

The research, conducted at the University of Groningen in The Netherlands, is published in the academic journal Proceedings of the National Academy of Sciences of the United States of America (PNAS).

Cooperation is of interest to both the natural and social sciences.

Biologists wonder how cooperation could have evolved by natural selection: it is puzzling how cooperation can be beneficial when it is possible to behave selfishly and take advantage of the cooperative efforts of your group.

Psychologists and economists try to understand why many people are willing to sacrifice their own welfare to benefit their social environment.

Understanding the decision-making process

Dr Molleman said: “The question that our research tries to answer is: ‘How do people make decisions when their actions can affect the welfare of others?’ More specifically, we want to know how people determine their behaviour when they have to cooperate in groups.”

In these situations, a beneficial outcome for the whole group can be achieved if everyone works together. Individually, however, people might be better off by making selfish choices. Because of the possibility of others taking a free ride, people pay close attention their fellow group mates when they make decisions. For instance, they cooperate if others also cooperate, but act selfishly when others do not cooperate.

Who is selfish and who isn't?

Two-hundred participants were invited to a computer lab at the University of Groningen.

They were asked to make decisions that affected their earnings. Groups were formed in which the participants could choose between a selfish option (increasing their own earnings) and an option that benefitted all members of their group.

In between making their decisions, people could gather information about their fellow group members; about the choices of the majority and information about which option paid off best.

Dr Pieter Van Den Berg from the University of Groningen said: “From previous research we know that people differ quite strongly in what kind of information they are interested in: some people are ‘majority-oriented’ and tend to look at the behaviour of the majority in their group, whereas others are ‘success-oriented’ and try to find out what kind of behaviour pays off best.

In this experiment we studied how these different types of people behave when they have to cooperate in groups.”

Dr Molleman said: “It turns out that behaviour in groups of success-oriented people was much more selfish than groups of majority-oriented people.

As a consequence, the people in the majority-oriented groups tended to earn more money in the experiment since they cooperated more.

- MNT

New website for CAISL Annual Academic Congress

The launch of the official event website for the 32nd Annual Academic Congress of the College of Anaesthesiologists and Intensivists of Sri Lanka scheduled to take place in January 2016 was held on February 15 at the OPA auditorium. The Chief guest Dr. Palitha Maheepala, Director General of Health Services launched the website on the invitation of Dr. Kanishka Indraratna, President-Elect of the College for 2016.

Dr. Indraratna, outlined the plans for the 32nd Academic Congress during his welcome address.

He said that the meeting is to be at the level of an international congress with a globally reputed faculty of nearly 30 foreign speakers, several workshops conducted by internationally recognised institutions and organisations and an interactive trade exhibition.

The three-day meeting will conclude with a Sri Lankan cultural show and concert.

Dr. Maheepala spoke on the crucial and leading role Anaesthesiologists and Intensivists have in the operating theatre and intensive care unit.

He also spoke about the continuing dire need for Consultants in Anaesthesiolgy for Sri Lanka and sought the cooperation of the College to address the issue.

The website (www.aicsl2016.org) provides details of the College and the meeting with separate pages for events, workshops, guest speakers’ details and links to tourist attractions and accommodation.