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STROKE: WHAT YOU NEED TO KNOW Issue # 1 11

Stroke: What you need to know

Nazarina V. Mwakasege-‐Minaya

STROKE AFFECTS UP TO 3 MILLION AMERICANS A YEAR IN THIS ISSUE

Stroke, also called a brain attack, or a cerebrovascular accident (CVA) or incident (CVI), is a serious medical emergency that affects 200,000 to 3 million people a year in the United Status. A stroke occurs when the blood supply to part of your brain is interrupted or severely reduced, depriving brain tissue of oxygen and nutrients. Within minutes, brain cells begin to die1 It is the fifth leading cause of death in the US, just under diseases like heart disease and cancer.2 With a high prevalence amongst women, minorities and children, 3 it is imperative that we educate ourselves on this destructive condition in which 80% of its occurrences are preventable.4 On a global scale, it is the second most common cause of death and is frequently a

cause of adult disability in the developed countries.5 With the US population rapidly aging6 and stroke generally affecting those 65 years and older7, it will be important for the health care system to work with these individuals, their families and communities at-‐large, to educate on the various risks that come with older age, and what methods they can use to prevent stroke. Feigin and Krishnamurthi state that approximately 38 million disability-‐adjusted life years or DALYs, defined as one lost year of "healthy" life were lost in 1990, this number is estimated to increase to 61 million DALYs in the year 2020, 5 less than five years from now, because of the rapid growth in the aging population.

Stroke in Children Stroke, unfortunately, is one of the top 10 causes of death in children between the ages of 1 and 19 years.8

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Stroke and Women 1 in 3 women die of heart disease and stroke, but this can be prevented.9 Read On!

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Overview of Stroke

Graphic Credit: Courtesy of Neuroaid.com

STROKE: WHAT YOU NEED TO KNOW | Issue # 1 2

Prevalence Between the years 2007 to 2010, the overall stroke prevalence in the United States was at an estimated 2.8%. It was during this time that an estimated 6.8 million Americans over the age of 20 had had a stroke. 10 The CDC gathered data in 2010 in which explained that 2.9% of men and 2.9 % of women over the age of 18 had had a history of stroke. These statistics included 3.0% of non-‐Hispanic whites, 3.8% of non-‐Hispanic blacks, 1.9% of Asian/Pacific Islanders, 1.8% of Hispanics (of any race) 5.8% of American Indian/Alaska Natives and 4.1% of other races/or multiracial people were reported to have had a history of stroke. Although the overall prevalence of stroke did not change between 2006-‐2010, a few specific groups were reported to have had higher risks than the rest of the population, these groups include: • Older adults • Blacks • People with lower education • People living in the southeastern

United States

Incidence Each year about 795,000 people experience either a new or recurrent stroke. Of that number 610,000 are first attacks, and the remaining 185,000 are considered recurrent attacks.8

There are three different kinds of strokes:

• Ischemic, the most prevalent, the

way in which 87% of strokes occur, is when an artery to the brain is blocked, blood clots.11

• Coming in second at 10% are ICH or

intra-‐cerebral hemorrhage strokes, described as when a diseased blood vessel within the brain bursts, allowing blood to leak inside the brain.12

• SAH or sub-‐arachnoid hemorrhage is the least common, in which it occurs in 3% of all strokes, happens when a blood vessel just outside the brain ruptures. The area of the skull surrounding the brain (the sub-‐arachnoid space) rapidly fills with blood.13

On average, an American suffers a stroke every 40 seconds. Every 4 minutes someone dies from stroke.

Women have a higher lifetime risk than men. 1 in 5 (20% -‐ 21%) women between the ages of 55 -‐ 75 years will have a stroke; the statistic is 1 in 6 (14% -‐ 16%) for men. If age is adjusted, women overall have a lower stroke incidence than men. This means the frequency at which women are diagnosed with new cases of this condition during the specified period is lower than that of men.

Morbidity

In this context, morbidity refers to the incidence of those who have suffered a stroke. The CDC reports 6.4 million of non-‐institutionalized adults have suffered a stroke, which is 2.7% of the country’s population.

Mortality

Between the years 2008-‐2010, age-‐adjusted data reports that the US average for stroke deaths was 40.3 per 100,000 died from having had a stroke.

Trends In a multi center cohort of black and white adults in US communities, stroke incidence and mortality rates decreased from 1987 to The decreases varied across age groups, but were similar across sex and race, showing that improvements in stroke incidence and outcome continued to 2011.

AFRICAN –AMERICANS AND STROKE

The highest age-‐adjusted stroke incidence rates among black men; followed by black women, white men, and white women. Age-‐adjusted case-‐ fatality rates tended to be higher among black participants and men.

The Epidemiology of Stroke


BEFORE 65: WHITE VS BLACK

% OF DEATHS 5 YR POST STROKE INCIDENT 14-‐1010

White Men 26% White Women 29% Black Men 36% Black Women 41%

White men and women fare better surviving one-‐year and five-‐year post-‐stroke incident before the age of 65.

White Men 57% White Women 55% Black Men 51% Black Women 50%

Black men and women tend to live longer one-‐year and five-‐year post-‐ stroke incident.

There are many social determinants associated with poor health outcomes including socioeconomic status, transportation, and housing. For the purpose of this brief, I will be focusing on socioeconomic status and its implication on those who suffer from stroke.

About 10 years ago in 2006 review of socioeconomic status or SES and stroke were found to have a generally consistent pattern of higher stroke incidence and mortality in lower SES groups15. Lower SES very often dictates your place of birth, nativity, place of residence as an adult – these environments in combination with regional diet, water and soil characteristics can lead to excess stroke mortalities if found to be negative. In lower SES groupings, the incidence rate of stroke was observed to be higher by 30%, more severe discrepancies and higher likelihood for fatality. Those with lower SES are also less likely to receive quality services to treat them post stroke. Variations in SES over the entire life course can possibly explain not only socioeconomic differences in stroke risk in adulthood but give evidence of those who many have increased risks because of worse socioeconomic status in childhood completely independent of their adulthood status.

Between the years 2005 and 2009, 8930 death occurred as a result of stroke. Of these deaths 82.8% or 7391 deaths were non-‐Hispanic whites, 1352 were non-‐Hispanic blacks and the remaining 187 were Hispanics of either race or an ethnicity undetermined. Per the data, non-‐Hispanic blacks fared substantially worse than non-‐Hispanic whites. Much in line with the US as a country, men and women of Arkansas between the ages of 35 – 64 had higher rates of stroke. Discrepancies in stroke mortality rates in terms of sex and race/ethnicity were most evident amongst younger adults, those between the ages of 35 – 64. Those 85 years or older, the ages at which most deaths from stroke occurred, had the least discrepancies. Within this body of research, it was concluded that neighborhood with larger proportions of non-‐Hispanic blacks would suffer higher stroke mortality rates. Why? These specific neighborhoods tended to have lower levels of education, which can ultimately taint compliance with the

instructions of prescribed medications. Other disadvantages of living in such a poorly resourced area included less access to healthy foods, less access to methods to maintain physical fitness i.e. sidewalks, gymnasiums, recreational facilities, parks etc. These same communities usually tend to have more fast food options, which has been directly linked to an increased risk of stroke.16

In concordance with the data found in the study done by Dr. Balamurugan et al. about black and white Arkansans, as you can see on the left the data from Framingham Heart Study, Atherosclerosis Risk in Communities study, and Cardiovascular Health Study of the National Heart, Lung, and Blood Institute from the American Heart Association, many more discrepancies are found for those under the 65, whereas the opposite is true after 65, in which blacks fare better, albeit a small percentage less, but still significant given how much worse they fare when younger.10

AFTER 65: WHITE VS BLACK % OF DEATHS 5 YR POST STROKE

INCIDENT 14-‐1010

Social Determinants of Health and Health Disparities


BEHAVIORAL ASPECTS OF STROKE Stroke has been associated with many behaviors, or in some cases, a lack thereof. Smoking, lack of physical activity, and not taking in the proper nutrition has been associated with an increased risk of stroke.10

SMOKING A person who is currently engaged in smoking behavior has at least a 2 to 4 times increased risk of stroke as compared with non-‐smokers or those who quit in a timespan of 30 years or more. This behavior is a risk factor for the most prevalent types of stroke, ischemic and for the least occurring stroke type, the SAH or the sub-‐arachnoid hemorrhage. This behavior is important to curbing SAH strokes as it has the highest population attributable risk. It has been proven in a variety of studies that the stopping of this behavior can lead to a reduction of risk for stroke across all ages, sexes, and races. Here’s how smoking increases one’s chance of suffering a stroke:

§ Smoking makes blood thicker and more likely to clot, the main cause of strokes.

§ Smoking can increase the culmination of plaque, a combination of fat, “bad” cholesterol, calcium and other substances) in blood vessels that lead to the brain.

§ Smoking can lead to eventual pain in the hands and feet.

§ Smoking damages blood vessels in the brain.

Simply being in vicinity where someone is smoking can cause an increase in stroke, because secondhand smoke can damage blood vessels, which can subsequently lead to a stroke given enough time.17

PHYSICAL ACTIVITY Physical activity has been strongly linked to decreased stroke risk. Exercise, a type of repetitive physical activity, can lower blood pressure, increase the level of “good” cholesterol, and improve health of the blood vessels and the heart. Physical activity also supports healthy weight. Inactivity can lead to being overweight or obese, which increases risk for stroke. Although time will vary for person to person, about 150 minutes of exercise per week is recommended to help maintain weight, even brisk walking or other moderately intense exercises can prevent stroke and other conditions associated with it including hypertension, diabetes, obesity, etc., these frequently appear as comorbidities of stroke. These activities can be difficult for someone who has suffered a stroke, or lacks the full-‐functionality of their legs or arms.18

EATING HEALTHY Eating a diet rich in certain food can help lower one’s risk of stroke. The foods include:

• Fruits • Vegetables • Whole-‐grain, high fiber • Dairy (fat-‐free and low fat) • Beans • Lean Meats • Fish (those high in Omega-‐ 3 acids)

o Salmon o Albacore Tuna o Mackerel o Herring o Trout

Such a diet reduces risk for stroke because of the reduced levels of “bad” cholesterol. These foods also decrease the ability of plaque to form clots that can cause blockages. This diet and types of food in general, of course, can be difficult to access for people who live in low-‐income areas an ecological or environment aspect of this condition.19

PSYCHOLOGICAL ASPECTS OF

STROKE A stroke is not only traumatizing to one’s physical being, but also their emotions. Some consequences of having had a stroke include weakness/paralysis, problems speaking, vision and depth perception issues, as well as trouble swallowing. 20

Imagine, one day being able to speak, walk and see, senses many of us take for granted, taken away very suddenly. Such a change in long-‐term functioning and quality of life can lead to depression, anxiety, distress, and social isolation, particularly in the initial months and years following the event.21 The decrease in supposed self-‐efficacy and can even reduce the affects of rehabilitation services. Survivors of stroke and those that care for them can experience a vast range of issues upon being discharged. Some may find it difficult to reintegrate themselves into their respective communities, especially with having to return to a workplace setting.22

Unfortunately, Susan Everson-‐Rose, PhD, MPH, a senior author and associate professor of medicine and associate director of the Program in Health Disparities Research at the University of Minnesota in Minneapolis, states that, “…stress and negative emotions often increase with age.” She continued on to state that it was important to pay attention, especially to older individuals who complain of stress. It is also important for people to be cognizant of the symptoms and their effects on health outcome and how they can effectively increase stroke risk.23

Although stroke occurs less frequently in younger persons, what kind of psychosocial effects can occur within this population? In an in-‐depth literature review done by Alison Gomes et al., it was found that children who suffered a stroke between birth to 18 years had a decreased level of social interaction, including:

• Reduced social acceptance • Mood instability • Decreased social support

Although results contained evidence in which 90% of participants in a study were employed and 79% of them could drive, very positive outcomes, living skills, communication and other forms of socialization, were found to be moderately low.24

Behavioral, Psychological, and Ecological Aspects of Stroke


ECOLOGICAL ASPECTS OF STROKE Not unlike the aforementioned psychosocial aspects of stroke in which, in a study using an ecological approach to activity after stroke, those who have suffered stroke found it difficult to reintegrate into their communities, in spite of some having something of a remarkable recovery. For the participants of the study who varied from ages 50 to 64,the resumption of activities was a process that involved multiple layers, which could begin with small tasks to the bargaining for access to support and inclusion in social situations. These circumstances, of course, did not only depend on the social network found in these communities, but the layers of interactions between the participants and the various factors found within their environments that could impact their participation.

The study, which used the socio-‐ecological model, described a microsystem, which is considered the setting in which the individual lives. The individual’s family, the individual his/herself and/or friends usually occupy the setting. The barriers associated with the activities to be engaged in within this system were commonly personal fear, the concept of individual responsibility and perceived exclusion. In a higher level, which includes much larger systems including health care institutions and community/local government, the barriers were typically paradoxical. A barrier in one context could easily be used as a facilitator in another, e.g. level of disability. Wherein some settings being disabled can allow you access to certain settings, for those that it does not, a person may be allowed additional access to even more because of entitlements. Those who were rendered less disabled were able to access needed services independently. The more visibly disabled were permitted access to exclusive services, which included personal care and basic activity support.

In this example, there is an obvious advantage of a stroke not leaving a participant very disabled, thus allowing them access to services better than someone who is, because they can physically participate. In the same grain, they are not allowed the more exclusive services because they are less visibly disabled. The opposite was true for those that were more visibly disabled after having suffered a stroke.25

MOVING FORWARD Stroke can affect any one at anytime, especially if his/her body is under certain detrimental distresses. This can be amplified by preexisting conditions or morbidities like diabetes, hypertension and obesity. Without the proper care or precautionary actions including eating healthy and exercising/ engaging in physical activity, as we grow older, we are more susceptible to such a condition, especially if these healthy activities are avoided. It is important that every primary care practitioner go over signs and symptoms of this terrible condition with their patients. It is important that people are instructed about the methods they can use to prevent stroke. Knowledge of stroke should be commonplace; it is too damaging a condition, not to mention a costly one 26, which can be preventable in a lot of cases. This is especially true for caretakers or families with older individuals, low-‐income communities, and those who are found to have a family history of cardiovascular disease.

PRACTICE RECOMMENDATION Education is key to better health outcomes. When a person is familiar with behaviors that can be detrimental to their health and are equipped with the tools to maintain health, a person can feel empowered and take control of their health. A step further than the research recommendation, it will be the onus of social workers and health professionals at-‐large to take the research of evidence-‐based practices proven to increase self-‐efficacy and disseminate the knowledge of research of pervasive conditions like cardiovascular diseases and stroke, in particular, and how best to educate patients, families, and communities to prevent and/or recognize the signs on a micro level. It will be the onus of those at the macro level to advocate and evaluate policies that ensure their locales are educated in helpful, life-‐saving health practices.

POLICY RECOMMENDATION Just as education is a practice recommendation, it is also a policy

recommendation. There should be national guidelines in place that dictate that health classes on the middle school and high school level, at the very least, should have mandatory content in which all children should have to pass courses in which recognizing the signs and symptoms of cardiovascular incidents as well as First Aid/CPR training. This would standardize and allow for the universalization of health knowledge of damaging conditions, not only to the individual, but to their families, communities, and economically as it costs our nation upward of $34 billion each year, including the cost of health care services, medications, and lost productivity.26

Practice Principles: Roles for Professionals


RELEVANT PRACTICE BEHAVIORS Earlier in the paper, we discussed the differences in stroke incidences and fatalities in a variety of groups, including women, children, whites and blacks, etc. It is important that with each population we, as social workers, recognize their Diversity and Difference and tailor our health education for them as their risks can differ. More women, for instance, suffer strokes than men. For a long time, research was targeted toward men, it was only very recently that we learned that the warning signs in men and women differ. Both men and women can experience numbness or weakness, sudden confusion, trouble seeing, trouble walking and a severe headache. Recognizing the diversity and difference, especially amongst a generally large, yet marginalized group – women has allowed for additional signs to be found. These unique signs for stroke in women include:

• Sudden face and arm or leg pain • Sudden hiccups • Sudden nausea • Sudden tiredness • Sudden chest pain • Sudden shortness of breath • Sudden pounding or racing

heartbeat

In acknowledgment of Diversity and Difference, the same must be done for Human Behavior and Social Environment and the relationship between the two concepts and their relation. For example, if it is known that a patient lives in high-‐stressed, low-‐resourced community, asking them to change their diet could be very difficult, a plan may need to be worked out where they can access fresh produce. A community organization could possibly provide transportation, by van or bus, for clients to access foods on a monthly basis. If gyms are not available, a social worker/ community health worker/ health practitioner can suggest an in-‐home workout plan in which they can do simple exercises and physical activities in their homes. Some in-‐home exercises suggestions are:

• Strength Training o Weight Machines o Free Weights o Elastic Band Weights

• Aerobic exercises o Walking o Stationary Bike o Swimming (Pool Therapy)

Compliance with exercise recommendations, diet restrictions, and prescription intake is not always negligence on the part of a patient, very often times there is an inability to access due to a variety of barriers such as lack of knowledge of certain techniques or transportation issues. Being cognizant and acknowledging such concerns and planning accordingly can change the trajectory of stroke and its consequences.

Want to Learn More?

1. CDC.Gov -‐ Stroke

The CDC or Center for Disease Control and Prevention is their online communication channel in which all news about the health of the American people is their primary concern. Here you can learn about stroke and what you can do to prevent or care for yourself and family after an incident.

2. Mayo Clinic -‐ Stroke

The Mayo Clinic is a non-‐profit organization dedicated to the health and well being of people from all walks of life and a trusted leader in medical care, research and education. Their site includes links to make an appointment in their vast health system as well as resources for you to share with your health care provider about stroke and a host of other illnesses.

3. National Stroke Association

For more than 30 years they have become the trusted source for free resources and education for the entire stroke community. They develop programs across the full continuum of stroke—prevention, acute treatment, and rehabilitation.

4. Stroke Health Center -‐ WebMD

WebMD provides valuable health information, tools for managing your health, and support to those who seek information. You can trust that our content is timely and credible. Here you can find news about strokes, videos and community resources, and more.

5. Women's Health.gov -‐ Stroke

The Office on Women's Health (OWH) provides national leadership and coordination to improve the health of women and girls through policy, education, and model programs. Their stroke website includes information on stroke for both women and men and links to resources to help and support individuals and those caring for them.


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