Older People With Strokes

An estimated 150,000 people have a stroke in the UK each year (Scottish Stroke Care Audit 2005/2006) with a mortality of over 67,000 (British Heart Foundation, 2005) . It is the third most common cause of death in England and Wales, after heart disease and cancer (NHS, 2001).This is in accordance with the report published by World Health Organization stating, “stroke is the third highest cause of morbidity and mortality in the developed countries of the world, immediately following ischemic heart disease and malignant diseases(WHO, 2008).Because strokes are common and lead to substantial disability and ill-health, a large proportion of the NHS budget is spent on treating people who have suffered a stroke. The direct cost of stroke to the NHS is estimated to be £2.8 billion. The cost to the wider economy is £1.8 billion (NHS, 2001).Thus a needs assessment of this population group might help understand the intricacies of this issue.

This assignment aims at giving a brief account of the factors influencing the health of people who have suffered stroke and further plan and justify a health needs assessment for the same. It will also attempt to provide a critical analysis of a relevant health policy and its impact on the affected population.

Stroke: Definition and Risk Factors

The World Health Organization defines stroke as “a condition caused by the interruption of the blood supply to the brain, usually because a blood vessel bursts or is blocked by a clot. This cuts off the supply of oxygen and nutrients, causing damage to the brain tissue”. The effects of a stroke depends on which part of the brain is injured and how severely it is affected. A very severe stroke can cause sudden death (WHO, 2008).

Various physiologic and medical conditions can precipitate stroke. The risk factors can be categorised into biological, environmental, socioeconomic and behavioural. There is often an interplay of two or more factors that attribute to morbidity.

Biological:

These include age, gender and genetic predisposition. The single most important factor that increases the chances of stroke threefold is the age of the individual (Fisher, 2001).

Age

People most at risk for stroke are older adults, particularly those with high blood pressure, who are sedentary, overweight, smoke, or have diabetes. Incidence rises exponentially with age and majority of them occur in persons older than 65 years (Fisher, 2001). Wolfe, Rudd & Beech (1996) states that the risk of stroke doubles with each successive decade over the age of 55. Older age is also linked with higher rates of post-stroke dementia.

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Gender

In most age groups except older adults, stroke is more common in men than in women. However, it kills more women than men, regardless of ethnic groups (Fisher, 2001). This may be partly due to the fact that women tend to live longer than men, and stroke is more common among older adults. Women account for about 6 in 10 stroke deaths (NHS, 2001).

Race and Ethnicity

In as diverse a population in England and Wales, the minority population, especially those belonging to the African and South Asian origin, face a significantly higher risk for stroke and death from stroke than the English (Wolfe, 1996). They also have a higher prevalence of obesity, diabetes, and hypertension than other groups. However, studies suggest that socioeconomic factors also affect these differences.

Lifestyle Factors

Smoking: People who smoke a pack a day have almost two and a half times the risk for stroke as nonsmokers. Smoking increases both hemorrhagic and ischemic stroke risk (Wolfe, 1996). The risk for stroke may remain elevated for as long as 14 years after quitting, hence an earlier quit is recommended (NHS, 2001).

Diet: Unhealthy diet (saturated fat, high sodium) can contribute to heart disease, high blood pressure, and obesity, which are all risk factors for stroke(Winter, 2001).

Physical Inactivity: Lack of regular exercise can increase the risk of obesity, diabetes, and poor circulation, which increase the risk of stroke.

Alcohol and Drug Abuse: Alcohol abuse, including binge drinking, increases the risk of stroke. Drug abuse, particularly with cocaine or methamphetamine, is a major factor of stroke in young adults. Anabolic steroids, used for body-building and sports enhancement, also increase stroke risk.

Heart and Vascular Diseases

Heart disease and stroke are closely tied for many reasons. People who have one heart or vascular condition (high blood pressure, high cholesterol, heart disease, diabetes, peripheral artery disease) are at increased risk for developing other related conditions (British Heart Foundation, 2005).

High Blood Pressure. High blood pressure (hypertension) contributes to about 70% of all strokes. Hypertensive people have up to 10 times the normal risk of stroke, depending on the severity of the blood pressure in the presence of other risk factors. Hypertension is also an important cause of so-called silent cerebral infarcts, or blockages, in the blood vessels in the brain (mini-strokes) that may predict major stroke. Controlling blood pressure is extremely important for stroke prevention. A meta-analysis of nine prospective studies, including 420,000 individuals followed for 10 years, found that stroke risk increased by 46% for every 7.5-mm Hg increase in diastolic blood pressure (Fisher,2001).

Atrial Fibrillation. Atrial fibrillation, a major risk factor for stroke, is a heart rhythm disorder in which the atria (the upper chambers in the heart) beat very quickly and nonrhythmically (British Heart Foundation, 2005). Between 2 – 4% of patients with atrial fibrillation without any history of TIA or stroke will have an ischemic stroke over the course of the year. Of those with atrial fibrillation, the risk generally is highest in those older than age 75, with heart failure or enlarged heart, coronary artery disease, history of clots, diabetes, or heart valve abnormalities (Winter, 2001).

Diabetes

Heart disease and stroke are the leading causes of death in people with diabetes. Diabetes is second only to high blood pressure as the main risk factor for stroke. The risk is highest for adults newly diagnosed with type 2 diabetes and patients with diabetes who are younger than age 55. African-Americans with diabetes are at even higher risk for stroke at a younger age (Wolfe, 1996). Diabetes is a particularly strong risk factor for ischemic stroke, perhaps because of accompanying risk factors, such as obesity and high blood pressure.

Obesity and Metabolic Syndrome

Obesity may increase the risk for both ischemic and hemorrhagic stroke independently of other risk factors that often co-exist with excess weight, including diabetes, high blood pressure, and unhealthy cholesterol level (Winter, 2001). Weight that is centered around the abdomen (the so-called apple shape) has a particularly high association with stroke, as it does for heart disease, in comparison to weight distributed around hips (pear-shape).

Stroke being a syndromic illness, the health needs of those at risk and post stroke survivors are varied and need due consideration.

Health Needs Assessment in Stroke Survivors

Health needs assessment according to the NHS health needs assessment workbook is a systematic review of the health issues facing a population leading to agreed priorities and resource allocation that will improve health and reduce inequalities. This ensures that any action taken minimises harm to health, and may improve it for those with the most to gain. In particular, stroke is a leading cause of adult disability (Raina, 1998). The trajectory of care for stroke is of sudden onset, acute hospital care followed by rehabilitation and return to community living. Of new stroke survivors, an estimated 56% go directly home after acute care, 32% go to inpatient rehabilitation, and 11% go to long-term care facilities (NHS, 2001). Stroke survivors returning to the community often have difficulties performing every day activities like dressing, eating, and mobility that can last well into the first year post-stroke (Mayo, 2002). It is also commonly associated with cognitive changes (e.g., 26.3% of ischemic stroke survivors are diagnosed with dementia (Desmond, 2000)). Caregivers provide essential support to these individuals when they return home with varying levels of physical and cognitive difficulty.

The assessment of health needs, involves a combination of epidemiological assessment of disease prevalence, the evaluation of the effectiveness of treatment and care options, and their relative costs and effectiveness, analysis of existing activity and resource data, and application of this knowledge to populations (Bowling, 2009). Thus according to pallant (2002) it is important to identify the ‘needs’ not ‘wants’ so as to achieve measurable improvement from an intervention. As this involves time and efforts and results in considerable long term benefits for those who undertake it and for the population assessed. Hence it has attracted the interest of policy makers, health economist and health professionals to satisfy individual and population needs to optimize resource utilization (Lari & Gari, 2005). In the present context the aim of health needs assessment for stroke is to lower the incidence of stroke, directed at reducing smoking, reducing socio-economic deprivation, lowering blood pressure and encouraging healthy lifestyles (Stevens, et al., 2004)

Thus the health needs of stroke survivors during various phases of their post stroke recovery period as discovered in the literature are summarized as follows

Biological aspect

Biological pathology of post-stroke is neuromuscular function impairment which hinge on the lesion area on the brain. Undoubtedly, sensory-motor assessment such as visual field defects, bladder in dysphasia, sensory impairment and muscle power weakness (Klara, 2006). Also, motor paralysis is still a major problem in stroke condition that presents a weakness on the affected side particularly upper and lower extremities, due to lack of muscle tone generation and imbalance of nerve impulse from cerebral cortex which leads to flaccidity and spasticity (Fawcus, 2000).

Therefore in order to evaluate post stroke management and care, use of a variety of standardized tests before physical rehabilitation training can help to assess the general and specific needs of the patients. For example, the Modified Ashworth Scale (MAS) can assess muscle spasticity, the Medical Research Council Motor Power Score (MRC-MPS) can measure motor power and strength of isolated group of muscle and Likert-type scales use to count pain condition (Fasoli et al. 2004). In addition, the Barthel Index can evaluate functional skills of activity of daily living (Shah et al. 1989). These instruments and therapeutic modalities can assess the accurate physical condition and abilities of the stroke survivor and help perform strategic plan for his rehabilitation.

Physical aspects

After the stabilization of the patients medical condition the clinical emphasis is on preparing the patients to return home. The most important physical competency to be monitored in the stroke survivors by the health professionals at this stage are related to activity of daily living (ADL skills). As Gresham (1986) suggests “independence in ADL will continue to be a suitable hallmark of physical restoration”. Therefore the aspects that need consideration include education and training of stroke survivors and care givers to help them safely perform the activity of daily living and adapt the training received in the hospital to the home environment. For example, in the home environment bathrooms may be smaller, hallways may be narrower, carpets may be difficult to manage, and stairs may be difficult to negotiate. The sudden transition to the home with an absence of health professionals with whom to consult as needed may also make caregivers anxious. As a result, caregivers may need advice from peers and/or health care professionals on how to manage the care recipients’ various needs (Cameroon & Gignac, 2008). They may require additional training, and they may need additional emotional support to address fears and anxiety associated with starting to provide care in the community.

Emotional and needs

Stroke survivors need continued practice and support in their activities of daily living and would benefit from the opportunity to test their skills in the home environment under the supervision of rehabilitation professionals and/or nurses (Pallant, 2002). These professionals could appraise and provide feedback about their functioning ability with the aim of enhancing stroke survivors’ skills and confidence. Emotionally, stroke survivors need support from social workers and/or family and friends to manage their mounting anxiety and uncertainty about their skills and competence in the community(Cameroon & Gignac, 2008). The types of resources include access to community care agencies, on-going rehabilitation, and support groups.

Behavioural needs

The first and foremost priority in post stroke rehabilitation is to control the modifiable risk factors in stroke survivors. Several modifiable risk factors that contribute to development and progression of stroke include hypertension, cigarette smoking, diabetes mellitus, excessive alcohol consumption, lack of physical activity, dietary and hyper-cholesterolaemia (Gariballa, 2004). Multidisciplinary team approach not only helps in prevention but also to identify the susceptible population at risk. It is the primary health care team including clinical governance who leads the team (Pallant, 2002). Studies have shown that hypertension is the single most attributable factor for stroke. Smokers are at three fold risk of stroke when compared with non- smokers and 10 fold risks when in combination with raised systolic blood pressure (Wolfe, Rudd & Beech, 1996). Diabetes accounts for 10-20% of all strokes whereas epidemiological studies have confounded that alcohol consumption has direct dose dependent effect (Lindley,2008). Thus patients and care giver counselling in improving the lifestyle related factors and regular monitoring of the patients during post stroke rehabilitation is mandatory for long term benefits.

However in order to make the life of the post stroke survivors and the care givers more comfortable appropriate policies and their implementation should be the highest priority of the government and the Department of Health.

Policy analysis in post-stroke from National Stroke Strategy [version 2008] (Department of Health, 2008)

From the information available, the national stroke strategy tried to give data, advice and support for clear and easy implementation of treatment plan. This policy provides opportunity for stroke survivors to participate and express their health needs. Also, this persuades all institutional services of stroke to prepare pertinent information and health support into the system service to help people access information and care easily. For instance, if stroke survivors need to change service and treatment, healthcare team should explain factual information and transfer them to the right modalities by finding an accurate therapy to support them. Furthermore, if there is a voluntary organization service to serve nearby stroke patients home, health professionals should advise them to encourage joint activity in their society. Conclusively, this guiding principle explores people’s need and open people to feed back information on stroke service attribute.

The essence of involving people in developing service and treatment programme lies in the policy makers’ view to incorporate stroke survivors and carers in decision making for development of strategic plan, focus management, delivery and scrutiny of appropriate service, to provide special tools and assistive support in case of severity. The strength of this stroke policy is evident from the relevant points and emphasis on the step by step sequencing of services regarding important concerns. Besides, guideline pattern has highlighted the key words that refer to reading awareness including consistency of cartoon painting which is easy to capture in perceptual context and comprehension. However, there are a few weaknesses of informative system that cannot explain the details of further information if people need to read in-depth and cannot show the feature of voluntary organization for connection of services.

Examine how to serve life after stroke, assessment and rehabilitation

Having completed basic stroke treatment, the life after stroke needs to be evaluated with an objective for providing a good quality of life and design services for people who have had a stroke and are supported to live with independence with possible availability of resources at their home and environment. The policy aims at stroke survivors and relatives requirement of high-quality rehabilitation training and medical support in order to promote better movement/mobility in day-to- day life, self hygiene and cooking, adequate communicative skills, distress/depression management problem solving ability and sexual

behavioural understanding. The outstanding Information can help many readers and healthcare providers to realize and understand the overview of stroke patients.

All healthcare professionals should follow this guideline on rehabilitation by concentrating on individual patient needs and differing needs of some ethnic groups depending on their culture and belief in environmental society. In addition, the plan of strategy has underlined the end-of-life care by considering severe stroke survivors who seem not to get better and help them join the right service programme with the right caregiver such as special care and needs, choice of place of death and assessment of the satisfaction of patient’s relatives about the end-of-life care. Therefore, the life after stroke policy is to distinguish, to follow and depict the important roles of healthcare team but which cannot see the pitfalls of service process. If the action plan can be manipulated, according to the patient requirement from the hospital to stroke’s home and community, the end result will definitely be much better.

Analyse the process of health service in long-term care support

In order to analyse the policy service system of stroke, the stroke strategy has to be formulated to facilitate easy-to-access services and to receive concomitant service from interdisciplinary team for long-term needs of stroke survivors. Outstandingly, provision of long-term care is essential and has become a part of health promotion because post-stroke pathology is different in each patient that needs to be rehabilitated in different modality intervention programmes. Nevertheless, this policy of long-term care support is difficult to manage a range of different rehabilitations because the activity involves various dimensions and a combination of facilities for different stroke cases and hence difficult to meet the complex social care needs.

Apart from this, the stroke policy provides only an overview of immediate management and does not explain how to set the long-term care and support for stroke survivors. Although the long- term care process can lead to a better quality of life after stroke, there are many factors that need to be planned, especially related to the individual stroke condition. The guidance should be planned and made elusive in terms of mild, moderate and severe stroke in long-term care and support which is necessary for reflection of different short and long term goals to be achieved in rehabilitation training. However, the policy services merely shows people’s needs assessment and do not describe the

effective planning that meets individual needs particularly related to long term care and hence should be considered accordingly to the level of stroke condition to identify specific social care needs, including the purpose of longer-term follow-up with evaluation in multispectral collaborative services.

Discuss home modification, return to work and community participation

To improve the quality of life in post-stroke environment, the stroke policy makers provide only with a framework for adapting the home to be compatible with patient’s needs for him/her to be independent but do not give details of provisions for daily life activities. The conceptual strategy has illustrated general requirement of services for transportation and housing management by pondering over housing needs related to adaptation and modification but does not analyse specific factors that may have both positive and negative impact on the development of post-stroke skills as well as that may obstruct independence in functional ability at their homes. Nevertheless, there are no details of home modifications that are mandatory in sample such as slope area, stairway, toilet, bed room and kitchen.

Conclusion

From the above it is clear that the burden of disease due to stroke and the its impact during the recovery period deeply affects the life of the survivor. The high incidence and prevalence of disease make it necessary to implement appropriate measures to prevent first ever and recurrent strokes. Moreover a well planned rehabilitation of the stroke survivors is vital for improved prognosis. Conclusively an assessment of the health needs of this population group can be used to optimize health care services and facilities in the best interest of the survivors. This can also be used by the policymakers in improving the relevant provisions in meeting the health needs of the deprived.

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