THE SOCIO-DEMOGRAPHIC PATTERNS OF RESPIRATORY STROKE AND ITS PREVENTIVE MEASURES AMONG MEN AND WOMEN OF 50 YEARS TO 80 YEARS

WHAT IS RESPIRATORY

Stroke is a leading cause of death and neurological disability in adults and impose a heavy emotional and financial burden on the family and so-society. I visited hospitals to describe the socio-demographic pattern of stroke among men and woman of age 50years to 80years and also describe the risk factors, effects of stroke in our practice setting and preventive measure of stroke.

The Socio-demographic pattern of stroke

The term “Socio-demographic” simply means involving the statistical study of human population. It refers to a group defined by its sociological and demographic characteristics. Demographic characteristics can refers to age, sex, place of residence, religion, educational level, marital status etc.

Methods

We prospectively studied one hundred and seven consecutive patients presenting to the neurology unit over a period of last years. The socio-demographic and clinical data collected.

Result

The 107 patients comprised of 60 males and 47 females with age between 50 years to 80 years. The major risk factors where hypertension and diabetes mellitus. Cerebral infarction was the most common subtype of stroke seen.

Conclusion 

Stroke, if not properly managed effectively poses some form of disabilities, and patients suffering from stroke are always at risk of losing their lives, however proper management and adhering to instruction that reduced the incidence of it will help create a stroke free world and give the patient a long life span.

AN OVERVIEW OF RESPIRATORY STROKE

Stroke is a global health problem and a leading cause of adult disability. It is predominantly a disease of the middle age and the elderly. Its occurrence in young age group is not rare. It has emerged as an important cause of morbidity and mortality in young adults between (50 to 80 years) especially in the developing countries.

Stroke is the leading cause of serious, long term neurological impairment and functional disability. It is also defined by the World Health Organization (WHO, 2008) as “rapidly developing signs of focal or global disturbance of cerebral or intracranial neuronal function with symptoms lasting for more than 24 hours or leading to the death of the patient with no apparent cause other than that of vascular origin. It can also be seen as a life threatening condition marked by a sudden disruption in the blood supply to the brain. (Krishnan, 2000)  

The major risk factors for stroke in Nigerian are hypertension, diabetes, hyper-lipidemia etc. Cerebral infarction (stroke) is the most common type of stroke seen occurring in 48% of patients while intracerebral hemorrhage occurs in 15.7% of patients and subarachnoid hemorrhage in 11.3% of patients. The mortality and severity of stroke is on decline in developing countries because of the lifestyle modification, increased use of preventive measures such as adequate blood pressure control, increased use of anti-lipid drugs and aspirin etc.

DESCRIPTION OF RESPIRATORY STROKE

Stroke, also called Cerebral Vascular Accident/attack (CVA), brain attack or a cerebral infarction, is a life threatening condition marked by a sudden disruption in the blood supply to the brain. Disruptions in the blood supply to the brain starve the brain of oxygen-rich blood and cause the nerve cells in that area to be damaged and die within minutes. The body parts controlled by those damaged brain cells lose their ability to function.

Brain cells need blood to supply oxygen and nutrients and to remove waste products. Depending on the region of the brain affected, a stroke can cause paralysis, loss of vision, speech impairment, memory loss and reasoning ability, coma or death. The effects of a stroke are determined by how much damage occurs, and which portion of the brain is affected.

About a third of all strokes are preceded by Transient Ischemic attack (TIAs) or mini strokes, that temporarily interrupt blood flow to the brain while TIAs cause similar symptoms (such as sudden vision loss or temporary weakness in a limb), they abate much more quickly than full-fledged strokes, usually within a few hours. Sometimes as quickly as a few minutes. (Krishnan, 2000)     

Classification/Causes of Strokes

According to Caplan, (2013), the different classes of stroke have different specific causes which include the following:

1.     Ischemic strokes:

        Ischemic strokes are the most common type of stroke. Ischemic simply means the deficiency of oxygen in vital tissue. They occur when a blood clot blocks the flow of blood and oxygen to the brain. Ischemic strokes are caused by blood bolts that are usually one of the four types:

v Thromboembolic stroke and atherosclerosis:

These types of stroke usually occur when an artery that carries blood to the brain is blocked by a thrombus (blood clot) that forms as the result of atherosclerosis (commonly known as hardening of the arteries). These strokes are also sometimes referred to as large artery strokes. The process leading to thrombotic stroke is complex and occurs over time:

-  The arterial walls slowly thicken, harden and narrow until blood flow is reduced, a condition known as stenosis.

In addition, other events contribute to the coming stroke

-  The artery is narrowed by cholesterol laden plaque that becomes susceptible to tearing, in the event, the thrombus (blood clot) forms.

- The blood clot then breaks off and travels to the brain, where it blocks an artery and shut off oxygen to part of the brain, a stroke occurs.

v Cardioembolic strokes & Atrial Fibrillation: An

Embolic stroke is caused by a dislodged blood clot that has traveled through the blood vessels (an embolus) until it becomes wedged in an artery. Cardioembolic strokes start with clot in the heart and may be due to various conditions:

-  In many cases, the blood clots originally form as a result of a heart rhythm disorder known as atrial fibrillation.

-  Embolic can also originates from blot clots that form at the site of artificial heart valves.

- Patients with heart valve disorder such as mitral stenosis are          at increased risk for clots when they also have atrial fibrillation.

- Embolic can also occur after a heart attack or in association   with heart attack or in association with heart failure;

- Rarely, embolic are formed from fat particles, tumor cells or air bubbles that travel through the blood stream

v Thrombotic strokes:

Thrombotic strokes occurs when a clot develops in a diseased artery right in the brain. Thrombotic strokes are less common than either type of embolic strokes. Thrombotic strokes tend to occur at night and their symptoms may develop in a stuttering fashion, more slowly than those of embolic stroke which is usually swift and sudden

v Small vessel (Lacunar) strokes:

Lucunar infarcts are a series of very tiny ischemic strokes which causes clumsiness, weakness and emotional variability. They make up the majority of silent brain. Infarctions are probably a result of chronic high blood pressure. They are actually a subtype of thrombotic stroke. They can also sometime serve as a warning signs for a major stroke. Many elderly people have had silent brain infarctions, small strokes that cause no apparent symptoms. They are detected in up to half of elderly patients who under imaging test for problem other than stroke. The presence of silent infarction indicates as well as dementia. Smokers and people with hypertension are a particular risk.

2.     Hemorrhagic strokes:

Hemorrhagic strokes are caused by arteries in the brain either leaking blood or bursting open. The hemorrhaged blood puts pressure in the brain cells and damages them. Blood vessels can burst or spill blood in the middle of the brain or near the surface of the brain, sending blood into the space between the brain and the skull. The ruptures can be caused by conditions such as hypertension, trauma, blood thinning, medications and aneurysms (weaknesses in blood vessel walls).

3.     Transient Ischemic attack (TIAs):

A transient ischemic attack (TIAs) also known as “mini stroke” is a brief period of symptoms similar to those you would have in a stroke. A temporary decrease in blood supply to part of your brain causes TIAs, which often last less than five minutes like an ischemic stroke, a TIAs occur when a clot or debris block blood flow to part of your brain. A TIA doesn’t leave lasting symptoms because the blockage is temporary.

Signs & Symptoms of stroke

Centres for Disease Control and Prevention (CDC), states that by knowing the signs and symptoms of stroke, you can be prepared to take quick action and perhaps save alife.

Signs of stroke in men and women:

v   Sudden numbness or weakness in the face, arm or leg

      especially on one-side of the body;

v   Sudden confusion, trouble speaking, or difficulty

      understanding speech

v   Sudden trouble walking, dizziness, loss of balance or

      lack of coordination.

v   Sudden severe headache with no known cause

Symptoms of strokes

      The symptoms of stroke can be indicating by acting F.A.S.T, which is a key for stroke. The acronym FAST is an easy way to remember signs of stroke and what to do if you think a stroke has occurred (The most important is to immediately call 9-1-1 for emergency assistance). F.A.S.T stands for:

v   F --------- Face: Ask the person to smile. Does one side of the

                      face droop?

v   A   --------- Arms. Ask the person to raise both arms. Does one

                        arm drift downward?

v   S   --------- Speech; Ask the person to repeat a simple phrase. Is

                        their speech slurred or strange

v   T   --------- Time if you observe any of these signs, call 9-1-1

                        immediately.

Note, the time when any symptoms fist appear. Some treatments for stroke only work if given in the first 3 hours after symptom appear. Call an ambulance so that medical personnel can begin life saving treatment on the way to the emergency room.

THE SOCIO-DEMOGRAPHIC PATTERN OF STROKE

The term “Socio-demographic” simply means involving the statistical study of human population. It can also be seen as a set of variables such as a given population’s age, ethnicity or SES (Socio economic status), whether they reside in an urban or rural area. Furthermore, it refers to a  group defined by its sociological and demographic characteristics refers to age, sex, place of residence, religion, educational level, marital status etc.

v Age: Stroke occurs in all age groups, studies show the risk of stroke doubles for each decade between the age of 55 to 80 years. But strokes also can occur in childhood or adolescence. Although stroke is often considered a disease ofageing, the risk of stroke in childhood is actually highest during the prenatal period, which encompasses the last few months of fetal life and the first few weeks after birth. The risk of stroke increases with age – the older a person is the higher the risk of stroke.

v Gender (Sex): Men have a higher risk for stroke, but more women die from stroke. Men generally do not live as long as women, so men are usually younger when they have their strokes and therefore have a higher rate of survival.

v Religion: Religion was reported to offer a set of belief that assist to find the meaning and goal of negative situation, as well as a gifts of feeling of hope, harmony and consistency, assisting acceptance and adaptation. Positive religious coping has been defined as strategies that include appraising a secure relationship with a benevolent God, a belief that there is meaning in life and seeking support from clergy/church member. Thus, there is need to understand how patients draw on their faith to help manage this disease called stroke.

v Educational Status: The educational activities and communication skills can help healthprofessionals better engage with patient increases clinician and patient satisfaction with these encounters and improve treatment outcomes. Education helps to reduce stroke risk by teaching patient on preventing or controlling high blood pressure and atrial fibrillation can greatly lower chance of having a stroke.

1.  Don’t smoke

2.  Get regular physical activity

3.  Maintain a healthy weight

4.  Limit alcohol to no more than two drinks a day for men or one drink a day for women.

5.  Eat a healthy diet that is high in fruits, vegetables, and whole grains include low fat dairy. Produces and limit salt, saturated fat, trans-fat and cholesterol.

6.  Monitor your blood pressure and work to help keep it at your goal.

7.  Take your medication as prescribed if you have high blood pressure or atrial fibrillation. 

v Marital status: Martial status was classified as single (including divorced) and married (including widowed). Result suggests that in midlife, the continuously married are among the healthiest in cardiovascular outcomes. People with multiple marital losses have a higher likelihood of cardiovascular diseases and will need significant formal and informal care as they advance into old age. (Piento Hayward & Jenkins, 2000).

v Race: African and Americans have a much higher risk of death from a stroke than Caucasians do. This is partly because blacks have higher risks of high blood pressure, diabetes and obesity stroke disease remains the leading cause of races. However, there are big differences in the rates of heart diseases and stroke between different racial and ethnic groups. Some minority groups are more likely to be affected by heart disease and stroke than others which contributes to lower life expectancy found among minorities. As of 2007, African American men were 30% more likely to die from stroke than non-Hispanic white men. African American adults of both genders are 40% more likely to have high blood pressure and 10% less likely than their white counterparts to have their blood pressure under control. African Americans also have the highest rate of high blood pressure of all population groups and they tend to develop it earlier in life than others.

DATA ANALYSIS

Below are the distribution data of stroke patients collected from hospitals in Enugu East LGA of Enugu State: 

Table 1: Gender distribution of stroke

Gender	Frequency (%)
Male	60 (56.1)
Female	47 (43.9)
Total	107 (100)

Table 2: Distribution of stoke patients by educational status

Educational status	Frequency (%)
Illiterate	17 (15.9)
Primary school	36 (33.6)
Middle school	26 (24.3)
High school and above	28 (26.2)
Total	107 (100)

 Table 3: Distribution of risk factors among patients with or without depression

Risk factors	Have depression (n=61) (%)	No depression (n=46) (%)	Total (107) (%)
Hypertension	36 (52.2)	33(47.8)	60(64.5)
Diabetes mellitus	7(38.9)	11(61.1)	18(16.8)
Ischemic heart diseases	10(62.5)	6(37.5)	11(56)
Current smokers	15(68.2)	7(31.8)	22(20.6)
Alcohol drinkers	8(57.1)	6(42.9)	14(13.1)

Figures in parenthesis in column 2 and 3 represent the row percentage  

EFFECTS OF STROKE

      The effects of stroke (brain attack) vary from person to person

based on the type, severity, location and number of stroke. The brain is extremely complex and each area of the brain is responsible for a special function orability. When an area of the brain is damaged, which typically occurs with a stroke, an impairment may result. Impairment is the loss of normal function of part of the body. Sometimes, impairment may result in a disability, or inability to perform an activity in a normal way.

The brain is divided into three (3) main areas:

1.   Cerebrum (consisting of the right and left side or hemisphere).

2.   Cerebellum

3.   Brain stem

      Depending on which of these regions of the brain the stroke occurs, the effect may be very different.

Effect that can be seen with a stroke in the cerebrum

      The cerebrum is the part of the brain that occupies the top and front portion of the skull. It is responsible for control of abilities, such as movement, thinking, reasoning, memory, version and regulation of emotions. The cerebrum is divided into right and left side or hemisphere.

      Depending on the area and side of the cerebrum affected by the stroke, any, or all, of the following body functions may be impaired:

-     Movement

-     Speech and language

-     Eating and swallowing

-     Vision

-     Cognitive (thinking, reasoning, judgment and memory) ability.

-     Perception and orientation to surrounding;

-     Self care ability

-     Bowel and bladder control

-     Emotional control

-     Sexual ability.

      In addition to these general effects, some specific impairment may occur when a particular area of cerebrum

The effects of a right hemisphere stroke may include the following:

-     Left sided weakness (Left hemiparesis or paralysis, left hemiplegia) and sensory impairment.

-     Denial of paralysis or impairment and reduced insight into the problems created by the stroke (this is called left neglect).

-     Visual problems, including an inability to see the left visual field of each eye (homonymous hemianopsia)

-     Spatial problems with depth perception of directions such as up or down and front or back.

-     Inability to localize or recognize body part

-     Inability to understand maps and find objects such as clothing or toiletry items.

-     Memory problems

-     Behavioral changes such as slack of concern about situation, impulsivity, inappropriateness and depression.

Effect of a Left Hemisphere Stroke in the Cerebrum

The effects of a left hemisphere stroke may include the following

-     Right side weakness (right hemiparesis) or paralysis (right hemiplegia) and sensory impairment

-     Problem with speech and understanding language (aphasia)

-     Visual problems including the inability to see the right visual field of each eye (homonymous hemianopsia).

-     Impaired ability to do what or to recognize reason and analyze items.

-     Behavioral changes such as depression, cautioness and hesitancy.

-     Memory problem

Effects can be seen with a stroke in the cerebellum

      The cerebellum is located beneath and behind the cerebrum. It receives sensory information from the body through the spinal cord and helps to coordinate muscle action and control, fine, movement, coordination and balance.

      Although strokes are less common in the cerebellum area, the effects can be severe

Four common effects of stroke in the cerebellum include:

-     Inability to walk and solve problems with coordination and balance.

-     Dizziness

-     Headache

-     Nausea and vomiting

Effects that can be seen with a stroke in the brain stem

      The brain stem is located at the very base of the brain right above the spinal cord. Many of the body’s vital “life support” function such as heart beat, blood pressure and breathing area controlled by the brain stem. It also helps to control the main nerve involved with eye, movement, hearing, speech, chewing and swallowing.

Some common effects of a stroke in the brain stem include problems with the following:

-     Breathing and heart functions

-     Body temperature control

-     Weakness or paralysis

-     Chewing, swallowing and speaking;

-     Vision

-     Coma

Unfortunately death is possible with brain stem strokes.     

PREVENTIVE MEASURES OF STROKE

Knowing your stroke risk factors, following your

doctor’s recommendations and adopting a healthy lifestyle are the best steps you can take to prevent a stroke. If you have had a stroke or a transient ischemic attack (TIA), these measures may help you to avoid having another stroke.

According to Centre for Disease Control and Prevention, CDC, (2015), many stroke prevention strategies are the same as

strategies to prevent heart disease. In general, healthy lifestyle recommendation include:

1.   Controlling high blood pressure (hypertension): One of the most important things you can do to reduce your stroke risk is to keep your blood pressure under control. If you have had a stroke, lowering your blood pressure can help prevent a subsequent transient ischemic attack or stroke. Exercising, managing stress, maintaining a healthy weight and limiting the amount of sodium and alcohol you eat and drink are always to keep high blood pressure in check. In addition to recommending lifestyle changes, your doctor may prescribe medications to treat high blood pressure.

2.   Lowering the amount of cholesterol and saturated fat in your diet: Eating less cholesterol and fat especially saturated fats and trans fats may reduce the fatty deposits (plaques) in your arteries. If you can’t control your cholesterol through dietary changes alone, your doctor may prescribe a cholesterol – lowering medication.

3.   Quitting tobacco use: Smoking raises the risk of stroke for smokers and non-smokers exposed to second hand stroke. Quitting tobacco use reduces your risk of stroke.

4.   Controlling diabetes: You can manage diabetes with diet, exercise, weight control and medication.

5.   Maintaining a healthy weight: Being overweight contributes to other stroke risk factors such as high blood pressure, cardiovascular disease and diabetes. Weight loss of as little as 10 pounds may lower your blood pressure and improve your cholesterol level.

6.   Eating a diet rich in fruits and vegetables: A diet containing five or more daily serving of fruits or vegetable may reduce your risk of stroke. Following the Mediterranean diet which emphasis olive oil, fruit, nuts, vegetable and whole grains may be helpful.

7.   Exercising regularly: Aerobic or “cardio” exercise reduce your risk of stroke in many ways. Exercise can lower your blood pressure, increase your level of high density, lipoprotein cholesterol and improve the overall health of your lose weight control diabetes and reduce stress. Gradually, work up to 30 minutes of activity – such as walking, jogging, swimming or bicycling – a most, if not at all, days of the week.

8.   Drinking alcohol in moderation if at all: Alcohol can be both a risk factor and a protective measure for stroke. Heavy alcohol consumption increases your risk of high blood pressure, ischemic stroke and hemorrhagic stroke. However, drinking a small to moderate amounts of alcohol such as one drink a day may help prevent ischemic stroke and decrease your blood’s clotting tendency. Alcohol may also interact with other drugs you are taking. Talk to your doctor about what’s appropriate for you.

9.   Treating obstructive sleep apnea, if present: Your doctor may recommend an overnight oxygen assessment to screen for obstructive sleep apnea (OSA). If OSA is detected, it may be treated by giving you oxygen at night or having your wear a small device in your mouth.

10. Avoiding illicit drugs: Certain street drugs such as cocaine and methamphetamines are established risk factors for Transient Ischemic attack (TIA) or a stroke. Cocaine reduces blood flow and can cause narrowing of arteries.

PREVENTIVE MEDICATION

      If you have had an ischemic stroke or TIS, your doctor may

recommend medications to help reduce your risk of having another stroke. These include:

1.   Anti-platelet drugs: Platelets are cells in your body that initiates clots. Anti-platelets drugs make these cells less sticky and less likely to clot. The most commonly used anti-platelet medication is aspirin. Your doctor can help you determine the right dose of aspirin. The doctor may also consider prescribing aggrenox, a combination of low dose aspirin and the anti-platelet drug dipyridamole to reduce the risk of blood clotting. If aspirin doesn’t prevent your TIA or stroke, or if you can’t take aspirin, your doctor may instead prescribe an anti-platelet drug such as clopidogrel (Plavix).

2.   Anti-coagulants: These drugs which include heparin and warfarin (Coumadin) reduce blood clotting. Heparin is fast acting and may be used over a short period of time in the hospital. Slower acting warfarin may be used over a longer time.  Warfarin is a powerful blood thinning drug, do you will need to take it exactly as directed and watch for side effects. Your doctor may prescribe these drugs if you have certain blood a clotting disorder, certain arterial abnormalities, an abnormal heart rhythm or other heart problem. Other newer blood thinner may be used if your TIA or stroke was caused by abnormal heart rhythm.

CONCLUSION

Stroke, if not properly managed effectively poses some form of disabilities, and patients suffering from stroke are always at risk of losing their lives, however proper management and adhering to instruction that reduced the incidence of it will help create a stroke free world and give the patient a long life span.

REFERENCES

Caplan, L., R., (2013) Etiology and classification of stroke. Retrieved

      on July 19, 2015 from http://www.uptodate.com/home

Centre for Disease Control and Prevention (CDC, 2013). National

      Institute of Neurological Disorders and stroke www.loweringbloodsugarfast.com

Edinburg., S., G., (2003). Management of Patients with stroke.

      British Association of stroke physician   www.removeacnescarnow.com

Krishnan, K. R. (2000). “Depression as a contributing factor in

      cerebrovascular disease. American Heart Journal 140

www.oilyskinfacemask.com

Understanding Stroke risk (2012). American Heart Association Inc.

retrieved on February 10, 2015 from www.strokeassociation.org/strokeORG