Life after a stroke

A stroke can have a dramatic effect on someone’s life, but many people recover and return home. Sometimes, patients feel abandoned after being dis­charged from the stroke clinic or day hospital. Fortunately, there are excellent services provided by the voluntary and charity sectors. Many of these charities offer a range of leaflets, help and advice and clubs and activity groups, as well as family support officers. Their contact details are listed in ‘Useful addresses’.

MOOD CHANGES

Some families note a slight change in the person’s personality or mood. This is not surprising because these parts of behaviour are controlled by the brain, which is affected by a stroke. A stroke can cause depression or anxiety, and anyone suffering from these should be encouraged to see their GP. Sometimes after a stroke, the person can experience mood swings and outbursts, such as cry­ing for no apparent reason. They may also show their frustration at their slow rate of recovery. These changes may improve after a few months, but sometimes they can be permanent.

HOBBIES AND ACTIVITIES

For some people, it is impossible to return to their usual activities, because of problems that remain after the stroke. Others are nerv­ous about returning to their usual activities and some are too fright­ened to restart hobbies or inter­ests. People need to be reassured that their activities will not bring on another stroke, and it is important to increase activities, as recovery allows, to return to as normal a life as possible. There are no major rules to follow (apart from the driving laws) and barriers should not be placed in the way of some­one trying to get back to normal.

Case history

A retired hospital consultant had a major stroke requiring six months’ rehabilitation. He was eventually discharged to his upstairs flat. The provision of a chair lift allowed him to visit his garden and he contin­ued to get great pleasure from supervising his wife at work!

SEXUAL INTERCOURSE

Resuming sexual activity following recovery from stroke is usually safe. However, if your stroke was caused by a bleed, you should consult your GP. Sexual sensations are often not affected by a stroke, but couples may need time to adapt to their new circumstances, especially if they have been left with disabilities. If problems occur, your family doctor can help to identify any obvious medical prob­lem. The Stroke Association can also provide you with information and advice (see ‘Useful address­es’, page 76).

Case history

A 60-year-old woman was attend­ing the day hospital because of problems with recurrent urinary incontinence. Despite a great deal of effort by the nurses and doctors, they were unable to improve the problem and a permanent uri­nary catheter was recommended. The patient was determined to avoid a catheter at all costs and, on further discussion, this was because she did not want ‘a tube’ to interfere with her sexual activity. None of the day hospital staff had asked about sexual activity and had not realised that she enjoyed regular intercourse with her husband. It is easy for medical staff to assume incorrectly that sexual activity stops with increasing age (or after a stroke).

DRIVING AFTER A STROKE

In the UK, the responsibility for informing the Driver and Vehicle Licensing Agency (DVLA) rests with the patient and not the doctor. If a person has had a stroke or TIA, with symptoms lasting more than a month, they have a statutory requirement to write to the DVLA and let them know. The address is: Drivers Medical Unit, DVLA, Swansea SA99 1TU.

If there is any doubt about a person’s fitness to drive, it is possible to undergo a special assessment by driving occupational therapists, who are able to check driving skills and write a report for the DVLA. If a person has an accident despite being told not to drive their car, their insurance will not be valid and they will not be insured.

Case history

A 70-year-old man had problems with his memory and intellect (early dementia) after a stroke. He asked his hospital consultant for permission to return to driving. The consultant established that the patient had adequate vision and strength in his muscles, but was concerned about the mild dementia. The consultant advised that he should not drive. The patient was unhappy with that decision and a formal occupational therapy driving assessment was arranged. The driving test was a disaster, with the patient consistently driving into the kerb. The therapist confirmed that the patient should not drive; he accepted the decision and the DVLA revoked the driving licence.

Driving restrictions

After a stroke or TIA, people must not drive for a month. At one month, it may be possible for the person to restart driving if they have made a good recovery from their stroke, that is, the stroke has not caused problems with muscle control, eyesight or coordination. It is probably wise for people to get advice from their doctor about this. A large visual field problem that remains after a stroke is a bar to driving. If people have frequent attacks of TIAs (for example, several attacks a week for a while), it is very important to stop driving and get medical advice.
There are more restrictive rules for people who make their living by driving (for example, heavy goods vehicle drivers). These rules are there to protect the public and the driver. If someone has an occupational driving licence and has a stroke, they will usually lose their occupational driving licence and, by implication, their job. Their doctor and employer will need to advise them on the rules for their particular circumstances.

SEIZURES AFTER A STROKE

If someone had a fit (also called a seizure) at the start of a stroke, but no subsequent fits, they should not drive for one month (the same rules as for a stroke) and they should inform the DVLA. If they have a fit later on in the recovery period, they should not drive for 12 months. It may be possible in the future to get a driving licence if the fits can be completely con­trolled, but specialist advice is recommended for this situation.

PREVENTING A SECOND STROKE

It is generally true that the risk of a second stroke is much greater than for someone who has never had a stroke. This means that prevention becomes much more important. In the year after a first stroke, the risk of another stroke is about ten per cent, or one in ten. This is about ten times the risk of a similar person who has never had a stroke. In the following years, the risk is lowered to about five per cent, or one in twenty. These estimates are true for most types of stroke.
To prevent a second stroke, patients may need to modify their lifestyle. In some cases, they may also be prescribed drugs or require surgery. The best methods of pre­venting a further stroke depend on the type of stroke previously expe­rienced. It is therefore important to know whether the stroke was caused by a bleed in the brain (a primary intracerebral haemor­rhage) or a blockage in the blood supply (an ischaemic stroke or cerebral infarct).

LIFESTYLE CHANGES

There is plenty that stroke patients can do themselves to prevent a second stroke or even prevent a first stroke. For details of how your lifestyle increases your risk of a stroke, see ‘Why have you had a stroke?’ (page 20). Self-help meas­ures to reduce the risk of a stroke include:
• stopping smoking
• eating a healthy, low-fat, low-salt diet
• losing excess weight
• taking regular exercise (once given the medical go-ahead)
• good control of diabetes if present, with a healthy diet, medication if necessary and regular monitoring of blood glucose levels
• reducing alcohol intake to with­in safe limits
• stopping oral contraceptives in younger women
• regular blood pressure checks.

Blood-thinning treatments

In the case of an ischaemic stroke, the next step to consider is a blood-thinning treatment to prevent future blood clots. These treatments include antiplatelet drugs and anticoagulants. The most commonly used anticoag­ulant is warfarin, which is more potent than aspirin in thinning the blood. Heparin is not usually used, as it has been associated with bleeding in the brain early after stroke and has to be given by injection. After a stroke caused by a bleed (primary intracerebral haemorrhage), patients should avoid medicines that thin the blood.

• Aspirin:

Aspirin has been used as a medical treatment for decades. In addition to helping with rheumatic-type pain and headaches, it has long been known to thin the blood by making part of the blood (the platelets) less sticky. Overall, aspirin has been shown to reduce the chance of blood clots for many conditions, and is now the standard treatment for heart attacks and most types of stroke.
Aspirin has side effects, like all drugs, and these include indiges­tion, as a result of aspirin’s effect on the stomach. This can some­times cause bleeding in the gut, which can occasionally be serious. Aspirin must therefore be taken regularly only on the advice of a doctor. The side effects can be reduced by using a very low daily dose (only a tiny amount of aspirin seems to be required). A dose of as low as 30 milligrams (mg) a day may be effective, but doses of between 75 and 300 mg a day are equally effective and are the sorts of doses generally used in the UK.

• Other antiplatelet drugs:

There are now other medicines available that can also make the
blood less sticky through an antiplatelet effect. These treat­ments include dipyridamole, clopidogrel and ticlopidine. These newer treatments have recently been the subject of much research, and will be increasingly used as alternatives to aspirin and, in the case of dipyridamole, in addition to aspirin. Recent work has concentrated on studying com­binations of antiplatelet drugs and the combination of aspirin and clopidogrel has been found to be beneficial if taken for a few months after a heart attack, although the same combination was not shown to be beneficial if taken after a stroke. Unfortunately, as you in­crease the intensity of blood thin­ning, you also increase the risks of bleeding. Newer trials are testing different combinations of antiplatelet drugs and seeing whether one drug is better than another.

• Anticoagulants:

Warfarin is the most widely used anticoagulant. It is a naturally occurring compound that makes the blood less sticky. It stops the formation of blood clots. The main role of warfarin is to thin the blood in people with a medical condition that causes abnormal blood clots.
The most important heart condition associated with blood clots causing strokes is the condition called atrial fibrillation (AF). In this condition, part of the heart beats abnormally, giving rise to an irreg­ular heart beat. The two atria beat irregularly, and often at a rate of 100 beats/minute or more. This causes the ventricles to beat at a similar (or lower) rate. Overall the heart pump is out of sync – the sequence of the beat is disturbed and the pulse feels erratic. This abnormality is associated with an increased risk of having a stroke because blood clots are more likely to form within the heart, from where they can travel up to the brain. If patients have this heart problem and have had a stroke caused by a blocked blood vessel, warfarin treatment is much better than aspirin, provided that patients can tolerate warfarin.
Unfortunately, the decision to use warfarin can be difficult. The effective dose varies from person to person and also from time to time. Frequent blood tests (called the INR or international normalised ratio) are needed when warfarin is first started and then regular blood tests (perhaps once a month) are needed while treatment is contin­ued. Warfarin can cause abnormal bleeding and therefore people who have a bleeding problem (for exam­ple, regular nose bleeds or a previ­ous major bleed in the brain or gut) should avoid warfarin.
Warfarin interacts with many other medicines and should not be taken with aspirin. It can even interact with paracetamol. If peo­ple have trouble reading medicine labels, fall a great deal or get con­fused, warfarin treatment can be quite risky. Despite these difficul­ties, tens of thousands of people are on warfarin in the UK. For safe­ty reasons, patients must always carry a warfarin card with them in case of a medical emergency. This will tell any doctor or nurse that the person is on warfarin if they need urgent treatment.

RECENT RESEARCH

Cholesterol lowering with medication

Despite following a healthy, low-fat diet after a stroke, recent research has shown that taking a cholesterol-lowering tablet can help prevent strokes and heart attacks. The ‘Heart Protection Study’ enrolled over 20,000 British people at risk of heart attacks and strokes, and found that a moder­ate dose of a cholesterol-lowering tablet from the ‘statin’ class helped reduce premature cardiac deaths and strokes. The surprising aspect of this study was that the treatment was effective even if the patient’s blood cholesterol level was considered ‘normal’. Most British people who have a stroke have a cholesterol level above the threshold used in the study (3.5 mmol/l) and are therefore potentially eligible for this treat­ment. An interesting fact to pon­der is that most people in the UK have a blood cholesterol level that, if lowered, would reduce their risk of heart attacks and strokes. The public health message is clear. Current British diets are not good for the heart and brain, and meas­ures to reduce fat in the diet will help reduce heart attacks and strokes. For the stroke survivor, lowering blood cholesterol with drugs is a new stroke prevention strategy and, furthermore, the lat­est research suggests that there is no upper age limit for this type of treatment.

The underlying message from this trial was that most British people with strokes have a blood cholesterol level that is an impor­tant cause of future heart attacks and strokes.

Blood pressure lowering with medication

Despite following a healthy, low-salt diet after a stroke, recent research has shown that taking blood pressure-lowering tablets can help prevent strokes and heart attacks. The PROGRESS trial enrolled over 6,000 people world­wide who had had a stroke or TIA and found that mod­erate blood pressure-lowering tablets (in this case well-estab­lished blood pressure medication called perindopril/Coversyl or indapamide/Natrilix) helped reduce premature cardiac deaths and strokes. The surprising aspect of this study was that the treatment was effective even if the patient’s blood pressure was considered ‘normal’. Most British people who have had a stroke are therefore potentially eligible for this treat­ment. An interesting fact to ponder is that most people in the UK have a blood pressure level that, if lowered, would reduce their risk of strokes and heart attacks. For the stroke survivor, lowering blood pressure with drugs is a new stroke prevention strategy and, further­more, the latest research suggests that there is no upper age limit for this type of treatment.
The underlying message from this trial was that most British people with strokes have a blood pressure level that is an important cause of future strokes and heart attacks.

More pills for secondary prevention

One consequence of this new research is that many more stroke survivors will be eligible for different pills to reduce the risk of stroke. For example, patients surviving an ischaemic stroke (a stroke caused by a blood clot) are likely to benefit from a blood­thinning tablet such as aspirin, a cholesterol-lowering tablet such as simvastatin (Zocor), and may­be two or even three blood pres­sure tablets. The prospect of taking four or five once-a-day tablets may be daunting to many people and this potential problem should be mentioned if patients are worried about the number of pills. Most people in the trials were taking a similar mix of tablets so the combination is, in general, safe and well tolerated. If taken regularly the combination of pills may halve the future risk of stroke, so the benefits are likely to outweigh the personal nuisance of taking regular daily medication over many years.

Public health strategy for cholesterol and blood pressure lowering for the population

The similarities of the results of the recent cholesterol- and blood pressure-lowering trials deserve some additional comment. Both studies (discussed above) were not simply a good idea tested in a large trial. Experienced teams of researchers who had meticulously studied the patterns of heart attacks and strokes in different communities – the science of epi­demiology – designed both trials. They had noticed that there wasn’t a magic threshold of blood pres­sure or cholesterol that suddenly made you at risk of heart attacks or strokes. In fact the evidence strongly suggested that the higher the blood pressure (and the higher the cholesterol), the higher your risk of heart attack or stroke over a large range of usual blood pres­sure and cholesterol ranges. In fact, these ranges include a large proportion of the healthy middle-aged and elderly British popula­tion. The trials have conclusively shown that, if you’ve already had a stroke, you should be considered for tablets to reduce your blood pressure and cholesterol, because you have a much higher risk of having another vascular event (such as a heart attack or stroke) than a similarly aged person who has never had a stroke.
But do the rest of us need tab­lets to lower our cholesterol and blood pressure? Maybe not all of us! However, the recent research sends an important public health message. Increasing blood presure and cholesterol are a very impor­tant cause of stroke in Western societies and we need to improve our lifestyles. Measures to reduce blood pressure include encourag­ing lifelong exercise (for example, enjoyable sports activities at schools) and stopping smoking. Dietary changes are the best way to reduce blood cholesterol and pro­moting lifelong daily consumption of fresh fruit and vegetables will help keep the population healthier.

SURGERY

In some people, the stroke (or TIA) has been caused by a very tight narrowing of the carotid artery, one of the two large blood vessels in the front of the neck supplying blood to the brain. For some, an operation to clear this blockage can be worthwhile, and will help prevent future major strokes. This operation is called a carotid endarterectomy. As the operation also carries a risk of a stroke, sur­gery is recommended only for those people who seem to have a really high chance of getting a stroke in the next few years.
Doctors use careful assessment and some special tests, such as a carotid Doppler, duplex scanning and angiography, to deter­mine whether an operation could be worthwhile.

Generally, surgery is suitable in people whose risk of having a stroke is over 30 per cent in the next two years, that is, a one in three chance of trouble. It is important to check that the per­son’s stroke (or TIA) was in the same part of the brain supplied by the carotid artery. The assessment should be done by groups of experts in stroke assessment, brain imaging specialists and carotid surgeons.