TAKING CARE OF A PATIENT AFTER BRAIN STROKE (PART 2)

TAKING CARE OF A STROKE SURVIVOR (PART 2)

NON-DRUG ASPECTS OF PATIENT CARE

In my previous article posted on 11th August 2011, I had discussed about the various medications that are required to be taken by a stroke patient. However, there are several other aspects of post-stroke care that are equally important to make the life of a stroke survivor better & more comfortable.

1. Assessment of swallowing

Eating food is probably the most important function and a normal swallowing ensures that the patient can take liquids and solid food. Swallowing can be impaired in a stroke of medulla oblongata (brain stem or posterior circulation) and also in bilateral hemispheric strokes. Sometimes, the patient may be too drowsy to swallow. In a person who is awake and conscious, the adequacy of swallowing can be assessed by a swallow test. The patient is made to sit up and asked to swallow a glass of clear water. If he can drink it within half a minute without coughing or choking, then the swallowing seems to be adequate and the patient may be started on oral feeding.

2. Feeding

Feeding and good nutrition is an important aspect of ensuring a good post-stroke recovery. For patients who can swallow, normal food can be given by mouth as early as possible. For people who can not swallow, there are two options. In the first option, a tube (Ryles tube or naso-gastric tube) is inserted from nose upto the stomach and is kept secured by an adhesive near the nose. Then, liquid diet (milk, juice, etc) can be given at 2-hourly intervals through the tube. Ensure that the patient is not lying down while feeding, and the patient head end should be elevated by 30-45 degrees and left so for at least half an hour after feeding. The other option is PEG (percutaneous endoscopic gastrostomy), where a tube is inserted directly into the stomach by a minor surgical procedure by the gastroenterologist. The advantage of PEG (over the naso-gastric tube) are two-fold: i) It can be kept for much longer periods. Ryle's tube needs to be changed every 2-4 weeks. ii) Different types of food can be given via PEG.

3. Physiotherapy

Physiotherapy is the only method by which the strength and balance of the person can be improved upon. Many patients have significant residual weakness and imbalance after brain attack (stroke). They may be unable to stand or walk without support. They may also be unable to use their hands for any meaningful work. This is where physiotherapy is very important. Physiotherapy should be done under guidance of qualified physiotherapists. It should be done on a regular basis. Many patients ask for medicines or operations to improve the muscle weakness; unfortunately there are none, but good & regular physiotherapy can definitely make the muscle power & strength better.

4. Speech therapy

Many stroke survivors have language dysfunction. This can range from difficulty in understanding spoken words, inability to read or write, speaking or repeating the spoken words. In right-handed individuals, language area is located in the left side of brain. Therefore, language problems are more common after strokes on the left side of brain (which causes right sided weakness also). Additionally, patients with stroke in cerebellum (posterior circulation) may have slurred speech, but they are able to understand and speak. Patients with speech problems benefit from speech therapy. This can be taken under the guidance of trained speech therapists/rehab experts.

5. Nursing care

Good nursing care is very important in the post-stroke recovery. This includes feeding, bladder & bowel care, frequent position changing, and bathing. A stroke survivor may be dependent on others for activities of daily living and this is where nursing care is important. If a person lies on the same position for long, bed sores may develop, so, the position of the patient should be changed every two hours. Patient may have urinary and fecal incontinence (lack of control leading to voiding of uring and stool in clothes). This can be overcome with the help of adult diapers or changing clothes/bedsheets as per the needs.

6. Prevention of deep vein thrombosis

Blood clots may develop in the leg veins of people who are immobile. Therefore, in stroke survivors with paralysis of legs, there is a higher chance of clots forming in the leg veins (deep vein thrombosis or DVT). This can be minimised by frequent passive movements of the paralsed leg by the care-giver. There are compression stockings available in the market, which can be worn by the stroke patient to prevent DVT.

7. Cognitive stimulation and counseling:

Patients with stroke are prone to develop dementia (memory loss and other cognitive dysfunction) and depression. The risk can be minimised by various measures. Firstly, the patient should be kept in a well-lit room where abundant natural light comes in. Some stroke survivors may have reversal of sleep rhythm (they may sleep during the day and keep awake at nights). This rhythm may delay the recovery from stroke. Therefore, the patient should be kept busy/engaged during the day and not allowed to sleep. If the patient finds it difficult to sleep during nights, a small dose of sleeping pill may be used. Patients may be encouraged to listen to songs/music (through head phones, etc); allowed to meet with various friends or relatives; talk as often as possible (if patients can not talk, even listening is important for brain stimulation, so the visitors should be encouraged to talk even if the patient does not respond).

Depression after stroke is also common. So, proper counseling and psychotherapy is important. Sometimes, antidepressant medications may also be required.

8. Sexual functions

There is no restriction as such, and sexual functions can be resumed as per the patients' ability. Sexual drive may diminish after stroke, and sometimes, there may be linmitations due to physical handicap. These can be overcome to a great extent with the halp of an understanding partner.

9. Diet

• A good diet is essential for proper recovery.
• A diabetic should follow the diabetic diet.
• Generally, the diet should be low in fat and cholesterol content.
• As constipation is common in post-stroke patient, the diet should be rich in fibre content.

10. Physical activity

Physical activity is encouraged in stroke survivors. They should be encouraged to stand and walk inside home or be taken for an evening or morning walk with an attendant. If these is a risk of fall, use of a walking stick or walker is encouraged. Prolonged sick leave or bed rest is not advised, and the patient should return to normal life activites as early as possible.

DR SUDHIR KUMAR MD (MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, JUBILEE HILLS, HYDERABAD

Email: drsudhirkumar@yahoo.com

Phone: 040-23607777/040-60601066

TAKING CARE OF A PATIENT AFTER BRAIN STROKE

MAKING LIFE BETTER AFTER BRAIN STROKE (PART 1)

Stroke is one of the four leading causes of death and disability in the world (the other three being heart attack, cancer and road traffic accidents). Stroke is common in all countries and in all races. The prevalence of stroke increases with age; however, the average age of stroke patients is much lesser in India & other Asian countries. This is because of higher incidence of hypertension (high blood pressure), more infections, dietary habits and other lifestyle differences.

The medical treatment of brain stroke has been rapidly advancing with thrombolytic therapies (drugs to dissolve the blood clot) and better intensive/acute care. However, a significant proportion of people are left with disabilities after stroke. The aim of this article is to focus on aspects of stroke care after the discharge from the hospital. Part 1 will focus on the medical (drugs and medications) aspects. Part 2 (next article) would focus on the non-drug aspects.

MEDICAL TREATMENT

A stroke survivor is supposed to take a number of medications. In this section, I will discuss the rationale and precautions for them.

1. Antiplatelet drugs: These are drugs which prevent the recurrence of brain stroke. They are also called as "blood thinners". Common medicines in this category include aspirin (ecosprin) and clopidogrel (plavix, clopitab, etc). These medicines are required lifelong. These should be taken after food. The main side effects of these drugs is bleeding. So, if you notice any bleeding such as gum bleeding while brushing, blood in urine, blood vomiting, etc, you should report to your doctor. Sometimes, bleeding may happen in the skin, resulting in reddish or bluish discoloration. Other precaution to be taken is that these drugs should be stopped for 3-5 days prior to any procedure or surgery, including extraction of teeth, etc. If a surgery is done while the patient is taking aspirin, there is a higher chance of bleeding during or after the surgery. One more side effect of aspirin is gastritis or acidity, which should be reported to the doctor.

2. Statins: Statins are universally prescribed to patients with brain stroke. They are cholesterol lowering drugs. These drugs have dual benefit- in addition to lowering the blood cholesterol, they also prevent the recurrence of brain stroke and heart attack (even in patients with normal blood cholesterol). Common drugs in this category are atorvastatin and rosuvastatin. It is commonly taken at bed time after dinner. Statins are generally safe, however, muscle aches and pain (myalgias) may occur and it should be reported to the doctor. Statins are also required for long-term.

3. Medicines for control of risk factors:

a) Diabetes mellitus- Medicines to keep the blood sugar under control (oral tablets or insulin) are required in patients with diabetes; and the dose needs to be adjusted as per sugar levels in the blood. One should watch for signs of hypoglycemia (low sugar) such as weakness,hunger, sweating, palpitations, etc.

b) Hypertension- Patients with high blood pressure need medicines to keep their BP in control. Blood pressure and sugars should be regularly checked and the dose of medications adjusted as per the levels found. These medicines are also required lifelong.

c) Cardiac drugs- Many patients may have co-existing cardiac illness and they should continue their cardiac medications as per the cardiologist advice. It should be noted, however, that there are several common medications (for heart and brain disease); so, do not forget to check with your doctor about any duplication of the drugs (show them the cardiologist prescription).

d) Drugs to lower homocysteine such as folic acid/pyridoxine may be required in some cases, where the serum homocysteine is found to be high.

4. Anticoagulants such as acitrom or warfarin is given to patients with cardio-embolic strokes (clots form in the heart and travel to brain causing brain stroke). Common indications are atrial fibrillation (AF), people with prosthetic heart valves, LV clot, very foor heart function (LV dysfunction, etc). Dose of anticoagulants is adjusted on the basis of a blood test- prothrombin time (PT/INR). So, a patient on warfarin should regularly check PT/INR and report to the doctor, so that the dose can be adjusted.

In summary, patients with stroke are supposed to take a number of medications for different purposes. One should write down all the medications to be taken on a single page with the timings (and before food, after food, etc); and get it verified by your doctor. As the stroke patient may not remember, the caregiver should verify if the medications are taken as per the instructions given by your doctor. Remember to discuss the indication and side effects of each drug which the patient is taking with your doctor. These simple points can make a remarkable difference in the life of a stroke survivor.

DR SUDHIR KUMAR MD (MEDICINE) DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, JUBILEE HILLS, HYDERABAD

Email: drsudhirkumar@yahoo.com

Phone: 040-23607777/040-60601066

HOW SHOULD YOU CHOOSE YOUR DOCTOR?

STEPS TO BE FOLLOWED WHILE CHOOSING A DOCTOR

Today, we have choices in every field of life. Whether it is eating out in a restaurant, choosing an airline, or buying a home appliance, there are multiple options available. We follow certain steps such as a comparison of the quality, convenience, cost, etc to arrive at the best choice. Various websites offer comparison between different brands of home appliances, and travel portals give us the flight timings, services and costs, helping us to choose an airline. However, there is not much help available to enable us to choose the best doctors. This article looks at all the important questions that crop up in our minds when we think of consulting a doctor.

Should you consult a doctor or try home remedies?

Many minor ailments are self-limiting in nature (they get better on their own); so one can try home remedies for them. These include viral fever, loose motions, cough & cold, minor occasional headaches, occasional sleep disturbance, minor bruises after a fall, etc. However, one should consult a doctor if symptoms are severe or persist beyond usual duration. For ex- if fever persists beyond 3 days, loose stools continue leading to dehydration, headaches are severe, one should seek a doctor's advice. Generally, one should consult a doctor if the symptoms are severe leading to impairment or interference with activitites of daily living or if the symptoms are recurrent in nature.

Should you consult a general practitioner (GP) or a specialist?

It is one of the most important issues to delibrate before choosing a doctor. GP is one who has the basic medical degree (MBBS in India). MBBS training requires four and a half years plus one year of internship (total duration of five and a half years). Certain specialised courses are available for GPs such as Family Medicine, but very few doctors are trained in that speciality in India. A specialist is one who has a postgraduate degree- MD (Doctor of Medicine). MD is offered in medical specialities and the equivalent surgical degree is MS (Master of Surgery). MD or MS can be done only after MBBS and it is of three year duration. For super-specialisation, one can then do DM (Doctorate in Medicine), which is of further three years duration. MCh is the equivalent degree in surgical specialities. Therefore, the highest medical degrees in India are DM (in medical field) and MCh (in surgical field), and it would take a minimum of about 12 years after +2 to get these degrees. Remember that there are entrance exams before MD and DM, and then one has to pass both theory and practical exams to be awarded these degrees. A thesis (research) is also mandatory during MD and DM. A point to note is that certain foreign countries award MD as the basic medical degree. So, an MD of USA, Russia or China is equivalent to MBBS of India.

Medical science is rapidly advancing and several new diagnostic tests & treatment modalities have become available in the past two decades. These include widespread use of MRI in 90s and PET scans (which show the functional activity of an organ) now. Infections and tumors can now be more accurately diagnosed. Similarly, several new treatment options are available- such as thrombolytic therapy in stroke, deep brain stimulation (DBS) surgery in Parkinson's disease, new medications for high BP & sugar, etc. It is not very difficult to believe that a GP would not be aware of these latest diagnostic & treatment modalitues.

On the other hand, when you consult a specialist, there could be some drawbacks. A specialist is likley to order more tests (such as coronary angiogram for a suspected cardiac problem), MRI scans in cases of headaches to exclude brain pathology, etc. In addition, the consultation fees could be more; it may be more difficult to get their appointments; you may not be able to discuss your problem in detail because of their busy schedules. For example, there are only 1500 neurologists (DM in neurology) out of a total of 1.5 million registered doctors in India (0.001%). This also translates to one neurologist for one million population. In addition, you may have to see several doctors if you happen to have multiple problems. For example, if you suffer from high BP, diabetes, thyroid problem and knee pain; you would have to consult a cardiologist, endocrinologist, and orthopedic surgeon. Sometimes, problems in other systems may remain undiagnosed, if you consulted a specialist of one system.

Therefore, it may be better to consult an MBBS or MD doctor in the beginning, if you have minor ailments or if you have multiple problems. However, please consult a specialist if your problem is serious or not getting better with treatment under a GP; having frequent reccurrences or if you wish so. In several countries such as UK or USA, one may not be able to consult a specialist unless referred by their GP; however, in India, you are free to consult any doctor of your choice including a specialist.

Identify the doctor of the correct speciality (as per your problem)

You need to choose the appropriate doctor, specialising in the disease you are suffering from. For ex- for ear discharge/ear pain/decreased hearing, you need to see ENT; for chest pain-cardiology; for knee pain-orthopedics, etc. Sometimes, you may not be aware of what speciality to consult. In this case, the receptionist or the secretary of the doctor can help you. If you happen to consult or know any doctor for any previous ailment, you could ask him to guide you in choosing the correct specialist for the current illness.

Should you go to a doctor in a clinic set-up or a multi-speciality hospital

Both clinics and hospitals have their advantages and disadvantages. Hospitals have multiple doctors in the same speciality, so, if one doctor is on leave, you can always consult another doctor. Also, if any cross-referrals are given (if you are asked to see another specialist), you could see them in the same hospital. Most investigations and medications are also available in the same hospital. Drawbacks of a hospital may include longer distance from home/office; higher costs; and uncomfortable surroundings. In a clinic, you tend to feel more familiar with a particular doctor, and you may find the surroundings more comfortable. Cost of treatment could be lower in a clinic. However, a serious illness usually can not be treated in a clinic. For ex- if you have suffered a heart attack or brain stroke, thrombolytic therapy may not be available in a clinic, and valuable time may be lost whie shifting from clinic to a bigger hospital.

Therefore, for a serious illness, you should prefer to consult a doctor in a hospital; and for a minor illness, you could consult a doctor in a clinic. Also, if your illness is undiagnosed, the chances of making an accurate diagnosis is more in a hospital because of availability of all investigations. So, your initial visit (prior to diagnosis) could be to a hospital, and subsequent follow up can be done in a small clinic.

How do you ascertain that a certain doctor is better than others in the same speciality?

Though it is not always easy to identify a better doctor, certain points can help you in this decision.

1. Look where the doctor got trained: If a doctor got trained at AIIMS, PGI Chandigarh, CMC Vellore or some other good colleges, their knowledge & expertise would be better than if they studied in a lesser known college or colleges that give seats after taking money (management quota). Certain magazines like India Today routinely come out with the rankings of top medical colleges and that could be one source for finding the best medical colleges in India.

2. Look at the degrees and qualifications: A doctor with MD (or MS) is better trained than those with MBBS alone, and those with DM (or MCh) are better trained than those with MD (or MS). Certain doctors may also obtain special fellowships in a more specific disease.

3. Number of years of experience: Senior doctors are generally better than the fresh pass-outs, and as the doctor becomes more experienced, he becomes better. This is true for both surgical and medical specialities. For ex- a surgeon who has performed 500 cases of spine surgeries is definitely better than the one who has performed only 20. Similarly, a neuroloigist who has treated 1000 cases of stroke is better than the one who has treated only 50. Every patient has a right to ask his doctor about the number of similar cases treated/operated by his doctor.

4. Any research in the specific field: A doctor with research experience in the field should be preferred over someone without any research experience. Similarly, if a doctor is on the editorial board of a journal or is routinely invited to give talks on a specific disease, he is considered to be an expert and should be preferred. These details can be obtained from different personal and public websites (such as Google scholar and PUBMED).

5. Look for reviews about a doctor or hospital on websites.

6. Knowledge of a specific language: Good communication is the key to a correct diagnosis and better treatment. So, if the doctor knows your language it is an advantage. Many doctors have translators for the benefit of their patients.

I have tried to discuss various issues in this vast topic, and I may have sounded vague at some places. I would welcome any suggestions from your side.

DR SUDHIR KUMAR MD (MEDICINE), DM (NEUROLOGY)

SENIOR CONSULTANT NEUROLOGIST

APOLLO HOSPITALS, JUBILEE HILLS

HYDERABAD, INDIA- 500033

Phone: 0091-40-23607777/60601066

Email: drsudhirkumar@yahoo.com