Every year, 41,000 people in the Netherlands suffer a first stroke. It is estimated that 190,000 people in the Netherlands are currently living with the consequences of a stroke (Bots et al, 2006). Due to the aging population in the Netherlands, this number is expected to increase rapidly in the future. (Palm, 2003). Because a stroke has different consequences for different patients, different types of care are also required (Meyboom-de Jong et al, 1995).
What is a stroke?
A stroke, also called a cerebrovascular accident (CVA), is an acute disruption of blood circulation in the brain. These circulation disorders are caused for 80% by blockages (so-called bloodless CVAs) and for 20% by cerebral haemorrhages (bloody CVAs). Closure is caused by a clot in the blood vessel or by a narrowing of the blood vessel. Bleeding occurs when there is a tear in the wall of a blood vessel. Bloodless strokes can be further classified into TIA and cerebral infarction. In a TIA (transient ischemic attack), there is a temporary shortage of oxygen in the brain due to a blood flow disorder in the vascular system. A TIA usually lasts no longer than ten minutes. The symptoms occur from one moment to the next and, unlike other forms of stroke, disappear within 24 hours. This could, for example, be temporary paralysis of a hand, leg or half of the body, as in the example in the introduction. A cerebral infarction is caused by an acute blockage of a blood vessel in the brain. This blockage causes limited blood flow to the brain. Just like a TIA, a cerebral infarction can suddenly occur out of nowhere in a (until then) healthy person. The main causes of a cerebral infarction are: Thrombosis (a blood clot in the blood vessel), Embolism (a blockage within the arteries) from the internal carotid artery and Embolism from the heart (Palm, 2003, pages 17-22).
The risk factors for having a stroke are: old age, high blood pressure, smoking, excessive alcohol consumption, obesity, lack of exercise, high cholesterol, heart disease, diabetes and hereditary predisposition. As we get older, the risk of a stroke increases. This has to do with a deterioration of the vascular system as a result of arteriosclerosis (Palm, 2003, p. 29).
What complaints do patients experience?
Usually a patient has various psychological and physical disorders. The disorders below are the most common.
Daily activities such as moving are made more difficult by movement disorders. The most common movement disorder is semi-paralysis. Due to little strength in the muscles, basic sensory-motor skills such as sitting and standing become difficult. Apraxia makes simple actions such as dressing or eating difficult, because the patient no longer has the overview in the brain in which the combination of movements of these actions is fixed (Staats, 1987, p. 16-18).
Perceptual disorders such as agnosia in which the patient unconsciously ignores one side. When you ask to look at that side, you can do so temporarily. This is different with hemianopia. The patient then really cannot see one side of the visual field. With socket vision, the patient can only see the center. Disturbances in perception are caused, among other things, by a disturbance in the body diagram, in which the patient no longer knows where a limb is. Because there is less feeling in the paralyzed part of the body, the patient cannot perceive temperature or pain, for example (Staats, 1987, p. 20-22; Meyboom-de Jong et al, 1995, p.68).
Dealing with others is made difficult by language and speech disorders. In dysarthria (speech disorder), the patient has a problem speaking, but can understand the language. With aphasia (language disorder) the patient cannot express and understand language. Emotional/psychological changes also make it difficult to interact with others. The most disturbing changes are apathy, childishness, increased or decreased sexual interest and increased reactivity (Staats, 1987, p. 23-24; Meyboom-de Jong et al, 1995, p. 67).
Cognitive disorders also occur. A memory disorder can manifest itself in different ways (recognition, short- or long-term memory or imprinting of information). Attention and concentration disorders occur in almost all patients. This makes it difficult to follow conversations and do multiple things at the same time. The patient also tires quickly. Due to failure to learn from experiences, a patient is unable to change his behavior after previous negative experiences (Meyboom-de Jong et al, 1995, p. 64-66).
Other complaints include pain, incontinence and swallowing and chewing disorders. Depression is also a possible complaint, but there is a debate about whether this is a primary consequence of a stroke (Meyboom-de Jong et al, 1995, p. 66-68).
What care is available in the acute phase of a stroke?
In the acute phase the emphasis is on medical diagnosis. A third of patients stay at home, and two-thirds are admitted to hospital. In the hospital, unnecessary diagnostics are often performed, and when people stay at home, essential diagnostics are often lacking (Meyboom-de Jong, 1995, p. 93-99). This is better in the so-called stroke units, departments where specialized care is offered (Franke, 2005). 60% of patients admitted to hospital are discharged home. These patients, and patients who have been cared for at home from the start, require home care. Patients who are constantly dependent on third parties are admitted to a nursing home. Information is very important in all phases, especially because the patient and those around him did not see the disease coming. (Meyboom-de Jong et al, 1995, p. 96 -102).
When treating a stroke, the prevention of complications and a new stroke is central. Medication is usually used, but surgery is also possible. If a patient has swallowing problems, he will be given a feeding tube. (Staats, 1987, 49-53).
What care is available in the recovery phase?
After a few weeks, the recovery phase begins, with the emphasis on rehabilitation (Meyboom-de Jong et al, 1995, p 93). A rehabilitation program is drawn up for the rehabilitation. This is carried out by a rehabilitation team. The rehabilitation doctor/nurse doctor coordinates the rehabilitation. From the start, the physiotherapist will help the patient regain control of the body with exercises. Language and speech problems are treated by a speech therapist, together with the patient’s family and friends. Neuropsychological disorders are treated by a (neuro)psychologist. With occupational therapy, the patient learns to perform daily activities again, such as washing and dressing. The occupational therapist will make the patient as independent as possible again, using exercises and aids.
During rehabilitation, the patient can live at home or, in the case of intensive rehabilitation, be admitted to a rehabilitation center (young people) or nursing home (elderly). Patients who live at home will receive home care during this period. Motivation and willpower of the patient himself is of great importance for recovery (Meyboom-de Jong, 1995, p. 117-118; Staats, 1987, p. 77-92).
What care is available in the chronic phase?
After a while, the rehabilitation will be completed and the chronic phase will begin. The maximum improvements through therapies have been reached, but small improvements can still occur through exercise. The patient will have to cope without all practitioners. During this period, the general practitioner and home care will mainly focus on supporting the patient and informal care (Meyboom-de Jong et al, 1995, p. 93; Staats, 1987, p. 103-104). Day care in a nursing home allows many patients to continue living at home (Meyboom-de Jong et al, 1995, p. 137).
What developments are there in the field of stroke care?
Stroke units have made great progress in stroke care. The percentage of patients who die or remain dependent on care is 56% when treated in stroke units, compared to 62% with traditional care. Medication is increasingly being used to prevent the recurrence of a stroke. The introduction of thrombolysis has improved the treatment of patients (RIVM, 2004).
Research is being conducted into new therapies. For example , a combination of medication and thrombolysis could be a good treatment method (Weinberger, 2006).
The period after a stroke is divided into three phases. The acute phase, the recovery phase and the chronic phase. In the acute phase, the diagnosis is made and complications and recurrence are prevented. During this period, the patient lives at home or is admitted to the hospital or nursing home. Patients who live at home receive home care here and in the recovery phase.
The recovery phase revolves around rehabilitation. This may involve a rehabilitation or nursing doctor, physiotherapist, speech therapist, (neuro)psychologist and an occupational therapist. During rehabilitation, a patient lives at home, in a rehabilitation center or a nursing home. The treatments are completed in the chronic phase. The patient must be able to save himself, but often receives help from the GP and home care.
Not all patients need all the types of care described above. Each patient experiences different consequences and therefore needs a different treatment plan/rehabilitation program.