LISA CLARK: Thanks for joining us for our webcast. I am Lisa Clark. This year nearly three quarter of a million people in the United States will suffer a stroke. In fact, strokes are the third leading cause of death in this country behind heart disease and cancer. Still roughly 75% of those who suffer a stroke survive it though most are left with permanent impairment. Many of these stroke victims are elderly and following the immediate crisis there are long term health care issues that their families face.
For families who choose in home care for these relatives, there are many practical and emotional questions to address. Joining us for the next few minutes to discuss home care for elderly stroke victims are two health professionals who do a lot of work with elder care. Dr. William Bulman, a general internist in the Department of Medicine at Columbia Presbyterian Medical Center. He is also a clinical instructor of medicine at the Columbia College of Physicians and Surgeons. He also maintains a private practice in internal medicine in Manhattan. Welcome.
Also joining us is Christian Baldasari, a licensed physical therapist on staff at the Doylestown Hospital in Doylestown, PA. In addition to many years experience in in-patient therapy, out-patient rehab, and home care, Ms. Baldasari also runs aquatic physical therapy programs and has done much work with brain injury patients including stroke victims I presume.
CHRISTINA BALDASARI, LPT: Yes.
LISA CLARK: Welcome to you.
CHRISTINA BALDASARI, LPT: Thank you.
LISA CLARK: First, Dr. Bulman can you give us a brief description of what actually happens during a stroke and what makes it such a debilitating event.
WILLIAM BULMAN, MD: A stroke is an injury or damage that occurs in a portion of the brain as a result of disruption of blood flow to the brain. That occurs either as a result of a blood clot coming from another portion of the body, the heart usually or one of the large arteries in the neck. The blood clot breaks off and blocks a smaller blood vessel in the brain causing the portion of the brain normally supplied by that blood vessel to die.
The second way a stroke can occur is a small blood vessel can rupture in the brain causing bleeding and then death of the tissue that that blood vessel was suppose to supply.
LISA CLARK: Now you want to mention how crucial immediate intervention is.
WILLIAM BULMAN, MD: What can be confusing for some individuals that a stroke can be a very variable, acute illness. It depends entirely on the portion of the brain that is affected and the size of that area of the brain that is affected. A stroke can cause as most people are commonly familiar with a weakness of one side of the body, either weakness of an arm and leg. It can also manifest as isolated weakness of just one side of the face. It can also result in difficulty speaking, difficulty swallowing, or blindness of one or both eyes. A stroke is a very varied thing.
If a person has acute onset of symptoms that suggests to them that they might be having a stroke, any weakness or loss of sensation in a body part, or any sudden change in their ability to speak or comprehend, they should seek medical care immediately. The reason being that in the last several years, we have developed acute treatments for stroke. If the stroke has occurred because of a blood clot we can dissolve the blood clot immediately and perhaps save the portion of the brain that was affected by the stroke.
The reason that I stress the word immediate is that there is a window of about six hours in which we can give this therapy to people if they are a candidate for it. When someone is outside that six hour window, we are left with treating the stroke as we had before we had this therapy available.
LISA CLARK: Time is really critical.
WILLIAM BULMAN, MD: Time is critical.
LISA CLARK: How common is it for stroke victims to require either in home care or facility care after they have a stroke after the hospital stay, of course?
WILLIAM BULMAN, MD: Approximately 40% of people who have a stroke and survive it will go onto to recover fully. The remaining 60% have some disability. That degree of disability that someone has at the initial time of their stroke is not necessarily the degree of disability that they will have forever.
There is definitely a recovery period. We use a simple rule of thumb. After about a month after a stroke with good aggressive physical therapy, approximately 50% of what we could expect to return in terms of function should have could have come back. After about 12 months, just about everything that you can expect to recover should have recovered. Most people outside the 12 month window are sort of left with the disability that their stroke has given them.
I would say that every stroke victim benefits from aggressive physical therapy irrespective of what type of stroke they have had or where their stroke is. Institution of physical therapy and occupational therapy immediately after the stroke will optimize the amount of recover that they are going to have from that stroke.
LISA CLARK: I want to get to that in just a minute but first I want to ask when families are trying to choose between home and facility care, what questions do they need to ask the doctor.
WILLIAM BULMAN, MD: Certainly, there are in-patient rehabilitation centers that have sprung just in the last few decades as we have come to recognize the extreme importance of rehabilitation after someone has had a stroke in terms of optimizing their recovery. The best way to make the determination that someone needs in-patient therapy vs. therapy in their home or in your home if you are bringing that person to come live with you is to discuss things with the health care team while the person is still in the hospital.
In that week after their initial stroke when the doctors are getting an idea of exactly what their disability, when the physical therapist is first meeting the person, or when the occupational therapist is first meeting the person and formulating a care plan, a family needs to engage the health care team in a discussion finding out exactly what the health care needs are going to be. If someone needs aggressive physical therapy more than a few hours a day, home might be the appropriate place for it. An in-patient rehabilitation stay might be more appropriate.
CHRISTINA BALDASARI, LPT: Also the level of progress they make in that short amount of time is important. If they are showing significant gains within the first 3-4 days after the stroke, then they usually go onto the rehabilitation center. Sometimes it takes a little longer but if they really aren't showing progress then that is usually the determination at times.
LISA CLARK: Having an older relative move in can be stressful enough when it has been a gradual health decline but when it is something that is as catastrophic as a stroke, it is traumatic for everybody involved. How do you assess what kind of adjustment that is going to be to your life?
WILLIAM BULMAN, MD: It is an extremely big adjustment to make. The decision to have an older person come home and live with you very often follows an acute event like a stroke. A very functional, independent person has a large or even a small stroke and all of a sudden is unable to live by themselves safely or is unable to do the things on a day to day basis that they need to do to live independently.
That is often the point in which a family gets together and says it's time to bring this person home to live with us. The most important a family can do is to be realistic in what their expectations are in terms of how much care they are going to provide and to be very practical in terms what they are actually able to do and able to give to that person.
LISA CLARK: Let's talk a little bit about the physical therapy requirements. It might be tempting to just try to settle down after something like this has happened but you have to be very aggressive with physical therapy in these cases. It's not just physical therapy. There are several things that need to go on. Tell us a bit about them.
CHRISTINA BALDASARI, LPT: When we first initially see a patient who has had a stroke, we assess their tone and their muscles. A lot times the patient is very flaccid which means that they don't have any muscle tone in one arm or one leg or both. They also have very poor balance sitting or standing. They sometimes have transfer problems, getting in and out of bed or rolling over and things like that. So we assess all of that.
We first work on trying to initiate tone in the muscle. That is the most important thing. The quicker we do that the better for the patient. Then as soon as they start getting tone in the muscles, then we start using that tone in a functional manner. With everyday activities such as getting up out of bed. Then the occupational therapist will come and assess their dressing and grooming. They will use that tone to help to feed themselves and everything that they need to do when they go home.
WILLIAM BULMAN, MD: One of the most important things after an acute stroke that has affected the motor function of a body part or a side of the body is to prevent what is called contractures. A limb that is paralyzed or significantly weakened from a stroke will have a tendency, if you don't use the muscles of that limb it will have a tendency to contract. The muscles become shortened and then eventually become scarred down with scar tissue. It makes it very, very difficult then to straighten an arm or extend a leg for example.
The physical therapist and occupational therapist work very hard in the period after an acute stroke at working on flexibility for a limp to prevent those contractures from forming. Even if a person never regains function in an arm or a leg or both, having a limb that is flexible makes it much, much easier for them or for their caregivers to dress them, to bathe them, and to get them on and off the toilet, if a person does need that kind of assistance. Preventing contractures is an extremely important thing for therapy early on after a stroke.
LISA CLARK: And speech therapy is very critical because not only is there possible impairment of your motor abilities to speak, there is aphasia that sometimes results from a stroke and you have to analyze exactly what is going on and a person's ability to communicate.
CHRISTINA BALDASARI, LPT: Also cognitive problems too. The speech therapist often times will work on cognition, memory, just everyday activities like looking up a phone number in a phone book, also their judgement and making sure they are safe in a kitchen, and all of these different areas of the house.
WILLIAM BULMAN, MD: It all goes back to what I mentioned earlier about strokes being a very variable illness. The portion of the brain that is affected by the stroke will determine exactly what a person's deficit is. You are absolutely right. A person who has weakness of their face may have a lot of difficulty speaking but there are other portions of the brain that can be affected and cause somebody to have difficulty comprehending language or putting together words. A speech therapist will work on all of that. They work on helping form words in terms of the muscle function of the speech. They also help with the more mental functions of understanding and putting together speech.
LISA CLARK: Now if you have chosen to provide in home care for a stroke patient, there are several things you really have to be on the look out for. I understand bladder problems, pneumonia, and bedsores are some very critical side things that can happen as a result of the stroke. Would you address those?
CHRISTINA BALDASARI, LPT: First of all, if a patient is bed bound and they are unable to move in bed. Their muscles aren't working so they are more apt to getting bladder infections and decubiti or bedsores. They should be turned in bed every two hours to prevent muscle contractures again. You want to do some gentle passive range of motion and the therapist can teach the family members how to do that safely. Also pneumonia because their muscles around their ribs become weak. So they are not able to cough effectively and things like that. It is important for the therapist to address these muscle weaknesses before they get a treatment program to address those --.
LISA CLARK: And also they may have some weakness in their mouth muscles so they may aspirate some of their food more commonly.
WILLIAM BULMAN, MD: Very commonly people have difficulty swallowing following a stroke if that portion of the brain is affected and when they eat or drink liquids, the food or liquids that are intended to go down the esophagus go down the trachea instead. The coordination and the control of the small muscles inside the throat that prevent that from happening aren't working and food and liquids go into the lung and cause what is called an aspiration pneumonia.
The initial assessment after a person had their stroke and is in hospital focuses on these issues. It is very important to determine whether a person has the ability to swallow effectively. If a person does not have the ability to swallow effectively or to protect their airway as we say, they often will require a feeding tube where liquid food is introduced directly into their stomach. These are all complex issues related to specific deficits after a stroke but they are all things that people need to watch for.
LISA CLARK: As a physician, I presume that you must be called upon sometimes to make the decision or help the families make a decision about what type of care is going to be best. People want to do in home care need to be very realistic about what is going to be demanded of them.
WILLIAM BULMAN, MD: Caring for a stroke patient who has a significant deficit, has a lot of difficulty moving, is bed bound, has difficulty with their bowel or bladder function is a very demanding job. You need to consider issues of supervision. Someone may need to be in the home 24 hours a day watching that person to make sure they are safe, comfortable, and that they are turned appropriately so they are not developing bedsores.
A person who has difficulty, as Ms. Baldasari mentioned, getting in and out of bed or getting on or off the toilet is going to need a strong individual who will be able to help them. Very often even the best intentioned families aren't set up to do, from either a physical stand point or from just a time stand point, the types of care and supervision that a person requires.
In home care is certainly an option, having either a home health attendant, private nursing, or visiting nurse service. My practice is in New York and we interact frequently with the visiting nurse service. They will provide nursing care and arrange for home attendant care. There are some very significant demands though and it is something that even the best intentioned family needs to take very seriously.
LISA CLARK: And to be realistic about. In addition to the profound physical changes that a stroke can bring about, it can also cause significant mental issues as well in terms of depression and not only for the stroke patient but for the caregivers as well.
WILLIAM BULMAN, MD: Depression after stroke is extremely common. It is a result of the loss of independence and autonomy that a person feels. It is often a direct consequence of decline in mental function that can sometimes accompany a stroke.
It is unfortunately very under recognized, particularly in people that as a consequence of their stroke have difficulty communicating. Very often those people will become tremendously depressed and people will not recognize it. Some of the subtle signs of depression such as not eating or not engaging family in what had been formerly pleasant activities can just be attributed to the stroke. People sometimes say my mother had a stroke and she has never been the same. Well some of that "never having been the same" may actually be depression and may be treatable depression. If a doctor recognizes it for what it is, the medications that treat depression in otherwise health individuals work just as well in older persons if they are dosed appropriately and can make the difference between a happy life with a deficit and a very miserable life after a stroke.
LISA CLARK: I would presume also that for caregivers depression -- depression may result in any circumstance when you have an in home care situation. If you feel that no matter what you do you are unable to help your parent improve or maintain a quality of life. It has to be very taxing emotionally in cases of stroke and I would assume as well for Alzheimer's. It must be emotionally wrenching for the families at times.
WILLIAM BULMAN, MD: It can be very, very difficult. Many caregivers will feel completely alone in the burden that they bear taking care of someone. In most cases, it is a welcoming born burden. You are caring for someone out of love and you want the best for them. You do everything that you possibly can for them but at the same time you are absolutely right. It can be very, very taxing and very emotionally draining. It can be very, very frustrating as you see an older person decline with age.
LISA CLARK: But you can get help.
WILLIAM BULMAN, MD: You certainly can get help. There are certainly support groups. Many community hospitals offer support groups for caregivers. You shouldn't fail to mention the fact that there are support groups for stroke survivors as well.
Learning more about elder care, recognizing that you are not doing this in a vacuum and that it is occurring in a large number of families, speaking with other caregivers, venting your frustrations, asking for help, and getting help when you have reached the limits of what you can do for someone in your home, all of these things can go to making it a less difficult thing.
If you do find yourself in a situation that has you truly depressed, seeking your medical care for your own self and not ignoring the fact that you need to be healthy and happy as well as you care for this person trying to make them healthy and happy.
LISA CLARK: Any final thoughts Christine?
CHRISTINA BALDASARI, LPT: No. I think if you also look for the signs of depression such as loss of appetite, sadness, crying, things that a caregiver can look for in the patient, then the caregiver can then get help from the doctor.
LISA CLARK: I can't thank both of you enough for being here today to discuss some very important issues for people who are considering in home care for their elderly relatives. I would like to thank you Dr. Bulman and Christina Baldasari. Thanks very much for being here. And thank you in our web audience for tuning in. We sure appreciate it. I'm Lisa Clark.