WEEK 2: Prevention of stroke.

Question 1

What is stroke?

Answer 1

Stroke is defined by the WHO as a clinical syndrome consisting of

*Rapidly developing clinical signs of focal (at times global) disturbance of cerebral function
*Lasting more than 24 h or leading to death with no apparent cause other than that of vascular origin.

Question 2

Define a non-disabling stroke.

Answer 2

A non-disabling stroke is defined as a stroke with symptoms that last for more than 24 hours but later resolve, leaving no permanent disability.

Question 3

Describe how stoke occurs.

Answer 3

A stroke occurs when a blood clot blocks a blood vessel or artery, or when a blood vessel breaks, interrupting blood flow to an area of the brain.

When a stroke occurs, it kills brain cells in the area surrounding where the clot or breakage occurs.

Question 4

Define the 2 types of strokes.

Which one is more common?

Which stroke is more deadly?

Answer 4

There are 2 types of stroke:

1. Ischemic strokes occur when a blood clot or other debris blocks a blood vessel leading to the brain, resulting in reduced blood flow and oxygen supply to a part of the brain.
2. Hemorrhagic Stroke:
   Hemorrhagic strokes occur when there is bleeding in the brain due to a ruptured blood vessel.

Ischemic= Clot
(makes up approximately 87% of all strokes)
Hemorrhagic= Bleed
Bleeding around brain
Bleeding into brain

Question 5

Describe the epidemiology of Ischemic stroke.

Discuss the 2 types of ischemic stroke.

Answer 5

*They are the most common type of stroke, accounting for about 87% of all strokes.

*Ischemic strokes can be further divided into two groups:

-Thrombotic strokes and embolic strokes.

*Thrombotic strokes occur when a blood clot forms within one of the arteries supplying blood to the brain.

*Embolic strokes occur when a blood clot or other debris forms elsewhere in the body (often in the heart) and travels to the brain, blocking a blood vessel there.

Question 6

Describe the epidemiology of hemorrhagic stroke.

Discuss the 2 types of hemorrhagic stroke.

Answer 6

They account for about 13% of all strokes.

Hemorrhagic strokes can be further divided into two types: intracerebral hemorrhage and subarachnoid hemorrhage.

*Intracerebral hemorrhage happens when a blood vessel within the brain ruptures and leaks blood into the surrounding brain tissue.

*Subarachnoid hemorrhage occurs when there is bleeding in the space between the brain and the thin tissues that cover it.

Question 7

Define a Transient Ischemic attack (TIA).

Answer 7

A transient ischemic attack (TIA) is defined as stroke symptoms and signs that resolve within 24 hours.

TIAs transient ischemic attacks are a serious warning of an impending stroke.

TIA symptoms are the same as for stroke.

TIAs are brief episodes of stroke symptoms that resolve within minutes or hours, unlike stroke symptoms which can last longer.

Question 8

Up to how many % of all persons who experience a TIA will go on to have a full stroke?
- Within two days of a TIA, how many % of patients will have a stroke?
- Within 90 days of a TIA, how many % will have a stroke?

What is the main aim of TIA management?

Answer 8

Up to 40% of all persons who experience a TIA will go on to have a full stroke.
- Within two days of a TIA, 5% of patients will have a stroke
- Within 90 days of a TIA, 10% to 15% will have a stroke

Management of TIAs focuses on preventing a future stroke.

Question 9

What is the significance of a transient ischemic attack?

Answer 9

Importance of a TIA

*A warning sign of a future stroke – up to 40% of TIA patients will have a future stroke.

*Symptoms of TIAs are the same as stroke.

*TIA symptoms can resolve within minutes or hours.

*It is important to seek immediate medical attention if TIA is suspected.

Question 10

State the epidemiological facts about stroke.

Answer 10

A leading cause of adult disability.

Up to 80% of all strokes are preventable through risk factor management.

On average, someone suffers a stroke every 40 seconds and someone dies from stroke every 4 minutes in America.

Question 11

What is the biggest single cause of cardiovascular disease accounting for 62% of strokes and 49% of heart disease?

Answer 11

Raised blood pressure

Question 12

What kills more people around the world than any other cause of death – around 12.7 million people each year?

Answer 12

Strokes and coronary heart disease kill more people around the world than any other cause of death – around 12.7 million people each year.

Question 13

Describe Stroke trends in Botswana Situation.

Answer 13

According to the latest WHO data published in 2017:

*Stroke, listed as the underlying cause of death, accounts for nearly 1,023 (6.98%) deaths in Botswana.

That’s about 1 of every 14 deaths in Botswana.

*Death Rate (Deaths per 100,000 population): 98.02

*Stroke is the 3rd leading cause of Death in Botswana, after HIV/AIDS and Ischemic Heart disease.

*Risk factors for CVD are increasing such as smoking, obesity, alcohol intake

Question 14

Who is at risk of having a stroke?

Answer 14

1. Age: The risk of stroke increases with age.

*While strokes can occur at any age, the likelihood of having a stroke rises significantly after the age of 55.

2. Sex:
   *Men have a higher risk of stroke at younger ages, but women tend to live longer, resulting in a higher lifetime risk of stroke for women.
3. Race and ethnicity:

Certain racial and ethnic groups, such as Black, Hispanic, and Native American populations, have a higher risk of stroke compared to white individuals.

4. Family history:

Having a close relative (parent, grandparent, sibling) who has had a stroke increases an individual’s risk.

5. Medical conditions:

Several medical conditions can increase the risk of stroke, including:
-High blood pressure
-Diabetes
-Heart disease
-High cholesterol levels
-Atrial fibrillation (an irregular heart rhythm)
*Sickle cell disease.

6. Lifestyle factors:

Unhealthy lifestyle choices, such as:

-Smoking
-Excessive alcohol consumption
-Physical inactivity
-Poor diet (high in saturated fats, trans fats, sodium, and cholesterol)

Question 15

Discuss the ABCD2 score.

Answer 15

Prognostic score to identify people at high risk of stroke after a TIA.

The two-day stroke risk is.
1% for an ABCD2 score of 0-3
4% for a score of 4-5
8% for a score of 6-7

It is calculated based on:

A – age (≥ 60 years, 1 point)

B – blood pressure at presentation (≥ 140/90 mmHg, 1 point)

C – clinical features (unilateral weakness, 2 points; speech disturbance without weakness, 1 point)

D – Duration of symptoms (≥ 60 minutes, 2 points; 10–59 minutes, 1 point)

D- presence of diabetes (1 point).

Total scores range from 0 (low risk) to 7 (high risk)

Question 16

One way to help remember the symptoms of stroke and what to do, is to learn the Face, Arms, Speech Test, otherwise known as F.A.S.T.:

Answer 16

F = Face: ask the person to smile
– Do both sides of the face move equally? (Normal) Or
-Does one side of the face not move at all? (Abnormal)

A = Arm: ask the person to raise both arms
– Do both arms move equally? (Normal) Or
-Does one arm drift downward compared to the other? (Abnormal)

S = Speech: ask the person to speak a simple sentence
– Does the person use correct words with no slurring? (Normal) Or
-Do they slur their speech, use inappropriate words or is unable to speak at all? (Abnormal)

T = Time/test all 3 symptoms
-Time: to call 911 – if you observe any of these symptoms, call 911 immediately. Every minute matters!

Question 17

Outline Common Symptoms of a Stroke.

Answer 17

The most common stroke symptoms are:
*Sudden numbness or weakness of face, arm or leg, especially on one side of the body

*Sudden confusion, trouble speaking or understanding

*Sudden trouble seeing in one or both eyes.

*Sudden trouble walking, dizziness, loss of balance or coordination

*Sudden severe headache with no known cause

Question 18

Outline the Modifiable Risk Factors of stroke.

Answer 18

Hypertension
Diabetes Mellitus
Dyslipidemia
Cardiac Disease
Obesity
Cigarette Smoking
Alcohol Misuse.

Question 19

How Do You Prevent a Stroke?

Answer 19

Many strokes are preventable if you pay attention to pre-existing medical conditions and control lifestyle factors such as diet and exercise.

Question 20

Discuss the Primary Prevention of stroke.

Answer 20

*If no history of previous stroke or transient ischemic attack
*Involves carrying out a cardiovascular risk assessment

Done through
-Management of pre-existing risk factors

*Medical conditions
*Modifiable risk factors

Question 21

Outline lifestyle modifications which can be done to prevent stroke.

Answer 21

Tailored exercise
Low-salt diet
Low fat diet
Smoking cessation
Reduced alcohol intake

Question 22

Outline the Pre-existing Medical Conditions to be targeted in primary prevention of stroke.

Answer 22

Hypertension
Atrial Fibrillation
Diabetes
Hypercholesterolemia
Carotid artery stenosis
Atherosclerosis

Question 23

What medical condition is the number one risk factor for stroke?

Answer 23

Hypertension

Question 24

Discuss how Hypertension Affects Target Organs.

Answer 24

1. HEART
   Angina pectoris
   Unstable angina
   Myocardial infarction
   Sudden death
   Heart failure
2. BRAIN
   TIA
   Ischemic stroke
   Hemorrhagic stroke
3. KIDNEYS
   Renovascular disease
   Renal failure
4. PERIPHERAL FOOT
   Claudication
   Aneurysm
   Critical limb ischemia

Question 25

How can we define Hypertension’ or High blood pressure’?

Answer 25

BY DEFINING THE BP LEVEL ABOVE WHICH IT IS BENEFICIAL TO REDUCE BP

This is the definition generally used
Arbitrary definition, changing over time
1950s DBP 120
1960s DBP 110
1980s DBP 100 SBP 160
Now DBP 90 SBP 140

Question 26

Discuss Studies of migration and BP.

Answer 26

-Generally, show that blood pressure patterns change (increase) to those of the host population:

*Change generally occurs within 6 months
*Strong evidence for ENVIRONMENTAL
influence on population BP
*May be exceptions – high BP in African-
Caribbean's may have genetic basis

Question 27

Causes of ‘essential’ hypertension
Factors contributing to higher BP (high vs low comparison)

Answer 27

SBP higher by:-

-High body mass index 15 mmHg
-High alcohol intake 8 mmHg
-High salt intake 5 mmHg
-Low potassium intake 5 mmHg
-Low fiber/high fat 2-3 mmHg
-Physical inactivity 2-3 mmHg
-Stress ????

Question 28

How strong are the relative risks of high blood pressure (60-69 years)?

Answer 28

-Usual systolic BP 20 mmHg higher: -
relative risk of stroke 2.32
relative risk of CHD 1.85

-Usual diastolic BP 10 mmHg higher: -
relative risk of stroke 2.50
relative risk of CHD 1.79

Applies above SBP 115, DBP 75 mmHg.

Question 29

Describe Stroke Rates by Blood Pressure Level.

Answer 29

Increase in systolic BP increases the rates of stroke starting from 140mmHg going upwards.

The peak in at more than 180mmHg.

Question 30

OUTLINE THE SOURCES OF DIETARY SALT

Answer 30

Processed food: 81%
Cooking salt: 6%
Table salt: 9%
Other sodium: 3%
Water: 1%

Question 31

Sodium Intake and BP

It is estimated that reducing salt intake by how many g a day could lead to
24% reduction in deaths from strokes
18% reduction in deaths from coronary heart disease
Preventing approximately 2.6 million stroke and heart attack deaths each year worldwide?

Answer 31

It is estimated that reducing salt intake by 6g a day could lead to
24% reduction in deaths from strokes
18% reduction in deaths from coronary heart disease
Preventing approximately 2.6 million stroke and heart attack deaths each year worldwide.

Question 32

Lowering blood pressure and relative risk of cardiovascular disease.

-If usual diastolic BP 10 mmHg lower:-

1. relative risk of stroke reduced by about how many %?
2. relative risk of CHD reduced by about how many %?

Answer 32

Sustained reduction in blood pressure over about 5 years effectively reverses the risks of the higher pressure.

-If usual diastolic BP 10 mmHg lower: -

1. relative risk of stroke reduced by about 60%
2. relative risk of CHD reduced by about 44%

Question 33

Who should have their BP lowered?

Discuss the following views:
-The traditional view:
-The new view
-The third (middle) way

Answer 33

-The traditional view:
The reason for lowering blood pressure is that it is high….

‘People who need their blood pressure lowered are those who have a high blood pressure.’

-The new view
The reason to lower blood pressure is to reduce the risk of cardiovascular disease.

‘People who need their blood pressure lowered are those who are at high risk of cardiovascular disease (almost irrespective of their blood pressure)’

-The third (middle) way
‘Blood pressure should be treated on its merits but should take account of overall CV risk’

It means that when managing high blood pressure, healthcare professionals consider not only the blood pressure reading itself but also the individual’s overall risk of developing cardiovascular diseases.

Question 34

BP Treatment

BP control for secondary prevention of stroke at an optimal target BP of 130/80mmHg unless a patient has bilateral severe carotid artery stenosis, in which case, a slightly higher systolic BP target of 150mmHg is recommended.

Why is a slightly higher systolic BP target of 150mmHg is recommended when a patient has bilateral severe carotid artery stenosis?

Answer 34

The slightly higher blood pressure target of 150mmHg for patients with bilateral severe carotid artery stenosis is recommended due to specific considerations related to this condition.

Carotid artery stenosis refers to the narrowing of the carotid arteries, which are major blood vessels in the neck that supply blood to the brain.

This narrowing can restrict blood flow to the brain and increase the risk of stroke.

In some cases, maintaining a slightly higher blood pressure can help ensure adequate blood flow to the brain through the narrowed carotid arteries. Lowering blood pressure too much in these individuals may further reduce blood flow to the brain, potentially worsening the condition.

Question 35

BP lowering should be initiated for secondary prevention after the acute phase (before hospital discharge or at two weeks).

Why not as soon as the stroke happens?

Answer 35

Because lowering BP earlier could reduce cerebral perfusion and lead to a worse outcome.

Question 36

State how much each of the following reduces the SBP.
Weight reduction
Adopt DASH food plan
Dietary sodium reduction
Physical activity
Moderate alcohol consumption

Answer 36

Weight reduction: 5-10 mmHg
Adopt DASH food plan: 8-14 mmHg
Dietary sodium reduction: 2-8 mmHg
Physical activity: 4-9 mmHg
Moderate alcohol consumption: 2-4 mmHg

Question 37

Discuss Carotid Artery Stenosis management.

Answer 37

Pooled data of carotid endarterectomy trials demonstrate that surgery reduces the five-year absolute risk of stroke by 16% in patients with 70-99% stenosis and by 4.6% in those with 50-69% stenosis.

Carotid angioplasty or stenting have been developed as alternatives to surgery for symptomatic patients, although stroke risk is increased with stenting.

During a carotid endarterectomy, a healthcare provider makes an incision on the side of the neck over the affected carotid artery. The artery is then opened, and the plaque is removed.

The procedure is usually performed in a sterile surgical suite or operating room, and the length of the procedure can vary but typically takes 1 to 2 hours.

Carotid endarterectomy is recommended as the first line of treatment for most people with carotid artery disease, as it has been shown to be more effective than other treatments in reducing the risk of stroke.

Carotid stenting, which is a less invasive procedure, may be considered in certain cases, but it carries a higher risk of stroke during the procedure, particularly if performed shortly after symptoms appear.

Question 38

Discuss secondary prevention methods of stroke.

Answer 38

*Occurs when a stroke has already happened
*Prevents deterioration of symptoms

-Statins
-Antithrombotic treatment
-Control of underlying medical conditions

Question 39

Acute Stroke Treatments

There are two types of treatment for ischemic stroke (caused by clots):

Name and describe them.

Answer 39

1. Clot busting medication: t-PA (Tissue Plasminogen Activator)

-Tissue Plasminogen Activator (t-PA) is a clot-busting medication used for the treatment of ischemic stroke, which occurs when a blood clot interrupts blood flow to a region of the brain

-It is a thrombolytic agent that helps break up blood clots and restore normal blood flow.

-The primary mechanism of action of t-PA is the activation of plasminogen, a precursor molecule, into plasmin, an enzyme responsible for the breakdown of clots.

-Plasmin acts by dissolving the links between fibrin molecules in the blood clot, leading to its breakdown

-By promoting the conversion of plasminogen to plasmin, t-PA helps restore blood flow that would otherwise remain impeded.

2.Clot-removing devices: Merci Retriever, Penumbra

*The Merci Retriever is a mechanical thrombectomy device that is used to physically remove blood clots from blocked arteries in the brain.

*It involves the use of a wire-cage device called a stent retriever, which is threaded through an artery in the groin up to the blocked artery in the brain. The stent opens and grabs the clot, allowing it to be removed.

2. Penumbra is another system used for mechanical thrombectomy in the treatment of acute ischemic stroke.

-It involves the use of catheters that use suction or deploy a stent retriever to remove the clot

-The catheters are inserted into a leg artery and slowly threaded through the body up to the blocked vessel in the brain

-The device removes the thrombus through 2 mechanisms: aspiration and extraction.

Question 40

Describe the following acute treatment of hemorrhagic Stroke (Brain Bleed)
Clipping
Coiling

Answer 40

CLIPPING

*During the clipping procedure, a neurosurgeon makes an incision in the scalp and creates a small opening in the skull to access the aneurysm.

*The surgeon then places a small metal clip around the neck of the aneurysm to stop the bleeding and prevent further rupture. The clip remains in place permanently, effectively sealing off the aneurysm.

*After the surgery, a post-operative angiogram is usually performed to ensure that the surgical clip has completely treated the aneurysm. This follow-up imaging helps confirm that the aneurysm is blocked off and reduces the risk of re-bleeding and further brain damage.

COILING

*Coiling, also known as endovascular coiling or coil embolization, is another treatment option for certain types of hemorrhagic strokes caused by ruptured intracranial aneurysms. It is a less invasive procedure compared to clipping and is performed by an interventional neuroradiologist.

*During coiling, a catheter is inserted into an artery, typically in the groin, and guided through the blood vessels to reach the site of the aneurysm in the brain.

*Once in position, tiny platinum coils are inserted through the catheter and into the aneurysm. These coils promote blood clotting and encourage the formation of scar tissue, effectively sealing off the aneurysm and preventing further bleeding.

Question 41

Discuss Lipid-lowering therapy as a secondary prevention method for stroke.

Answer 41

The Stroke Prevention with Aggressive Reduction of Cholesterol Levels (SPARCL) trial

So far is the only published study investigating the efficacy of statin therapy in the secondary prevention of stroke or TIA in patients with no past history of coronary events.

It demonstrated thatatorvastatin 80mg once a day caused an RR reduction of stroke by 15% over five years.

These results have led to current international guidelines advocating that all patients with a total cholesterol >4.0mmol/L or LDL cholesterol >2.0mmol/L who have had an ischaemic stroke or TIA should be treated with a statin unless contraindicated.

Avoid or use statins with caution in patients with intracerebral haemorrhage.

Question 42

Discuss Anticoagulation-AF as a secondary prevention method for stroke.

Answer 42

There is evidence of the superiority of anticoagulation withwarfarin compared with aspirin in the prevention of stroke in patients with AF approximating a two-thirds risk reduction.

Anticoagulation may be started immediately after a TIA or minor non-disabling stroke but is recommended to commence at two weeks after acute cardio-embolic stroke to reduce the risk of hemorrhagic transformation.

WARFARIN MOA
By inhibiting the vitamin K conversion cycle, warfarin reduces the production of biologically active coagulation factors II, VII, IX, and X, which are essential for blood clotting.

(3, 7, 9, 10)

Question 43

Discuss Antiplatelet therapy as a secondary prevention of stroke.

Answer 43

RCTs involving thousands of patients worldwide have demonstrated the beneficial effect of aspirin in secondary prevention of ischemic stroke.

Giving aspirin to patients who have had an ischemic stroke in doses above 75mg daily reduces the risk of stroke by about 13%.

MOA

*Aspirin works by irreversibly inhibiting the enzyme cyclooxygenase-1 (COX-1) in platelets.

*COX-1 is responsible for the production of thromboxane A2 (TXA2), a potent platelet aggregator and vasoconstrictor.

*By inhibiting COX-1, aspirin reduces the production of TXA2, thereby inhibiting platelet aggregation and reducing the risk of blood clot formation.

*Aspirin’s antiplatelet effects are primarily due to its ability to inhibit the production of TXA2, which is involved in amplifying platelet aggregation responses to various stimuli, including collagen, thrombin, and ADP.

*By reducing the production of TXA2, aspirin helps prevent the formation of blood clots on the surface of damaged arterial walls

Dipyridamole and clopidogrel are two other antiplatelet agents used for stroke prevention.

Trials have demonstrated that:

*Aspirin + dipyridamole=clopidogrel alone in efficacy

*Aspirin + dipyridamole or clopidogrel are better than aspirin alone

Question 44

There’s still so much we don’t know about how the brain can seemingly repair itself from the functional damage caused by stroke.

Some brain cells may be only temporarily damaged and may resume functioning.

In some cases, the brain can “relearn” what was lost. Sometimes, a region of the brain “takes over” for a region damaged by the stroke.

People who have had a stroke sometimes experience remarkable and unanticipated recoveries that can’t be explained.

State the % for the following events:

*Stroke survivors recover almost completely

*Recover with minor impairments

*Experience moderate to severe impairments requiring special care

*Require care within either a skilled-care or other long-term care facility

*Die shortly after the stroke

Answer 44

*10% of stroke survivors recover almost completely

*25% recover with minor impairments

*40% experience moderate to severe impairments requiring special care

*10% require care within either a skilled-care or other long-term care facility

*15% die shortly after the stroke

Question 45

Outline Lifestyle Changes for Survivors and Caregivers of stroke.

Answer 45

Daily living skills
Dressing and grooming
Diet, nutrition and eating difficulties
Skin care problems
Pain
Sexuality/Intimacy

BEHAVIORS

1. Depression:

Many survivors experience a form of depression after stroke. It can be overwhelming, affecting the spirit and confidence of everyone involved. Family can help by trying to stimulate interest in other people, encouraging leisure activities and providing opportunities to participate in spiritual activities. Chronic depression can be treated with individual counseling, group therapy or antidepressant drugs.

2. Emotional Liability:

Sudden laughing or crying for no apparent reason and difficulty controlling emotional responses, known as emotional liability, or Pseudo Bulbar Syndrome, affects many stroke survivors. The “inappropriate” emotional behavior will occur randomly and end as quickly as it started.

3. Neglect:

Some stroke survivors neglect the side of their world opposite the side of their stroke brain injury. This may impact their ability to complete some activities. Examples: eating only on one side of a dinner plate or recognizing only one side of a clock.

4. Memory Loss:

Memory loss  also called vascular dementia can be so subtle the family may not notice it at first. A stroke survivor may be anxious and cautious, needing a reminder to finish a sentence or follow-through with a behavior.

5. Communication Problems: If a stroke causes damage to the language center in the brain, there will be language difficulties or aphasia. Communication problems are among the most frightening after-effects of stroke for both the survivor and the family, often requiring professional help.

Question 46

There are 2 types of Stroke Rehabilitation.

Physiotherapy (PT)
Occupational Therapy (OT)

Describe them and their aims.

Answer 46

Physiotherapy (PT)
-Walking, range of movement
-Improves paralysis
-Improves balance & foot drop

Occupational Therapy (OT)
-Taking care of oneself
-Activities of daily living are re-learned
-Speech Language Therapy
-Communication skills, swallowing, cognition
-Recreational Therapy
-Cooking, gardening

Question 47

Describe the following Types of Recovery Services.

*Rehabilitation unit in the hospital

*In-patient rehabilitation facility

*Home-bound therapy

*Home with outpatient therapy

*Long-term care facility

*Community-based programs

Answer 47

1. Rehabilitation Unit in Hospital:

Many general hospitals now offer a variety of rehabilitation services.

A rehabilitation unit in the hospital is a specialized department within a hospital that provides comprehensive rehabilitation services to patients who require intensive therapy and medical supervision.

2. In-Patient Rehabilitation Facility: Patients admitted to a rehabilitation hospital must be able to tolerate a minimum of three hours of intensive therapy per day.

An in-patient rehabilitation facility is a specialized healthcare facility that provides intensive rehabilitation services to individuals who require a higher level of care than what can be provided in other settings, such as home or outpatient clinics.
These facilities are designed to offer comprehensive rehabilitation programs for patients recovering from serious illnesses, surgeries, or injuries.

These hospitals may also offer less intensive programs known as sub-acute rehabilitation units similar to those in long-term skilled nursing facilities.

3. Home-Bound Therapy:

This form of rehabilitation is for patients who cannot leave their homes after discharge from an inpatient setting.

A variety of therapies, along with follow-up nursing and social services, may be available.

Clinicians can focus on personalized needs and unanticipated concerns for patients in this setting.

4. Home with Outpatient Therapy

Home with outpatient therapy refers to a combination of receiving rehabilitation services at home while also attending outpatient therapy sessions at a clinic or facility. This approach is suitable for individuals who are capable of managing their daily activities at home but still require ongoing therapy to support their recovery.

In this scenario, patients receive regular visits from healthcare professionals who provide therapy sessions in the patient’s home. These home-based sessions are complemented by scheduled outpatient therapy sessions at a clinic or facility, where patients can access a wider range of rehabilitation services and equipment.

5. Long-Term Care Facility

A long-term care facility, also known as a skilled nursing facility or nursing home, is a residential facility that provides care and support to individuals who require assistance with daily activities and medical supervision over an extended period. These facilities cater to individuals who have chronic illnesses, disabilities, or conditions that require ongoing care and support.

Long-term care facilities offer a range of services, including assistance with activities of daily living (ADLs), medication management, medical monitoring, and rehabilitation services. Rehabilitation services in a long-term care facility may include physical therapy, occupational therapy, and speech therapy, depending on the needs of the residents.

6. Community-Based Programs

Community-based programs refer to rehabilitation services and support programs that are provided within the community, outside of a hospital or facility setting. These programs are designed to help individuals with disabilities, chronic conditions, or functional limitations to improve their quality of life and participate fully in their communities.

Community-based rehabilitation programs can include a variety of services, such as physical therapy, occupational therapy, vocational training, social support, and educational programs. These programs are often delivered by community organizations, non-profit agencies, or government-funded initiatives.

Question 48

Treating Unusual Causes

In approximately 25% of stroke patients, younger patients in particular, no obvious cause of stroke is found.

More extensive investigations are required to exclude what associated factors?

Answer 48

-Cervical dissection
-Intracranial disease
-Prothrombotic states
-Patent foramen ovale

Question 49

Discuss Initiating Medical Therapies For Asymptomatic Conditions as a secondary prevention of stroke.

Answer 49

*Generally, suffer from poor adherence

*Can be explained through psychological and behaviour change models

*The Health Belief Mode

Question 50

Outline factors which can be used for Predicting engagement in health behaviors.

Answer 50

Factors associated with performance of health behaviors.

1. Age
   Appears to show a curvilinear relationship with much health behaviors.
2. Gender
   Females are less likely to smoke and drink.
3. Ethnic status
   Alcohol consumption habits can be linked to ethnicity.
4. Socio- economic status
   Higher levels of stress and fewer resources are associated with health compromising behaviors such as smoking alcohol abuse, prostitution.
5. Social factors
   Parental models are important in instilling health behaviors early in life.

Question 51

Describe the Health Belief Model.

Answer 51

Tries to explain health seeking behaviour
*People take action to prevent, screen, or control ill-health conditions if :

*They believe themselves to be susceptible to the condition
*They believe it would have potential serious consequences
*They believe that course of action will be beneficial in reducing susceptibility or severity
*benefits outweigh anticipated costs or barriers

Question 52

Describe the 4 components of the health belief model.

Answer 52

1. Perceived susceptibility

-One’s subjective perception of the risk of contracting a health condition.

2. Perceived Severity/threat
   -Consequences
3. Perceived benefits

-Action perceived as feasible and efficacious.
Benefits must outweigh the cost and inconvenience.

4. Perceived barriers
   -The potential negative aspects of a particular health action may act as impediments to undertaking the recommended behavior.

Question 53

Discuss Public Health Approaches to CVD.

Answer 53

Public health approaches, (e.g. reducing calories, saturated fat, and salt in processed foods) can achieve a downward shift in a population’s BP.

Reducing overall BP by only a few mm Hg could affect overall CVD morbidity and mortality by as much or more than treatment alone.

Public Health approaches provide an attractive opportunity to interrupt and prevent the costly cycle of managing hypertension and its complications.