Its not just a minor stroke'''

1
Its not just a minor stroke...

• Dr. Teri Green
• University of Calgary
• Calgary Stroke Program

2
Goals

• To present nursing research findings related to
  minor stroke
• Identify functional and psychosocial reactions
  following minor stroke
• Describe nursing strategies for promoting
  adaptation, health well-being
• Describe the significance of continuity of care
  and community re-entry
• Or simply lull you into submission

3
The Definition of Stroke/TIA

• A clinical syndrome
• characterized by the sudden
• onset of a focal neurological
• deficit, presumed to be on a
• vascular basis

4
Major Stroke Decreasing in All Categories
Rothwell et al. Lancet 2004 363 1925-1933
5
Minor Stroke and TIA Vast Majority
Morgenstern LB et al. Neurology 200462895-900
6
Why are the minor ones important?

• Systems of care streamlined for acute stroke.
• Patients are presenting early.
• Few receive thrombolytic therapy.
• Among patients deemed too mild for thrombolytic
  therapy, up to one third are dependent or dead at
  hospital discharge.
• Barber PA et al. Neurology 2001561015-1020

7
Sticks and Stones will break my bonesnames will
never harm me

• Minor
• Transient
• Mini-stroke
• Little stroke
• Need something that scares and emphasizes the
  high risk? Unstable stroke

8
its not just a minor stroke

• An Examination of Male Patient, Wife-Caregiver,
  and Marital Dyad Outcomes Over a 12-Month Period
  Following Minor Stroke

9
BACKGROUND

• 50,000 Canadians have a stroke annually minor
  stroke or transient ischemic attacks account of
  82 of all cerebrovascular disease
• Having a stroke creates a need for short and
  long-term adjustments for the patient as well as
  the family
• Minor stroke patients are discharged from acute
  care shortly after their stroke event
• There is little empirical evidence available
  regarding
• the effect of minor stroke on patients
  abilities to return to their previous roles and
  functions and
• how this seemingly minor event influences the
  marital dyad in the immediate post-discharge
  period

10
RESEARCH QUESTIONS

• Primary Question
• What are the changes in patient functional
  status, patient and wife-caregiver health related
  quality of life (HRQOL) and depression,
  wife-caregiver strain, and marital dyad
  functioning between hospital discharge and
  12-months following the stroke event?
• Secondary Questions
• What are the predictors of marital function at
  3-months following a minor stroke?
• Tertiary Question
• What do minor stroke patients and
  wife-caregivers identify as factors affecting
  their HRQOL and/or caregiver strain over
  12-months following discharge?

11
RESEARCH METHODS

• Prospective pilot study of 38 male stroke
  patients and their wife-caregivers
• Demographic and clinical information obtained
  from the health record and in-person interviews
  at time of discharge
• Questionnaires administered, using standardized
  measures, at discharge , 1-2-3-6-9 -12 months
  post-stroke using
• SS-QOL
• SF-12v2
• BDI-II
• FADGFS
• BCOS

12
Demographic Characteristics
13
Stroke Characteristics

• Stroke Type ischemic 36 (95), hemorrhagic 2
  (5)
• Lesion Side right 21 (55), left 17 (45)
• Location supratentorial 27 (63), brainstem 4
  (11), unknown 7 (18)

14
Stroke Severity Functional Outcomes
15
Changes in Psychosocial Measures between
Discharge and 12-months Post-discharge
16
Changes in Depression and Marital Function
between Discharge and 12-months Post-discharge
17
Predictors of Marital Function at 3 12-months
18
Qualitative Data

• Content analysis of responses to open-ended
  questions
• SS-QOL
• BCOS
• Hsieh Shannon (2005)

19
Content Analysis

• Overarching Themes
• Being vulnerable
• Realization of the new self and changing
  relationships
• Subthemes
• Masculine image
• Hyper-vigilance
• Loss

20
Being Vulnerable

• Gossiped about
• Stigmatized
• Isolated abandoned
• Insecure
• Financial/work stability challenged
• Mood changes and stress

21
Being Vulnerable

• Uncertainty
• - Fear of recurrent stroke vulnerable to the
  disease
• Frustration over recovery process
• Lack of assurance about the future
• - health status
• - work and financial situations
• - lifestyle
• Wife-caregiver hypervigilance

22
Realization

• Increasing awareness and insight
• Apprehension about ability to put their lives
  back together
• Continuity of the family
• Maintenance of relationships

23
Realization

• Adaptation
• Acceptance and denial
• Incorporation of physical deficits
• Ongoing challenges of emotional and cognitive
  changes
• Stabilization changing priorities
• Recognition of need for continuous adaptation

24
Key Threads

• Masculinity imposed limitations, life-changes
• Hyper-vigilance protective monitoring, control
• Loss physical, emotional, social

25
Masculinity

• I was surprised by the long term effects of the
  strokenot prepared for the loss of energy and
  changes in mood, thinking and personality.
• The stroke has made me useless. I cant do the
  things for my family like protect them. If an
  intruder came in I couldnt even defend my
  family. I wouldnt even have the strength to
  fight off a child.

26
Masculinity

• The largest challenge has been the feelings of
  depression that have been part of life since the
  stroke. Its a struggle to accept that I am not
  the person I used to be, that I cant contribute
  like I used to, it seems like Im not worthwhile
  as I was before.
• I am feeling blue and I cry at the drop of a
  hatfear and anxiety are new to me.

27
Hyper-vigilance

• always watching
• Since I am his wife and I am the one closest to
  him, the only one who can really take care of
  him, I really do feel this as a responsibility
  and yet it is so different to have him here in my
  space
• my husband would kill me if he knew that I
  check on him in the night to see if he is still
  breathing.
• My husband accuses me of babying him, but my
  over-protectiveness is an automatic reaction
  because I am afraid to let him go.

28
Loss

• I am feeling the burden of having to make many
  life decisions because my husband doesnt want to
  make any decisions himself.
• I feel trapped by my husband and sometimes I
  would like to run awayI have to spend all my
  time with him and this has negatively impacted my
  relationship with friends and family.
• I am feeling overwhelmedthe whole family system
  is disrupted.

29
Loss

• marital relationship is tense and negative with
  arguments over everything.
• I am not the same person that I was before.
• I always pride myself in being healthy and
  athletic, now I feel so weak. Physically I am
  going soft.

30
Participants Personal Reflections

• There is more to life than tangibles, and I have
  learned to count my blessings.
• I realize how devastating the stroke could have
  beenI am humbled by everything and I am most
  grateful.
• more reflective and more aware of what is
  important

31
Participants Personal Reflections

• I am entering a transitional period, where I
  will have to learn to get over my past
  perceptions of self-image. Perhaps it is time to
  focus on other thingsPreviously I had a
  dichotomy between my physical and emotional
  needs. The stroke has highlighted the need to
  develop all aspects of myself in order to have a
  better quality of life. It has taught me the
  importance of moderation and balance.

32
Participant Suggestions

• Lose the term minor stroke as it does not
  convey the seriousness of the event and the need
  for life changes
• Non-disabling stroke has many different
  connotations
• Dont slam the door shut behind them as they
  leave the hospital
• Follow-up to see how they are coping in the
  community

33
Nursing Strategies

• Pay attention to discharge planning, even for
  minor stroke patients
• Talk to patients about their recovery
• Emphasize lifestyle implications
• Ensure the caregiver is up to the task
• Provide resources
• Determine when how to follow-up

34
Continuity of Care

• Feedback to primary care physicians and allied
  health
• Follow-up with the patient caregiver
• When? How?
• Lobby for a (nursing) follow-up clinic for all
  patients with stroke
• Assess coping, mood, reintegration, etc.
• Assess need for information timely, appropriate

35
Role of Nurses in Secondary Stroke Prevention

• Screening and monitoring of high risk population
• Assessment and education about risk factors,
  lifestyle management issues (exercise, smoking,
  diet, weight, alcohol, stress management)
• Counseling about possible strategies to modify
  lifestyle and risk factors

36
CONCLUSIONS

• its not just a minor stroke
• Patients experienced significant improvement in
  functional status over time however their overall
  psychosocial status did not improve
• Significant deterioration was noted in mood and
  marital function over time

37
Conclusions

• Qualitatively, patients and wife-caregivers
  reported difficulty returning to previous life
  roles (including family, work, and social roles)
  over the 12-month period
• The lack of complete functional recovery over
  time created a disconnect between the hope and
  the reality of having a minor event

38
Thank You!