1. © 2010 Public Health Module Venue Date Unit: Public Health Aspects of Stroke

2. Aims of Unit This unit of study will: Explore how common strokes are and the evidence of their impact on quality and length of life Familiarise students with the major risk factors for stroke Explore the efficacy and ethics of interventions for the prevention and management of strokes WB4 2 2 LTPHN/JH/HB © 2010

3. What is health? WB6 WHO Definition‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ Antonovosky:Salutogenic model ‘sense of coherence’ Seedhouse and Duncan:Achievement of potential Empirical Lack of health 3 LTPHN/JH/HB © 2010

4. What is public health? WB7 ‘the science and art of preventing disease, prolonging life and promoting health through the organized efforts of society’ C.E.A. Winslow, 1920 4 LTPHN/JH/HB © 2010

5. The wider determinants of health Source: Dahlgreen and Whitehead, G and Whitehead M (1991) WB7 5 LTPHN/JH/HB © 2010

6. The challenge for public health WB7 6 LTPHN/JH/HB © 2010

7. Statistical description of nation’s health WB8 Census data Health Inequalities data Infant Mortality Rates 7 LTPHN/JH/HB © 2010

8. What is a stroke? A stroke is an interruption in the blood supply to the brain. Also known as cerebrovascular accident or CVA Usually because 1.Blood vessel has ruptured 2.Blood vessel blocked by a blood clot Reduced blood supply results in Decreased oxygen/nutrient supply to the brain Damage to the brain tissue WB8 8 8 LTPHN/JH/HB © 2010

9. Types of stroke There are two main types of stroke: 1. Ischaemic – caused by a blockage (80% of all strokes) 2.Haemorrhagic – caused by a bleed (20% of all strokes) WB9 9 9 LTPHN/JH/HB © 2010

10. Ischaemic Stroke Result of an obstruction blocking an artery carrying blood to the brain Causes include: –Cerebral thrombosis – blood clot (thrombus) forms in a main artery –Cerebral embolus – obstruction caused by a blood clot, air bubble or globule of fat (embolism) formed elsewhere in the body and carried to the brain WB9 10 LTPHN/JH/HB © 2010

11. Haemorrhagic Stroke Results of a burst blood vessel, causing haemorrhage into the brain Haemorrhagic stroke may result from: –Intra-cerebral haemorrhage where a blood vessel bursts within the brain –Sub-arachnoid haemorrhage when a blood vessel on the surface of the brain bleeds into the sub-arachnoid space between the brain and the skull WB9 11 LTPHN/JH/HB © 2010

12. Epidemiology of Stroke Around111,000 people have a stroke each year in the UK Second most common cause single cause of death in UK Significant numbers left with moderate or severe disabilities Stroke consumes 5% of all NHS costs Incidence has fallen by 40% over the past 20 years WB10 12 LTPHN/JH/HB © 2010

13. WB12 Modifiable Non-modifiable Risk Factors for Stroke Diet Raised cholesterol Physical inactivity Alcohol High blood pressure Smoking Sleep apnoea Obesity Diabetes mellitis Atrial Fibrillation Previous Transient Ischaemic Attack Age Gender Ethnicity 13 LTPHN/JH/HB © 2010

14. Preventing Stroke In order to prevent stroke, we need to: 1.Understand factors associated with stroke 2.Know how individual causal factors contribute to the aetiology of stroke 3.Understand these issues at both an individual and population level Primary prevention: preventing disease in healthy individual and population Secondary prevention: preventing the onset of stroke in patients with risk factors Tertiary prevention: preventing the recurrence of stroke in patients who have previously had a stroke or TIA WB14 14 LTPHN/JH/HB © 2010

15. Methods of Prevention Methods include: Controlling high blood pressure Monitoring elevated blood cholesterol and controlling this where appropriate Prescribing drugs to thin the blood Stopping smoking Dietary improvements including avoiding excess fat, and avoidance of excess alcohol intake Maintaining a healthy weight Exercising regularly Optimising control of diabetes WB15 15 LTPHN/JH/HB © 2010

16. Epidemiological data and prevention Studies have demonstrated that the incidence of major stroke has fallen by 40% over the past 20 years (OXVASC) Stroke registers also hold a wealth of data on the descriptive epidemiology of stroke, as well as its natural history and impact Adequate data coverage and accuracy are crucial WB16 16 LTPHN/JH/HB © 2010

17. NHS Health Checks Preventative checks for those aged 40-74 Assess risk of vascular disease, including stroke –Objective measurements (e.g. weight) –Self-reporting of lifestyle characteristics (e.g. smoking) Patients advised how to reduce their risk Can an intervention like this really change behaviour? WB16 17 LTPHN/JH/HB © 2010

18. Symptoms of a stroke Symptoms may include any of the following: Problems with speech Weakness or sensory loss on one side of the body Dizziness, nausea, balance and coordination problems Visual problems: loss or double vision WB20 18 LTPHN/JH/HB © 2010

19. Diagnosis of Stroke Head CT or MRI ECG Echocardiogram Carotid Duplex Heart Monitor Cerebral angiography Blood tests for cholesterol, glucose, clotting tendency etc WB20 19 LTPHN/JH/HB © 2010

20. Angiography Severe narrowing of the internal carotid artery: WB20 20 LTPHN/JH/HB © 2010

21. Emergency Management Effectiveness of emergency management directly impacts outcome Ideally, patients transported direct to stroke unit –Rapid triage –Specialist clinicians –Rapid brain imaging Thrombolysis for ischaemic strokes – use of thrombolysis units WB21 21 LTPHN/JH/HB © 2010

22. Determinants of Prognosis Long term outcome depends on: –Effectiveness of emergency intervention –Extent of damage to brain –Associated medical problems –Predisposition to recurrence (i.e. risk factors) WB21 22 LTPHN/JH/HB © 2010

23. WB21 23 LTPHN/JH/HB © 2010

24. Economic Cost of Stroke Stroke care costs the NHS approximately: –£7 billion per year in total –£2.9 billion in direct care costs 1 in 5 acute hospital beds and 1 in 4 long-term beds are occupied by stroke patients For each stroke patient, the cost to the NHS is around £15,000 over five years WB21 24 LTPHN/JH/HB © 2010

25. Economic Cost of Stroke Total societal costs (treatment + productivity losses) = £8.9 billion a year –50% direct care costs –27% informal care costs –24% indirect costs Human, personal cost to stroke survivors and their families WB22 25 LTPHN/JH/HB © 2010

26. Quality of Life Individual’s perception of position in life in cultural, social, + environmental context Influenced by: –Physical –Material –Social –Emotional well-being –Personal development –Purposeful activity WB22 26 LTPHN/JH/HB © 2010

27. Quality of Life after a Stroke 1/3 will be left with significant disabilities Measurement of health status must include an estimation of well being Important factors include disability, depression, age and social support Depression is also a common consequence of stroke WB22 27 LTPHN/JH/HB © 2010

28. Targets for 2010:  under 75 rates met National Stroke Strategy 10 point plan for action Government strategies for stroke WB23 28 LTPHN/JH/HB © 2010

29. Summary WB26 Stroke is declining but still big killer and disabler in UK Stroke is preventable and treatable but requires: Reliable data Focus on prevention and risk reduction as well as treatment with healthprofessionals able to identify modifiable risk factors and support lifestyle behaviour change A fully engaged public health workforce – including the ‘wider’ workforce/third sector etc 29 LTPHN/JH/HB © 2010