Women and Stroke
Stroke is largely preventable. Yet worldwide, 15 million people suffer strokes each year. Of these, five million die and five million are left permanently disabled, placing a burden on family and community. i Indeed stroke is now the second leading cause of death worldwide, after ischemic heart disease. Demographic projections to 2020 suggest that it will remain so, given the aging of many populations. ii In the coming decades a marked increase in the number of stroke events is expected worldwide, particularly in South American and Asian countries.iii In parallel, stroke will be among the five most important causes of disability in developed and developing countries.iv
Stroke in review A type of cardiovascular disease, stroke is a sudden loss of brain function caused by reduced blood flow to the brain (ischemic stroke) or the rupture of blood vessels in the brain (hemorrhagic stroke). Because neurons in the area die, a variety of effects can result, depending on where the brain was injured and the extent of the damage. A stroke can affect a person’s emotions, behaviour and personality, as well as their ability to move and coordinate movement, communicate, reason, understand, remember, and more. 1
Why focus on women? Stroke is an important public health issue for women and men alike. Traditionally, however, it has been seen as a man’s disease − a faulty and dangerous perception. The reality is that stroke accounts for a higher proportion of deaths among women than men (11 percent vs. 8.4 percent v ), despite comparable stroke rates. In developing countries, half of all deaths of women over 50 are due to heart disease and stroke. vi And in the United States, one in 2.5 women die of heart disease, stroke and other cardiovascular diseases compared with one in 30 who die of breast cancer. vii Despite this, only 13 percent of women in the United States believe heart disease and stroke are the greatest health threat to women; women’s knowledge of stroke warning signs remains low. viii
Beyond mortality statistics, studies have shown that women who survive a stroke are more likely than men to have a poor outcome. ix More stroke survivors over age 65 are women, x and because of women’s longer life expectancy, those who survive strokes are more likely to live alone than men. This means a woman’s hospital stay will generally be longer than a man’s. Women are also more likely to be transferred to a chronic care facility rather than go home or to rehabilitation, xi markedly affecting their independence and quality of life.
Stroke risk factors While women and men share many risk factors for stroke, women face additional gender-specific risk factors. For example, hormone replacement therapy and oral contraceptive use increase stroke risk. xii
Most risk factors can be modified, treated or controlled, but some cannot. The more risk factors a person has, the greater their chance of having a stroke.
Risk factors that can be modified xiii include:
Hypertension
Diabetes
Smoking, especially when combined with oral contraceptives
Heart disease
Atrial fibrillation
Obesity and overweight
Physical inactivity
Unhealthy diet
Stress
Excessive alcohol intake
High total cholesterol
High triglyceride levels
Carotid artery disease
Transient ischemic attacks
Risk factors that cannot be modified include: xiv
Advancing age
Gender
Ethnicity/race
Family history of early stroke
Previous stroke
Stroke prevention Knowledge of risk factors and how to minimize them is the first step in stroke prevention. Preventive measures that can have a significant impact include: xv
regular monitoring of blood pressure, cholesterol and glucose levels;
smoking prevention or cessation;
regular exercise;
eating a diet that includes polyunsaturated and monounsaturated fats and is rich in fruits, vegetables, fish or omega-3 fatty acids, whole grains and nuts;
maintaining a healthy weight; and
limiting alcohol intake.
Preventive treatment, where indicated, may include the use of anticoagulants (e.g. warfarin) or antiplatelet agents (e.g. aspirin); carotid endarterectomy to surgically remove blood vessel blockages; or balloon angioplasty or stents to remedy fatty buildup that is clogging a vessel. xvi
Warning signs and symptoms Just as important as learning how to prevent stroke is knowing how to recognize one, because when a stroke occurs time is of the essence. Immediate medical care is critical to minimize brain damage and disability. As an American Stroke Association slogan underlines: Learn to recognize a stroke. Because time lost is brain lost. If an individual experiences any of the following they may be having a stroke and need immediate emergency care:
Sudden numbness or weakness of the 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. xvii
Of interest is a 2003 study that documented, reportedly for the first time, a significant difference in the way women and men describe their symptoms while they’re having a stroke. Women were 62 percent more likely than men to say they were feeling sensations not on the list of “traditional” stroke symptoms. In particular, women were more likely to report pain and changes in consciousness or disorientation. They were also generally more likely than men to report non-neurological symptoms like shortness of breath and chest pain. Study researchers say the results may help explain findings from other research showing that women often don’t get stroke treatment as quickly as men . xviii
Acute treatment Yet, it is immediate treatment that leads to improved outcomes. Acute treatment for stroke varies depending on whether the stroke is ischemic or hemorrhagic. For ischemic stroke, interventional therapy with a “clot-busting” drug, where available, must be administered within three hours of the stroke’s onset to work best. For hemorrhagic stroke, treatment may include surgery to prevent rupture and bleeding of aneurysms or arteriovenous malformations. Alternatively, less-invasive endovascular procedures may be used. xix
Beyond acute treatment Stroke is different in everyone. Some people make a good recovery while for others the end of acute treatment is the beginning of a long road to a dramatically different life. In particular, individuals with disability face weeks, months, perhaps years of re-learning and rehabilitation. Feelings of depression and worthlessness are common. But small gains can bring great joy; these must be celebrated. Hope is important.
Families, too, must adjust to a different pace and a changed loved one. They wonder if and when life will ever get back to normal. It may not. Fatigue is common, especially in family members who are full- or part-time caregivers. Strong, resilient families gradually find a way to support each other while supporting their loved one. Family and caregiver self-help groups can be helpful for families finding it difficult to cope.
Implications for nurses While helping women and families affected by stroke, nurses can also work with women of all ages to help evaluate their risk of stroke and support them in healthy choices aimed at enhancing stroke prevention. Smoking prevention and cessation is one area where nurses can be particularly effective (see the ICN fact sheet Nurses for Tobacco-Free Life xx ).
Promoting healthy lifestyles in girls and young women should be a high priority. Although cardiovascular disease generally reveals itself in middle age or beyond, risk factors are in large part determined by behaviours learned in childhood and continued in adulthood, such as smoking, lack of exercise and poor diet. According to the World Health Organization, these risks are starting to appear earlier than they once did. xxi
Nurses are also well placed to educate women on the symptoms and warning signs of stroke; available treatments; helpful resources; and expectations for acute and longer term care. Families should be provided with information, included in care decisions and encouraged to seek respite opportunities where needed.
On a broader level, nurses can draw on their professional knowledge and expertise to lobby for and contribute to the development of policies that support health promotion and disease prevention initiatives. This includes initiatives focused on and supportive of nurses themselves. Finally, nurses can contribute to the collection of stroke-related data that can enhance decision-making.
Current initiatives Reliable stroke data helps justify why a government should invest in stroke prevention and treatment. With this in mind, the World Health Organization has developed an international stroke surveillance system, STEPS-stroke. The framework provides standardized definitions that will facilitate comparison of stroke occurrence within a country over time, and allow comparisons between populations in many countries. Of particular value, the system will evaluate preventive efforts and guide health planning. xxii
Facts and figures
Each year in the United States, roughly 700,000 Americans have a new or recurrent stroke, with nearly 40,000 more women than men dying of a stroke. xxiii
African-American women are 1.5 times more likely to have a stroke and 1.3 times more likely to die of a stroke than white women. xxiv
Stroke death rates for women are higher in Central and Eastern Europe than in Northern, Southern and Western Europe. For example, the death rate in women aged 35 to 74 living in the Russian Federation is 14 times higher than in Switzerland. xxv
Almost 60 percent of the 50,000 strokes in Canada each year affect women. xxvi
Resources The Atlas of Heart Disease and Stroke. Published in September 2004 by the World Health Organization, in conjunction with the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services. Downloadable at www.who.int/cardiovascular_diseases/resources/atlas/en.
World Heart Federation: www.worldheart.org.
American Heart Association: www.americanheart.org.
American Stroke Association: www.americanstroke.org.
Heart and Stroke Foundation of Canada: www.heartandstroke.ca
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