Neurological Disorders in Elderly (Stroke)

STROKE

Definition

A stroke is usually understood to be the sudden onset of neurological deficits due to local disturbances in the blood supply to the brain, i.e. a vascular occlusion (ischemic infarct) or a vascular disruption (hemorrhage).

Risk Factors

  • Age: After age 55, the risk for stroke doubles every 10 years.
  • Sex: Male > female for all age groups below 75 years.

Clinical Features

  • The neurological deficit reflects the size and site of the lesion.
  • At the time of onset, the level of consciousness is more depressed in patients with cerebral hemorrhage than those with ischemic stroke.
  • Acute focal stroke presents with variable symptoms. Most common is a haemiplegia with

or without the signs of focal higher cerebral dysfunction, for example aphasia. Other symptoms are related with sensory, visual, cognitive and language deficits.

  • Subarachnoid hemorrhages are not common in elderly individuals. Typically they presents with a sudden, unusually severe headache that lasts for hours or even days, often accompanied by vomiting.
  • Table 9.1 presents clinical features of most common forms of stroke.
  • Following the onset of stroke with hemiplegia, a state of flaccidity exists from hours to weeks or months. This is followed by the development of patterns of returning muscle function and spasticity.

 

clover-care-centre-heart-and-stroke-foundation-canada-haemorrhagic-stroke-and-ischemic-stroke

Table 9.1: Clinical features of most common forms of stroke

Ischemia

Middle cerebral artery:  Contralateral paralysis and sensory deficit

  • Aphasia
  • Homonomous hemianopsia
  • Hemineglect
  • Numbness: face, arm > leg
  • Apraxia
  • Impaired ability to judge distance
  • Loss of conjugate to opposite side

Anterior cerebral artery

  •  Weakness: leg > face, arm
  • Numbness: leg > face, arm
  • Urinary incontinence
  • Contralateral grasp reflex, sucking reflex
  • Amnesia

Vertebrobasilar artery

  • Ataxia
  • Dizziness, nausea, vomiting, nystagmus
  • Dysmetria
  • Dysarthria
  • Dysphagia
  • Visual field deficits
  • Quadriplegia in complete basilar syndrome

Hemorrhage

Intracerebral hemorrhage

  • Headache
  • Lethargy or coma
  • Focal symptoms resembling ischemic stroke

Subarachnoid hemorrhage

  • Severe, unusual headache, often during physical exertion
  •  There may be loss of consciousness or vomiting at onset
  • Nuchal rigidity takes about 6 hrs to develop
  • Cardiac symptoms such as chest pain, syncope, arrhythmias
  • Focal hemisphere signs at onset due to an associated intracerebral hematoma
  • Focal hemisphere signs developing after some days due to arterial vasospasm
  • A 3rd nerve palsy due to local pressure from an aneurysm of the posterior communicating artery

Investigations

  • CT/MRI: To confirm the vascular nature of the lesion
  • ECG, ultrasound scanning, Doppler ultrasound, contrast angiography: To investigate the underlying vascular disease
  • Serum glucose, complete cell and platelet blood count, cholesterol, prothrombin and partial

thromboplastin time, electrolytes: To investigate the risk factors

Evaluation and Assessment

  • Level of consciousness: The Glasgow Coma Scale records motor response to pain, verbal responses to auditory as well as visual clues, and eye opening.3
  • Cranial nerves: Ocular movements; strength of facial muscles; labyrinthine auditory, laryngeal

and pharyngeal function, should be checked.

  • Sensation: Light touch, deep pressure, pain, temperature, kinesthesia, two-point

discrimination, proprioception, appreciation of texture and size, and vibration should be assessed.

  • Musculoskeletal: Muscle strength as well as range of motion especially ankle dorsiflexion

and shoulder movements should be assessed thoroughly.

  • Movement pattern: Physical therapist should know whether the movement produced is in

normal pattern or not. Initiation pattern, sequencing and control of firing patterns, balanced

return are the indicators of controlled smooth movement pattern.

  • Hypertonicity: Physical therapist dealing with stroke patients should understand the difference

between ‘true spasticity’ and ‘hypertonicity’. According to Burke5 and Sheean6, ‘true spasticity’ depends upon afferent information from feedback following movement of the stretched muscle whereas hypertonicity which is a form of sustained efferent muscular hyperactivity, depends upon continuous supraspinal drive to the alpha motoneurones. This results into increased tonic muscle contraction which continues in the absence of movement. As a consequence, hypertonicity in hemiplegia gives rise to abnormal postures such as flexion of upper limb and extension of lower limb.

  • Pain: Shoulder pain is the most common pain complaint after stroke.10 It can be assessed

by using Visual Analogue Scale.

  • Edema: The distal parts of extremities should be observed for the presence of edema.
  • Communication: Physical therapist should be aware of aphasia or dysarthria as well as

alternate modes of communication such as auditory or visual deficits.

  • Behavior: Cognitive function and behavior problems should be noted, as discussed in chapter

XI.

  • Balance: The Berg Balance Assessment is easy to administer and has good reliability for

stroke patients.57

  • Posture: Postural problems in regard with alignment or rotation, midline orientation, and the

position of extremities should be evaluated in detail.

  • Gait: Gait pattern is an important component of evaluation of a hemiplegic patient. Loss of

controlled planter flexion and normal combinations of movement patterns in swing and stance

phases of gait, are some of the common abnormalities. Wisconsin Gait Scale (WGS) 58,59

provides the qualitative evaluation of the gait of hemiplegic patients. (Appendix- VIII)

  • Appliances: Use or a need to use the assistive devices, splints for positioning, orthotic

devices or wheelchair should be noted down

 

Reference:

http://www.rhc.ac.ir/Files/Download/pdf/nursingbooks/Principles%20of%20Geriatric%20Physiotherapy-CD.pdf

 

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