Policy & Practice

Building Partnerships | Policy Development

Stroke Prevention, Care and Rehabilitation : April 2002

1. The Problem

Strokes are a major cause of avoidable, early death and ill health in the United Kingdom. Strokes have two main causes: the blocking of blood vessels in the brain cutting off the oxygen supply to the brain tissue (ischaemic cerebrovascular accidents) and bleeding under the membrane that covers the brain (subarachnoid haemorrhage). Data for England suggests that there will be roughly 100,000 cases of first stroke annually. Of these:

• 25% will be aged under 65 years;
• 29% will be aged 65 to 74 years;
• 46% will be aged over 75 years.

At the same time, deaths from first or recurrent stroke will occur in some 64,000 cases annually. This represents 12% of all death; 9% of all deaths under the age of 65 years and 5% of all deaths in the 65 to 74 age group.

Roughly 13% of people who survive a first stroke will have a recurrent stroke within the year. In subsequent years, this will fall to about 5%.Higher death rates occur in:

• women in older age;
• people from lower socio-economic backgrounds;
• ethnic minorities.

Stroke is one of the single largest causes of physical disability, especially in later life. Factors increasing the risk of stroke include high blood pressure; smoking; high lipid (fat including cholesterol in the blood) concentrations; obesity and excessive consumption of alcohol.

2. Approaches to reducing the scale of the problem

a. Individual behaviour

The risk of stroke may be reduced by individual action in a number of ways:

i. The first thing is to ensure, as far as possible that blood pressure is normal. High blood pressure increases the risk of stroke seven-fold and because high blood pressure often has no symptoms, it is important to have regular blood pressure checks. GPs now regularly measure blood pressure when a patient visits the surgery, but if this has not been done for two or three years for someone over fifty, it is advisable to make an appointment to have a check of blood pressure.

ii. Smoking has been shown to increase the risk of stroke three-fold so a major reduction in the risk of stroke in an individual may be achieved by stopping smoking.

iii. The old adage of 'eat five portions of fruit and vegetables a day' holds true for stroke prevention. For example, an orange at breakfast, two apples with lunch and two portions of vegetables with the evening meal.

iv. Research shows that those who are physically more active are less likely to suffer a stroke. Simple changes in behaviour such as taking the stairs rather than the lift or walking to the shops instead of taking the car help by lowering blood pressure and in a number of other ways.

v. Avoidance of excess consumption of alcohol will also reduce risk of stroke. The maximum daily intake, as recommended by the Department of Health, should not exceed 4 units for men and 3 units for women. ½ pint of beer or 1 small glass of wine is the equivalent of 1 unit.

b. Public health measures at population level and among high-risk groups.

Effective intervention to reduce the incidence of stroke at the population level should include helping individuals to change their behaviour in the areas listed in section 2a above. The degree to which population interventions to reduce blood pressure, lipid concentration, obesity and alcohol consumption are effective is subject to debate, although there is clear evidence that smoking cessation programmes are effective.

High-risk groups include those suffering from high blood pressure; high blood fats; diabetes; vascular disease; mild, transient warning strokes and those having already had a stroke.

Medical management of blood pressure and high lipid concentrations is effective, provided that the person at risk can be identified and complies with the treatment. Optimisation of outcomes in acute stroke care requires:

• Rapid diagnosis - especially rapid access to MRI to determine stroke aetiology;
• Rapid availability of anti-coagulation therapy;
• Early access to specialist stroke management teams;
• Early access to therapy assessment and rehabilitation programmes.

Rehabilitation after strokes is essential to promote independence. "Acute" rehabilitation that continues beyond hospital discharge and "maintenance" rehabilitation which ensures that re-acquired skills and function are not lost over time are both required.

3. Action by the Royal Institute

The Royal Institute aims to contribute in three main areas:

• to make representations on health policy to government
• to organise training to improve understanding and therefore, service provision
• to organise seminars individually and jointly with other suitable professional bodies.

Any or all of these approaches could be applied to reducing the problem of stroke. April 2002