Maintaining Continence: Life After Stroke

A stroke is a medical emergency that can have varying effects on the body, depending on the area of the brain affected and the severity of the stroke. While some people may recover completely from a stroke, others may experience long-term disabilities, including physical, cognitive, and emotional symptoms. One common effect of stroke is incontinence, which can manifest as urinary or fecal incontinence. Urinary incontinence occurs due to neurogenic bladder, leading to incomplete bladder emptying, while fecal incontinence is often a result of stroke-related bowel issues. Incontinence can impact a person's independence and quality of life, requiring management strategies such as catheters, diapers, or bowel programs. Additionally, it is associated with a higher risk of mortality in stroke survivors.

The impact of a stroke on bowel and bladder control

A stroke occurs when the blood supply to the brain is disrupted, killing brain cells. The effects of a stroke depend on the severity of the stroke, the area of the brain affected, the speed of emergency medical response, and the patient's health.

Bowel and bladder control

Following a stroke, patients often experience variable degrees of urinary frequency, urgency, or incontinence due to a neurogenic bladder, leading to incomplete bladder emptying. The exact mechanism of urinary incontinence after a stroke is unclear. Urinary incontinence can be managed through the exclusion of exacerbating factors, such as urinary tract infections, certain drugs, and faecal impaction. Anticholinergic medications can be used to reduce urgency and frequency, and in some cases, an external catheter or diapers may be necessary.

New-onset faecal incontinence is also common after a stroke, with an incidence of 56% acutely, 30% at 7-10 days, and 11% at three months. Older patients, women, and those with severe strokes are most at risk. This can be managed through skin care, pads, faecal collectors, and anal plugs. Bowel programmes such as daily codeine phosphate with twice-weekly enemas have been successful in achieving bowel continence in nursing home patients.

Other health complications

In addition to bowel and bladder control issues, a stroke can lead to a range of other health complications, including:

• Swallowing problems, which can increase the risk of chest infections or pneumonia.
• Immobility, which increases the risk of deep vein thrombosis (DVT) and pulmonary embolism.
• Heart attacks, which share many of the same risk factors and health problems associated with strokes.
• Seizures, which have been linked to an increased risk of death and disability.

Recovery

The recovery process after a stroke can be long and challenging, and it may take weeks, months, or even years. Some patients may have lifelong disabilities, while others may recover completely. The first three months after a stroke are typically the most critical for recovery, with most patients making the most improvement during this time. Rehabilitation is crucial during this period, and it aims to restore function as closely as possible to pre-stroke levels or develop compensation strategies.

Even after the initial recovery period, improvements are still possible, but they will be slower. Most stroke patients reach a relatively steady state after six months, with some achieving a full recovery, while others experience ongoing impairments, known as chronic stroke disease.

Prevention

Given the risk of a second stroke is much higher after an initial stroke, it is essential to manage risk factors such as blood clotting, high blood pressure, and heart problems. A healthy diet, exercise, medication adherence, and regular visits to a healthcare provider are also important in reducing the risk of another stroke.

The role of caregivers in stroke recovery

Caregivers play a crucial role in supporting stroke survivors on their road to recovery and helping them regain their independence. They are often family members who take on the responsibility of providing long-term care and ensuring continuity of care. The caregiver's role can be challenging and demanding, requiring them to manage the stroke survivor's personal hygiene, monitor their health, administer medications, plan and coordinate social activities, and manage finances.

Challenges Faced by Caregivers

The caregiving role comes with various challenges and burdens, including physical, financial, and emotional strains. Caregivers often experience a significant shift in their lives, giving up their dreams, aspirations, and work situations to fulfil their new responsibilities. This can lead to feelings of loneliness, confinement, and mental and emotional stress, ultimately impacting their own health and well-being.

Support for Caregivers

Recognising and addressing the needs of caregivers is essential. Caregivers should be provided with proper support, education, and training to prepare them for their role and help them make informed decisions. This includes understanding the disease, rehabilitation process, decision-making, and the model of care to ensure optimal recovery for the stroke survivor. Additionally, access to support services and programmes, such as those offered by organisations like the Stroke Foundation and Carer Gateway, can provide caregivers with the necessary skills and knowledge to navigate the challenges of caregiving.

Caregiver Engagement in Stroke Recovery

Engaging caregivers in the stroke recovery process is vital to improving the effectiveness and sustainability of care. Caregiver engagement refers to the active partnership between patients, families, and healthcare providers, aiming to improve health outcomes and deliver person-centred care. Caregivers should be involved in information-seeking, consultation, decision-making, and shared leadership to develop better health policies. Their engagement can lead to reduced healthcare costs, improved care processes, and better patient outcomes.

Care Planning and Policy-Making

Caregivers often report feeling unprepared and uncertain about the future once the stroke survivor is discharged from the hospital. This highlights the need for efficient coordination of community services and better communication about the care process and available services. Caregivers should be included in the development of health policies to ensure that their needs and requirements are considered, leading to improved health outcomes.

Rehabilitation and Decision-Making

Rehabilitation is a critical aspect of stroke recovery, and caregivers often play a crucial role in supporting the stroke survivor during this process. However, engaging caregivers in rehabilitation and decision-making can be challenging, as it requires a certain level of knowledge and understanding of the disease and its management. Caregivers should be provided with the necessary education and support to effectively participate in these processes and ensure optimal recovery for the stroke survivor.

In conclusion, caregivers play an essential role in supporting stroke survivors during their recovery journey. By addressing their needs, providing them with the necessary support and resources, and engaging them in the recovery process, caregivers can make a significant positive impact on the health and well-being of stroke survivors.

The emotional impact of a stroke

A stroke is a medical emergency that can have lasting physical and mental effects on survivors. The emotional impact of a stroke can be significant and far-reaching, affecting both the patient and their caregivers. Emotional symptoms are common after a stroke and can include depression and impulsivity.

Emotional Challenges

The emotional aftermath of a stroke can be complex and multifaceted. Stroke survivors may experience a range of emotions, including sadness, anxiety, fear, anger, and frustration. These emotions can be overwhelming and may fluctuate or intensify over time. The emotional fallout from a stroke can be attributed to several factors, including the sudden and traumatic nature of the event, the physical and cognitive impairments that may result, and the lifestyle changes that are often necessary post-stroke.

Coping with Emotional Challenges

Recognising and addressing the emotional impact of a stroke is crucial for both patients and their caregivers. It is important to acknowledge that emotional challenges are a normal part of the stroke recovery process and should be addressed proactively. Seeking professional help from rehabilitation psychologists or neuropsychologists can be beneficial. These specialists can provide screening, assessment, and tailored interventions to address emotional difficulties. This may involve psychotherapy, counselling, or support groups, which can help individuals develop coping strategies and foster resilience in the face of significant life adjustments.

Support for Caregivers

The emotional toll of a stroke is not limited to the patient but extends to their caregivers as well. Caregivers often experience a range of emotions, including worry, stress, guilt, and burnout. It is essential for caregivers to prioritise their own emotional well-being and seek support when needed. This can include accessing resources and services specifically designed for caregivers, such as support groups, counselling, or respite care, which can provide much-needed assistance and help prevent caregiver fatigue.

Long-term Emotional Effects

The emotional repercussions of a stroke can persist long after the initial event. While many individuals demonstrate resilience and adapt to their new circumstances, some may continue to experience emotional difficulties. Long-term emotional challenges may arise from the ongoing adjustments and lifestyle changes required, as well as the potential presence of physical or cognitive impairments. For some individuals, the emotional impact of a stroke may lead to the development of mental health disorders such as depression, anxiety, or post-traumatic stress disorder (PTSD).

In conclusion, the emotional impact of a stroke is a critical aspect of the recovery process, influencing both the patient and their caregivers. Addressing emotional challenges is an integral part of holistic stroke rehabilitation, and seeking professional support can help foster emotional well-being and resilience in the face of adversity.

The physical impact of a stroke

A stroke occurs when the blood supply to the brain is disrupted, killing brain cells. The physical impact of a stroke depends on the severity of the stroke, the area of the brain affected, and the speed of emergency medical response. While some patients may recover completely, others may experience long-term physical disabilities.

Physical Symptoms

The physical symptoms of a stroke vary from person to person but may include:

• Weakness or paralysis
• Difficulty swallowing
• Dizziness or imbalance
• Difficulty walking or moving
• Seizures
• Spasticity and hypertonicity, especially in the hemiplegic side
• Hemiplegic shoulder pain
• Wrist and hand flexion contractures
• Incontinence

Recovery

The recovery process after a stroke can be long and challenging, and may involve intensive care, acute care, or rehabilitation. Rehabilitation typically includes physical and occupational therapy, speech-language therapy, and psychological support. The first three months after a stroke are the most crucial for recovery, with most patients making the most improvement during this time. However, some survivors continue to recover well into the first and second year.

Complications

Serious strokes can lead to dangerous swelling in the brain, which may require surgery to reduce the pressure. Additionally, being immobile for long periods after a stroke increases the risk of deep vein thrombosis (DVT) and pulmonary embolism. The risk of a second stroke is also much higher after the first, and if the person already has brain damage, a subsequent stroke can be even more detrimental.

The risk of another stroke

After a stroke, the chance of having another is much higher. As many as 5 to 14% of stroke survivors have a second stroke within a year, and this risk increases over time. This makes it all the more important for survivors to make active lifestyle changes to prevent further strokes.

Factors that Increase the Risk of Another Stroke

• Blood clotting
• High blood pressure
• Heart problems
• Hypertension
• Diabetes mellitus
• Elevated low-density lipoprotein (LDL) cholesterol and triglyceride levels
• Atrial fibrillation
• Smoking

Reducing the Risk of Another Stroke

There are several preventative measures that can be taken to reduce the risk of another stroke:

• Antithrombotic therapy
• Treatment of hypertension and diabetes mellitus
• Reduction of elevated low-density lipoprotein (LDL) cholesterol and triglyceride levels
• Anticoagulation for atrial fibrillation
• Cessation of smoking
• Healthy diet
• Exercise
• Taking medications as prescribed
• Regular visits to a healthcare provider
• Intensive rehabilitation

Frequently asked questions