Will I Get A Stroke? Stroke Risk Awareness

A stroke can be a very devastating event; it can even lead to death. What most people are afraid of is not necessarily dying but rather surviving with severe disability. Whereas some people may recover fully after a stroke others might suffer from the effects for the rest of their lives. They might become bed-bound, unable to swallow, unable to speak and with severe damage to their cognition (vascular dementia).

Strokes are "brain attacks"

What is a stroke? 

Simply put a stroke is a “brain attack”. There is either lack of blood flow to areas of the brain (called ischemic stroke) or a sudden brain bleed (hemorrhagic stroke).

What are some of the symptoms of a stroke?

As per the National Stroke Association (NSA) these are the symptoms of stroke:

• Sudden numbness or weakness of 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

Other important but less common symptoms include:

• Sudden nausea, and vomiting - different from a viral illness because of how fast it begins (minutes or hours vs. several days)
• Brief loss of consciousness or a period of decreased consciousness (fainting, confusion, convulsions or coma)

If you have any of these symptoms or see them in someone else, call 911!

Treatment can be more effective if given quickly. 

Every minute counts!

What is a TIA or a mini-stroke?

TIA stands for transient ischemic attack and it basically means that stroke-like symptoms appear and then spontaneously resolve without causing an actual infarction of the brain (Easton et al in Stroke 2009).

Up until recently the definition included the time window of 24 hours: if your neurological findings resolved within 24 hours this was considered a TIA.

We now recognize that even 2 hours of neurological symptoms may lead to actual damages in your brain.

Additionally, a TIA is a serious warning sign that a larger stroke may occur within the next 24-72 hours!

You may need brain imaging when stroke is suspected.

Can I do anything to prevent having a stroke? 

Yes, you most definitively can!

The majority of strokes are potentially preventable!

How do I prevent a stroke?

Know your risk factors and adjust your lifestyle!

Some Risk factors for stroke that you have no control over:

• Your age (the older you are the higher your risk)
• Your gender (more women have strokes than men per year, partly because women live longer)
• Your race (African Americans have highest risk)
• Family or own history of stroke / TIA

STOP smoking!

Risk factors for stroke that you can control or treat: 

• Smoking
• Drinking too much alcohol
• Obesity
• High Blood Pressure
• Diabetes
• High Cholesterol
• Atrial Fibrillation
• Atherosclerosis

Click here to access the Stroke Risk Scorecard of the National Stroke Association. 

If you think you may have any of these risk factors, speak to your physician about it and then work with your physician to reduce your stroke risk.

• STOP smoking, if you smoke (it is recommendable for many reasons!)
• Start exercising (even if it only 30 min of brisk walking 3 times a week)
• Open a conversation about your wishes at severe illness or end of life (check blog post on documentation at end-of-life on Health Care Proxy for more info).

Make the best of the life you have!

Make the best out of the life you have! 

Be well,

Dr. B

PS: For more info check out NSA website. 

Aggression– A Difficult Behavioral Disturbance In Demented Persons

If you have a loved one who has dementia then you know how many everyday things become problems.

Tasks and abilities that we take for granted gradually and surely turn into difficult challenges.

Dementia is a vast topic and there are many points that can be made about it. There will be several other posts which will address other facets of dementia.

Aggression in Dementia

Today I want to talk about aggressive behavior that may be seen in patients with dementia. 

When I say aggressive behavior, I mean shouting, yelling, throwing things, being very agitated, maybe even punching someone.

Let’s first consider the following: a hot tempered person who has been easily agitated and borderline violent all his or her life will not all of a sudden turn into this calm persona when demented (at least not typically). When people have normal cognition they are usually inhibited to some degree and will not allow their aggressive impulses to reign freely. Demented persons on the other hand often lose their inhibitions. They speak their minds freely and they don’t necessarily “pull themselves together” in order to act “socially appropriate”. There are no medications that can treat how a person is.

This is not easy to accept. We often wish there were easy solutions but unfortunately, there are not.

When there are new behaviors of violence or aggression in a demented person we have to stop and analyze: What is going on? A demented person cannot clearly articulate and express what bothers or hurt them.

The first question to answer is this: What were the circumstances of the event? What has led to it? Who were the people involved? What was the environment like? Was there some kind of provocation?

Possible triggers may be: 

There are many reasons for aggressions

• Change in environment
• Change in care taker
• fear
• A loud noise
• Temperature too hot or too cold (in room or water when washing)
• Aggressive care giver with little patience
• Rough care taking without soothing explanations

The best way to figure this one out is to put yourself into the person’s position. If someone came to you and treated you that particular way would that agitate you?

When there is a change from someone’s regular behavior it is always something to worry about and should trigger evaluation by a nurse, or a physician.

Causes for these behaviors may be: 

• Pain
• Hunger, Thirst
• Infection
• Constipation
• Soiled diapers



Aggression can be ugly

• Side effects from medications

Aggressive behavior in people with dementia is one of the most common reason for institutionalization. It really poses a huge problem. You should not face it alone. Seek help from physicians, home care services, nurses and support groups.

Remember also that these behaviors are not really “against” you. They need to be interpreted in context and often are rudimentary expressions of a person who can no longer express accurately.

Here is a wonderful resource from the website of National Institute of Aging: click here.

Stay calm, don’t argue, de-escalate, and get help! You are not alone!

I really hope you find the support that you need. 

Don't lose hope!

Be well,

Dr. B

Prognostication – Do Physicians Have The Magic Ball?

As per dictionary.com the definition of “to prognosticate” is as follows:

Do physicians have a magic ball?

prog·nos·ti·cate 

1. to forecast or predict (something future) from present indications or signs; prophesy

2. to foretoken; presage: birds prognosticating spring

3. to make a forecast; prophesy

Is it only me, or does this sound very sobering? In other words, to prognosticate means to foretell the future. And who can really do that?

As a physician who deals with a lot of seriously ill people I have faced this problem many times: how can I estimate someone’s prognosis?

Why is this important? Does it really matter?

Time is running out.

I think it does. I believe that prognostication gives a framework to patients, their families and physicians. It makes a big difference whether someone expects to go on living for several more years or whether he has a high likelihood of dying within the next few weeks. There may be things to take care of, amends to be made, trips to be had. Making peace with the idea of the impeding departure from life on this planet may lead to appreciation of the time left and the chance to resolve open issues.

As we already discovered, prognostication is not an easy task, if not borderline impossible. Who can predict the future? None of us, really! 

How do we address prognostication scientifically then?

There are different tools that attempt to aide physicians with this problem.

How to predict somebody's life expectancy?

Ultimately, it comes down to looking at the patient as a whole:

• How old are they?
• How many illnesses do they have? 
• How well controlled are their illnesses?
• Do they have any terminal disease?
• At what stage is that disease?
• What is their functional status? (see previous blog post on that topic: click here)
• How rapidly did they decline? (e.g. compared to how they were doing 6 months ago)

Statistics provide framework

In June 2001 Dr. Walter and Dr. Covinsky published an article in JAMA titled: Cancer Screening in Elderly Patients in which they pointed out that more than just age alone a person’s overall life expectancy should be crucial to whether or not certain screening tests should be performed (more about these issues of cancer screening in future blog posts, click here for link to their article). They used statistics published by the CDC called “United States Life Tables” to categorize life expectancies (click here for an example of such a report).

They put these statistics into tables divided by genders and stratified by age groups. Then they looked at the life expectancy of the average person (50^th percentile) of an age group as well as the life exptectancies of people healthier (top 25^th percentile) or sicker (lowest 25^th percentile) than the average group.

Therefore, when a physician is trying to estimate someone’s general life expectancy he/ she is looking at whether the person is about average in health status or sicker versus healthier than average.

In oncology there is a commonly used term “median survival”. Dr. Eldridge explains this well on about.com (click here for link):

“Median survival is defined as the time after which 50% of people with a particular condition are still living, and 50% have died. For example, a median survival of 6 months would indicate that after 6 months, 50% of people with that condition would be alive, and 50% would have passed away.”

This concept may be difficult to grasp when it affects you. Ask your doctor how to apply this to your life.

Some tools frequently used are called ECOG Performance Scale (click here) and “Karnofsky Performance Status Scale” (click here for link) which help physicians estimate how functionally impaired a person is from the disease burden. The ECOG is often used in palliative care or oncology. As a matter of fact, the ECOG is one of the most important factors that oncologists take into consideration when assessing whether someone is a candidate for treatment or not.

I want you to keep something in mind: physicians are normal humans, not prophets that know the future. We are striving to learn more and more about the subject of prognostication and we are trying to do a good job. In the end of the day it remains an estimation based on a multitude of factors. We also don’t like to give “bad news” and often shy away from facing how ill a person is. Many times this does not get communicated to patients and their families.

Also, consider that physicians consistently overestimate prognosis. A very simplistic tool is the "surprise question": Moss et al. published an article in the Journal of Palliative Medicine in July 2010 (abstract here). Oncologists were posed with 853 patients and had to ask themselves: "Would I be surprised if this patient died in the next year?" There was a correlation between this question and the 1 year mortality of the patients. In a way this "surprise question" evokes a gut answer by the physician and as the study showed, sometimes a gut answer is not so far off.

Time is fleeting.

Don’t accept concrete numbers, though. Nobody can say “you will die in 2.5 months”, the only thing that can be said is “there is a high likelihood of her dying within the next few weeks to few months” (or hours to days, days to weeks, months to years… I think you see what I mean). 

The search for the perfect tools to prognosticate goes on. There are many potential benefits in knowing and accepting the limitation of time.

In the end of the day, nobody knows the future. It is wise to plan ahead with the right documentation (see my previous blog posts on Health Care Proxy and MOLST form) and the discussion about the topic with your loved ones.

No matter how you look at it. Life is short and full of surprises.

Make the best of today. Be prepared for the future but don’t allow anxiety and fear to dominate your present.

Make today count.

Make peace with others.

Forgive who has done you wrong and don’t hold grudges. 

Make today count.

I wish you well,

Dr. B

Social Isolation and Depression - serious problems

Large cities can be isolating

In today’s day and age everybody is busy, rushed and doesn’t really have much time for anything. Even though big cities are full of people many elderly feel isolated and alone.

Social Isolation leads to loneliness, which leads to sadness and may even lead to clinical depression. Depression is a serious illness that impacts not only quality of life but also affects your health and may possibly increase your risk of dying in certain circumstances. 

Social Isolation and Depression Haunt

Unfortunately, there is a vicious circle. Once people are depressed it becomes very difficult to think of fun things to do or to even enjoy simple pleasures. Additionally, depression affects energy level, motivation and may lead to increased pain perception – which in turn diminishes morale, energy and motivation even more. And there we are: even more social isolation and sadness.

Best is not to even get there. And if you did: Break the cycle! There is hope! 

I will come back to this topic of depression regularly, as it is relevant and important.

Today I want to encourage you to stay involved, active and to participate in meaningful activities. Check the internet for activities in your area. Ask around. If you really have no clue: find a senior center, a social worker or case manager to help you. (If you don’t know how to find those: ask your doctor).

In New York there is an amazing organization on the Upper West Side. It is called Dorot (click here for their website). They have a bunch of volunteers of all ages who are committed to spend time with elderly in the community. All different kind of activity can be arranged. They even have what they call “University without walls” a curriculum (click here to see it) of diverse classes that can be accessed from the comfort of your own home via the phone. Quite amazing!

I encourage you to look for resources like this in your community as well. Ask around. There will always be lovely people who are willing to give their time in order to enrich someone else’s life!

If you feel terribly depressed, and you cannot concentrate on simple tasks or even live your daily life anymore:

Speak to your physician!

There is hope!

This is a serious problem and it is not your fault! There is an imbalance in the chemistry of your brain and we have options how to treat these. For the most severe cases you may even need a psychiatrist. Don’t shy away from it.

Nobody likes to be ill but the first step for getting better always includes facing reality.

I wish you well.

And remember: you are not alone! 

Dr. B

Wear sunscreen – encore

Based on several questions that came up after the "wear sunscreen" article I wanted to write a few small additional note:

• The amount of SPF in makeup is not sufficient to cover you properly

• Even in the winter you should wear sunscreen on your face, neck, and hands

• There are special formulations for the face, these "milks" absorb much faster and feel nicer on the skin (I like Neutrogena: click here)

• Use high SPF on face, hand, neck (at least 55 SPF) all year round

• Even on a cloudy day you are not protected from UV radiation without sunscreen

• Sprays can be difficult to handle:

1. You inhale much of it while spraying
2. They are greasy and make your skin feel sweaty
3. When you spray them indoors they leave a film on your carpet, hardwood floors or tiles
4. The film on the tiles or hardwood floor can get dangerously slippery and you may fall on it (this almost happened to me)
5. You never know whether you applied the right amount of spray

When to use spray?

• It might be easier to use spray on small children rather than the lotion
• Outdoors or at the beach the spray falls into the sand rather than on your furniture
• If you don't have anybody to help you lotion your back you might be able to spray it yourself (might be tricky for some of you)

Otherwise, look for a lotion

• There are lighter formulations in lotions out there and I would really continue looking until you find what you like
• I would definitively use the highest SPF you can get for the days spent outside
• we usually don't apply the amount recommended (so we already lose SPF from that)
• after 45 min of sweating or in the water you cut your SPF in half

Example:   

• you start with 50 SPF lotion
• you put on too little: now you are at ~ 30 SPF
• after 45 min of sweating you are down to about 15 SPF
• You continue to lose half of that every 45 min without re-applying...
• So: Reapply, reapply, reapply

In the end of the day: Be a role model for others.

And don't get frustrated. I can't even get my own husband to use sunscreen regularly; but I won't give up!

Be well,

Dr. B

Wear Sunscreen

I am sure you have heard this over and over and yet I think it is so important that it cannot be said enough times:

Wear Sunscreen !!  

I attended a presentation by a dermatologist yesterday and got inspired to write to you today (I also went to CVS immediately after and restocked on highest SPF in the house!!)

Each time you get a sunburn you significantly increase your risk of getting melanoma. Melanomas are malignant cancer of the skin that can kill. These cancers don’t just stay confined to the skin but they can travel all over your body and seed in other organs like your brain or your lungs.

When you tan without burning you put yourself at acquiring other forms of skin cancers such as basal cell cancer – which is the most common cancer in humans.

It is true that the lighter you are the more susceptible you may be for burns and certain skin cancers, however, having dark skin does not protect you and you should still use sun screen.

What to do? 

• Use sunscreen every day even when you are not going to the beach (light or dark colored skin)
• Use sunscreen even when you wear clothing (a light white T-Shirt provides only about 15 SPF and next to none when wet)
• Use the highest SPF (sun protection factor) as it loses its protective factor when you sweat or get wet (after about an hour of sweating it may have lost half its SPF already)
• Reapply SPF frequently and use a “shot glass” amount on the whole body (a family of 4 at the beach should use one whole bottle of sun screen –scary, isn’t it? These bottles often last 2 summers!)
• Stay in the shade but beware: at the beach the sun will still reflect UVB radiation onto your skin and will still increase your skin cancer risk! So, even in the shadow: sun screen! 
• Wear a hat with a brim to protect your scalp

By the way, for the vain ones amongst us: one of the main factors contributing to the aging of our skin is UV radiation! So, the less exposure the younger you may look.

What about vitamin D?

You may have heard that it is necessary to be exposed to sunlight in order for the production of vitamin D to occur in your skin. This is true, however, 15 min per day are already enough for most of us. You don’t need to fry for hours!

There is a lot of information out there on the internet, check out this woman’s personal experience: click here.
Here some tips on sun screen brands by a dermatologist: click here.

And when in doubt: ask your doctor or see your dermatologist.

It probably is a good idea to see a dermatologist at some point and get the recommendation on how frequently you should return for follow ups.

Stay cool out there and remember:

Wear sun screen!

Dr. B

What is a MOLST form? Do I need it? Planning for end-of-life...

MOLST stands for “Medical Orders for Life­Sustaining Treatment”. 

It is a form filled out by a physician and it contains actual orders in regards to important end-of-life issues. Other health care professionals in different settings must follow these orders.

The Department of Health New York really promotes its use. It is recommended for persons with a serious illness or anybody who lives in a long­term care facility or requires long­term care services.

This form covers important topics that are relevant at the end of life. Here are these topics:

Pink Original MOLST form

• Resuscitation

• Framework for Treatment Guidelines: 

1. Comfort care
2. Limited medical interventions
3. No limitations on medical interventions

• Instructions on the use of breathing machines (intubation)

• Future Hospitalizations

• Use of artificial iv hydration and nutrition

• Antibiotic use

• Other instructions

The orders may entirely focus on avoiding any aggressive measures and making sure that the patient’s wishes of comfort care, no resuscitation, no use of antibiotics ne honored.

It is also possible to tailor these orders to an individual’s beliefs and values. Somebody may not want to be on breathing machines but they might still want workup for some of their symptoms (e.g. a CXR) and treatment with antibiotics.

A wonderful aspect of these orders is that they provide the option of “no hospitalization”. There are many people who would very much prefer not to go to the hospital and to stay in the home setting; event if it meant they’d die at home. (Of course, most of those should probably be on hospice – more about that in a future blog post)

By the way, the original MOLST form (in NY it is pink) always stays and travels with the patient from nursing home to hospital to rehab back to nursing home. The doctors and institutions keep copies only.

Not all states are using the MOLST form, some states even call it the POLST form. Talk to your doctor about what options you have. I would strongly encourage you to look into this.

Check out the MOLST form for New York State: Department of Health Website MOLST.

And remember, nothing is written in stone. You will always have the right to change your mind. Your doctor should periodically check in with you about your wishes to make sure that your MOLST is still up to date (there is a section the physician may sign).

This all may seem very scary but it shouldn’t be.

Planning for your future health care today ensures that you are able to voice all your concerns and make your own choices.

I wish you all the best for this endeavor,

Dr. B

PS: Check this article by elder lawyer Nancy Burner for more info on the MOLST form.