Stroke and Alzheimers

Transient Ischemic Attack (TIA)

• Definition: A TIA is considered a "warning sign" of a potential future stroke. It involves transient focal neurologic dysfunction.

• Pathophysiology: It is caused by a brief interruption in cerebral blood flow.

• Etiology:

  • Cerebral vasospasm.

  • Systemic arterial hypertension.

Stroke (Cerebral Vascular Accident / Brain Attack)

• General Definition: A change in the normal blood supply to the brain, which often causes increased intracranial pressure (ICP).

• Causative Agents:

  • Hypertension.

  • Arteriovenous malformation.

• Major Types of Strokes:

  • Ischemic Stroke: These are caused by an obstruction within a blood vessel supplying blood to the brain.

    • Thrombotic Stroke: The process of clot formation (thrombosis) results in a narrowing of the lumen, which blocks the passage of blood through the artery.

    • Embolic Stroke: An embolus is a blood clot or other debris circulating in the blood. When it reaches an artery in the brain that is too narrow to pass through, it lodges there and blocks the flow of blood.

  • Hemorrhagic Stroke: A burst blood vessel allows blood to seep into and damage brain tissues until clotting shuts off the leak. A massive hypertensive hemorrhage can rupture into a lateral ventricle of the brain.

• Risk Factors:

  • Modifiable: Smoking (all types, including cigars), substance use, obesity, sedentary lifestyle, oral contraceptive use, and use of phenylpropanolamine (PPA) found in antihistamine drugs.

  • Non-modifiable: Family history, race, and ethnicity.

Stroke Assessment and Identification

• Initial Priority: The first priority is to transport the patient to a certified stroke center.

• Focused History:

  • When did the symptoms begin?

  • What was the patient doing at the time?

  • How did the symptoms progress?

  • Medical history, current medications, and social history.

• Five Most Common Signs:

  1. Sudden confusion, trouble speaking, or understanding others.

  2. Sudden numbness or weakness of the face, arm, or leg.

  3. Sudden trouble seeing in one or both eyes.

  4. Sudden dizziness, trouble walking, or loss of balance/coordination.

  5. Sudden, severe headache with no known cause.

• BEFAST / SOS Stroke Identification:

  • B - Balance: Loss of balance, headache.

  • E - Eyes: Blurred vision.

  • F - Face: One side of the face is drooping.

  • A - Arms: Arm or leg weakness.

  • S - Speech: Speech difficulty.

  • T - Time: Time to call for an ambulance immediately.

• National Institute of Health Stroke Scale (NIHSS):

  • A valid and reliable assessment tool used to determine eligibility for IV fibrinolytic drugs.

  • Consists of $11$ areas of assessment.

  • Score ranges from $0$ to $40$.

Neurologic and Physiological Manifestations of Stroke

• Cognitive Changes: Denial, spatial/proprioceptive dysfunction, impaired judgment, memory issues, and problem-solving deficits.

• Motor Changes: Hemiplegia (paralysis), hemiparesis (weakness), and ataxia (gait issues).

• Sensory Changes: Unilateral inattention (body neglect) syndrome, ptosis, and nystagmus.

• Cranial Nerve Assessment:

  • CN V: Ability to chew.

  • CN IX & X: Ability to swallow.

  • CN VII: Facial paralysis.

  • Dysphagia: Difficulty swallowing.

• Cardiovascular Assessment: Heart murmur, dysrhythmias (specifically atrial fibrillation), and hypertension. Atrial fibrillation increases the risk for embolic stroke.

• Lateralization of Brain Damage:

  • Right-brain Damage (Stroke on right side):

    • Paralyzed left side (hemiplegia).

    • Left-sided neglect.

    • Spatial-perceptual deficits.

    • Tendency to deny or minimize problems.

    • Rapid performance and short attention span.

    • Impulsive behavior and safety problems.

    • Impaired judgment and time concepts.

  • Left-brain Damage (Stroke on left side):

    • Paralyzed right side (hemiplegia).

    • Impaired speech/language (aphasias).

    • Impaired right/left discrimination.

    • Slow performance and cautious behavior.

    • Awareness of deficits leading to depression and anxiety.

    • Impaired comprehension related to language and math.

Diagnostics and Thrombolytic Therapy

• Laboratory Tests: There is no definitive lab test for stroke. Prothrombin time (PT/INR) and Partial Thromboplastin time (PTT) are used to establish a baseline before starting anticoagulation.

• Imaging: Cat Scan (CT), Magnetic Resonance Imaging (MRI), and Carotid duplex scanning.

• IV (Systemic) Thrombolytic Therapy:

  • Drug: rtPA (tissue plasminogen activator), specifically Alteplase, is the only approved drug to re-establish blood flow.

  • Eligibility: Based on a CT scan to confirm ischemic stroke and the time of symptom onset.

  • Timeframes: Must be given within $3$ hours of onset generally, or within $4.5$ hours with specific exceptions.

  • Priority of Care: Observe for signs of intracerebral hemorrhage (e.g., changes in mental status like drowsiness) and other signs of bleeding (epistaxis).

Glasgow Coma Scale (GCS)

• Eye Opening Response:

  • $4$: Spontaneously

  • $3$: To speech

  • $2$: To pain

  • $1$: No response

• Verbal Response:

  • $5$: Oriented to time, person, and place

  • $4$: Confused

  • $3$: Inappropriate words

  • $2$: Incomprehensible sounds

  • $1$: No response

• Motor Response:

  • $6$: Obeys command

  • $5$: Moves to localized pain

  • $4$: Flex to withdraw from pain

  • $3$: Abnormal flexion

  • $2$: Abnormal extension

  • $1$: No response

Medical and Nursing Interventions for Stroke

• Physiological Monitoring: Monitor ICP and facilitate ongoing drug therapy including Aspirin (ASA), Calcium Channel Blockers (Nimodipine), stool softeners, analgesics, and anti-anxiety medications.

• Safety and Nutrition:

  • Priority: Keep the client NPO until a swallowing assessment is complete to prevent aspiration.

  • Unilateral Neglect: Approach the patient from the unaffected side. The unaffected side should face the door. Position the affected arm on a pillow.

• Communication:

  • Expressive (Broca’s or Motor) Aphasia: Difficulty producing language.

  • Receptive (Wernicke’s or Sensory) Aphasia: Difficulty understanding language.

• Psychosocial: Provide support for post-stroke depression.

Seizures and Epilepsy

• Definitions:

  • Seizure: Categorized as Generalized, Partial, Unclassified, or Secondary.

  • Epilepsy: Primary or idiopathic condition.

• Classification of Seizures:

  • Partial Seizures: Consciousness may be alert (Simple) or altered (Complex).

  • Generalized Seizures: Probable altered consciousness. Types include Generalized tonic-clonic, Absence, Myoclonic, Tonic, Clonic, and Atonic.

• Causes: Metabolic disorders, acute alcohol withdrawal, electrolyte disturbances, heart disease, high fever, stroke, and substance abuse.

• Diagnosis: Electroencephalogram (EEG), CT scan, or MRI.

• Seizure Precautions:

  • Available Oxygen and Suction equipment.

  • Maintain patent Airway and IV access.

  • Siderails up (per policy).

  • Contraindication: No tongue blades; nothing should be forced into the mouth.

• In-the-Moment Management:

  • Note time and duration (record beginning and end).

  • Lower patient to the ground/position in bed in lowest position.

  • Cushion head with a pillow and loosen tight clothing.

  • Turn to side-lying position to prevent aspiration and allow drainage of secretions.

  • Do Not restrain the patient or leave them unattended.

Status Epilepticus

• Definition: A seizure lasting greater than $5$ minutes or repeated seizures over a $30$-minute period.

• Urgency: This is a medical emergency.

• Causes: Sudden withdrawal from antiepileptic drugs, infection, alcohol/drug withdrawal, head trauma, cerebral edema, and metabolic disturbances.

• Management:

  • Priority: Establishing an airway.

  • Medications: Lorazepam (Ativan), Diazepam (Valium), Diastat (diazepam rectal gel), IV Phenytoin (Dilantin), or Fosphenytoin (Cerebyx).

Dementia and Alzheimer’s Disease (AD)

• Dementia: A syndrome characterized by cognitive dysfunction, loss of memory, and progressive loss of brain function. Older age is the most important risk factor.

• Alzheimer’s Disease: The most common form of dementia. It is a chronic, progressive, and degenerative disease of the brain.

• Early Warning Signs ($10$ Signs):

  1. Memory loss that affects job skills (going beyond forgetting a name).

  2. Difficulty performing familiar tasks (cooking a meal but forgetting to serve it).

  3. Problems with language (forgetting simple words or inappropriate substitutions).

  4. Disorientation to time and place (becoming lost on one’s own street).

  5. Poor or decreased judgment (wearing a bathrobe to the store).

  6. Problems with abstract thinking (difficulty with basic calculations).

  7. Misplacing things in inappropriate places (utensils in clothing drawers).

  8. Changes in mood or behavior (rapid swings for no reason).

  9. Changes in personality (becoming angry, suspicious, or fearful).

  10. Loss of initiative.

• Progression and Late Stage Symptoms:

  • Intermediate: Dysphasia, Apraxia, Visual agnosia, Dysgraphia, wandering.

  • Late: Long-term memory loss, inability to communicate, inability to perform ADLs, incontinence, and unresponsiveness.

• Diagnostic Tools: Mini-Mental State Examination (MMSE) helps document the degree of cognitive impairment and provides a baseline. PET scans can show hypometabolism in advanced AD brain. A brain biopsy is a definitive (though rarely clinical) diagnosis.

• AD Drug Therapy:

  • Cholinesterase Inhibitors: Increase acetylcholine. Examples: Donepezil (Aricept), Rivastigmine (Exelon), Galantamine (Razadyne).

  • NMDA Receptor Antagonist: Memantine (Namenda).

  • Antidepressants: SSRIs (Fluoxetine, Sertraline, Citalopram). Tricyclic Antidepressants are used with caution due to confusion and constipation risks.

AD Nursing Care and Behavioral Management

• Priority: Providing a safe environment is the priority goal.

• Routine: Maintain familiar routines for sleep, meals, and meds. Do not test orientation at every encounter if it causes agitation.

• Behavioral Problems: Occur in $90\%$ of patients; includes repetitiveness, delusions, hallucinations, agitation, and aggression.

• Sundowning: Agitation and confusion that worsens in the late afternoon/evening.

  • Interventions: Calm environment, maximize daylight exposure, limit caffeine/naps, and evaluate meds.

• Communication Guidelines:

  • DO: Treat as adults, use gentle touch, direct eye contact, simplify tasks, and use distraction/redirection.

  • DO NOT: Criticize, argue, rush, or use condescending terms (e.g., "honey").

• Nutrition in Middle/Late Stages:

  • Provide pureed food, thickened liquids, and finger foods to allow self-feeding.

  • Use easy-grip utensils and offer liquids frequently.

  • Short-term options: NG or PEG tube feedings.

Delirium

• Definition: A medical emergency that is often preventable and treatable. It is characterized by more confusion than normal.

• Risk Factors (DELIRIUM mnemonic):

  • D: Dehydration

  • E: Eyes and ears (sensory deficits)

  • L: Limited mobility

  • I: Infection

  • R: Reduce pain

  • I: Impaired cognition

  • U: Up at night (sleep deprivation)

  • M: Medication

• Identification: Single Question to identify Delirium (SQID): "Are they more confused than normal?" Use the 4AT rapid assessment test.

• Management: Treat the cause, avoid transfers, reorient to place/time, adequate fluids, and use of eyeglasses/hearing aids.

Questions & Discussion

• Q: Which statement about preventing stroke indicates a need for further teaching?

  • A: "I only smoke cigars, which is better than smoking cigarettes." (Teaching: All types of smoking increase stroke risk).

• Q: What finding is the highest priority for a patient on alteplase?

  • A: Client continues to be drowsy. (Indicates potential brain bleed/change in mental status).

• Q: Priority action for acute ischemic stroke admission?

  • A: Keep NPO until swallowing assessment is complete.

• Q: Nursing diagnosis for impaired memory intervention?

  • A: Maintain familiar routines of sleep, meals, and drugs. (Structure is very helpful; avoiding constant questioning reduces agitation).

• Q: How is dementia defined?

  • A: A syndrome characterized by cognitive dysfunction and loss of memory.

• Q: What is the clinical diagnosis of dementia based on?

  • A: Patient history and cognitive assessment. (Biopsy is definitive but usually post-mortem or rare; CT/MRI help rule out other things).

• Definition: A TIA is considered a "warning sign" of a potential future stroke, serving as an important indicator of heightened stroke risk. It involves brief episodes of focal neurologic dysfunction that typically last less than 24 hours, most often just a few minutes to an hour. While symptoms may resolve quickly, the occurrence of a TIA markedly increases the likelihood of a subsequent stroke in the future.

• Pathophysiology: The transient nature of a TIA is caused by a brief interruption in cerebral blood flow, often due to an embolism or a thrombus that obstructs arterial supply to a specific brain region. This disrupted blood flow leads to temporary neuronal dysfunction without resulting in permanent brain damage.

• Etiology:

  • Cerebral Vasospasm: An acute narrowing of the cerebral arteries, often due to increased muscle tone or irritative factors affecting the blood vessels.

  • Systemic Arterial Hypertension: Chronic high blood pressure can damage blood vessels, increasing the risk of embolism and clot formation that may lead to TIAs.

  • Cardiac Factors: Atrial fibrillation and other arrhythmias can result in the formation of clots in the heart that can lead to obstruction of cerebral arteries.

  • Atherosclerosis: Buildup of fatty deposits and other substances within arterial walls can restrict blood flow and contribute to TIAs.

• Symptoms: Symptoms are similar to those of a stroke but are temporary and resolve quickly. They can include:

  • Sudden weakness or numbness on one side of the body, particularly in the face or limbs.

  • Sudden confusion or difficulty speaking, understanding speech, or finding the right words.

  • Sudden visual disturbances in one or both eyes.

  • Dizziness, loss of balance, or difficulty walking.

  • A sudden severe headache with no known cause.

• Diagnosis: Diagnosis is primarily clinical based on symptoms and patient history, but imaging studies like CT or MRI can be employed to rule out other causes or confirm ischemia. Additionally, carotid ultrasound may be used to assess for potential vascular blockages.

• Management and Prevention: Management focuses on preventing subsequent strokes, emphasizing:

  • Lifestyle Modifications: Encouraging healthy eating, regular exercise, smoking cessation, and weight management.

  • Medications: Anti-platelet agents (e.g., aspirin, clopidogrel) and anticoagulants for patients with specific cardiac abnormalities. Statins and antihypertensive medications may also be prescribed to manage underlying conditions.

  • Monitoring and Risk Assessment: Regular follow-up to evaluate risk factors and implement further preventive strategies as needed.

  • Patient Education: Informing patients about warning signs of impending stroke and the critical importance of immediate medical attention if symptoms occur again, even if transient.

  • Referral to neurology for high-risk patients may be considered to assess for further preventive interventions, including possible surgical options to address significant carotid artery stenosis.