Stroke is a leading cause of mortality & mortality globally. This presentation deals a case of stroke & issues of healthcare of elderly

1. Presenter
Dr Md Abu Bashar
Junior Resident
Community Medicine
PGIMER, Chandigarh
Moderator
Dr Sonu Goel
Assistant Professor
School of Public Health
4/19/2015 1

2. Name Age/Sex Education Occupation Income Health
Status
Gorakh
Ram
65/M Matric Retired BSF
inspector
35000 Hypertensiv
e recently
diagnosed
Bidya Devi 54/M 8th Housewife Nil Type 2 DM
Kairon Devi 87/F Nil Ex-trained
Dai
Nil Hypertensiv
e with h/o
Stroke(CVA)
leading to
hemiparesis
4/19/2015 2
SES- UPPER MIDDLE CLASS(II) A/C to UDAY PARIKH
SCALE

3.  Kairon Devi, w/o late Hansraj, 87 yrs old from
kheri village of Raipur Rani block of distt
Panchkula, Haryanabedridden for 1.5 yrs in
her house following attack of stroke in
june,2013
4/19/2015 3

4.  Weakness of Right side of body
 Speech difficulties
 Unable to stand or walk
 Pain in right upper and lower limbs with
inability to extend fully
4/19/2015 4

5.  Was hypertensive for 30 years
 Was on medications from PGI Health Center
in Kheri and CHC Raipur Rani
 Sustained a attack of stroke while performing
Puja in evening of 12th June,2013.
 Pt fell on the ground and started having
tremors.
 Subsequently developed partial loss of speech
along with right sided paralysis.
4/19/2015 5

6.  Pt was brought to military Hospital,
Chandigarh in their private vehicle next day
only
 was shown in emergency and got admitted in
ICU
 Was put on constant monitoring of vitals
 Was inserted Nasogastric(NG) tube for
feeding as she was unable to swallow and
Foley’s catheterization.
4/19/2015 6

7.  shifted to wards from ICU on 3rd day
 Was administered I.V. Fluids along with
Neurobion injections during stay in ICU
 Continued to put on NG Feeding in wards
along with IV fluids
 Was discharged on day 16 of hospitalization
 Was diagnosed as case of CVA with right
sided hemiparesis
 Developed UTI during hospitalization and was
given oral antibiotics
4/19/2015 7

8.  Was advised massage and exercises during
hospitalization by the physiotherapist
 Physiotherapists only told the method of
exercises and massage but didn’t performed.
 Daughter-in-law performed for some
duration(1-2 months) but left due to her ill
health
 Currently no physiotherapy is being given to
the pt
4/19/2015 8

9.  Pt’s family member contacted some
traditional faith healers too
 Received 5 inj.(content unknown) for cure of
paralysis soon after being discharged from
hospital
 No improvement reported from above
therapy
4/19/2015 9

10.  k/c/o hypertension for last 30 years
 On regular treatment from PGI center at Kheri
 On tab. Hydrochlorthiazide 12.5 mg BD
 Never undergone Lipid Profile, Kidney
Function Tests or ECG
 Was taking regular NSAIDs(tab. Brufen) for
relief of pain knee joint from PGI center
4/19/2015 10

11.  Currently receiving
 Tab. Ecosporin (150 mg) HS
 Tab. Atorvas (40mg) HS
 Tab. Beclofen (10mg) HS
 Syp. Lactulose (30mg)HS
 Tab. Atenolol (25mg) OD
Prescribed from Military Hospital, Chandigarh
 Adherence to medications – good( A/c Morisky adherence
rating scale)
 Was on tab. Hydrochlorthiazide (12.5 mg) BD Before attack
 Compliance- poor
 Was regularly taking painkiller (tab. Brufen) for B/l pain
knee joints.
 known Allergy to any drug- Absent
4/19/2015 11

12.  Brother was hypertensive, died of heart
ailment as told by son
 Two of the sons are hypertensive
 No family h/o Diabetes, stroke
4/19/2015 12

13.  Non-smoker, Non-alcoholic
 Vegetarian
 Have 3 sons & 2 daughter, all alive
 Was working as trained Dai in the village
 Religious
4/19/2015 13

14.  Good interpersonal relations in the family
 As she was a trained Dai, villagers use to
come to her for advice for pregnant women
and have good rapport with the neighbours
 Basically from Hamirpur distt of HP, migrated
40 years back
 Use to attend local meetings and was an
active member of Various groups like mahila
mandal/SMS
 Received training for performing home
deliveries in past and use to conduct home
deliveries
4/19/2015 14

15.  Living in a Pukka House with his second son
and his wife
 3 rooms in the house with separate kitchen
and toilets
 ventilation- adequate
 Lighting- adequate
 Source of cooking – LPG cylinders
 Source of Drinking water – filtered water
 indoor air pollution - Absent
4/19/2015 15

16.  Passive smoking- Absent
 Flies – present outside house
 Mosquitoes and rats – Absent
 Toilet – western and Indian both
4/19/2015 16

17.  For minor ailments, family use to visit PGI
center at kheri and CHC Raipurani
 For major ailments, use to visit Military
Hospital, Chandigarh
 Currently under treatment from military
hospital, Chandigarh
 Irregular in visits, last visit 2 months back
4/19/2015 17

18.  Pt seems to get affected by disturbances in
the family
 Feeling concerned for the marriage of her
grandson as told by the daughter-in-law
 Pt use to recall the days when she use to be a
trained Dai and use to give advice to
pregnant women in the village
 Son and daughter-in-law takes care of her
but feel burdened of taking care of her
4/19/2015 18

19. Timing Content of diet Kilo Calories provided
7 AM 1 Cup of TEA + 2 SMASHED
BISCUITS
250
9 AM 1 PHULKA+ 1 GLASS MILK 250
1 PM 2 PHULKA+ ½ KATORY DHAL 260
5PM 1 CUP OF TEA + 2 SMASHED
BISCUITS
250
9PM 2 PHULKA + 1 GLASS MILK 340
TOTAL 1450
4/19/2015 19
TOTAL CALORY DEFICIT = 1850-1450=
400 kcal

20.  Pt conscious, orientation to T/P/P
 Built & Posture - Average , Non-obese, kyphotic
spine
 Pulse- 96/min RR- 16/min
 BP- 150/90 mm of Hg
 Temperature – Afebrile
 Pallor- ++
 Icterus, Clubbing, cynosis, lymphadenopathy, edema
– Absent
 Jugular veins- Not engored
 Thyroid – not enlarged
 weight, height, BMI- could not done
 Arm span- could not be done
4/19/2015 20

21.  Oral cavity –
 Teeth – absent(edentulous), Gums- spongy
Tongue- coated, papilla absent, Tonsils- not
enlarged, hygiene- poor
 Eyes –
 vision-right eye 6/18, left eye 6/36
 senile immature cataract present in left eye
 Ptosis of right eye lid
 Pupil equally reacting to light
 Ear –
 wax present, no discharge seen,
 hearing diminished on both sides
4/19/2015 21

22.  Respiratory system
 Inspection – trachea central, right chest wall
lower than left moving equally with
respiration
 Palpation- no chest wall abnormality felt, no
tenderness present
 Percussion – resonant note found all over
chest wall
 Auscultation – normal vesicular breath
sounds, Air entry equal on both side, no
crepts or rhonchi heard
4/19/2015 22

23.  Cardiovascular system
 Inspection – jugular veins not engorged
 Palpation- apical impulse felt in left 5th
intercostal space
 Auscultation – S1 S2 Heard, no murmur heard
4/19/2015 23

24.  Abdominal examination
Inspection – abdominal wall normal in shape with
no scars, moving equally with respiration
wrinkles present over abdominal wall
umbilicus inverted
Palpation – liver, spleen – not enlarged
bladder – not distended
Percussion – no fluid thrill or shifting dullness
heard
Auscultation – bowel sounds present
4/19/2015 24

25.  Nervous system –
A. Global & Functional assessment –
 Katz ADL is the most appropriate tool to
assess it.
 A score of 6 indicates full function, 4
moderate impairment and 2 or less severe
functional impairment
4/19/2015 25

26. PT SCORE ON
ACTIVITIES
POINTS(1 OR
0)
INDEPENDENCE(1 POINT)
NO supervision, direct or
personal assistance
DEPENDENCE (0 POINT)
WITH supervision, direct,
personal assistance or total
care
BATHING
POINTS - 0
(1 POINT) Bathes self completely
or needs help in bathing only a
single part of body
(0 POINT) Needs help in
bathing more than one part of
body. Requires total bathing
DRESSING
POINTS -0
(1 POINT) Gets clothes from
closets and puts on clothes
complete with fasteners
(0 POINT) Needs help with
dressing self or need to be
completely dressed
TOILETING
POINTS -0
(1 POINT) Goes to toilet, gets on
and off, clean genital area
without help
(0 POINT) Needs Help
transferring to the toilet,
cleaning self or uses bedpan
or commode
TRANSFERRIN
G
POINTS - 0
(1 POINT) Moves in or out bed
or chair unassisted.
(0 POINT) Needs help in
moving from bed to chair
CONTINENCE
POINTS- 0
(1 POINT) exercise complete
self control over urination or
defecation
(0 POINT) Is partially or totally
incontinent of bowel or
bladder 4/19/2015 26

27.  Motor system
 Power – Right upper limb- 1/5 Left UL-4/5
right lower limb- 1/5 Left UL -
4/5
 Tone- increased tone in right upper and
lower limbs
 Bulk of Muscles- contractures in muscles of
upper and lower limbs
 Gait – pt unable to walk
 Reflexes - Superficial reflexes- absent on
affected side
Deep tendon reflexes –
exaggarated on affected side
 Sensory system – Normal 4/19/2015 27

28.  Higher mental functions
 Memory- impaired
 Orientation – oriented to time/place/person
 Judgement – intact
 Speech – hesitancy in word production,
difficulty in articulation, normal fluency
4/19/2015 28

29.  MRI Brain(15/06/13)- finding s/o thromus @
left MCA with multiple anterior ischemic
infarcts
 Lipid profile(14/06/13) – WNL except raised
triglycerides
 ECG(6/12/13) – Atrial flutter with
predominant 2:1 AV block
 HB(14/06/13) – 9 gm/dl
 LFT, BLOOD COUNTS- WNL
4/19/2015 29

30.  A 85 old Hindu vegetarian female belonging
to 3 member family of upper middle class a/c
to Uday parikh scale, k/c/o hypertension for
past 30 years currently suffering from right
sided hemiparesis with speech difficulties
following a attack of stroke in year 2013
alongwith left eye cataract & hearing
impairment & mild anaemia
4/19/2015 30

31.  Investigations needed
 Lipid profile
 Renal function tests
 Serum calcium & vitamin D3 levels
 Coagulation profile
 Dexa scan
 Mammography and pap smear
 ECG
 Routine urine & urine culture
4/19/2015 31

32.  Drug therapy
 Continue prescribed medications
 Tab. Amlodepine (5 mg) 1 tab OD
 Tab. Fe(100 mg) 1 tab OD
 Tab. Calcium(500 mg) 1 tab OD
 Tab. Becosule-Z 1 tab 0D
 Avoiding NSAIDS
 Ensuring compliance to medications and
regular monitoring of Blood Pressure
4/19/2015 32

33.  Dietary advice
 Adding one serving of fruit per day
 Reducing salt intake
 Adding vegetables in the diet
 Consultations
 Opthalamology consultation for Sx of left eye
cataract and correction of refractive errors
 ENT consultation for hearing assessment and
correction by hearing aids and speech therapy
 physiotherapy consultation for exercises for
improvement of weakness of limbs
4/19/2015 33

34.  Rehabilitation after stroke aims to preserve or
improve range of motion, muscle strength, bowel and
bladder function, and functional and cognitive
abilities.
 Preventive measures for pressure ulcers- frequent
change of posture by the care giver
 Joint mobility- each affected joint is passively
exercised through normal range of motion 3-4
times/d and active exercise of unaffected extremities
 Ambulation – patient should be made to stand and
walk with support
 ADL- activities like moving in bed, turning, changing
position, sitting up should be practiced with support
from caregaver/s
4/19/2015 34

35.  Screening - All family members should be screened
for hypertension and Diabetes
 Lifestyle changes & compliance-Those already
diagnosed( Son and daughter-in-law) should be
compliant to medications along with lifestyle changes
like regular exercise, low salt intake, dietary
modifications like adding fruits and vegetables in diet
and regular follow up
 Training- family members should be trained on
methods of home based care of the patient
 Ensuring physiotherapy – family members may be
trained about the various exercises so that they could
perform at home too.
 Counseling - regarding providing emotional support
to the patient
4/19/2015 35

36.  Social & Financial Support for elderly
 National Programme for control of Cancer,
Diabetes, Cardiovascular diseases and
Stroke(NPCDCS)
 National Programme for healthcare of
elderly(NPHFE)
 Stroke helplines
 Creating awareness about prevention of NCDs
 Sensitization of community towards need of
elderly
 Rehabilitation measures
4/19/2015 36

37.  National schemes-
 Indira Gandhi National Old Age Pension Scheme-Rs 1000/-
month is given to all citizens below poverty line who are > 60
yrs
 Varishtha Pension Bima Yojna- will provide monthly pension
ranging from Rs 500 to Rs 5,000 to senior citizens.
 Annapoorna -10 kgs. of food grains per beneficiary per
month are provided free of cost to those senior citizens who
remain uncovered under the old age pension scheme.
 Integrated Programme for Older Persons (Plan Scheme) -
Financial assistance upto 90% of the project cost is provided
to NGOs for establishing and maintaining Old Age Homes,
Day Care Centers, Mobile Medicare Units and to providing
non-institutional services to older ones.
 Income tax rebate upto an income of Rs. 2.5 lakhs p.a. for
>60 yrs and upto 5 lakhs for >80 yrs
4/19/2015 37

38.  State initiatives
 Old age Samman Allownce scheme- pension
@1000/- month for all residents of Haryana
>60 yrs having income<2 Lakhs/annum
 Widow Pension Scheme – pension @1000/-
month for women>18 yrs & having income<2
Lakhs/annum
4/19/2015 38

39. 4/19/2015 39

40.  Tobacco, alcohol, unhealthy diet ,physical
inactivity, high salt intake, high BP & obesity are
major risk factors common to many NCDs.
 Keeping in view that there are common
preventable risk factors for Cancer, Diabetes,
CVD & Stroke, GOI initiated it during 2010-11
 Focus of NPCDCS is on promotion of healthy life
styles, early diagnosis & M/m of diabetes, HTN,
CVD including stroke & common cancers
 Implemented in 100 pilot districts across 21
states during 2010-12.
4/19/2015 40

41.  Activities consists of opportunistic screening of
persons above the age of thirty years for diabetes
and hypertension ,at the point of primary contact
with any health facility
 Each District hospital will have regular NCD clinic
for screening, management , and counseling &
awareness generation for NCDs
 6-10 bedded Cardiac care Unit(CCU)/ICU would
be established in at least 25% DHs.
 The districts will be supported with certain
essential drugs including TPA for stroke patients.
4/19/2015 41

42.  NPHCE is an articulation of the International and
national commitments of the Government as envisaged
under the UN Convention on the Rights of Persons with
Disabilities, National Policy on Older Persons & Section
20 of “The Maintenance and Welfare of Parents and
Senior Citizens Act, 2007”
 The Vision of the NPHCE are:
 To provide accessible, affordable, and high-quality
long-term, comprehensive and dedicated care services
to an ageing population;
 Creating a new “architecture” for Ageing;
 To build a framework to create an enabling environment
for “a Society for all Ages;”
 To promote the concept of Active and Healthy Ageing.
4/19/2015 42

43.  Community based PHC approach including domiciliary visits by
trained health-care workers
 Dedicated services at PHC/CHC level including provision of
machinery, equipment, training, additional human resources, IEC
etc.
 10 bedded wards for elderly at District Hospitals
 Strengthening of 8 Regional Medical Institutes to provide
dedicated tertiary level medical facilities for the elderly,
introducing PG courses in geriatric medicine, and in-service
training of health personnel at all levels
 IEC using mass media, folk media and other communication
channels to reach out to the target community
 Continuous M & E of the Program & research in geriatrics
 Promotion of public private partnerships in geriatric health-care
 Mainstreaming AYUSH
 Reorienting medical education to support geriatric issues.
4/19/2015 43

44.  These helplines are available in different cities by different
numbers
 The goal is to get the stroke victim to a hospital as quickly as
possible to confirm the diagnosis because every minute is
important.
 In Mumbai, in year 2006, a group of neurologists launched an
24 hr helpline by name” ambulance access to all” in which
anyone having symptoms of stroke can contact on the
helpline to be picked by nearest ambulance for treatment
 The ambulance is equipped with life saving equipment
including defibrillator, ECG, cardiac monitor, ventilator and
resuscitation kit.
 PGIMER, Chandigarh too launched a stroke helpline in year
2014 to help patients with possible attack of stroke
4/19/2015 44

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