ATrain Education

 

Continuing Education for Health Professionals

Stroke: Emergency Care and Rehabilitation

Module 5

Gender, Age, and Racial Disparities

[This section taken from NINDS, 2015a, unless otherwise noted.]

Although men have a higher risk for stroke (1.25 times that for women), more women die from stroke. Because men do not live as long as women and are usually younger when they have a first stroke, men have a higher rate of survival than women. Even though women have fewer strokes than men, women are generally older when they have strokes and are more likely to die from them.

During the acute onset of a stroke, women report nontraditional symptoms more frequently than men, including pain and reduced level of consciousness. Women may also have other symptoms, such as nausea, face, arm or leg pain, hiccups, feeling very tired, chest pain, shortness of breath, or a racing heartbeat (womenshealth.gov, 2012). Recognizing nontraditional symptoms is critical in order to prevent a delay in diagnosis and treatment of stroke.

Some risk factors for stroke apply only to women (eg, pregnancy, childbirth, menopause) and are tied to hormonal fluctuations and changes that affect a woman in various stages of life. Research in the past few decades has shown that high-dose oral contraceptives can increase the risk of stroke in women by as much as 20%; fortunately, they have been replaced with safer and more effective ones containing lower doses of estrogen. Some studies have shown the newer low-dose oral contraceptives may not increase the risk of stroke in women significantly.

Pregnancy and childbirth can also put a woman at an increased risk for stroke. Pregnancy increases the risk of stroke as much as 3 to 13 times, although it still remains a relatively small risk—approximately 8 in 100,000 women. Up to 25% of strokes during pregnancy end in death, and hemorrhagic strokes are the leading cause of maternal death in the United States. Subarachnoid hemorrhage, in particular, causes 1 to 5 maternal deaths per 10,000 pregnancies.

The risk of stroke during pregnancy is greatest in the six weeks following childbirth. The risk of ischemic stroke after pregnancy is about 9 times higher and the risk of hemorrhagic stroke is more than 28 times higher for postpartum women than for women who are not pregnant or postpartum. Both preeclampsia and eclampsia cause a rise in blood pressure and an increased tendency to form blood clots that can contribute to this increased stroke incidence.

Hormonal changes at the end of the childbearing years can increase the risk of stroke. Several studies have shown that menopause can increase a woman’s risk of stroke and that hormone replacement may reduce that risk. The mechanism by which estrogen can prove beneficial to postmenopausal women could include its role in cholesterol control. Studies have shown that estrogen acts to increase levels of HDL while decreasing LDL levels.

Stroke in Young People

[This section taken from NINDS, 2015a, unless otherwise noted.]

People 18 to 45 years of age are considered young adults and have risk factors for stroke such as drug use, alcohol abuse, pregnancy, head and neck injuries, heart disease or heart malformations, and infections. Some other causes of stroke in the young are linked to genetic diseases.

Hemorrhagic stroke is the most common type of stroke in young adults. Hemorrhagic strokes represent 20% of all strokes in the United States and young people account for many of these. Intracranial hemorrhage accounts for 41% and subarachnoid hemorrhage accounts for 17% of these strokes. The remaining 42% of strokes due to ischemia in the young adult usually require a more exhaustive workup to determine the cause. Despite advances in diagnostic procedures, 20% of strokes in young people continue to be of unknown etiology (Slater, 2014).

Stroke in Children

[This section taken from NINDS, 2015a, unless otherwise noted.]

Medical conditions that can lead to stroke in children include intracranial infection, brain injury, vascular malformations, occlusive vascular disease, and genetic disorders such as sickle cell anemia, tuberous sclerosis, and Marfan’s syndrome.

The symptoms of stroke in children are different from those in adults. A child experiencing a stroke may have seizures, a sudden loss of speech, a loss of expressive language (including body language and gestures), hemiparesis, hemiplegia, dysarthria (impairment of speech), convulsions, headache, or fever. It is a medical emergency when a child shows any of these symptoms.

In children with stroke, the underlying conditions that led to the stroke should be determined and managed to prevent future strokes. For example, giving blood transfusions to young children with sickle cell anemia greatly reduces the risk of stroke.

Most children who experience a stroke will do better than most adults after treatment and rehabilitation. This is due in part to the young brain’s greater plasticity and the ability to adapt to deficits and injury. Children who experience seizures along with stroke do not recover as well as children who do not have seizures. Some children may experience residual hemiplegia, though most will eventually learn how to walk.

Stroke in Ethnic and Racial Minorities

African Americans are affected by stroke more than any other racial or ethnic group in the U.S. These differences are related to higher rates of hypertension and diabetes, sickle cell anemia, and high rates of smoking and obesity (NSA, 2014b). When compared to White Americans, African Americans experience strokes at a younger age and are twice as likely to die from stroke (NSA, 2014b).

The incidence of stroke in African American males is 93 per 100,000 and in African American females it is 79 per 100,000 compared to 63 per 100,000 in Caucasian males and 59 per 100,000 in Caucasian females (MD Guidelines, 2014).

Hispanic Americans are also disproportionately affected by stroke. Compared to White Americans, they have strokes at a younger age. After a first stroke, those with atrial fibrillation have a higher risk of another, more severe stroke. In addition, language barriers and lack of transportation contribute to Hispanic Americans delaying care, avoiding visits to the doctor, and stopping treatment once they feel better (NSA, 2014b).

American Indians and Alaska Natives are more than twice as likely as White Americans to have a stroke. Hypertension, smoking, diabetes, and obesity are major risk factors for stroke in this population (NSA, 2014b).

Racial and Ethnic Disparities in Post Stroke Rehabilitation

There are significant racial and ethnic disparities related to post-stroke rehabilitation. This is despite the fact that African Americans, Hispanics, and other minorities are at a greater risk of stroke, have strokes at younger ages, and experience greater stroke severity, mortality, or residual impairments (Ellis et al., 2014).

When looking at potential disparities in post-stroke rehabilitation outcomes between various ethnic and racial groups in the U.S., the majority of the studies between at least two groups demonstrated that racial/ethnic minorities were less likely to achieve equivalent outcomes compared to their nonminority counterparts, despite both groups receiving rehabilitation. African American stroke survivors frequently achieved lower post-rehabilitation discharge scores, fewer gains and changes, and lower efficiency scores. African Americans are also more likely to have residual post-stroke activity limitations (e.g., walking, bending, carrying, etc.) when compared to Whites Americans (Ellis et al., 2014).

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