Case Study - Mike, Preventing Another Stroke

In September 2001, Mike, aged 70, capped off a summer of golf by winning the “best golfer” award in his division at the annual awards banquet at his club. The next night he suffered a significant stroke and lost the use of his left side. Mike was taken to the small local hospital where he was stabilized then given limited rehabilitation.

Mike is a large man, 6’5”and exceeding 250 pounds - a commanding man in size and presence. Some years before his stroke, he had back surgery and subsequently suffered from chronic pain. After his stroke, Mike resisted efforts to increase his mobility in physiotherapy programs because of pain and after about three months, the hospital staff felt he had progressed as far as he could. Staff recommended that Mike be transferred to a nursing home. Although he is severely limited physically, Mike strongly rejected this option and his wife Susan, aged 69 began preparations to have Mike return home.

Susan and Mike have a daughter Janice, aged 48, a son Robert who is 46 years old. Janice has two grown sons in their early 20s – John and Jason.

Mike and Susan live in a small town in Southern Ontario where they rent their multilevel home. Prior to Mike’s discharge, Susan scrambled to have a stair lift installed; Robert, also a large man, built a ramp for the front door of the house then quit his job to work as his father’s “human crane”. When Susan went to the hospital to organize Mike’s transport home, she was handed an envelope with 13 or 14 different pills. Susan thought at the time,“My God,what have I done. Have I made the right decision? Am I going to know how to take care of Mike?”

Susan’s big concern is their multilevel home. There is no place with a banister where Mike can walk. She describes Mike as a big man who loves food but needs to be more active. He does receive some home care and assistance with walking. A rehabilitation day program exists but Mike is too large to be transported by the normal van and the costs for private transport are too high. Although Mike is a long-standing member of the golf course, it is not wheelchair accessible, and even if he got inside, he could not get to a washroom.

Susan feels very alone, as though she is the only one advocating for her husband’s health. The local stroke recovery group has disbanded because no one has the time to coordinate meetings and families with a stroke survivor are all struggling alone.

SECONDARY PREVENTION -- FOR MIKE

Goal: To prevent another stroke. Mike's stroke factors put him at risk for another stroke.

• Strong family history of heart disease and stroke. Both Mike's father and paternal grandfather had strokes, his mother had congestive heart failure and his maternal grandfather had "a massive heart attack". More recently, Mike's younger brother had carotid endarterectomy following a mini-stroke and his son (Mike's nephew) died of a massive heart attack at age 45.
• Mike developed heart problems about 10 years before his stroke. The problems included atrial fibrillation.
• Mike had smoked but although he quit nearly 25 years ago, was exposed to his wife's smoking until she quit 3 years ago.
• Mike has been inactive over the past 10 years. As a young man, he was athletic. He played hockey and baseball and had considered a professional hockey career prior to a knee injury. In later life Mike played golf and after retirement played 5 or 6 times a week. For about 10 years he has used a golf cart because his knees bother him.
• Mike has always been overweight. Susan admits that they were never very ‘health conscious' about food. About ten years ago when Mike learned he had heart problems, he and Susan cut out most fried foods and reduced the amount of red meat in their diet. Susan reports he has improved his eating to include a banana and has orange juice daily but he "loves his sweets".
• They have been essentially alcohol free for the past 10 years although years ago they "enjoyed a good time" and were "social drinkers".
• Mike can not recall any warning of a stroke. Mike and Susan don't remember any TIAs but are unsure about the symptoms of a TIA.
• Mike does take his heart medication.
• As small business owners, Mike and Susan do not have a company pension plan. Their home no longer meets Mike's reduced mobility needs, but since it is a rental they lack equity to purchase a more suitable home, and due to their age and financial circumstances, they are unable to obtain a mortgage.
• There is a lack of affordable assisted transportation to programs such as the day hospital for recreation and increased activity.

As part of the coordinated stroke strategy, stroke clinics using the best practices for stroke care and rehabilitation are being developed across Ontario. Mike’s outcomes might have been very different if he had suffered his stroke in a community with a hospital that offered the clot busting drug tPA to new stroke patients. He might have had few or no serious limitations following the stroke. The opportunity to ‘reverse a stroke’ using new ‘clot-busting’ drugs impacts on the patient directly, on the patient’s family, and on an already stretched health care system. In Mike’s case, some of the immediate financial costs that might have been avoided include:

• three months hospital stay
• long term care placement (declined)
• ongoing medications
• rehabilitation and long term home care services
• son’s loss of income to help care for his father
• modifications to home to enhance accessibility

SECONDARY PREVENTION CHECKLIST - MIKE

Goal for Mike: To prevent another stroke occurrence.