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Preventing strokes

Primary prevention to reduce the incidence of stroke should be targeted at the whole population and groups that are at increased risk by increasing awareness and promoting healthy lifestyles that reduce the risk factors for stroke.

THE brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage, and possibly death of the brain cells.

A stroke, which is also called a cerebrovascular accident (CVA), is a condition in which the blood supply to a part of the brain is cut off. It is a medical emergency and the earlier treatment is provided, the less likely will be the damage.

Strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum (i.e. every hour, six people experience a stroke).

The risk for recurrent vascular events after a stroke or transient ischaemic attack (TIA) is about 5% per year for stroke, 3% per year for heart attack, and 7% per year for any one of stroke, heart attack or vascular death. The risks are higher in patients who are at an increased risk of CVA or who have carotid stenosis.

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA.

As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes.

Risk factors

A risk factor increases the chances of getting or having a certain health condition. Some risk factors for stroke cannot be changed, but others can be prevented. Changing risk factors over which a person has control will assist in achieving a longer and healthier life.

Strokes are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

·Age – The risks are increased in the older person, although about a quarter of strokes occur in the young. The risk doubles in each successive decade after 55 years of age.

·Gender – The risks are increased in males (except in older adults, when it evens out).

·Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.

·Medical history – The risks are increased if one has had a heart attack, stroke or TIA. The risks are also increased in pregnancy, abnormal heart beats, chronic renal disease, cancer, some types of arthritis, and in those with abnormal blood vessels or weakness in the wall of an artery.

·Family history – The risks are increased if a close relative has had a stroke.

Primary prevention is vital in any programme to reduce the incidence of stroke. This should be targeted at the whole population and groups that are at increased risk by increasing awareness and promoting healthy lifestyles that reduce the risk factors for stroke.

Secondary prevention are measures used to prevent recurrence of a stroke. They are individualised depending on the person’s pathogenesis based on neuroimaging and other investigations.

The prevention of stroke is similar to the prevention of coronary heart disease.

High blood pressure

High blood pressure (hypertension) is a major risk factor for stroke. The incidence increases in proportion to both the systolic and diastolic blood pressures. Isolated systolic hypertension (systolic blood pressure of more than 160mm Hg and diastolic blood pressure of less than 90mm Hg) is an important risk factor for senior citizens.

A reduction in blood pressure reduces the incidence of stroke. A reduction of the systolic blood pressure by 10mm Hg is associated with a reduction in risk of stroke by about a third, regardless of the baseline blood pressure levels.

Hypertension is controlled by diet, exercise and medicines.

Hyperlipidaemia

There is an association between raised blood lipids and risk of ischaemic stroke. Hyperlipidaemia is controlled by diet, exercise and medicines.

The use of statins in those at increased risk, e.g. those with cardiovascular disease, diabetes, reduces the incidence of coronary events and ischaemic strokes even in individuals whose blood cholesterol levels are normal (less than 5.0mmol/L).

Diabetes

Diabetes increases the risk of ischaemic stroke by 1.8 to 6 times. The incidence of stroke is significantly reduced by stringent control of hypertension in diabetics.

Scientific studies have indicated that strict control of the blood glucose (Hb A1c less than 6%) is critical.

Diabetes is controlled by diet, exercise and medicines.

Diet

Foods rich in fat lead to fatty deposits in the artery walls. The overweight are at risk of hypertension. A low-fat, high-fibre diet, which includes abundant fruits and vegetables (at least five servings daily), is recommended.

Unsaturated fats which increase the blood cholesterol, e.g. meat, ghee, lard, should be avoided. However, a balanced diet has to include some unsaturated fat like fish, olive and vegetable oils.

The daily intake of salt should not be more than 6gm (0.2 oz), which is about one teaspoonful.

Exercise

A combination of a healthy diet with regular exercise is the best method to maintain a healthy weight, which reduces the risk of developing hypertension.

Regular exercise ensures that the heart and circulation are efficient, keeps the blood pressure normal, and lowers the blood cholesterol.

The recommendation is that there be at least 150 minutes of exercise of moderate intensity, e.g. fast walking, per week (about 30 minutes daily).

A person who has had a stroke should discuss with his healthcare provider about possible exercise plans. It may not be possible to have regular exercise immediately after a stroke, but exercise should begin when there has been progress with stroke rehabilitation.

It is essential that weight be maintained at healthy levels. Many people go on weight reduction programmes only to find that they gain back the kilogrammes they lost. It would be better to accept a steady rate of weight loss instead of overnight success.

Programmes that promise an ideal weight within a short period of time do not usually work out in the long term. The key to keeping the weight loss is to make changes to diet and lifestyle that one can live with. One has to adhere to these changes for life; they have to be part and parcel of everyday life.

Smoking

Both active and passive smoking increase the risk of stroke. Smoking doubles the risk as it leads to narrowing of the arteries and increases the likelihood of the blood clotting.

Smoking cessation can reduce the risk of a stroke by up to half. In addition, it will also improve general health and reduce the risk of developing other serious conditions like heart disease and lung cancer.

Smokers who have stopped for more than five years have the same risk of stroke as non-smokers.

Alcohol consumption

Heavy alcohol consumption increases the risk of stroke by three times as it can lead to high blood pressure and irregular heart beats, which are both major risk factors for stroke. In addition, alcohol causes weight gain because they are high-calorie compounds.

Consumption of more than three units a day (one unit = one glass of wine = a peg of hard liquor) increases the risk while light or moderate alcohol intake protects against all strokes.

Aspirin

Aspirin has been reported to be of benefit to women aged 65 years or more in the primary prevention of stroke due to its blood thinning effects.

There is substantial evidence of the benefits of aspirin in secondary prevention of recurrent strokes, with a 25% reduction in risk in all patients with strokes who have received aspirin.

When given within 48 hours of a stroke, it has also been beneficial in reducing recurrent strokes and death.

Other anti-platelet medicines

Alternative antiplatelet medicines are prescribed in patients intolerant or allergic to aspirin, have contraindications to aspirin, or when aspirin has failed. The medicines include ticlopidine and clopidogrel.

It is essential to take aspirin or other anti-platelet medicines under the supervision of a doctor. In addition, one should take measures to avoid falls or tripping when taking these blood-thinning medicines.

In a nutshell

There are several measures that can be taken to prevent a stroke or a recurrent stroke, if one has had a stroke. The following will reduce the likelihood of a stroke or recurrent stroke:

  • Control high blood pressure through diet, exercise, and medicines, when necessary.
  • Control diabetes through diet, exercise, and medicines, when necessary.
  • Control raised cholesterol through diet, exercise, and medicines, when necessary.
  • Exercise at least 30 minutes a day.
  • Maintain a healthy weight by eating healthy foods, eating less, and joining a weight reduction programme, if necessary.
  • Do not smoke, or stop smoking.
  • Limit alcohol consumption to one drink a day for women and two a day for men.
  • Avoid illicit drugs.
  • Have regular medical checks and consultations with the family doctor or physician.

Source: Dr Milton Lum

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The harder you work during rehabilitation, the better your chances of significant recovery after a stroke.

THERE are many questions that come to the minds of stroke victims and their caregivers. Some people view a stroke negatively, whilst others take up the challenge of recovery and restoration of function as much as is possible.

Importantly, the stroke victim’s attitude has a substantial influence on recovery.

The care of stroke patients requires a multidisciplinary approach. The ideal is for all stroke patients to be managed in a stroke unit, which is a dedicated unit in the hospital that only manages strokes. Such a unit would be staffed by neurologists, geriatricians, general physicians with an interest in stroke, trained nurses, physiotherapists, occupational therapists and speech therapists. It would also include neurosurgeons, social workers and dietitians.

The extent of recovery of motor functions is often influenced by the extent of compliance with the rehabilitation plan.

The specially trained staff of the unit provides co-coordinated multidisciplinary 24-hour care throughout the year. There is ample evidence that stroke patients managed in such units have significantly lower death, dependency and institutionalisation rates. In addition, their length of hospital stay is lower when compared to management in general medical wards.

The benefits of a stroke unit include early acute treatment, reduced infection rates, reduced systemic complications and effective rehabilitation. The benefits are independent of the patients’ age, gender, extent of the stroke and the presence of other medical conditions.

The functioning of a stroke unit is enhanced by an efficient referral and rehabilitation network that includes the family doctor.

Cognitive matters

Every human brain has processes and functions which it uses to process information from the environment. These cognitive functions include thinking, memory, concentration, communication skills, spatial awareness and praxis, which is the ability to carry out skilled physical activities.

After a diagnosis of stroke has been made, the doctor and other healthcare professionals will make an assessment of the patient’s cognitive functions, especially the degree to which it has been affected by the stroke.

The assessments, which may take a few days to be completed, enable the formulation of treatment and rehabilitation plans that are specific for the individual patient.

Most cognitive functions affected by the stroke will return with the passage of time, especially with compliance to the treatment and rehabilitation plans. However, full recovery may not occur in some patients.

Many stroke patients have problems with understanding, speech, reading and writing, a condition called aphasia. This results from damage to the part of the brain that controls language, or the muscles involved in speech may be affected.

In such situations, the patient’s recovery of cognitive functions will require interactions with other healthcare professionals, e.g. a speech therapist to assist in the recovery of communication skills.

Various other methodologies are used to assist the patient who has lost some particular cognitive function, e.g. memory aids or diaries for daily tasks.

Recovering physical functioning

Many stroke patients have weakness or paralysis of one side of the body. Many also have difficulties with balance and co-ordination of the body’s movements.

There is often marked tiredness in the initial weeks after the stroke. There may also be problems getting to sleep, thereby aggravating the tiredness.

As soon as a patient’s medical condition permits, he or she should be attended to by a physiotherapist who will formulate a treatment and rehabilitation plan after making an assessment of the degree of physical disability. The primary goal of rehabilitation is to achieve an improvement in the patient’s functional status.

There are various phases in a rehabilitation plan. It starts with evaluation, which is followed by setting of objectives, delivery of management, task reacquisition and environmental modification.

The initial objectives are to improve balance and then to regain muscle strength and control. The exercises are of a short duration initially, which then increases with the recovery of motor function, e.g. the patient may have to pick up an object initially, and later, stand up and walk.

It is vital to follow the instructions and advice of the physiotherapist, although progress may be perceived as difficult and slow initially. The extent of recovery of motor functions is often influenced by the extent of compliance with the rehabilitation plan.

The involvement of a family member or caregiver is always encouraged because the physiotherapist can teach the patient and the caregiver the exercises that can be carried out at home.

The duration of physiotherapy varies and can last for months, or sometimes, years. The decision as to when to stop physiotherapy should only be made after a full discussion with the doctor and physiotherapist.

Bladder and bowel function may be affected if the part of the brain which controls these functions is damaged by the stroke. This can lead to urinary and/or bowel incontinence.

Most patients recover these functions within a fortnight or so. If the problem persists, help could be sought from nurses, and supplemented by aids like incontinence pads.

There are occasions when a stroke leads in damage to the parts of the brain that receive, process and interpret information from the eye(s). This results in various visual problems like double vision, and partial or total blindness in one eye. The management of these problems would require the expertise of an eye specialist (ophthalmologist).

Some patients give up on sex after a stroke. It is important to know that sex does not increase the risk of another stroke. Although there is no guarantee that another stroke will not recur, there is no reason why it should occur while having sex.

Other ways of having sex can be found even if there is severe disability. If there are any problems, a discussion with the doctor will be helpful. This is especially so as sex drive (libido) is reduced by certain medicines.

Some stroke patients enquire about driving. This depends on residual disabilities and the type of vehicle in question. An assessment by a specialist or family doctor will be helpful. The patient’s medical status and the safety of other road users will have to be taken into consideration.

Psychologically speaking

The majority of psychological disorders after a stroke are depression, in which there are feelings of hopelessness and withdrawal from social life, and anxiety disorder, in which there is intense and often uncontrollable fear and anxiety.

These psychological disorders impact upon family and sexual relationships. They are common but will usually disappear with the passage of time. Doctors and other healthcare professionals will provide advice and assistance in addressing the psychological aspects of stroke. They will usually carry out regular reviews of the patient’s psychological functioning.

If the psychological disorders are severe or persistent for a long period of time, a referral will be made to a psychiatrist, who will use various modalities to manage the patient. This includes medicines, counselling and cognitive behavioural therapy.

Looking towards the future

After a stroke, many patients and their caregivers are interested in what the future holds (prognosis) .

The prognosis of stroke depends on the type, size and location of the pathology. A Malaysian study in 2003 reported that mortality is higher in haemorrhagic stroke (27.3%) compared to ischaemic stroke (11%). However, there is better neurological and functional recovery in haemorrhagic stroke.

Strokes that involve the brainstem or are large have a poorer prognosis. The lowest mortality rates are in small focal strokes.

Deaths in the initial month after a stroke are often due to direct effects of the brain damage. Subsequent mortality is usually due to the complications of immobilisation, i.e. bronchopneumonia, deep vein thrombosis, recurrent stroke and coronary heart disease.

In general, a third will recover almost completely and should be able to lead a normal life. Another third will have substantial disability which is variable, eg requiring assistance with bathing (which is mild) and assistance with getting in and out of bed (which is severe). Another third will be severely affected and will die within a year, with the majority of deaths occurring in the initial weeks after the stroke.

Recent studies have reported that mortality rates after a first-ever stroke (all types) were 10% at one week, 20% at one month, 30% at one year, 60% at five years and 76% at 10 years.

The risks of recurrent stroke are 4% in the first month and 12% in the first year. The risks decrease subsequently to about 4-5% per year so that 30% will have suffered a recurrent stroke five years after the first stroke.

The incidence of deaths following a stroke has decreased in the past few decades in both sexes. This has been due to the introduction of stroke units and better prevention in those with risk factors.

Source: Dr Milton Lum

The management of stroke and ‘mini-strokes’. THE brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage and possibly death of the brain cells.

A stroke, which is also called a cerebrovascular accident (CVA), is a condition in which the blood supply to a part of the brain is cut off.

A transient ischaemic attack (TIA) is due to a temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. Its features are similar to that of a stroke, but the duration is about a few minutes. The TIA usually resolves within 24 hours.

TIAs provide a warning that further TIAs or a stroke is on the way.

The incidence of TIA is not well known as many people who have TIA do not seek medical attention.

Imaging tests like computerised tomography (CT) scan and magnetic resonance identify the type of stroke and TIA, its location in the brain and the extent to which the brain is affected. – Courtesy of HSC Medical Centre

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA. As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes.

Strokes and TIAs are medical emergencies, and the earlier management is instituted, the less likely will be the damage to the brain, and consequently, the affected part of the body.

Making a diagnosis

There are two main types of strokes.

Ischaemic strokes, which comprise the majority of stroke cases, occur when the blood supply to the brain stops because the vessel is blocked by a blood clot. This may be due to thrombosis, in which a blood clot forms in one of the brain’s arteries, or to an embolism, in which a blood clot formed elsewhere in the body gets into the brain’s arteries to reach a blood vessel small enough to block its passage.

Haemorrhagic strokes occur when bleeding results from the bursting of a blood vessel supplying the brain because of weakness in its wall. The blood collection compresses the brain, causing damage and loss of function.

The diagnosis of stroke and TIA is made from a detailed history-taking, physical examination and selected diagnostic tests. The history provides vital information, and every effort should be made to obtain information from the patient, family members, friends, or witnesses.

The diagnosis provides answers to questions about the type of stroke, its site in the brain, the extent to which the brain is affected, why it occurred, as well as the potential complications and prognosis.

The investigations for stroke and TIA have been discussed in previous articles. Imaging tests like computerised tomography (CT) scan and magnetic resonance identify the type of stroke and TIA, its location in the brain and the extent to which the brain is affected.

Ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan) help to identify causes of stroke and TIA. Dye may be injected into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

Other tests include blood tests like clotting factors, glucose and cholesterol, electrocardiogram to detect any abnormal heart rhythms, and chest and other x-rays to exclude other medical conditions.

Managing ischaemic strokes

The restoration of perfusion to the ischaemic brain is a vital therapeutic strategy. Although a core of brain tissue might not be salvageable in a stroke, the adjacent dysfunctional tissue may be saved if its circulation is restored and metabolism is normalised.

Ischaemic strokes are treated with medicines that dissolve blood clots (thrombolysis). These medicines are effective if given intravenously within about three to four hours after the onset of the stroke. After that, the medicine has not been shown to have beneficial effects. The earlier thrombolysis is instituted, the better the likelihood of recovery. However, thrombolysis cannot be prescribed for all patients.

Patients will also be prescribed aspirin, which reduces the stickiness in platelets, thereby reducing further blood clot formation. Other medicines will be prescribed if there is allergy to aspirin.

Some patients may be prescribed blood thinning (anti-coagulant) medicines, i.e. heparin or warfarin, that alter blood composition to prevent blood clot formation. However, the use of heparins is not routinely recommended as it does not reduce the mortality in patients with ischaemic stroke.

Anticoagulants are often prescribed in those with an irregular heartbeat.

Ischaemic strokes that are due to narrowing (stenosis) of the carotid artery in the neck are treated surgically, especially if the stenosis is severe. A surgical incision is made in the neck and the fatty deposits in the carotid artery removed.

Management of haemorrhagic strokes

Haemorrhagic strokes are managed by emergency surgery to remove blood from the brain and to ligate any burst blood vessels. The procedure, called a craniotomy, involves a surgical incision of the skull to allow access to the bleeding site(s). After the blood collection has been removed and any bleeding stopped, the bone removed from the skull will be replaced.

The patient may need to be put on a ventilator in the intensive care unit to assist his or her breathing. Medicines will also be prescribed to reduce the likelihood of further strokes, e.g. medicines to lower blood pressure and reduce swelling of the brain (cerebral oedema).

General management of strokes

The objectives are to provide supportive care and treatment of acute complication(s) in order to avoid mortality and functional disability.

Oxygen and airway support are necessary to ensure adequate tissue oxygenation and potential worsening of brain injury.

Regular monitoring and observations are necessary for detection of impaired lung and circulatory function. As high blood pressure is common following a stroke, it is gradually reduced with various medicines.

As there is an association between raised blood sugar following an acute stroke and subsequent mortality and impaired recovery, whether in diabetics or non-diabetics, it is vital that the blood sugar be well controlled.

Strokes may lead to impaired swallowing and consequent aspiration, which increases mortality. As such, a water-swallowing test is performed in all stroke patients before they are allowed to drink or eat. Incomplete oral-labial closure or a coughing reflex is indicative of an increased risk of swallowing. If the patient fails the swallowing test, a nasogastric tube is inserted for feeding.

When a fever occurs, doctors will localise the infection. Antibiotics are prescribed for infections, especially of the lungs and urinary tract, which are the commonest complications after a stroke.

Urinary catheters are avoided, if possible. Anti-pyretics are prescribed for fever, which is also associated with an increased risk of mortality and morbidity.

The majority of stroke patients are prescribed bed rest initially. Mobilisation is initiated as soon as the patient’s condition is stabilised (to prevent complications). Frequent turning, alternating pressure (ripple) mattresses and passive and full-range-of-motion exercises are beneficial.

There has to be close skin monitoring for early detection of bed sores and measures have to be taken to avoid falls.

Management of TIA

The objective is to address the risk factors that led to TIAs in order to prevent a stroke from occurring.

The treatment prescribed depends on the cause(s) of the TIA. High blood pressure, which is the single most important risk factor, is treated with hypotensive medicines.

High blood cholesterol levels are treated with diet, exercise and statins.

Diabetes is treated with diet, exercise, oral hypoglycaemic agents or insulin.

Smoking cessation is vital as smoking doubles the likelihood of TIA or stroke because of the chemicals in the cigarette.

Carotid artery stenosis may require surgery (endarterectomy) to remove the fatty plaques.

Time is of the essence

The effective treatment of stroke and TIA saves lives and prevents long-term disability. The window of opportunity is no more than three to four hours in the case of stroke. Therefore, it behoves everyone with risk factors of stroke and TIA and their caregivers to remember that time is of the essence. In short, TIME = BRAIN.

Source: Dr Milton Lum

Transient ischaemic attack is a warning sign that a stroke may just be around the corner.

A TRANSIENT ischaemic attack (TIA) is due to a temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. Its features are similar to that of a stroke, but the duration is about a few minutes. The TIA is usually resolved within 24 hours.

TIAs provide a warning that further TIAs or a stroke is on the way. Its incidence is not well known as many people who have TIA do not seek medical attention. However, strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum, i.e. strokes occur in six persons every hour.

It has been estimated that without treatment, the likelihood is one in 10 that a stroke will occur within a month after a TIA. As strokes lead to disability and even death in some instances, TIAs should be treated as seriously as strokes. Its early investigation and treatment will markedly reduce the risk of another TIA or stroke.

High blood pressure (hypertension) is the single most important risk factor for stroke.

Anatomy of a TIA

The brain receives its blood supply primarily from the carotid arteries in the front of the neck and secondarily from the vertebral arteries in front of the backbone. These arteries branch into smaller vessels that supply blood to all parts of the brain.

One of these smaller blood vessels gets blocked off during a TIA. This blockage is temporary, lasting a few minutes, and the blood supply is restored soon after, unlike a stroke, in which the blockage lasts a longer period of time. The lack of a constant supply of oxygen-rich blood leads to damage, and later, death of the brain cells.

The blockage is due either to a narrowing of the arteries or as a result of a blood clot formed elsewhere in the body getting into the brain’s arteries to reach a blood vessel small enough to block its passage.

The brain’s arteries are narrowed or blocked by cholesterol deposits (plaques) on its inner lining due to atherosclerosis. Everyone’s arteries get narrower with age, but the process is hastened by factors like high blood pressure, poorly controlled diabetes, raised blood cholesterol, obesity, smoking, excessive alcohol intake, obesity, and a family history of diabetes or heart disease.

TIAs can also result from blood conditions like leukaemia, abnormally thickened blood (polycythaemia), or overproduction of platelets (thrombocythemia).

A TIA can result from blood clots formed in an artery (from elsewhere in the body), which gets “thrown” off (emboli) and eventually blocks the brain’s blood supply. This may be due to irregular heartbeats, the causes of which include high blood pressure, coronary artery disease, disease of the heart’s mitral valve, overactive thyroid gland and excessive alcohol intake.

It is rare that a brain haemorrhage causes a TIA.

TIAs, like strokes, are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

·Age – The risks are increased in the older person, although TIAs can occur at any age, including the young.

·Gender – Men are more likely to have TIAs than pre-menopausal women. However, the likelihood of TIA and stroke increases in postmenopausal women. Although the reason for this is not well elucidated, it is believed that the female hormones, oestrogen and progesterone, affect the elasticity of the body’s ateries.

·Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.

·Medical history – The risks are increased if one has had a heart attack, stroke or TIA.

·Family history – The risks are increased if a close relative has had a TIA or stroke.

There are several other factors (preventable) that increase the risks of TIAs and strokes. They include:

·High blood pressure (hypertension) is the single most important risk factor. The hypertension leads to extra strain on the arteries, causing them to narrow or be easily blocked.

·Diet – Atherosclerosis is more likely to develop with a diet high in saturated fats and excessive salt intake.

·Diabetes increases the likelihood of TIA because of the increased risk of atherosclerosis.

·Smoking doubles the likelihood of TIA or stroke because the chemicals in the cigarette smoke cause thickening of the arteries, thereby increasing the likelihood of clotting.

Features of TIA

The features vary depending on the part of the brain that is affected and the extent to which it is affected.

The common features of TIAs and strokes are:

·Face – There may be an inability to smile, open the mouth or the face or eye may hang downwards.

·Arms – There may be an inability to lift one or both arms due to numbness or weakness.

·Legs – There may be an inability to move one or both legs due to numbness or weakness.

·Speech – There may be slurring of speech or an inability to talk at all although awake.

Other features may include sudden vision loss, dizziness, difficulty talking and understanding what others say, difficulty swallowing, balancing problems, sudden headache, and blacking out.

Diagnosis

Immediate medical attention should be sought if one has or knows another person who has features of a TIA. This will reduce the likelihood of another TIA or stroke.

The diagnosis of a TIA is made by history taking and physical examination even if one thinks that the symptoms have gone. The objective is to check the patient’s neurological status and to rule out other conditions which may have caused the symptoms.

If a TIA is suspected, a referral will be made to a physician, geriatrician or neurologist for further evaluation. This should be done within a week of the occurrence of a TIA and immediately if there is more than one TIA in a period of seven days.

There are several investigations that are carried out after a TIA to check for the underlying conditions that may have caused it. They include:

·Blood tests like clotting factors, glucose, cholesterol

·Electrocardiogram to detect any abnormal heart rhythms

·Chest x-ray may be done to exclude other medical conditions

·Imaging

The common methods of brain imaging are computerised tomography (CT) scan and magnetic resonance imaging (MRI).

The CT scan involves multiple x-ray imaging to produce detailed three dimensional images of the brain and will provide information about factors that may have caused the TIA, e.g. haemorrhage or tumour. The MRI involves use of magnetic and radio waves to produce detailed images of the brain.

Both the CT scan and MRI are used to take images of the brain’s blood vessels as well the blood vessels in the neck that connect the heart and the brain’s blood vessels. This procedure, called a CT or MR angiogram, involves injecting a dye into a vein in the arm.

The brain imaging modality used depends on the availability of CT scan and/or MRI.

Other investigations of the cardiovascular system will be carried out to determine the cause of the TIA. It includes ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan). It can also include injecting dye into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

The management of TIA will be discussed in a subsequent article.

Source: Dr Milton Lum

When blood supply to the brain is compromised, it can lead to damage, and possibly death, of the brain cells, a condition called stroke.

THE human brain has been compared to a supercomputer. But the brain is much more complicated than that, a fact that is confirmed with each new discovery about its capabilities, which is still largely unknown.

This single organ controls all the body’s functions, which include heartbeat, breathing, sexual function, thinking, speech, memory, emotions, movement, and sleep. It influences the immune system’s response to ill health, and determines, to some extent, how a person responds to medical treatment.

In short, the brain makes us human and separates us from other living creatures on planet Earth.

The brain, which is encased in the bony skull, is divided into two sides (hemispheres), each controlling the opposite side of the body.

Different parts of the brain have different functions. The frontal lobe is responsible for the highest intellectual functions like thinking and problem-solving. The parietal lobe is responsible for sensory and motor function. The hippocampus is involved in memory. The thalamus is the relay station for almost all of the information coming into the brain, and the hypothalamus, the relay stations for the systems regulating the body’s functions.

The midbrain has cells that relay specific sensory information from the sense organs to the brain. The hindbrain comprises the pons and medulla oblongata, which control breathing and heart functions, and the cerebellum, which controls movement and cognitive processes that require precise timing.

The brain’s functions depend on a constant blood supply for the oxygen and nutrients needed by its cells. The restriction or stoppage of this supply leads to damage, and possibly death, of the brain cells. This is called a stroke.

A stroke, also called a cerebrovascular accident (CVA), is a condition whereby the blood supply to a part of the brain is cut off. It is a medical emergency, and the earlier treatment is provided, the less severe it will be.

Strokes are the third most common cause of death in Malaysia. It is estimated that there are about 52,000 strokes per annum, i.e. strokes occur in six persons every hour.

Different types

There are two main types of strokes.

Ischaemic strokes, which comprise the majority of stroke cases, occur when the blood supply to the brain stops because the vessel is blocked by a blood clot. This may be due to thrombosis, in which a blood clot forms in one of the brain’s arteries, or to an embolism, in which a blood clot formed elsewhere in the body gets into the brain’s arteries to reach a blood vessel small enough to block its passage.

Haemorrhagic strokes occur when bleeding results from a burst blood vessel supplying the brain because of weakness in its wall. The blood collection compresses the brain, causing damage and loss of function.

A related condition is transient ischaemic attack (TIA) in which there is temporary interruption of the blood supply to part of the brain, leading to a “mini-stroke”. As TIAs provide a warning that a stroke is on the way, they should be treated seriously.

Causes of stroke

Strokes are preventable as lifestyle changes can reduce many of the risk factors. However, there are some risk factors that are not preventable. They include:

·Age – The risks are increased in the older person, although about a quarter of strokes occur in the young.

·Ethnicity – The risks are increased in Indians and Malays because the incidence of diabetes and hypertension are higher in these groups.

·Medical history – The risks are increased if one has had a heart attack, stroke, or TIA.

·Family history – The risks are increased if a close relative has had a stroke.

Ischaemic strokes occur when the brain’s blood supply is blocked by clots formed where the arteries are narrowed or blocked by cholesterol deposits due to atherosclerosis.

Everyone’s arteries get narrower with age, but the process is hastened by factors like high blood pressure, poorly controlled diabetes, raised blood cholesterol, smoking, excessive alcohol intake, obesity and a family history of diabetes or heart disease.

An irregular heartbeat leads to blood clots being thrown off to block the brain’s blood supply. The causes of irregular heartbeats include high blood pressure, coronary artery disease, disease of the heart’s mitral valve, overactive thyroid gland and excessive alcohol intake.

Haemorrhagic strokes occur when a blood vessel of the brain bursts, resulting in bleeding into the brain itself (intracerebral haemorrhage). Sometimes, the bleeding is on the brain surface (subarachnoid haemorrhage).

The primary cause of haemorrhagic stroke is high blood pressure, the risk factors of which include smoking, overweight or obesity, lack of exercise, excessive alcohol intake and stress.

Blood-thinning medicines can also cause haemorrhagic strokes, which can also occur from blood vessel malformations in the brain or an aneurysm, which is a balloon-like swelling of a blood vessel.

Trauma can also cause bleeding in the brain. Although the cause is usually apparent, bleeding into the brain’s lining (subdural haematoma) may occur without signs of trauma.

A rare cause of stroke is blood clot formation in the brain’s veins, which is usually due to clotting abnormalities.

Signs and symptoms

The features vary depending on the part of the brain that is affected and the extent to which it is affected. Strokes usually occur suddenly.

The common features are:

·Face – There may be an inability to smile, open the mouth or the face or eye may hang downwards.

·Arms – There may be an inability to lift one or both arms due to numbness or weakness.

·Legs – There may be an inability to move one or both legs due to numbness or weakness.

·Speech – There may be slurring of speech or an inability to talk at all.

Other features may include sudden vision loss, dizziness, difficulty talking and understanding what others say, difficulty swallowing, balancing problems, sudden and severe headache, and blacking out.

Awareness of the above features is crucial, particularly for those at increased risk of a stroke, and their caregivers.

The complications of stroke include swallowing problems (dysphagia), which affect about a third of stroke patients. This leads to small food particles entering the respiratory tract causing lung infection (pneumonia).

Stroke can also lead to excess cerebrospinal fluid (CSF) in the brain’s ventricles (hydrocephalus) in about 10% of haemorrhagic strokes. CSF, which is produced by the brain, is continuously drained away and absorbed by the body. When its drainage is stopped following a haemorrhagic stroke, the excess CSF causes headaches, loss of balance, nausea and vomiting.

A small percentage of stroke victims who have lost some or all movement in their legs will have blood clot formation in their legs. The features of this deep vein thrombosis (DVT) include swelling, pain, tenderness, warmth and redness, especially in the calf. Urgent diagnosis and treatment is necessary to avoid the clot moving to the lungs, causing pulmonary embolism, which is potentially fatal.

Diagnosing stroke

The diagnosis of a stroke is made by history taking and physical examination. However, imaging of the brain is essential to determine if it is an ischaemic or haemorrhagic stroke, the part of the brain that is affected, and the severity of the stroke.

As the treatments of the different types of stroke vary, a speedy diagnosis will facilitate its management.

The common methods of brain imaging are computerised tomography (CT) scans and magnetic resonance imaging (MRI).

The CT scan involves multiple x-ray imaging to produce detailed three-dimensional images of the brain. MRI involves the use of magnetic and radio waves to produce detailed images of the brain.

Both the CT scan and MRI are used to take images of the brain’s blood vessels, as well as the blood vessels in the neck that connect the heart and the brain’s blood vessels. This procedure, called a CT or MR angiogram. involves injecting a dye into a vein in the arm.

The brain imaging modality used depends on the availability of a CT scan and/or MRI. A CT scan provides enough information if the suspected stroke is major. The MRI is useful if there are complex symptoms, the extent or location of the affected area is unknown, and in patients who have recovered from a TIA.

Brain imaging should be done early; in some patients, within an hour of admission.

A swallow test is usually done for all stroke patients because of the risk of aspiration pneumonia due to dysphagia. This involves giving a few teaspoons of water to the patient and if there is no choking or coughing, to be followed by half a glass of water.

Other investigations of the cardiovascular system will be carried out to determine the cause of the stroke.

It includes ultrasound examination of the heart (echocardiogram) or carotid artery in the neck (Doppler scan). It can also include injecting dye into the carotid or vertebral arteries (arteriography) to enable a detailed examination of the arteries in the brain.

The management of stroke will be discussed in a subsequent article.

Source: Dr Milton Lum

The term autism encompasses a range of behaviours that adversely affect social interaction and communication.

AUTISM is a developmental disability that results in problems with social interaction and communication. Its features vary with individuals.

One person may have mild symptoms, whilst another may have serious ones. That is why healthcare providers consider autism a “spectrum” disorder, which includes an autistic disorder, Asperger syndrome, and pervasive developmental disorder (atypical autism).

Children who have an autistic disorder have major problems with language, social interaction and behaviour. Many also have learning problems and intelligence that is below average.

Children with Asperger syndrome have milder symptoms affecting social interaction and behaviour. Their language development is usually alright but they can have problems in certain aspects of language, for example, understanding humour. Their intelligence is usually above average. Some are skilful in memory, logic and creativity, eg in music, and pure sciences.

Children who have some, but not all of the features of autistic disorder and/or Asperger syndrome, are said to have a pervasive developmental disorder. Most have milder symptoms than autistic disorder but do not possess the good language and above average intelligence of Asperger syndrome.

Looking at the causes

Autistic spectrum disorder (ASD) can be due to primary or secondary factors. There is no medical condition in the former, which comprises 90% of ASD. A medical condition is thought to be wholly or partially responsible for the latter, which comprises 10% of ASD.

The conditions in secondary ASD are fragile X syndrome, tuberous sclerosis, and Rett syndrome.

Fragile X syndrome affects about one in every 3,600 boys and 6,000 girls, who have characteristic long faces, large ears and flexible joints. Tuberous sclerosis affects about one in 6,000 children, who have multiple, non-cancerous tumours all over the body. Rett syndrome affects about one in 20,000 girls who have ASD, and they have problems with physical movement and development.

Primary ASD is associated with genetic, environmental, neurological and psychological factors.

Although there is no specific gene identified, ASD is known to occur in families. If a child has ASD, there is about a 5% chance that another child born to the same parents will have ASD. If an identical twin has ASD, the chance of the other twin developing the condition is 60%.

The environmental factors associated with ASD are viral infection and maternal smoking during pregnancy, and the father’s age. Pregnant women exposed to rubella have a 7% chance of having an ASD child. The chance of pregnant women who smoke daily having a child with ASD is 40%.

First time fathers above 40 years of age are six times more likely to father a child with ASD.

Studies on neurological factors have focused on the brain’s amygdala, which acts like a switchbox between the cerebral cortex and the limbic system. The former processes sensory information and is responsible for all the brain’s higher functions like thought, language, and problem-solving, while the latter controls a person’s emotions.

The amygdala chooses the emotion to match the situation a person is in. Brain imaging studies suggest that connections between the cerebral cortex, amygdala and limbic system are altered in ASD.

Other studies have focused on mirror neurones which are thought to enable copying of the actions of others, eg an infant returns a mother’s smile. As the child grows up, the mirror neurones may be involved in the brain’s higher functions like language, learning, and recognition and understanding of others’ emotions.

Brain imaging studies have found that the response of mirror neurones is altered in ASD. This mirror neurone dysfunction may be responsible for the problems with language, social interaction and some aspects of learning in ASD.

The focus of research on psychological factors is the concept of “theory of mind” (TOM). TOM refers to a person’s ability to understand the mental states of others, ie the ability to see the world through another person’s eyes. It is believed that most children understand TOM fully by about four years of age. Children with ASD have a limited or non-existent understanding of TOM, which may explain their problems with social interaction.

Although there are reports of links between vaccines and autism, none have held up to scientific scrutiny. There is no conclusive evidence that any part of a vaccine or combination of vaccines causes autism. There is also no evidence that any material used to make or preserve vaccines play a role in the causation of autism.

Symptoms of ASD

The features of autism involve communication, social interaction and behaviours. Communication can be verbal or non-verbal, eg eye contact, smiling, pointing. The social interactions include holding a conversation and understanding how others feel and think. The behaviours are repetitive, and include repeating actions or words, play and obsession with routines.

Some features may be typical of ASD while others may be a delay in the child’s development.

Features are related to a child’s development and may appear as early as six to 18 months when the baby may not follow a gaze nor appear to recognise or respond to a voice, but there is awareness of other sounds. The baby does not “babble” and appears expressionless. The baby has little interest in the surroundings or rarely makes gestures like pointing or waving.

The features are more obvious as the child becomes older. Language and social interaction problems become noticeable, together with unusual behaviours. Speech development may be delayed, or there is none at all. Speech can also be monotonous and repetitive.

The child does play in an imaginative but repetitive way. There is limited or no awareness of people in their surroundings. They may form friendships with other children only to behave inappropriately.

Many ASD children exhibit repetitive physical behaviours, eg rocking back and forth or licking objects. They prefer strict routines, which, if disrupted, would lead to temper tantrums or even attempts at self-harm. They often dislike certain foods.

There is usually an improvement as the child begins school. However, those with severe ASD may find school stressful, which may trigger disruptive behaviour.

Although most older children improve their language skills, specific difficulties may remain, eg repeating words in a “parrot” fashion, inability to understand humour, or sarcasm. Their lack of understanding of social interaction often hampers their friendships with other children of the same age. They need strict routines.

Children with Asperger syndrome do well with subjects involving facts, figures and logic, but they may have problems with subjects requiring abstract thought, eg literature.

A parent who is worried about a child’s development would benefit from a consultation with his regular doctor who may carry out a brief screening test. This involves several questions and some assessment exercises with the child.

If the doctor suspects ASD, a referral will be made to a paediatrician, psychiatrist or psychologist who will carry out a detailed assessment, which would include a physical examination and other investigations.

When there is a diagnosis of ASD, it facilitates the parents understanding of their child’s condition and plans can be then instituted to help the child.

Managing the problem

There is no cure for autism; neither is there a single treatment for ASD. The objectives of management are to enhance learning and minimise its features.

There are several effective education and behavioural programmes. According to the American Academy of Paediatrics, “the principles and components of effective early childhood intervention in ASD include:

· Entry into intervention as soon as an ASD diagnosis is seriously considered rather than deferring until a definitive diagnosis is made;

· Provision of intensive intervention, with active engagement of the child at least 25 hours per week, 12 months per year, in systematically planned, developmentally appropriate educational activities designed to address identified objectives;

· Low student-to-teacher ratio to allow sufficient amounts of one-on-one time and small-group instruction to meet specific individualised goals;

· Inclusion of a family component (including parent training as indicated);

· Promotion of opportunities for interaction with typically developing peers to the extent that these opportunities are helpful in addressing specified educational goals;

· Ongoing measurement and documentation of the individual child’s progress toward educational objectives, resulting in adjustments in programming when indicated;

· Incorporation of a high degree of structure through elements such as predictable routine, visual activity schedules, and clear physical boundaries to minimise distractions;

· Implementation of strategies to apply learned skills to new environments and situations (generalisation) and to maintain functional use of these skills; and

· Use of assessment-based curricula that address:

1. Functional, spontaneous communication;

2. Social skills, including joint attention, imitation, reciprocal interaction, initiation, and self-management;

3. Functional adaptive skills that prepare the child for increased responsibility and independence;

4. Reduction of disruptive or maladaptive behaviour by using empirically supported strategies, including functional assessment;

5. Cognitive skills, such as symbolic play and perspective taking; and

6. Traditional readiness skills and academic skills as developmentally indicated.”

The management options include educational interventions, behavioural therapy and medicines.

The ideal educational intervention is to involve parents, teachers, psychologists and others to develop an individualised education plan that forms a structured framework for the child’s school experience.

Studies have shown that ASD children benefit from visual information. Speech and language therapy improves language skills and the child’s ability to interact socially. There are a variety of techniques that improve communication skills, eg listening and attention skills, as well as the ability to understand the social and/or emotional context of specific language and non-literal language.

Behaviour therapy reinforces appropriate behaviours and reduces inappropriate behaviours. Skills are broken down into small tasks and rewarded in a structured manner. Speech therapists, occupational therapists and physiotherapists have an important role in improving communication and interaction skills, adjusting tasks to match abilities and needs, and improving motor skills respectively.

There are no medicines that can cure ASD. But medicines are available to treat some of the symptoms, eg repetitive thoughts and behaviour, and aggressive behaviour. The selective serotonin reuptake inhibitors (SSRIs) – fluoxetine and paroxetine – which alter the brain levels of serotonin, a chemical which affects mood and behaviour, are used often.

Other medicines used include anti-psychotics, tricyclic compounds and anxiolytics. All these medicines are prescription items.

There is no evidence that complementary and alternative medicines are effective, and some may even be dangerous.

The outlook for ASD depends on its severity and the child’s intelligence. Those with mild to moderate ASD and average or above average intelligence often grow up to be independent adults with jobs and family. Those with severe ASD and below average intelligence are unlikely to be independent adults and would require care and assistance for the rest of their lives.

Source: Dr Milton Lum

We take a look at ADHD.

ATTENTION deficit hyperactivity disorder (ADHD) comprises behavioural symptoms of inattentiveness, impulsiveness and hyperactivity. People with ADHD have a short attention span, are easily restless, get distracted easily and fidget incessantly.

Whether ADHD is an extreme form of normal behaviour, or part of a separate range of behaviour, is not well understood.

It is estimated ADHD affects about 3-9% of schoolgoing children and young people, and about 2% of adults. It is the most common behavioural disorder in many countries.

ADHD starts at an early age and becomes obvious when the child’s situation changes, eg starting school. It is more common in males. Whether ADHD can occur in adults without it occurring in childhood has not been elucidated.

It is estimated that at age 25, about 15% of childhood ADHD patients still have a full range of symptoms, and 65% have symptoms affecting their daily lives.

What causes ADHD?

The causes of ADHD are not well understood. It is believed to be due to a combination of genetic and environmental factors.

ADHD occurs in families. Both parents and siblings of a child with ADHD are four to five times more likely to have ADHD.

Brain function in ADHD is different from people without the condition. It is believed that there is impaired function of the brain chemicals that transmit messages. Activities in the sections of the brain that control attention and activity appear to be less. There are also findings that indicate impaired function of the frontal lobes that control decision-making, and altered levels of chemicals like dopamine and noradrenaline.

Pregnant smokers and alcohol and drug abusers have an increased risk of giving birth to a child with ADHD.

Males are more likely to be diagnosed with ADHD. This may be because loud and disruptive behaviour are more noticeable in males. It may also be that the diagnosis is missed in females because they are more likely to have attention deficit disorder (ADD), which is a type of ADHD.

Although there is insufficient evidence linking television to ADHD, it is believed that watching tv for several hours a day by children below three years of age could be a contributing factor to attention problems and ADHD later.

There are suggestions of associations between ADHD and common food allergens like milk and wheat. Other suggested causes are premature birth (before 37 weeks of pregnancy), low birth weight, brain damage in utero or in the first few years of life.

Symptoms of the

disease

The features of ADHD can be classified into two: inattentiveness, and impulsiveness and hyperactivity.

There are three types of ADHD, ie mainly inattentive, mainly hyperactive-impulsive, and combined.

The combined type is the most common. The mainly inattentive is also known as ADD. As females are more likely to have ADD, it is possible that the condition is more common than thought because of underdiagnosis.

The features of inattentiveness are a short attention span; easy distraction; forgetfulness; carelessness; inability to concentrate, carry out instructions and carry out time-consuming tasks; and constant changing of activity.

The features of impulsiveness are acting without thinking; interrupting conversations; inability to wait for a turn; breaking of rules; and inability to appreciate danger.

The features of hyperactivity are inability to stay still; continuous fidgeting; excessive movement and talking; and inability to carry out tasks.

ADHD is associated with other conditions like epilepsy, involuntary movements and sounds, sleep disorders, learning difficulties, anxiety disorders, depression, and conduct disorders, which is usually associated with antisocial behaviour.

However, there is no effect of ADHD on intelligence.

The features of ADHD in adults are more subtle. They include carelessness, forgetfulness, restlessness, inability to focus or prioritise, irritability, mood swings, risk taking and poor organisational skills. There may be problems in respect of relationships, drugs, employment and crime.

ADHD is associated with obsessive compulsive, bipolar and personality disorders.

There is no single diagnostic test for ADHD. If the condition is suspected, an appointment with the doctor is advisable.

The doctor will ask about the symptoms and its impact on the child’s quality of life, any changes in social circumstances, family history of ADHD, other health problems and any functional effects, eg inability to make or keep friends or to wash or eat, underachievement in school, and disciplinary problems.

A referral to a specialist may be made for a detailed assessment which includes a physical examination; tests for short-term memory, concentration and problem-solving skills; and a series of interviews or reports from parents, teachers and/or partners.

There are diagnostic criteria in children. They must show symptoms continuously for at least six months beginning before the age of seven (in some cases, a diagnosis can still be made if symptoms do not start until after); having symptoms in at least two different settings, eg at home and at school; and showing symptoms that make social, academic or occupational lives more difficult, which are not just part of a developmental disorder or difficult phase, and are not accounted for by another condition.

There are no diagnostic criteria for adults. Currently, a diagnosis of adult ADHD cannot be made unless symptoms have been present since childhood. The symptoms cause impairment of daily activities, eg keeping friends and relationships, underachievement at work or in education, and dangerous driving.

Managing ADHD

There is no cure for ADHD. However, treatment reduces its severity and makes life less problematic. A combination of medicines and therapy is the best approach. Treatment is usually prescribed by a psychiatrist and can be monitored by the general practitioner.

The medicines include central nervous system stimulants, eg methylphenidate and dexamfetamine, and a selective noradrenaline uptake inhibitor, ie atomoxetine. The medicines provide a short period after each dose for the ADHD person to be calmer, less impulsive, concentrate better, and learn and practise new skills.

All the medicines used in treating ADHD are prescription items. The dosages will be small initially, and may then be increased gradually.

The factors considered by the doctor before prescribing include the presence of any other health conditions, its side effects, its contraindications, and whether the dosage prescribed interferes with school or work.

All three medicines cannot be prescribed for pregnant or lactating females. Methyphenidate cannot be prescribed for patients with glaucoma or severe depression. Dexamfetamine cannot be prescribed in patients with car-diovascular disease, eg high blood pressure or overactive thyroid (hyperthyroidism). Atomoxetine cannot be prescribed for those with glaucoma.

As is the case with most medicines, all three have side effects.

Regular check-ups by the doctor are necessary to assess the effectiveness of the medicine. If there is improvement, the doctor may advise a break from medicine for a short period to assess how the patient manages without the medicine.

There are different modalities of therapy.

Psychotherapy involves the patient discussing the condition and its effects. This can help the patient to cope and live with the condition.

Behaviour therapy involves managing behaviour with a system of rewards and penalties. This also provides support for parents, teachers and carers. Appropriate behaviour is rewarded with praise and encouragement, while there is a small penalty for inappropriate behaviour.

Cognitive behavioural therapy (CBT) involves the therapist trying to change how the ADHD patient feels about a circumstance, which would in turn lead to a change in behaviour. This would help increase self-esteem, reduce negative thoughts, and improve problem-solving skills.

Social skills training involve the child participating in role-play. Its objective is to teach the child how to behave socially by learning how their behaviour affects others.

Parents and caregivers can also learn management skills, eg specific ways of talking to the child and working with them to improve attention and behaviour. This also increases the parents’ confidence in their ability to care for their children and their relationship with their child.

As with everyone in the population, regular exercise is beneficial for a person with ADHD.

Other treatment modalities used include omitting the consumption of certain foods and the taking of supplements. However, there is no scientific evidence that they work.

Needless to say, it would be prudent to seek medical advice prior to embarking on these modalities as they are potentially harmful if carried out in the long term.

Although there is no cure for ADHD, it can be managed with a combination of medicines and psychological, social and education therapies. Continual compliance with treatment will make life more manageable for patients, parents, carers and teachers.

Source: Dr Milton Lum

Although dyslexia is considered a learning disorder, there is no relationship between dyslexia and intelligence.

SOME people have a learning disability that leads to difficulty in learning and using certain skills. The skills that are usually affected are reading, writing, listening, speaking, reasoning, and doing mathematics.

The terms used for these disabilities are dyslexia, which refers to difficulties in reading and spelling; dysgraphia, which refers to difficulties in writing; and dyscalculia, which refer to difficulties in doing mathematics.

This article is about dyslexia, which is derived from the Greek works, dys (difficulty), and lexia (use of words). The symptoms range from the very mild to the very severe. People with dyslexia have difficulties with phonemic awareness, verbal memory and verbal memory speed.

Phonemic (or phonological) awareness is the ability to learn how speech sounds make up words, connecting the sounds to alphabet letters, and learning how to blend the sounds into words. Changes in the sounds lead to different words with different meaning. This ability is believed to be crucial in early reading and spelling development.

Verbal memory is the ability to remember a sequence of verbal information for a short time.

Verbal processing speed is the time taken to recognise and process familiar verbal information, e.g. this speed is the time taken to recognise the letters, A, S, E, A and N, process it, and then realise that it refers to the Association of South East Asian Nations.

Although dyslexia is considered a learning disorder, there is no relationship between dyslexia and intelligence. Dyslexia has been defined well by Shaywitz, who stated that, “Dyslexia is a reading difficulty in a child or adult who otherwise has good intelligence, strong motivation and adequate schooling … Dyslexia reflects a problem within the language system in the brain.”

Dyslexia is reported to affect about 10% of schoolchildren, with about 4% having severe difficulties that affect their learning ability in school. The incidence in males is estimated to be 1.5 to three times more than that in females. It affects all ethnic groups.

Roots of dyslexia

Dyslexia is a genetic condition. However, there are various theories about the causes.

It occurs in certain families. It is estimated that a child of a dyslexic has a 40% to 60% chance of developing the condition. If an identical twin has the condition, it is very likely that the other twin would also have the condition.

Scientists have detected genes that may lead to dyslexia, but their effects on the brain have yet to be elucidated.

The phonological processing impairment theory is believed by many to explain how dyslexia affects reading and writing. The ability to understand spoken language is an innate capacity of the brain, which recognises a word as a whole and does not register it by the units of sound that constitute a word (phonemes).

However, reading and writing requires the ability to recognise the letters in a word, identify from the letters the phonemes, and then bring them together to form a word. This process, which is termed phonological processing, is believed to be impaired in dyslexics.

There is evidence from magnetic resonance imaging (MRI) that the part of the brain (left hemisphere) involved in producing, analysing and identifying written words demonstrate less activity in dyslexics when they read. This may impact upon phonological processing.

MRI has also shown that the activity in the cerebellum of dyslexics is different from those without the condition. The cerebellum, which is found at the lower back of the brain, is believed to be crucial to the processing of language, coordination and assessment of time. This may explain why dyslexics have difficulties with coordination and time management.

Distinctive features

There is individual variation in the features of dyslexia. Each affected person would have distinctive features.

The features in a pre-school child include delayed speech development when compared to children of the same age; speech problems, like an inability to pronounce long words; problems expressing spoken language, like an inability to remember the right word to use; lack of understanding or appreciation of words that rhyme; or lack of interest in learning the letters of the alphabet.

It is not always possible to detect dyslexia in a pre-school child.

The features in the early school years include problems learning the names and sounds of letters, erratic spelling, problems copying written language, and poor phonological awareness, i.e. the ability to recognise that words are comprised of smaller sound units (phonemes) and new words can be created by altering the phonemes.

The child may also have difficulty in making sense of unfamiliar words by considering smaller words or collection of letters.

The features in the later primary school years include problems with spelling, problems understanding and recognising new words, and slow reading speed.

The features in secondary school include problems with reading fluency, slow writing speed, and problems expressing knowledge in writing.

Some dyslexics reach adulthood without the diagnosis ever being made. Their features include avoidance of reading and writing and hiding these difficulties from others, reliance on memory and verbal skills instead of reading and writing, poor spelling, and poor time management.

Dyslexia is associated with poor numerical skills, poor short term memory, poor concentration, poor time and organisational management as well as problems with physical co-ordination.

The earlier dyslexia is diagnosed, the more likely its management will be effective.

If a child has difficulties with reading and writing, a discussion with the teaching staff and a consultation with the family doctor would be helpful. The latter would exclude health problems which affect the child’s ability to read and write, e.g. vision problems, poor hearing, and other conditions like attention deficit hyperactivity disorder. The former would help in a review of the teaching methodology and provide alternative approaches and support, which is helpful for many children, including those with mild or moderate dyslexia.

If the problem persists despite the above, an assessment by an educational psychologist would be advisable. The latter is a specialist who assists children with problems in their educational progress because of emotional, psychological, cognitive (learning), or behavioural factors. This can be challenging as there are not many educational psychologists available in the country.

Alternatively, assistance can be sought from the Dyslexia Association of Malaysia, which has centres in Peninsular Malaysia. Its contact details are 6, Persiaran Kuantan, Off Jalan Setapak, 53200 Kuala Lumpur (Tel: 03-4025-5109).

The assessment includes an evaluation of the child’s reading and writing abilities as well as other skills like vocabulary, memory, reasoning, language development, processing speed of visual and sound information, organisational skills, and approaches to learning.

A diagnosis of dyslexia is made if the child’s reading and writing skills are poor despite appropriate teaching methodology and the child’s logic and verbal skills are unaffected.

Adults can also have similar assessments done.

Treating dyslexia

There is currently no cure for dyslexia. However, there are many interventions that can assist dyslexics. The degree and type of intervention is determined by the severity of the problems.

Interventions before a child goes to school are effective in achieving long term improvements in the condition. There is evidence that interventions which improve the ability to identify and process sounds (phonological skills) are effective.

These interventions, which are called phonics, concentrate on recognition and identification of sounds in spoken words (phonemic awareness) and instruction on phonics, spelling, writing, vocabulary, comprehension, and fluency.

There is evidence that effective methods of teaching phonics to dyslexics have certain features:

● Teaching is structured, with gradual increase based on what has been learnt previously.

● Use of different senses.

● Reinforcement with regular practice.

● Development of other useful skills.

● Recognition that there are different learning methods and approaches and then selecting the appropriate one for different situations.

● Breaking down the dyslexic’s emotional barriers, like anxiety and frustration, with empathy, encouragement, and promotion of the dyslexic’s self-esteem.

Many older children find the use of educational software applications useful rather than text or exercise books.

Similar approaches are useful in adult dyslexics.

In a nutshell

It is useful to remember that about 95% of dyslexic children respond well to educational interventions, with reasonable to good progress in reading and writing. About 5% continue to experience difficulties and would need more rigorous and long-term support.

It must be emphasised that although dyslexic children encounter daily challenges, even those with severe dyslexia can go on to have full and productive lives.

Source: Dr Milton Lum

The are several factors that increase the risk of a person commiting sucide.

EVERYONE’S life has its ups and downs, with feelings and emotions accompanying many of these situations. Most people adapt and cope with the downs. However, there are some who are so overcome with these emotions that they take their own life.

Suicide is an individual’s intentional act of ending his or her life.

Many suicide attempts are preceded by a history of self-harm, in which there is deliberate injury that a person inflicts on his or her body. This does not mean that the person who self-harms wants to commit suicide, but is an effort by the person to cope with intense emotions.

However, self-harm is an indication that the person needs immediate assistance.

Suicide is a common cause of death in young people worldwide. According to the National Health and Morbidity Survey 2006, there was a 6.3% rate of acute suicidal ideation, and 25.8% of chronic suicidal ideation. The highest prevalence rate of suicidal ideation of 11% was found in those aged between 16 and 24 years.

The National Suicide Registry Malaysia (NSRM) 2008 report stated there were 290 suicides in that year, of which 219 were men and 71 women, with Chinese comprising 53.5%, Indians 27.3%, and Malays 13.9%.

The youngest suicide victim was 12 years, while the oldest was 83 years. The NSRM estimated that there were 425 suicides between January and August 2010, averaging 60 per month, ie two daily.

It is estimated that the suicide rate is similar to that of the United States.

Although women are more likely to attempt suicide and other self-harm behaviour, it is the men who are more likely to succeed in suicide. The suicide rate in men in many countries is about three times that of women.

Risk factors

The reasons why some people commit suicide while others in similar situations do not, have not been determined. However, there are some factors that increase the risk of suicide.

Genetics is believed to be a risk factor as suicide has been found to be more common in certain families. There are several genetic mutations reported that may alter the chemicals in the brain, increasing the vulnerability to suicidal thoughts and behaviour. However, no specific gene for suicide has been identified.

Mental health conditions are the most significant risk factor, particularly serious and chronic mental health conditions. It has been estimated that about 90% of people who commit or attempt suicide have a mental health condition.

Severe depression is associated with misery and hopelessness – there is a 20-fold increase in the likelihood of attempted suicide than the general population.

Sufferers of bipolar disorder alternate between extreme joy to severe depression. About a third of these sufferers attempt suicide, and about 10% commit suicide.

Patients with schizophrenia are unable to think logically, and have difficulty differentiating between real and unreal experiences, with about 5% committing suicide. The risk is greatest when the diagnosis is made, but with the passage of time, they are better able to cope with their situation.

Anorexia nervosa is a condition in which anxiety about body weight leads to extreme efforts at limiting food consumption. About a fifth of anorexics will attempt suicide.

Patients with borderline personality disorder have altered thinking, unstable emotions, impulsive behaviour and unstable relationships. About half of these sufferers will attempt suicide, with an increased risk in those who were sexually abused in childhood.

It is believed that a combination of other factors increases the risk of suicide. These factors may or may not be significant, depending on the person’s vulnerability at the point in time. They include:

·History of a recent traumatic experience, eg end of a relationship, bullying, loss of job, bereavement.

·History of a traumatic experience in childhood, eg sexual or physical abuse, bereavement, parental neglect.

·A parent with a serious mental health condition, eg severe depression, bipolar disorder, schizophrenia, or who committed suicide.

·A previous attempt at suicide.

·Social isolation, with few family members or friends.

·Misuse or abuse of drugs and alcohol .

·Unemployment or poor job satisfaction or security.

·Debt.

·Occupations which permit access to the means to attempt suicide, eg doctor, nurse, pharmacist, planter.

Danger signs

There are warning signs that indicate that a person is suicidal. They include talking or writing about death or suicide threats to injure or kill himself or herself, and actively seeking methods of committing suicide, eg stockpiling medicines, particularly sleeping pills, and/or pills used to treat serious mental conditions.

Other warning signs include:

·Complaints, talk or behaviour that indicate hopelessness or a meaningless life.

·Loss of interest in personal appearance, eg poor dressing, cessation of use of make-up.

·Reckless or risky behaviour without concern for the consequences.

·Sudden mood changes, anxiety, agitation.

·Increased withdrawal from interactions with family members and friends.

·Insomnia or sleeping all the time.

·Abuse or misuse of drugs or alcohol.

·Putting their affairs in order.

When warning signs are noticed, it would be useful to encourage the affected person to talk about it and to listen attentively. One should listen to what the person has to say to let them know that there is someone who cares about them.

A non-judgemental manner and empathy are essential. One should not influence what is said, but rather, facilitate honest and frank conversation.

Any questions raised by the listener have to be open-ended, and not end the conversation.

At the same time, the person’s doctor or nurse should be contacted. If it is not possible to do so, the accident and emergency department of the nearest hospital should be contacted as to how to get professional help for the affected person. If one assesses that the affected person has a high risk of dying by suicide before the arrival of professional help, one should contact the nearest ambulance service.

At the same time, any possible means of suicide should be removed from the immediate environment of the affected person. This would include medicines, household chemicals, sharp objects, etc.

Providing care to a suicidal person is stressful and distressing, and it can impact upon the carer’s mental health. Professional help may be required to address the carer’s emotions after the event.

Preventing suicide

Mental health is no different from physical health. Measures can be taken to improve mental health so that one is stronger emotionally and better able to cope with the downside of life, thereby reducing the risk of developing mental health conditions like depression.

Exercise is effective in the management of depression. Physical activity reduces stress and anxiety, improves mood, and promotes the release of brain chemicals called endorphins, which makes one “feel good”.

A healthy diet not only provides protection against physical health problems, but may also be vital in maintaining mental health.

Avoidance of social isolation is an important measure as it is a risk factor for suicide. Having friends is beneficial for mental health. If there is individual difficulty in making friends, you should consider joining a local activity group or support group. There is evidence that people involved in providing assistance to others through voluntary or charity organisations are mentally healthier than the general population.

Having a positive attitude is vital as persistent negative thoughts increase the risk of isolation. Cognitive behaviour therapy (CBT) is a type of talking treatment that assists in the management of problems by changing the thoughts and actions of the affected person.

Many people use drugs to help them cope with life’s problems. Their misuse or abuse may lead to more problems and increases the risk of developing serious mental conditions like depression.

Even recreational drugs like marijuana, which is perceived to be less harmful, increase the risk of depression and schizophrenia in some people.

Many people use alcohol to help them cope with life’s problems. Its misuse or abuse may lead to more problems and increases the risk of depression. It would be prudent to avoid exceeding the recommended daily alcohol consumption limits – ie three to four units for men and two to three units for women. A unit is the equivalent of about half a pint of normal strength lager, a small glass of wine, or 25ml of spirits.

A consultation with your regular doctor would be helpful if there are problems with drug usage or alcohol consumption.

However, the evidence is that an effective preventive strategy is to educate doctors on how to recognise and treat depression, and restricting access to lethal methods of suicide. Another promising strategy is to train particular groups of people on how to identify those at risk and refer them for treatment.

Support groups provide counselling and practical advice to people who are depressed, or have suicidal thoughts. The local support group are the Befrienders and their contact details are 95, Jalan Templer, Petaling Jaya 46990 (Telephone: 03 7956 8144 or 03 7956 8145; email: sam@befrienders.org.my)

If you do not like the idea of talking to someone on a helpline, you can talk to a family member, trusted friend, doctor or religious leader. You should also consult your doctor, who can prescribe treatment for mental health conditions.

Source: Dr Milton Lum

Schizophrenia is a form of psychosis where sufferers cannot distinguish their own thoughts and ideas from reality.

SCHIZOPHRENIA is a chronic mental health condition with a variety of symptoms. The word is derived from the Greek words “skhizein”, ie “to split”, and “phren”, ie mind. However, it does not mean that a sufferer with the condition has a “split mind”.

It is classified as a psychosis – the sufferers cannot distinguish their own thoughts and ideas from reality. Patients with schizophrenia are unable to think logically, and have difficulty in differentiating between real and unreal experiences.

The National Mental Health Registry 2003-2005 recorded 7,351 schizophrenia cases, of which 3,714 (50.5%) were new cases. The incidence rate from this report is about five cases per 100,000 population per year, whereas the expected cases are about 100 cases per 100,000 population per year. Two thirds of the patients were between 20 and 40 years old, and 23% had a family history of the condition, while about 20% had another condition, with substance abuse being the commonest (about 80%).

Drug abuse or misuse increases the risk of schizophrenia, and may also precipitate the condition. The drugs include cannabis, cocaine and amphetamines.

Childhood-onset schizophrenia is rare, but if it occurs, there may be difficulty in distinguishing it from developmental disorders like autism.

There are misconceptions about schizophrenia because it is often not well understood by the public. It is not the same as “multiple personality disorder” or “split personality”. On the other hand, schizophrenic patients have a mind that is dysfunctional and disordered.

Although there are many studies that report a link between violence and schizophrenia, violent acts by schizophrenics are rare. Violence is more likely to be associated with substance abuse or misuse or alcohol. The schizophrenic is much more likely to be a victim of violence rather than be the perpetrator.

Cause unknown

It is not known for certain what causes schizophrenia. It is believed an interaction of genetic and environmental factors causes the condition. Some people may have some risk factors that increase their likelihood of developing the condition, which is then precipitated by a stressful or emotional life event. It is not understood why some people with risk factors develop the condition while others do not.

The risk factors include:

·Genetics

Schizophrenia is more common in families, but there is no single gene responsible. If one identical twin has schizophrenia, the other twin has a one in two chance of having the condition. If one non-identical twin, who has only half of the other twin’s genetic make-up, has schizophrenia, the other twin has a one in seven chance of having the condition.

This compares with a one in 100 chance of having the condition in the general population.

·Brain

There are differences in the brain structure and/or the distribution or number of brain cells in schizophrenics. However, these changes are not found in all schizophrenics, and they are also found in people who have no mental conditions.

There are studies which suggest that schizophrenia may be due to an imbalance between dopamine and serotonin, which are neurotransmitters, ie chemicals that pass messages between brain cells. Other studies suggest that schizophrenia may be due to an altered sensitivity to the neurotransmitters.

·Infections

There is some evidence that the polio and influenza viruses may play a causative role.

·Pregnancy and childbirth

Certain pregnancy and childbirth conditions may increase the risk. They include bleeding, gestational diabetes, pregnancy induced hypertension, intra-uterine viral infection, growth retardation, and birth asphyxia.

·Head injury

Traumatic head injury increases the risk, but the mechanism is unknown.

There are some known precipitating factors, which include:

·Stress

The usual precipitating factors are stressful or emotional life events, eg loss of job, end of a relationship, bereavement, or abuse. These factors do not cause schizophrenia by themselves but does so in a person who has risk factors.

·Drug abuse

Drug abuse or misuse increases the risk and may also precipitate the condition. The drugs include cannabis, cocaine and amphetamines.

Clinical features

The clinical features usually develop slowly over months or years. There may be occasions when there are many symptoms, while there are few or no symptoms on other occasions.

The initial symptoms of increased irritability or tenseness, difficulty sleeping and/or difficulty concentrating may be difficult to identify. As these symptoms often develop during adolescence, they may be attributed to “normal” adolescent behaviour and ignored.

The initial symptoms often appear several years before the first acute schizophrenic episode (prodromal period). They usually begin gradually and then worsen slowly. The patient becomes more withdrawn and exhibits an increasing lack of care about personal appearance and hygiene. There is loss of interest in relationships, sex, and life activities. This often leads to relationship problems with family and friends.

As the condition develops, changes in thoughts or behaviour develop. They include:

·Hallucinations occur when the patient experiences a sensation which does not exist. It can involve any of the senses, but hearing voices are the most frequent. Brain scans have demonstrated changes in the speech area of schizophrenics when they hear voices, indicating that their experience is real, ie their brain mistakes thoughts for real voices. The voices heard are usually critical, abusive or annoying, but some report pleasant voices.

·Delusions are strongly held beliefs that are not based on reality. They may occur suddenly or gradually develop over weeks or months.

·Changes in thoughts. Some schizophrenics experience difficulty in concentrating and drift between unrelated topics (loose associations). Others feel that their thoughts are controlled by someone else, their thoughts are not their own, or their thoughts are being “removed” and that someone else is controlling their mind.

·Changes in behaviour. The schizophrenic’s behaviour may become unpredictable or even bizarre. There may be inappropriate behaviour or extreme agitation, with shouting and swearing for no reason.

The clinical features may vary, depending on the type of schizophrenia:

·Paranoid schizophrenics have false beliefs that others are trying to harm them or their loved ones and may be anxious, angry, argumentative, or aggressive.

·Catatonic schizophrenics are inactive with minimal or no response to other people. Their posture and muscles may be rigid, with odd facial grimaces.

·Disorganised schizophrenics have confused thoughts and problems expressing ideas. They show little emotion (flat affect), are apathetic, and exhibit child-like behaviour.

·Undifferentiated schizophrenic may have clinical features of more than one type.

There is no single diagnostic criterion for schizophrenia. It is usually diagnosed if:

·There are at least two of the following, ie hallucinations, delusions, changes in thoughts or behaviour, or features like flat affect;

·The features have been present for more than six months;

·There is significant impact on studies, work or activities of daily living;

·Other possible conditions like depression, bipolar disorder, or drug abuse or misuse have been excluded.

When a family doctor suspects a patient has schizophrenia, a referral will usually be made to a specialist. As the person with suspected schizophrenia may be reluctant to consult a doctor, it may be necessary for a family member or friend to persuade the person to do so.

If the acute schizophrenic episode is worsening, the patient may have to be taken to the accident and emergency (A&E) department of a hospital. If it is severe, the psychiatrist may request for compulsory detention in the hospital for assessment and treatment under the Mental Health Ordinance.

Managing schizophrenia

There are various guidelines regarding the quality of care for schizophrenia. The National Institute for Health and Clinical Excellence (NICE) of the United Kingdom recommends that anyone providing treatment and care for people with schizophrenia should:

·Develop a supportive relationship with patients and their carers;

·Explain causes and treatment options to everyone, keep clinical language to a minimum, and provide written information at every stage of the process;

·Enable easy access to assessment and treatment as soon as possible through all stages of care; schizophrenics receive an assessment by a multidisciplinary team and are routinely monitored for other conditions;

·Work with patients, and their families and carers, if they agree, to write advance statements about their mental and physical healthcare, especially if they have severe episodes or have been treated under the Mental Health Act (these should be included in the care plans);

·Take into account the needs of the patient’s family or carers, including physical, social and mental needs, provide information about schizophrenia, and how families and carers can help, and offer a carers’ assessment; and

·Encourage patients and their families and carers to join self-help and support groups.

The availability of newer antipsychotic medications in the past two decades have, in the opinion of most psychiatrists, revolutionised the treatment of schizophrenia. These medications are effective in treating all the symptoms equally well and the incidence and severity of side effects are less.

Schizophrenics and their carers can manage the condition better by:

·Being able to spot the signs of an acute episode.

·Taking the medicines as directed.

·Avoiding drugs and alcohol.

·Regular attendance at clinic appointments.

·Taking responsibility for self-care.

Source: Dr Milton Lum