A Neurologist Discusses the Link Between COVID-19, Younger Adults, and Stroke

WORDS DR JOYCE PAULINE JOSEPH

FEATURED EXPERT
DR JOYCE PAULINE JOSEPH
Consultant Neurologist
Aurelius Hospital Nilai

The COVID-19 pandemic has fundamentally altered the physiological landscape of individuals around the globe. The virus has demonstrated its ability to traverse various bodily functions, leaving a trail of physiological changes in its wake. From the intricate dynamics of the immune response to cardiovascular issues, COVID-19 has brought about unprecedented impacts on human health in various ways.

But what are the correlations, if any, between COVID-19 and an increase in stroke incidences especially amongst the young? In light of the increasing number of cases of COVID-19 in Malaysia again, we attempt to investigate the links.

THE LINK TO STROKE

Traditionally, when we speak about strokes, it tends to be an “elderly persons” disease, a health concern prevalent amongst those aged 50 and above.

However, over the past 3 years since the first outbreak of COVID-19 pandemic, a worrying connection has emerged between the virus and incidences of strokes in younger individuals.

COVID-19 is associated with a higher risk of stroke, a majority of them being ischaemic strokes caused by a blockage in an artery that supplies blood to the brain.

A study suggested a connection between the high prevalence of vascular risk factors and concurrent elevation of proinflammatory and procoagulation biomarkers in this.

In the same study, it has been proposed that the virus that causes COVID-19 infects the cells that line the inside of the blood vessels.

These infected cells release several pro-inflammatory factors that attract other immune cells to the affected area.

In turn, this leads to damage to the lining cells, activating platelets and other factors involved in clotting.

This chain of events eventually increases the risk of a blood clot that could potentially travel up to the brain and cause a stroke.

Hypercoagulability and inflammatory response cause vascular complications, increasing the risk of strokes, regardless of age.

Findings from another large-scale study suggested that COVID-19 is a risk factor for deep vein thrombosis, pulmonary embolism, and bleeding.

The risk of developing blood clots in the lungs and legs is significantly elevated for up to 6 months upon contracting COVID-19.

After the initial 30 days of infection, individuals afflicted with COVID-19 displayed heightened susceptibilities and endured a year-long burden of newly emerging cardiovascular conditions.

These conditions range from cerebrovascular issues and dysrhythmias to inflammatory heart disease, ischaemic heart disease, heart failure, thromboembolic disease, and assorted cardiac disorders.

Strikingly, these risks manifested consistently across various demographic factors, such as age, race, and gender, as well as other established cardiovascular risk factors like obesity, hypertension, diabetes, chronic kidney disease, and hyperlipidemia.

Notably, even those without any pre-existing cardiovascular conditions prior to exposure to COVID-19 exhibited these risks, suggesting a propensity for these complications to manifest in individuals traditionally considered at low risk for cardiovascular diseases.

IN SUMMARY

The data and evidence gathered do point to a heightened risk of stroke brought about by COVID-19, regardless of age.

Even though it remains an uncommon occurrence, it remains a risk especially for individuals pre-existing health conditions that are known to boost the risk of stroke.

While the correlation between incidences of stroke, COVID-19 and how it affects younger individuals remains a subject of ongoing research and study, it remains crucial in recognizing the potential risks and taking appropriate and proactive measures.

References:

  1. Mbonde, A. A., O’Carroll, C. B., Grill, M. F., Zhang, N., Butterfield, R., & Demaerschalk, B. M. (2022). Stroke features, risk factors, and pathophysiology in SARS-CoV-2-infected patients. Mayo Clinic proceedings. Innovations, quality & outcomes, 6(2), 156–165. https://doi.org/10.1016/j.mayocpiqo.2022.01.003
  2. Xie, Y., Xu, E., Bowe, B., & Al-Aly, Z. (2022). Long-term cardiovascular outcomes of COVID-19. Nature medicine, 28(3), 583–590. https://doi.org/10.1038/s41591-022-01689-3

How Robotics Can Help a Stroke Survivor’s Brain to Relearn How to Walk at a Faster Rate

WORDS LIM TECK CHOON

FEATURED EXPERT
DR KOK CHIN YONG
Consultant Neurologist and Internal Medicine Physician
Sunway Medical Centre Velocity
FIRST, LET’S TAKE A LOOK AT STROKE

Stroke is a medical emergency caused by the disruption of blood flow to your brain.

Without enough oxygen, your brain will stop working properly. This is why stroke is often considered the brain’s version of a heart attack.

 

Ischaemic stroke

This occurs when there is blood flow disruption to the brain. This can occur when the blood vessels in your brain are blocked by blood clots or other substances.

This is the most common type of stroke and is often linked to poorly controlled type 2 diabetes, high blood pressure, and/or high blood cholesterol levels.

Haemorrhagic stroke

This type of stroke occurs when there is internal bleeding in the brain. Accumulated blood in certain areas of the brain can exert pressure to brain tissues in these areas and damage these tissues.

While not as common as ischaemic stroke, this type of stroke is especially dangerous because the affected person’s symptoms can get worse very quickly and urgent medical attention is needed to prevent permanent brain damage and even death.

MOST STROKE SURVIVORS EXPERIENCE GAIT DISABILITY

Stroke is one of the main causes of disability.

2005 statistics from the American Heart Association revealed that more than 80% of stroke survivors suffer from gait disability—the loss of mobility due to impaired ability to walk normally.

Gait disability can affect the survivor’s quality of life.

However, there are also other repercussions of this disability on the person: the person’s confidence and sense of independence can be compromised.

Furthermore, gait disability is linked to increased risks of cardiovascular diseases and death in people approaching 80.

Because of this, gait therapy is an important aspect of rehabilitation for a stroke survivor.

ALL IS NOT LOST, AS THE BRAIN HAS A CHANCE TO ADAPT & RECOVER

The brain is an amazing organ. The network of nerves and other tissues involved in brain function can adapt to changes by reorganizing themselves, or ‘rewire’ in response to these changes.

“This can happen after a stroke,” Dr Kok explains, “as the brain begins to compensate for the damage caused by the stroke.”

This process, called brain neuroplasticity, can involve the formation of new connections between remaining healthy nerves and ‘recruiting’ other parts of the brain to take over the functions that were handled by the now-damaged part of the brain.

Much research is being done on the neuroplasticity of the brain to explore possible ways to improve the rehabilitation process of people that had a stroke or other brain injuries that affect their normal day-to-day function.

Currently, research data increasingly suggests that techniques that can stimulate the part of the brain affected by stroke can help improve the rehabilitation of the lost function linked to that part of the brain.

HENCE, GAIT THERAPY IS AN ESSENTIAL COMPONENT OF A STROKE SURVIVOR’S REHABILITATION

Dr Kok Chin Yong mentions that the restoration of a stroke survivor’s ability to walk can be a complex process.

The stroke survivor’s inability to walk normally is usually due to the stroke disrupting the function of the nerve pathways in the region of the brain that plans and controls movement called the motor cortex.

Furthermore, the stroke survivor also often suffers from other debilitations that make it harder for them to walk, such as changes in their muscle tone and strength as well as impaired heart function.

Additionally, the more gait therapy is delayed, the harder it is to achieve a good outcome because the organs involved in walking will further weaken and waste away due to lack of use.

Hence, gait therapy should be prioritized as soon as it is feasible to do so.

ROBOTICS-ASSISTED GAIT THERAPY CAN BENEFIT STROKE SURVIVORS CONSIDERABLY
If you have not read Dr Foong Chee Chong’s explanation of what robotic-assisted gait therapy is, you can do so by clicking here. Have a read, and then hit the back button to come back here and continue reading—it will help you better understand the rest of this article!

Dr Kok explains that the first line of rehabilitation is conventional physiotherapy.

“During this stage, we will assess the patient’s suitability for robotics-assisted gait therapy,” he explains, adding that the criteria for suitability are similar to those explained by his colleague Dr Foong is the above-linked article.

“The main benefit of the use of robotics is that many patients can regain their normal physiological walking at a faster rate than conventional physiotherapy,” he shares.

He elaborates that this is due to the robotic exoskeleton stimulating the neuroplasticity of the patient’s brain, helping it to relearn how to order and control the movement of the patient’s lower limbs at a much faster rate.

He reiterates that such outcome is more likely achieved when the robotics-assisted gait therapy is initiated as early as it is feasible to do so.

Hence, he encourages stroke survivors to consult their doctors further on whether such a therapy is suitable for them.

THIS IS THE SECOND PART OF THE SERIES LEARNING TO WALK AGAIN

Below are the articles in this series:

  1. A Rehab Specialist Explains How a Robot Can Help You to Learn Safely & Successfully to Walk Again
  2. How Robotics Can Help a Stroke Survivor’s Brain to Relearn How to Walk at a Faster Rate (you’re reading this article now)

References:

  1. Duncan, P. W., Zorowitz, R., Bates, B., Choi, J. Y., Glasberg, J. J., Graham, G. D., Katz, R. C., Lamberty, K., & Reker, D. (2005). Management of adult stroke rehabilitation care: A clinical practice guideline. Stroke, 36(9), e100–e143. https://doi.org/10.1161/01.STR.0000180861.54180.FF
  2. Newman, A. B., Simonsick, E. M., Naydeck, B. L., Boudreau, R. M., Kritchevsky, S. B., Nevitt, M. C., Pahor, M., Satterfield, S., Brach, J. S., Studenski, S. A., & Harris, T. B. (2006). Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. JAMA, 295(17), 2018–2026. https://doi.org/10.1001/jama.295.17.2018
  3. Su, F., & Xu, W. (2020). Enhancing brain plasticity to promote stroke recovery. Frontiers in neurology, 11, 554089. https://doi.org/10.3389/fneur.2020.554089
  4. Selves, C., Stoquart, G., & Lejeune, T. (2020). Gait rehabilitation after stroke: review of the evidence of predictors, clinical outcomes and timing for interventions. Acta neurologica Belgica, 120(4), 783–790. https://doi.org/10.1007/s13760-020-01320-7

Food for All: Modifying Food Texture for People With Dysphagia

WORDS AINUL SYAFIQAH MOHD AZAHARI & DR NURUL HUDA RAZALLI

FEATURED EXPERTS
AINUL SYAFIQAH MOHD AZAHARI
Nutritionist and Student of Master Clinical Nutrition
Faculty of Health Sciences
Universiti Kebangsaan Malaysia
DR NURUL HUDA RAZALLI
Dietetic Programme
Centre for Healthy Ageing and Wellness (H-CARE)
Faculty of Health Sciences
Universiti Kebangsaan Malaysia

DYSPHAGIA: IT MEANS DIFFICULTIES IN SWALLOWING FOODS & LIQUIDS

  • Dysphagia comes from  Greek word ‘dys’, which means difficulties, and ‘phagia’, which means swallowing.
  • Medically, dysphagia is a term for swallowing difficulties. Someone with dysphagia takes more time and effort to move food or liquid from their mouth down to their stomach.
  • Episodes of dysphagia can be intermittent or progressive.
IT IS A SYMPTOM FOR MANY MEDICAL CONDITIONS
  • In adults, dysphagia is very common in adult that has a history of stroke, dementia, Alzheimer’s disease, neck cancers, and gastroesophageal reflux disease (GERD).
  • It could also be present in children with attention deficit hyperactivity disorder (ADHD), autism, Down syndrome, and cerebral palsy.
  • Dysphagia can also be a sign that there are some issues with the many nerves and muscles that are involved in swallowing activities.
YOU MAY HAVE DYSPHAGIA IF YOU EXPERIENCE THE FOLLOWING
  • Persistent drooling of saliva
  • Coughing or choking when eating or drinking
  • Bringing food back up, sometimes through the nose
  • Feeling as though food is stuck in your throat or chest
  • Being unable to chew food properly
PEOPLE WITH DYSPHAGIA FACE ISSUES THAT CAN JEOPARDIZE THEIR HEALTH & WELL-BEING

Choking and lung infection

Individuals with dysphagia are susceptible to choking. Due to difficulties in swallowing normally, consumed foods or liquids can accidentally enter the airway into the lungs. This could result in aspiration pneumonia, often known as a lung infection and can be fatal.

Poor nutrition intake
  • The prevalence of malnutrition among people with dysphagia is reported to be anywhere between 3% and 29%, which is quite a high number.
  • Malnutrition leaves people with dysphagia more vulnerable to diseases, should they not receive enough essential nutrients for optimal body function.
  • Muscle wasting, underweight, and stunting could be other issues that arise. Hence, people with dysphagia needs to be aware of any weight loss, hair loss, feeling of coldness, and fatigue as these are the early symptoms of malnutrition.
Loss of appetite and fear of mealtimes
  • People with dysphagia often lose their appetite in conjunction with their reduced swallowing ability.
  • They might develop some degree of “laziness” when it comes to drinking more often, which may lead to dehydration.
  • Because their eating experiences can be difficult, uncomfortable, and unpleasant, they may develop anxiety during mealtimes.
Inability to talk fluently
  • Dysphagia can hinder one’s ability to talk fluently and, combined with difficulties in eating, may cause the affected person to experience low self-esteem and lead to self-isolation.
  • The decrease in social engagement will give a negative impact in the person’s quality of life.
  • Thus, social support from their carer, family members, and close friends are crucial. A little extra kindness and help will give a huge impact in their life and sometimes even touch their heart.
Proper nutrition management for people with dysphagia involves providing adequate nutrients through modification of food texture and fluid consistency.

We need to also keep an eye out for symptoms of dehydration such as dry mouth or tongue, thirst, headache, and lethargy. 

Also, be alert to any unexplained weight loss, hair loss, feeling of coldness and fatigue—these could be early symptoms of malnutrition.
IF YOU ARE WORRIED THAT YOU OR SOMEONE CLOSE TO YOU HAVE DYSPHAGIA

Consult a speech language pathologist, a healthcare professional trained to diagnose dysphagia, for a proper diagnosis.

People with dysphagia can consult with dietitians for their nutritional concerns or if they want to assess their nutritional adequacy.

TIPS FOR INDIVIDUALS WITH DYSPHAGIA TO ACHIEVE GOOD NUTRITION

Understand the extent of one’s dysphagia

Discuss with the speech language pathologist and other relevant healthcare professionals on the degree of swallowing ability in the person with dysphagia.

Refer to the International Dysphagia Diet Standardization Initiative (IDDSI) Framework

This guideline has seven levels. Flow test, spoon tilt, and fork drips are used as measurement methods to determine each level.

Click to view a larger and clearer image.

Further information can be obtained from the IDDSI website (link opens in a new tab).

Modify foods into certain textures 

For more detailed information on how to modify the textures of various foods, you can refer to this page on the IDDSI website (link opens in a new tab).

  • While modifying the textures of foods into appropriate textures, take into consideration the nutritional content (carbohydrates, protein, fat, as well as vitamin and minerals). Daily meals should provide all the nutrients to improve the person’s nutritional status.
  • Always choose softer food options if texture modification is not possible. For example, choose papaya instead of apple, and ‘soften’ a dish with gravy.
  • Add special thickening powder to watery liquids. This thickening allows for easier swallowing.
Useful tips for eating
  • Have the person with dysphagia sit upright to prevent choking.
  • Have them tilt their heads to prevent liquids from going into their air passage.
  • Encourage the person to take smaller bites, and give enough time to chew the food thoroughly.
  • If small pieces of food or liquid are stuck, have them cough a little.

Dysphagia is a journey of eating experience that may switch an individual’s life 360 degree. Hence support and motivation play an important role in the management of one’s dysphagia.

References:

  1. O’Rourke, F., Vickers, K., Upton, C., & Chan, D. (2014). Swallowing and oropharyngeal dysphagia. Clinical medicine (London, England), 14(2), 196–199. https://doi.org/10.7861/clinmedicine.14-2-196
  2. Shaheen, N. A., Alqahtani, A. A., Assiri, H., Alkhodair, R., & Hussein, M. A. (2018). Public knowledge of dehydration and fluid intake practices: Variation by participants’ characteristics. BMC public health, 18(1), 1346. https://doi.org/10.1186/s12889-018-6252-5
  3. Ueshima, J., Momosaki, R., Shimizu, A., Motokawa, K., Sonoi, M., Shirai, Y., Uno, C., Kokura, Y., Shimizu, M., Nishiyama, A., Moriyama, D., Yamamoto, K., & Sakai, K. (2021). Nutritional assessment in adult patients with dysphagia: A scoping review. Nutrients, 13(3), 778. https://doi.org/10.3390/nu13030778
  4. World Health Organization. (n.d.). Fact sheets – malnutrition. https://www.who.int/news-room/fact-sheets/detail/malnutrition

Get the Flu Shot to Prevent a Heartbreaking Holiday Season!

In Malaysia, flu can occur year-round. Older persons, especially those with chronic diseases such as diabetes and high blood pressure, are advised to make flu vaccination an annual priority, especially during the holiday seasons when mingling and traveling are often inevitable. It’s important to strike a balance between staying safe and creating beautiful memories!

DO YOU KNOW THAT YOU COULD END UP WITH A HEART ATTACK OR STROKE WHEN YOU GET THE FLU?

Recent studies have cautioned that influenza increases the risk of heart attack by more than 10 times in the first 7 days after contracting the flu.

This is especially so if you are 65 and over, regardless of whether you have a history of heart disease or are living with chronic illnesses such as heart disease, diabetes, lung disease and kidney disease. In industrialized countries, most deaths associated with flu occur among older persons aged 65 years and above!

Among older persons, influenza can present as a relatively mild respiratory illness; it may also present without any symptoms (no fever and/or no cough). It can also lead to fatigue and confusion, potentially setting off a sequence of catastrophic events.

Professor Datuk Dr Zulkifli Ismail, Technical Committee Chairman of the Immunise4Life Programme, explains: “It is not just a fever, runny nose, cough and body aches, it could seriously harm your heart.”

HOW THE FLU AFFECTS YOUR HEART

When the flu virus enters your system, your immune system strings into action.

Just like fights in real life, collateral damage may result; when an infection triggers a strong response from your immune system, the immune cells can also damage your own healthy tissues and organs.

One example is COVID-19, which can trigger very high activation of the immune system, resulting in the uncontrolled release of cytokines, small molecules that aid cell-to-cell communication in immune responses and stimulate the movement of cells towards sites of infection.

This uncontrolled release (“cytokine storm”) may lead in failure and death of many organs in the body.

 

An illustration of cytokine storm, sometimes called hypercytokinemia, and how it affects both healthy and infected cells. Click on the image for a larger version.

Studies suggest that the same inflammatory response described above can trigger effects that can damage the heart (cardiovascular events) when you have an influenza infection.

Dr Alan Fong, the President of the National Heart Association Malaysia (NHAM) and a consultant cardiologist, shares that your body’s immune response, when present along the direct effects of flu on the inner lining of your blood vessels or atherosclerotic plaques, may cause rupture of such plaques or blockage in the arteries–effects that can lead to a heart attack or stroke.

OLDER PERSONS ARE ESPECIALLY AT RISK WHEN THEY CATCH THE FLU

In older persons, there are changes that occur in the immune system that leads to a decline in the ability of the body to fight off infections such as the flu; this is known as immunosenescence.

Professor Dr Tan Maw Pin, a consultant geriatrician that chairs the Flu & Older Persons Sub-Committee of the Malaysian Influenza Working Group (MIWG), tells us: “In addition to this, ageing contributes to chronic, non-infectious, low-grade inflammation—known as inflammaging—which plays a key role in the cause and progression of chronic conditions such as cardiovascular diseases.”

She further adds that ageing also promotes the development and progression of atherosclerosis, the most common cause of acute coronary syndrome. This syndrome gives rise to situations in which the blood supplied to the heart is suddenly blocked.”

“Hence, when an older person gets the flu, all these factors put them at higher risk of developing a heart attack and stroke,” Prof Tan reiterates.

FLU VACCINATION CAN PROTECT YOUR HEART

Studies have found that the flu vaccination was associated with a 34% lower risk of major adverse cardiovascular events, and those that have recent acute coronary syndrome had a 45% lower risk.

There is also an 18% reduced risk of death reported in patients with heart failure.

For people with type 2 diabetes mellitus, studies have shown that the flu vaccination reduces the risk of heart failure by 22%, stroke by 30%, heart attack by 19% and pneumonia by 15%.

Flu vaccination does not require behaviour change or a daily intervention, yet it prevents cardiovascular events as well as as other evidence-based approaches such as statin therapy, antihypertensive therapy, and smoking cessation.

This article is contributed by Immunise4Life (IFL), a collaboration of the Ministry of Health Malaysia with the Malaysian Paediatric Association (MPA) and the Malaysian Society of Infectious Diseases & Chemotherapy (MSIDC).

The article has been edited by HealthToday for publication on this website.

For more information on flu, you can visit IFL’s website Act of Love (link opens in a new tab).

References:

  1. Warren-Gash, C., Blackburn, R., Whitaker, H., McMenamin, J., & Hayward, A. C. (2018). Laboratory-confirmed respiratory infections as triggers for acute myocardial infarction and stroke: a self-controlled case series analysis of national linked datasets from Scotland. The European respiratory journal, 51(3), 1701794. https://doi.org/10.1183/13993003.01794-2017
  2. Michos, E. D., & Udell, J. A. (2021). Am I getting the influenza shot too?: Influenza vaccination as post-myocardial infarction care for the prevention of cardiovascular events and death. Circulation, 144(18), 1485–1488. https://doi.org/10.1161/CIRCULATIONAHA.121.057534
  3. Modin, D., Jørgensen, M. E., Gislason, G., Jensen, J. S., Køber, L., Claggett, B., Hegde, S. M., Solomon, S. D., Torp-Pedersen, C., & Biering-Sørensen, T. (2019). Influenza vaccine in heart failure. Circulation, 139(5), 575–586. https://doi.org/10.1161/CIRCULATIONAHA.118.036788
  4. Vamos, E. P., Pape, U. J., Curcin, V., Harris, M. J., Valabhji, J., Majeed, A., & Millett, C. (2016). Effectiveness of the influenza vaccine in preventing admission to hospital and death in people with type 2 diabetes. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 188(14), E342–E351. https://doi.org/10.1503/cmaj.151059
  5. King, S. C., Fiebelkorn, A. P., & Sperling, L. S. (2020, November 2). Influenza vaccination: Proven and effective cardiovascular disease prevention. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2020/11/02/14/42/influenza-vaccination-proven-and-effective-cvd-prevention
  6. Vetrano, D. L., Triolo, F., Maggi, S., Malley, R., Jackson, T. A., Poscia, A., Bernabei, R., Ferrucci, L., & Fratiglioni, L. (2021). Fostering healthy aging: The interdependency of infections, immunity and frailty. Ageing research reviews, 69, 101351. https://doi.org/10.1016/j.arr.2021.101351