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A pilot study regarding knowledge of stroke risk factors in an urban community
A Pilot Study Regarding Knowledge of Stroke Risk Factors in an Urban Community Seemant Chaturvedi, MD, and Lorraine Femino, RN
Background: The premise of the "brain attack" concept is that early intervention may salvage ischemic neurons. Early intervention depends on adequate knowledge of stroke so that patients seek urgent medical attention. Objective: To assess knowledge of stroke risk factors and warning signs in an urban, predominantly black community. Methods: A 20-item questionnaire was administered to two patient groups. Group 1 had a diagnosis of first-ever stroke or transient ischemic attack (TIA). Group 2 (controls) was without a history of cerebral ischemia. Results: Thirty patients in group 1 answered 57.5% of the questions correctly. Thirty patients in group 2 answered 63.1% of the questions correctly (P = .15). Patients showed misperceptions regarding the warning signs of a stroke and were unfamiliar with the concept of a TIA. Conclusions: Although preliminary because of a limited sample size, the results from our urban medical center suggest that knowledge of stroke is deficient among high-risk individuals who developed cerebral or retinal ischemia. This would mean that opportunities for effective prevention and treatment of stroke are being missed in minority patients. Recruitment of patients for acute stroke trials will also face impediments in urban commtmities unless a massive educational effort is undertaken. Key Words: Stroke--Knowledge regarding stroke--AfricanAmericans.
Several surveys of the general public have shown that knowledge regarding stroke is deficient in the United States. In a 1996 study of adults over age 50, 40% of the general population did not know where in the body a stroke occurs, and only one in three respondents was able to identify speech difficulty as a potential sign of a stroke. 1 Although this is concerning, the stroke risk of the general population is relatively low. Published reviews of the literature indicate that the annual stroke rate for the general population is approximately 0.6%. 2 What would be more concerning is if those individuals at highest risk for stroke were deficient in their knowledge of stroke warning signs and stroke prevention practices. Therefore, we undertook a pilot study of stroke
From the Department of Neurology, Wayne State University/ Detroit Medical Center, Detroit, MI. Received December 1,1996; accepted March 4,1997. Address reprint requests to Seemant Chaturvedi, MD, 6E-UHC, Department of Neurology, Wayne State University, 4201 St. Antoine, Detroit, M148201. Copyright 9 1997by National Stroke Association 1052-3057/97/0603-0009503.00/0
426
knowledge among patients with either a recent stroke or transient ischemic attack (TIA). This population would have a recurrent stroke rate of 2% to 13% per year, depending on the underlying pathology. Our hypothesis was that knowledge of stroke would be deficient in high-risk individuals with recent episodes of cerebral or retinal ischemia.
Methods Subjects were recruited from in-patient and out-patient settings of a university medical center. The first group of patients had experienced a cerebral/retinal stroke or TIA in the previous month. A second group of control subjects was recruited from an adjacent orthopedics clinic. These individuals were free of cerebral ischemia by history. We sought to assess knowledge regarding stroke in an urban community, and therefore, subjects were considered eligible only if they were residents of the city of Detroit. With local demographic characteristics, the study group was approximately 80% African-American. Study patients were excluded from participation if they
Journal of Stroke and Cerebrovascular Diseases, Vol. 6, No. 6, 1997: pp 426-429
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PATIENT KNOWLEDGE OF STROKE
had one or more of the following: dysphasia, dementia (as assessed by the Mini-Mental Status Examination3), illiteracy. Patients with a previous stroke or TIA were also excluded because they may have received teaching/ counseling on stroke prevention practices with the earlier event. Study patients and controls were given a 20-item multiple-choice questionnaire. The content of the questionnaire included the following areas: (1) the nature of a stroke, (2) the significance of stroke as a public health problem, (3) risk factors for stroke, (4) causes of stroke, (5) the warning signs of a stroke, (6) facts regarding hypertension/diabetes, (7) dietary/lifestyle factors and stroke, (8) pharmacological options for stroke prevention, (9) the prognosis for stroke survivors. The questionnaire was administered in rooms devoid of any stroke educational materials. Prior approval was obtained from the Institutional Review Board.
Results The questionnaire was administered to 30 patients with a history of stroke/TIA and 30 control subjects. Patients correctly answered 57.5% of the questions. Control subjects correctly answered 63.1% of the questions (t5s = 1.47, P = .15, using the independent t-test). The percentage of correct responses to each question can be found in Table 1. The most commonly missed questions concerned the following areas: 1. The significance of stroke as a public health problem Table 1. Responses to individual questions
Content of question 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Nature of a stroke Stroke and disability Stroke and death Risk factors for stroke Causes of stroke Risk factors for atherosclerosis Stroke and age Warningsigns of stroke Nature of a TIA Responding to stroke symptoms Gender differences in stroke Symptoms of hypertension Lifestyle factors and hypertension Lifestyle factors and diabetes Diet and stroke Smoking and stroke Rationale for aspirin use Side effects of aspirin Prognosis for stroke Alcohol and stroke
% % Correct Correct (patients) (controls) 77 53 40 67 77 27 70 37 37 97 50 43 57 47 47 97 83 63 80 20
90 50 40 77 93 23 80 57 57 97 63 27 73 57 57 100 80 47 90 13
2. Factors contributing to atherosclerosis 3. The warning signs of a stroke 4. The concept of a TIA 5. Symptoms of hypertension and lifestyle factors leading to improved blood pressure control. Regarding symptoms of hypertension, the question was designed to emphasize the point that the most common symptom of hypertension is no symptoms at all, reinforcing its role as the "silent killer." 6. Advice regarding alcohol for a stroke survivor Patients performed best on questions that assessed the following: (1) action to take in the event that one had stroke-like symptoms, (2) Advice regarding smoking cessation, (3) Rationale for the use of aspirin in stroke prevention, and (4) Prognosis for stroke patients. Notable responses included the following: (1) 57% of patients thought that lack of exercise does not contribute to atherosclerosis. (2) One third of patients answered that chest pain is a warning sign of a stroke. (3) Only one in three patients was familiar with the concept of a TIA.
Discussion The results of this study lend support to the hypothesis that individuals at high risk for stroke in an urban community are deficient in their knowledge of stroke prevention practices. However, some methodologic criticisms could be raised. For example, the small sample size in our study precludes any definitive conclusions. To achieve adequate statistical power to discern a 20% difference between the two groups in this study would have required more than 100 patients in each group. This was beyond the scope of this project. In addition, we did not systematically assess age or educational attainment of the respondents or determine literacy levels. These are important potential confounding variables. Because control subjects were taken from the clientele of the same medical center and were also urban residents, we do not think that educational disparities would explain the results. Also, the subjects should have been fairly evenly matched according to race, given the patient population of our medical center. One could speculate that perhaps patients with a recent stroke would fare more poorly on a task requiring comprehension of written material. We tried to eliminate this possibility by excluding dysphasic a n d / o r demented patients. Many patients had either TIA or retinal infarction and had intact cognitive abilities. Patient knowledge of stroke has not been widely investigated in the past. Wellwood et al. found that 22% of British stroke survivors could not discriminate between a stroke and heart attack. 4 These investigators also found that 55% of stroke patients thought that nothing could have been done to prevent the stroke. The patients in the British study may not be entirely comparable with the patients in our report given the major differences in the
428 health care systems of Great Britain and the United States and the decreased access to care of minority groups in the United States. In the past decade, clinical trials have shown the effectiveness of medical and surgical options for stroke prevention (e.g., warfarin for atrial fibrillation and carotid endarterectomy for severe, symptomatic stenosisS.6). However, for patients to benefit from procedures such as a carotid endarterectomy after a carotid distribution TIA, they must become educated regarding what the symptoms of a stroke are and they must recognize that even fleeting symptoms deserve medical evaluation. It is somewhat discouraging that our patients were not familiar with the concept of a TIA, and it is possible that many urban patients ignore TIAs and present to medical attention at a later stage with enduring symptoms and/or carotid occlusion. This would be consistent with an earlier publication in which 47% of patients did not seek medical attention for a TIA.7 Recent months have also seen the demonstration that acute ischemic stroke is a potentially treatable condition. 8 However, for patients to benefit from thrombolysis for acute stroke or any other acute treatment that is developed in the future, they must be adequately educated about the warning signs of stroke. Therefore, it is important to recognize that our patients could not reliably identify the signs of a stroke. This may lead to an underuse of thrombolytics because patients with symptoms amenable to acute treatment may not be seeking prompt medical attention. This possibility could also lead to greater neurological disability and increased economic costs to society. The fact that our survey was administered to an urban, predominantly African-American population also deserves mention. African-Americans have a disproportionate share of morbidity and mortality caused by cerebrovascular disease. 9They also have an incidence of hypertension that is approximately twice that of other groups, t~ Therefore, it was particularly sobering to note that our patients had misperceptions regarding symptoms of hypertension and lifestyle modifications for improved blood pressure control. This finding has implications for the secondary prevention of stroke in African-Americans. In summary; this study shows that knowledge of stroke prevention practices is suboptimal among urban patients at high risk for stroke. It also suggests that opportunities for stroke prevention and treatment are being missed, especially among African-American patients. To decrease the human and economic toll of stroke in urban areas, educational efforts should concentrate on high-risk individuals, and more clinical research should be focused on African-American patients at risk for stroke. Future studies should address whether variables such as age or educational attainment significantly influence the level of stroke knowledge and whether the implementation of
S. CHATURVEDI A N D L. FEMINO
educational programs have an impact on knowledge regarding stroke among African-American patients. Acknowledgments: The authors thank Dr. Raywin Huang for his statistical assistance and Dr. Philip Gorelick for his thoughtful comments.
Appendix: Stroke Survey for Patients 1. What is a stroke? A A type of convulsion B An interruption of blood supply to the brain C A type of heart attack D A problem related to Alzheimer's disease 2. The leading cause of disability in North America is related to: A Heart attacks B Cancer C Stroke D Motor vehicle accidents 3. The leading cause of death in North America is related to: A Heart attacks B Cancer C Stroke D Motor vehicle accidents 4. All of the following increase the risk of a stroke except: A High blood pressure B Elevated blood sugar (diabetes) C Cigarette smoking D Stomach ulcers 5. What is the most common cause of a stroke? A Heart attacks B Irregular heart beats C Weak blood vessels D Narrowing or blockage of blood vessels 6. Which of the following does not contribute to the narrowing of blood vessels? A Alcohol B Smoking C High blood cholesterol D Lack of exercise 7. The rate of stroke increases with age. A True B False 8. All of the following are possible warning signs of a stroke except: A Decreased vision in one or both eyes B Difficulty speaking or understanding C Chest pain D Numbness or weakness on one side of the body 9. A Transient Ischemic Attack (TIA) is: A A type of seizure or convulsion B Warning signs of a stroke which go away by themselves C A type of migraine headache
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PATIENT KNOWLEDGE OF STROKE
D When you meet someone but cannot remember their name 10. What should you do if you have warning signs of a stroke? A Go lie down and try to sleep B Drink a glass of water C Take two tablets of Tylenol D Call your doctor or go to the emergency room 11. Men are at higher risk for stroke than women. A True B False 12. The most common sign of high blood pressure is: A Headache B Feeling as if you are about to faint C Confusion D No signs at all 13. Which of the following does not help to control blood pressure? A Losing weight B Stress management C High salt intake D Taking blood pressure medication regularly 14. Which of the following does not help to control diabetes? A Losing weight B Restricting intake of calories C Exercise D Taking diabetes medication when you feel poorly 15. All of the following are good eating habits for a person at risk of stroke except: A Avoid excess fat and cholesterol B Avoid excess salt C Avoid excess green, leafy vegetables D Avoid excess calories 16. If you have been smoking cigarettes for 30 years, there is no point in stopping at this point. A True B False 17. Aspirin is frequently given to patients at risk of stroke because it: A Thickens the blood B Thins the blood C Brings down a fever D Helps the pain of arthritis 18. A possible side effect of aspirin is: A High fever
B Headache C Disturbed sleep D Easy bruising 19. If someone has a stroke, then: A The situation is hopeless B The person should stay home and maybe the problem will go away C One in three patients can make an almost complete recovery D Rehabilitation programs are not worthwhile 20. The best advice regarding alcohol for a person at risk of stroke is: A Avoid alcohol completely B Consume alcohol only on holidays C Moderate alcohol intake (one to two drinks per day) may be helpful D Four to five drinks per day will reduce your risk of a stroke
References 1. National Stroke Association. Gallup poll on awareness and knowledge of stroke prevention. 1996, unpublished. 2. Wilterdink JL, Easton JD. Vascular event rates in patients with atherosclerotic cerebrovascular disease. Arch Neuro11992;49:857-863. 3. Folstein MF, Folstein SF, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198. 4. Wellwood I, Dennis MS, Warlow CP. Perceptions and knowledge of stroke among surviving patients with stroke and their careers. Age Ageing 1994;23:293-298. 5. European Atrial Fibrillation Trial Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischemic attack or minor stroke. Lancet 1993;342: 1255-1262. 6. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-453. 7. Shelton JE, Gaines KJ. Patients' attitudes towards TIA. Virginia Med Q 1995;122:24-28. 8. The NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-1587. 9. Caplan LR, Gorelick PB, Hier DB. Race, sex, and occlusive cerebrovascular disease: A review. Stroke 1986;17:648655. 10. Saunders E. Hypertension in African-Americans. Circulation 1991;83:1465-1467.
Background: The premise of the "brain attack" concept is that early intervention may salvage ischemic neurons. Early intervention depends on adequate knowledge of stroke so that patients seek urgent medical attention. Objective: To assess knowledge of stroke risk factors and warning signs in an urban, predominantly black community. Methods: A 20-item questionnaire was administered to two patient groups. Group 1 had a diagnosis of first-ever stroke or transient ischemic attack (TIA). Group 2 (controls) was without a history of cerebral ischemia. Results: Thirty patients in group 1 answered 57.5% of the questions correctly. Thirty patients in group 2 answered 63.1% of the questions correctly (P = .15). Patients showed misperceptions regarding the warning signs of a stroke and were unfamiliar with the concept of a TIA. Conclusions: Although preliminary because of a limited sample size, the results from our urban medical center suggest that knowledge of stroke is deficient among high-risk individuals who developed cerebral or retinal ischemia. This would mean that opportunities for effective prevention and treatment of stroke are being missed in minority patients. Recruitment of patients for acute stroke trials will also face impediments in urban commtmities unless a massive educational effort is undertaken. Key Words: Stroke--Knowledge regarding stroke--AfricanAmericans.
Several surveys of the general public have shown that knowledge regarding stroke is deficient in the United States. In a 1996 study of adults over age 50, 40% of the general population did not know where in the body a stroke occurs, and only one in three respondents was able to identify speech difficulty as a potential sign of a stroke. 1 Although this is concerning, the stroke risk of the general population is relatively low. Published reviews of the literature indicate that the annual stroke rate for the general population is approximately 0.6%. 2 What would be more concerning is if those individuals at highest risk for stroke were deficient in their knowledge of stroke warning signs and stroke prevention practices. Therefore, we undertook a pilot study of stroke
From the Department of Neurology, Wayne State University/ Detroit Medical Center, Detroit, MI. Received December 1,1996; accepted March 4,1997. Address reprint requests to Seemant Chaturvedi, MD, 6E-UHC, Department of Neurology, Wayne State University, 4201 St. Antoine, Detroit, M148201. Copyright 9 1997by National Stroke Association 1052-3057/97/0603-0009503.00/0
426
knowledge among patients with either a recent stroke or transient ischemic attack (TIA). This population would have a recurrent stroke rate of 2% to 13% per year, depending on the underlying pathology. Our hypothesis was that knowledge of stroke would be deficient in high-risk individuals with recent episodes of cerebral or retinal ischemia.
Methods Subjects were recruited from in-patient and out-patient settings of a university medical center. The first group of patients had experienced a cerebral/retinal stroke or TIA in the previous month. A second group of control subjects was recruited from an adjacent orthopedics clinic. These individuals were free of cerebral ischemia by history. We sought to assess knowledge regarding stroke in an urban community, and therefore, subjects were considered eligible only if they were residents of the city of Detroit. With local demographic characteristics, the study group was approximately 80% African-American. Study patients were excluded from participation if they
Journal of Stroke and Cerebrovascular Diseases, Vol. 6, No. 6, 1997: pp 426-429
427
PATIENT KNOWLEDGE OF STROKE
had one or more of the following: dysphasia, dementia (as assessed by the Mini-Mental Status Examination3), illiteracy. Patients with a previous stroke or TIA were also excluded because they may have received teaching/ counseling on stroke prevention practices with the earlier event. Study patients and controls were given a 20-item multiple-choice questionnaire. The content of the questionnaire included the following areas: (1) the nature of a stroke, (2) the significance of stroke as a public health problem, (3) risk factors for stroke, (4) causes of stroke, (5) the warning signs of a stroke, (6) facts regarding hypertension/diabetes, (7) dietary/lifestyle factors and stroke, (8) pharmacological options for stroke prevention, (9) the prognosis for stroke survivors. The questionnaire was administered in rooms devoid of any stroke educational materials. Prior approval was obtained from the Institutional Review Board.
Results The questionnaire was administered to 30 patients with a history of stroke/TIA and 30 control subjects. Patients correctly answered 57.5% of the questions. Control subjects correctly answered 63.1% of the questions (t5s = 1.47, P = .15, using the independent t-test). The percentage of correct responses to each question can be found in Table 1. The most commonly missed questions concerned the following areas: 1. The significance of stroke as a public health problem Table 1. Responses to individual questions
Content of question 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Nature of a stroke Stroke and disability Stroke and death Risk factors for stroke Causes of stroke Risk factors for atherosclerosis Stroke and age Warningsigns of stroke Nature of a TIA Responding to stroke symptoms Gender differences in stroke Symptoms of hypertension Lifestyle factors and hypertension Lifestyle factors and diabetes Diet and stroke Smoking and stroke Rationale for aspirin use Side effects of aspirin Prognosis for stroke Alcohol and stroke
% % Correct Correct (patients) (controls) 77 53 40 67 77 27 70 37 37 97 50 43 57 47 47 97 83 63 80 20
90 50 40 77 93 23 80 57 57 97 63 27 73 57 57 100 80 47 90 13
2. Factors contributing to atherosclerosis 3. The warning signs of a stroke 4. The concept of a TIA 5. Symptoms of hypertension and lifestyle factors leading to improved blood pressure control. Regarding symptoms of hypertension, the question was designed to emphasize the point that the most common symptom of hypertension is no symptoms at all, reinforcing its role as the "silent killer." 6. Advice regarding alcohol for a stroke survivor Patients performed best on questions that assessed the following: (1) action to take in the event that one had stroke-like symptoms, (2) Advice regarding smoking cessation, (3) Rationale for the use of aspirin in stroke prevention, and (4) Prognosis for stroke patients. Notable responses included the following: (1) 57% of patients thought that lack of exercise does not contribute to atherosclerosis. (2) One third of patients answered that chest pain is a warning sign of a stroke. (3) Only one in three patients was familiar with the concept of a TIA.
Discussion The results of this study lend support to the hypothesis that individuals at high risk for stroke in an urban community are deficient in their knowledge of stroke prevention practices. However, some methodologic criticisms could be raised. For example, the small sample size in our study precludes any definitive conclusions. To achieve adequate statistical power to discern a 20% difference between the two groups in this study would have required more than 100 patients in each group. This was beyond the scope of this project. In addition, we did not systematically assess age or educational attainment of the respondents or determine literacy levels. These are important potential confounding variables. Because control subjects were taken from the clientele of the same medical center and were also urban residents, we do not think that educational disparities would explain the results. Also, the subjects should have been fairly evenly matched according to race, given the patient population of our medical center. One could speculate that perhaps patients with a recent stroke would fare more poorly on a task requiring comprehension of written material. We tried to eliminate this possibility by excluding dysphasic a n d / o r demented patients. Many patients had either TIA or retinal infarction and had intact cognitive abilities. Patient knowledge of stroke has not been widely investigated in the past. Wellwood et al. found that 22% of British stroke survivors could not discriminate between a stroke and heart attack. 4 These investigators also found that 55% of stroke patients thought that nothing could have been done to prevent the stroke. The patients in the British study may not be entirely comparable with the patients in our report given the major differences in the
428 health care systems of Great Britain and the United States and the decreased access to care of minority groups in the United States. In the past decade, clinical trials have shown the effectiveness of medical and surgical options for stroke prevention (e.g., warfarin for atrial fibrillation and carotid endarterectomy for severe, symptomatic stenosisS.6). However, for patients to benefit from procedures such as a carotid endarterectomy after a carotid distribution TIA, they must become educated regarding what the symptoms of a stroke are and they must recognize that even fleeting symptoms deserve medical evaluation. It is somewhat discouraging that our patients were not familiar with the concept of a TIA, and it is possible that many urban patients ignore TIAs and present to medical attention at a later stage with enduring symptoms and/or carotid occlusion. This would be consistent with an earlier publication in which 47% of patients did not seek medical attention for a TIA.7 Recent months have also seen the demonstration that acute ischemic stroke is a potentially treatable condition. 8 However, for patients to benefit from thrombolysis for acute stroke or any other acute treatment that is developed in the future, they must be adequately educated about the warning signs of stroke. Therefore, it is important to recognize that our patients could not reliably identify the signs of a stroke. This may lead to an underuse of thrombolytics because patients with symptoms amenable to acute treatment may not be seeking prompt medical attention. This possibility could also lead to greater neurological disability and increased economic costs to society. The fact that our survey was administered to an urban, predominantly African-American population also deserves mention. African-Americans have a disproportionate share of morbidity and mortality caused by cerebrovascular disease. 9They also have an incidence of hypertension that is approximately twice that of other groups, t~ Therefore, it was particularly sobering to note that our patients had misperceptions regarding symptoms of hypertension and lifestyle modifications for improved blood pressure control. This finding has implications for the secondary prevention of stroke in African-Americans. In summary; this study shows that knowledge of stroke prevention practices is suboptimal among urban patients at high risk for stroke. It also suggests that opportunities for stroke prevention and treatment are being missed, especially among African-American patients. To decrease the human and economic toll of stroke in urban areas, educational efforts should concentrate on high-risk individuals, and more clinical research should be focused on African-American patients at risk for stroke. Future studies should address whether variables such as age or educational attainment significantly influence the level of stroke knowledge and whether the implementation of
S. CHATURVEDI A N D L. FEMINO
educational programs have an impact on knowledge regarding stroke among African-American patients. Acknowledgments: The authors thank Dr. Raywin Huang for his statistical assistance and Dr. Philip Gorelick for his thoughtful comments.
Appendix: Stroke Survey for Patients 1. What is a stroke? A A type of convulsion B An interruption of blood supply to the brain C A type of heart attack D A problem related to Alzheimer's disease 2. The leading cause of disability in North America is related to: A Heart attacks B Cancer C Stroke D Motor vehicle accidents 3. The leading cause of death in North America is related to: A Heart attacks B Cancer C Stroke D Motor vehicle accidents 4. All of the following increase the risk of a stroke except: A High blood pressure B Elevated blood sugar (diabetes) C Cigarette smoking D Stomach ulcers 5. What is the most common cause of a stroke? A Heart attacks B Irregular heart beats C Weak blood vessels D Narrowing or blockage of blood vessels 6. Which of the following does not contribute to the narrowing of blood vessels? A Alcohol B Smoking C High blood cholesterol D Lack of exercise 7. The rate of stroke increases with age. A True B False 8. All of the following are possible warning signs of a stroke except: A Decreased vision in one or both eyes B Difficulty speaking or understanding C Chest pain D Numbness or weakness on one side of the body 9. A Transient Ischemic Attack (TIA) is: A A type of seizure or convulsion B Warning signs of a stroke which go away by themselves C A type of migraine headache
429
PATIENT KNOWLEDGE OF STROKE
D When you meet someone but cannot remember their name 10. What should you do if you have warning signs of a stroke? A Go lie down and try to sleep B Drink a glass of water C Take two tablets of Tylenol D Call your doctor or go to the emergency room 11. Men are at higher risk for stroke than women. A True B False 12. The most common sign of high blood pressure is: A Headache B Feeling as if you are about to faint C Confusion D No signs at all 13. Which of the following does not help to control blood pressure? A Losing weight B Stress management C High salt intake D Taking blood pressure medication regularly 14. Which of the following does not help to control diabetes? A Losing weight B Restricting intake of calories C Exercise D Taking diabetes medication when you feel poorly 15. All of the following are good eating habits for a person at risk of stroke except: A Avoid excess fat and cholesterol B Avoid excess salt C Avoid excess green, leafy vegetables D Avoid excess calories 16. If you have been smoking cigarettes for 30 years, there is no point in stopping at this point. A True B False 17. Aspirin is frequently given to patients at risk of stroke because it: A Thickens the blood B Thins the blood C Brings down a fever D Helps the pain of arthritis 18. A possible side effect of aspirin is: A High fever
B Headache C Disturbed sleep D Easy bruising 19. If someone has a stroke, then: A The situation is hopeless B The person should stay home and maybe the problem will go away C One in three patients can make an almost complete recovery D Rehabilitation programs are not worthwhile 20. The best advice regarding alcohol for a person at risk of stroke is: A Avoid alcohol completely B Consume alcohol only on holidays C Moderate alcohol intake (one to two drinks per day) may be helpful D Four to five drinks per day will reduce your risk of a stroke
References 1. National Stroke Association. Gallup poll on awareness and knowledge of stroke prevention. 1996, unpublished. 2. Wilterdink JL, Easton JD. Vascular event rates in patients with atherosclerotic cerebrovascular disease. Arch Neuro11992;49:857-863. 3. Folstein MF, Folstein SF, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198. 4. Wellwood I, Dennis MS, Warlow CP. Perceptions and knowledge of stroke among surviving patients with stroke and their careers. Age Ageing 1994;23:293-298. 5. European Atrial Fibrillation Trial Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischemic attack or minor stroke. Lancet 1993;342: 1255-1262. 6. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-453. 7. Shelton JE, Gaines KJ. Patients' attitudes towards TIA. Virginia Med Q 1995;122:24-28. 8. The NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333:1581-1587. 9. Caplan LR, Gorelick PB, Hier DB. Race, sex, and occlusive cerebrovascular disease: A review. Stroke 1986;17:648655. 10. Saunders E. Hypertension in African-Americans. Circulation 1991;83:1465-1467.