An enjoyable subject, no. Confronting, yes. But put denial on the back burner for the few minutes it takes to read this article, it might save your life. When strokes happen we and the people around us need to know what to do and where to go.
Strokes are an interruption of blood supply to the brain and are usually associated with known risk factors such as age, high cholesterol, high blood pressure, smoking, family history of stroke and diabetes. But we probably know people who have had strokes without any of these factors.
In ascending order of severity, we’re looking at Transient Ischemic Attacks (TIAs), Non-Hemorrhagic strokes (NHS) and Hemorrhagic strokes (HS). A CAT scan is needed to establish the kind of stroke because the treatments differ.
In the past few years I’ve known several people who’ve experienced TIAs, which are mini-strokes usually lasting just a few minutes and often causing no permanent damage. They’re typically caused by a blood clot lodged in an artery that supplies the brain. The neurosymptoms of TIA include tingling of the face, slight weakness on one side, slight confusion or a change in voice. If you suspect you’re having a TIA look in the mirror, smile, raise your eyebrows and look for any asymmetry.
My sister was with our mother when a TIA occurred. “When I found her it appeared as if she was sleeping and it was very difficult to wake her. When she did come around she couldn’t speak and did not appear to understand what I was saying. She was unsteady on her feet and appeared drunk in her movements. As a First Responder I also witnessed a number of elderly people who had or were having TIAs. All were temporary with no obvious lasting symptoms.
A friend in Ubud had a TIA a year ago. She tells me she felt flu-ish and unwell the day before, the next day felt really unwell, sat down and collapsed slowly with her head on the table. She remembered thinking, “I’m having a stroke” and could not think or move; her mouth drooped on one side. A CAT scan and MRI showed a lesion on the left frontal cortex. She has made a full recovery.
Even if a TIA is mild and the effects pass off quickly, it’s still imperative to seek immediate medical attention in case it progresses to a full blown stroke.
Most strokes are Ischemic or Non-Hemorrhagic strokes which occur as a result of an obstruction (a blood clot or plaque) within a blood vessel supplying blood to the brain. The symptoms of an ischemic stroke depend on which part of your brain is affected and can include:
- Sudden numbness or weakness of your face, arm, or leg, often on one side of the body
- Problems speaking or understanding others
- Dizziness, loss of balance or coordination or trouble walking
- Vision loss or double vision
- Sudden severe headache
- One side of the face may droop when the person tries to smile
Treatment of NHS may require the rapid intravenous injection of tissue plasminogen activator (tPA), also called alteplase, to dissolve the clot. This potent clot-busting drug ideally is given within three hours or up to 4.5 hours after initial symptoms appear. It restores blood flow by dissolving the blood clot causing the stroke, and it may help people who have had strokes recover more fully. Or the neurointerventionist may use a catheter to remove the clot (thrombectomy).
Hemorrhagic strokes (HS) are due to a ruptured blood vessel within the brain; the symptoms are the same. These are treated by controlling the bleeding, sometimes with surgery. These are much rarer (only about 15 percent of all strokes are hemorrhagic) but more serious, accounting for 40 percent of all stroke deaths.
Any stroke is a medical emergency. Early treatment can reduce brain damage. Always have a friend, partner or family member with you in an emergency situation in Bali and take a list of your prescription medications.
Where To Go
According to the very helpful doctor I interviewed at Ubud Care Clinic, most hospitals have a neurologist but your hospital of choice should have a neurointerventionist in case it’s necessary to remove a blood clot. Currently only Siloam and Balimed offer this subspecialty. Most hospitals have a CAT scan but only Siloam and Kasih Ibu Denpasar have an MRI. The tPA is only available at Siloam, Balimed, Mandara Hospital Sanur and Kasih Ibu Denpasar. So the one-stop stroke hospitals which have all three elements — a neurointerventionist, MRI and tPa — are Siloam for English speakers and Balimed for Indonesian speakers.
The severity of the stroke will influence recovery. The most rapid recovery usually happens within the first four months but improvement can continue over a year or two. Rehabilitation is very important. Bali has several physiotherapists who can train family and staff to help the patient with exercises and movements, usually short sessions several times a day.
Recovery depends on many different factors: speed of treatment, location in the brain the stroke occurred, how much of the brain was affected, the patient’s motivation, caregiver support, the quantity and quality of rehabilitation, and how healthy the survivor was before the stroke. It’s important to avoid comparisons because every stroke and stroke survivor is unique.
I was primary caregiver to my father, then 88, beginning 6 weeks after a major stroke. He was a kind, funny, considerate man and as our daily routine developed we worked together to make it as interesting as it could be. We sought the dark humour in each challenge, although we never did find the lighter side of incontinence. Papa recovered his speech and mobility very well and lived another seven years; he never lost his sense of humour.
Stroke recovery is a long, steep journey for both the patient and the caregiver. It’s a privilege to care for our loved ones, but it can be exhausting. Clinics and home care services in Bali will rent canes, walkers, wheelchairs, hospital beds and other equipment. Even here in Bali where we are fortunate to have support for housework, cooking, laundry and driving that still leaves visits to doctors and therapists, frequent short physio practices, walks, medication, feeding, bathing and encouragement. Depression and anxiety in the patient are not uncommon during stroke recovery and need sensitive management. Stroke patients need a lot of rest. So do the caregivers.
As caregivers, it’s important for the partner/family to understand that this is a long term commitment and they’ll need to practice self care in order not to burn out. Take advantage of the products and services that are available here. Bali One Care is a health care service that supplies all kinds of equipment and also home nursing care services to provide respite for care givers.
Sada Jiwa is small private care facility located in Mengwi, about 40 minutes from Ubud, on four hectares of attractive garden. This is an excellent alternative to home care for post-stroke patients, or to provide a week of respite for the carer periodically. Sada Jiwa has a residential post-stroke rehab program which is run in partnership with a Dutch hospital. Staff is caring, English speaking and attentive; two of the nurses were trained in aged care in Japan.
Compared to private care in North America, residence at Sada Jiwa is very affordable. A private room with 24 hour nursing care, a doctor on call, meals, medication and physiotherapy costs Rp 500,000 to 800,000 a day. Sada Jiwa also provides home care nurses. www.sadajiwabalicom
The time to think and plan is now. If you have a stroke, how will you pay for the acute care and lengthy recovery period? Who will care for you?
Medical insurance is not optional, even if you’re a visitor and especially if you live here. If you can’t afford it, you can’t afford to be in Bali. We’ve seen far too many cases of illness/accident where patient costs have devolved on the community or crowdfunding to pay for desperately needed medical care.
Then there’s the issue of ready money – do you have cash or credit cards to cover costs until the insurance kicks in? Does your partner/a trusted friend have access to your bank account? Talk to your friends your family or your doctor.
It will probably never happen but we’re not getting any younger here. Wishing you robust health in 2019.
By Ibu Cat
The Boomer Corner is a column dedicated to people over 60 living in Bali. Its mandate is to cover topics, practicalities, activities, issues, concerns and events related to senior life in Bali. We welcome suggestions from readers.
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