In my field of practice, three of the most common chronic conditions I encounter are epilepsy, dementia, and stroke. I’m a Neurophysiology Technologist and primarily perform a brainwave test called an electroencephalogram (EEG). This dynamic test examines brain function. Generally speaking, the purpose is to inform the treating team if the patient has an underlying seizure disorder and if he/she in status epilepticus (ie. state of persistent seizures).
Patients with epilepsy require follow-up EEGs in order to ensure medication levels are adequate (ie. the threshold for having a seizure is not too low, indicated by a highly active EEG with lots of epileptiform) and to monitor their electrographic background. Sometimes, patients have intractable epilepsy and require surgical intervention (Healthwise Staff, 2019). This may involve a surgical resection, most commonly of the mesial temporal lobe or hippocampus (Healthwise Staff, 2019). At Vancouver General Hospital, surgical candidates come to our seizure investigation unit. Here, we reduce their anti-epileptics, watch them have seizures, find the the seizure focus, and decide if they can have that portion of the brain removed. Another treatment option in some cases is a vagus nerve stimulator (VNS), which can help stop the evolution of a seizure (Healthwise Staff, 2019). VNS can be helpful for patients that are unable to undergo a brain resection. VNS can reduce seizure frequencies in those with bilateral seizures (ie. seizures that can generate from both hemispheres of the brain as opposed to same origin on one side). A less invasive option is the ketogenic diet (Healthwise Staff, 2019).
Neurophysiology Technologists typically perform EEGs on patients with dementia to track the progression of the disease (ie. degree of slowing of brainwave activity). Also, sometimes the altered level of consciousness and awareness is due to ongoing seizure activity, and not simply attributable to dementia. Stroke patients are commonly seen since hemorrhagic strokes produce irritation to the brain that can result in a seizure focus. Similarly, portions of the brain impacted by ischemic strokes can disrupt electrical activity of the brain and cause seizures. Depending on the degree of the stroke, these patients may require anti-epileptic drugs to prevent seizures outside the acute period.
When it comes to management of chronic conditions, patients with these brain disorders benefit the most from having an EEG. That is why I see these patients the most frequently in the lab setting, seizure investigation unit, and several wards in the hospital. Even some of the ICU or ER patients I see have acute on chronic strokes, known seizure disorder, or history of dementia.
Epilepsy
Social determinants of health not only influence the likelihood of having a seizure disorder, but also have a major impact on hospitalizations, medication compliance, surgical interventions, and overall treatment outcomes (Szaflarski, 2014). Many social factors are unjust and modifiable, in particular, access to health systems and structural context (Szaflarski, 2014). A national health report recognized the consequences of social determinants of health for epilepsy. For instance, a consistent finding across studies is that people from lower income households are significantly more likely to have epilepsy than those from annual household incomes of $100,000 and above (Gilmour et al., 2016). The main individual factors include socioeconomic status, race/ethnicity, behaviours (eg. adherence), age, and gender (Szaflarski, 2014). Stigma, a psychosocial factor, is also highlighted as being a contributing factor to poor health outcomes for patients with epilepsy (Szaflarski, 2014).
Although epilepsy can be diagnosed at different stages of life for different patients, the vast majority of people were discovered to have epilepsy in childhood/young adulthood, with 75% being diagnosed before the age of 30 (Gilmour et al, 2016). Interestingly, 39% of Canadians with epilepsy reported that they did not feel overall that their life was impacted (Gilmour et al, 2016). However, those that had a negative experience with epilepsy reported having negative interactions with others, trouble sleeping, restrictions on driving, employment difficulties, and educational limitations (Gilmour et al., 2016). Moreover, they were more likely to have a mood disorder or experience incontinence compared to the general population (Gilmour et al, 2016). There are unique challenges that females face with epilepsy. The fluctuations in hormones during menstrual cycles, puberty, and menopause can have an impact on seizure frequency (BC Epilepsy Society, n.d). Also, women that are going through menopause are more likely to have a fracture from a fall during a seizure since anti-epileptic medications may decrease bone density, particularly in women (BC Epilepsy Society, n.d.). Issues relating to reproductive health, including the use of anti-epileptic medications while using contraception or during pregnancy also need to be considered (BC Epilepsy Society, n.d.). There are risks on a developing child due to anti-epileptic medication as well as due to increased seizure frequency or severity (BC Epilepsy Society, n.d.). Overall theory-based researched is crucial to improving efforts to provide the best care and help eliminate health disparities for this population (Szaflarski, 2014).
Dementia
Tips to keep the brain active included challenging yourself, changing yourself with novel tasks, and learning something new (Brennan, 2013). Video 1 illustrates the importance of staying active both physically and socially (Brennan, 2013). Physical exercise improves the size of the hippocampus, a brain structure that is involved with the formation of memories (Brennan, 2013). Performing aerobic exercise for just 30 mins, 5 times per week, strengthens brain connections and promotes brain health (Brennan, 2013). Video 1 describes how the brain requires a protein called brain-derived neurotrophic factor (BDNF), in order to “fertilize” the brain for neuronal growth and brain cells (Brennan, 2013). BDNF is created when a person does physical exercise (Brennan, 2013). The role of the community and engagement with others is also an important social determinant of health (Alzheimer Society, n.d.). In fact, depression and social isolation increased the chances for dementia (Alzheimer Society, n.d). Cognitive decline is one of the consequences of loneliness; therefore, avoiding social isolation and loneliness, particularly as you get older, can help minimize this risk (Brennan, 2013). Alzheimer Society (n.d.) believes an active social life will reduce stress, enhance your mood, and improve interpersonal relationships. Video 1 promotes active engagement in order to stimulate the brain and help prevent a poor brain health outcomes (Brennan, 2013).
Video 1. Keeping your brain healthy (Brennan, 2013)
Alzheimer Society (n.d) encourages a healthy, balanced lifestyle and stresses the importance of modifiable factors to minimize your risk of dementia. For example, making conscious and safe choices can reduce some of the risk factors associated with dementia (Alzheimer Society, n.d.). This includes head injuries, high alcohol consumption, hearing loss, living near busy roads, and smoking (Alzheimer Society, n.d.). The conditions of the environment that a person lives in also impacts their safety and likelihood of getting dementia (Alzheimer Society, n.d.). Some of the questions to ask yourself are (Alzheimer Society, n.d.):
Do you live in an area exposed to loud sounds or vehicle pollution? Does your home have handrails or grab bars to help prevent falls?
From a social determinants of health perspective, there are several Alzheimer’s disease and related dementias (ADRDs) risk factors (MacDonald et al., 2018) . Physical inactivity, diabetes, obesity, hypertension, diet, smoking, alcohol use, depression, chronic psychological stress, post-traumatic stress disorder, and low educational attainment are key contributing factors (MacDonald et al., 2018). Research shows that individuals who have higher levels of education have an increased “cognitive reserve” and greater capacity to resist damage during aging (MacDonald et al., 2018). The accumulation of amyloid plaque and rate of hippocampal atrophy was slowed in people with higher levels of education (MacDonald et al., 2018). Hospitalization rates are 23% higher for seniors with dementia in low-income neighbourhoods compared to affluent areas (Canadian Institute for Health Information, n.d.). Individuals with dementia from lower-income neighbourhoods had higher rates of injuries related to falls (Canadian Institute for Health Information, n.d.). Studies show that dementia is more prevalent among women than men (Canadian Institute for Health Information, n.d.). Another key finding is that Canadians with early onset dementia, being diagnosed before the age of 65, face special challenges (Canadian Institute for Health Information, n.d.). This cohort is more likely to encounter stigma and have the rare genetic forms of the disease (Canadian Institute for Health Information, n.d.). Many of them are likely to still be working which causes additional difficulties (Canadian Institute for Health Information, n.d.).
Indigenous communities in Canada are also vulnerable because there are challenges associated with diagnosing ADRDs in this population group (MacDonald et al., 2018). Typically, these communities have a lack of awareness and knowledge about dementias (MacDonald et al, 2018). This is in part due to a lack of geriatric care specialists in their area (MacDonald et al., 2018). Urban centres offer the specialized health care services, which requires people from Indigenous communities to travel to gain access to appropriate diagnostic tools (MacDonald et al., 2018). Barriers to health care access creates a delay in the timeline and prevents early interventions (MacDonald et al., 2018). Changes at the policy level have resulted in improvements in many jurisdictions (Canadian Institute for Health Information, n.d.). For example, the use of antipsychotics and restraints in long-term care facilities have been reduced (Canadian Institute for Health Information, n.d.).
Stroke
In Canada, stroke is the third leading cause of death (Government of Canada, 2019). Stroke symptoms can include facial drooping, weakness or loss of sensation often on one side of the body, confusion or difficulty speaking (Government of Canada, 2019). Sudden vision loss, severe headaches, poor coordination, and difficulties with balance are also common (Government of Canada, 2019). The symptoms or subsequent complications of a stroke can persist and impact the quality of life (Government of Canada, 2019). National stroke data shows it is the tenth largest contributor to disability-adjusted life years (Government of Canada, 2019).
Modifiable Risk Factors:
(Boehme et al,. 2017; Government of British Columbia, n.d.; Government of Canada, 2019)
1) Hypertension
2) Smoking
3) Diet
4) Physical inactivity
5) Alcohol consumption
6) Management of co-morbidities (such as diabetes hyperlipidemia, and cardiovascular disease)
Co-morbidities are important to consider when thinking about possible triggers for a stroke. Some of the more common problems in stroke patient’s medical histories have been found to be inflammatory disorders, infection, and cardiac atrial disorders (Boehme, 2017). Managing other medical conditions, such as hypertension and diabetes, helps prevent stroke (Boehme, 2017). Other stroke prevention strategies include behavioural modification (Boehme, 2017; Government of Canada, 2019). In order to support a healthy lifestyle, people should maintain a healthy weight, eat healthy foods, exercise regularly, control blood cholesterol, avoid smoking, and limit the amount of alcohol consumed (Government of Canada, 2019; Government of British Columbia, n.d.). Weight control and aerobic exercise reduce the chance of stroke (Government of British Columbia, n.d.). A healthy diet includes fruits, vegetables and low-fat dairy produce (Government of British Columbia, n.d.).
Non-Modifiable Risk Factors:
(Boehme et al,. 2017; Government of British Columbia, n.d.; Government of Canada, 2019)
1) Race/ethnicity
2) Previous stroke or TIA
3) Family history
4) Genetics
5) Sex
6) Age
On an individual level, genetics play an important role as some rare genetic disorder have stroke as a primary manifestation (Boehme, 2017). Across all ages below 85 years, more men than women who’ve ever had a stroke die (Government of Canada, 2019). More individuals above the age of 85 that have a history of stroke that die are female (Government of Canada, 2019). The reason for this is felt to be due to women having a longer life expectancy (Government of Canada, 2019). Figure 1 shows the data comparing stroke in men and women and different age groups (Government of Canada, 2019).
Figure 1. Stroke occurrence (%) and number of people, by five-year age group and sex in Canada 2012-2013 (Government of Canada, 2019)
In addition to differentiating risk factors based on being modifiable or non-modifiable, Boehme et al. (2017) also examined which triggers pose short-term risks (eg. sepsis or stress) versus intermediate (eg. hyperlipidemia) or long-term risks (eg. race or sex). Boehme et al. (2017) describe the differences and similarities for risk factors for hemorrhagic and ischemic strokes. Atrial fibrillation was attributed to higher risk of cardioembolic stroke (Boehme et al, 2017). Individuals with atrial fibrillation were found to be 3 to 5 times more likely to have an ischemic stroke (Government of British Columbia, n.d.). In general, more than 20% of strokes are attributed to atrial fibrillation (Government of British Columbia, n.d.). It is argued that developing countries, where hypertensive disorders are prominent, have a higher prevalence of hemorrhagic stroke (Boehme et al., 2017). As Western style diets is introduced to these regions, the proportion of hemorrhagic strokes decrease and the amount of ischemic strokes as well as cardiovascular disease increases (Boehme et al, 2017). Beijing, China can be used as an example; the incidence of hemorrhagic stroke declined by 1.7% annually but the incidence of ischemic stroke increased by 8.7%, from 1984 to 2004 (Boehme et al., 2017).
Alzheimer Society (n.d). Brain-healthy tips to reduce your risk of dementia. Alzheimer Society. Retrieved from https://alzheimer.ca/en/about-dementia/how-can-i-prevent-dementia/brain- healthy-tips-reduce-your-risk-dementia BC Epilepsy Society (n.d.) Women in mind. BC Epilepsy Society. Retrieved from http://bcepilepsy.com/programs/women-in-mind Boehme, A.K., Esenwa, C., & Elking, M.S.V. (2017, February 3). Stroke risk factors, genetics, and prevention. Circulation Research, 120(3). Retrieved from https://doi.org/10.1161/CIRCRESAHA.116.308398 Brennan, S. [Sabrina Brennan]. (2013, October 9). What can you do to keep your brain healthy? [Video]. Vimeo. https://vimeo.com/76537801 Canadian Institute for Health Information (n.d). Dementia in Canada:Summary. Retrieved from https://www.cihi.ca/en/dementia-in-canada/dementia-in-canada-summary Gilmour, H., Ramage-Morin, P. & Wong, S.L. (2016, September 21). Epilepsy in Canada: Prevalence and impact. Statistics Canada. Retrieved from https://www150.statcan.gc.ca/n1/pub/82- 003-x/2016009/article/14654-eng.htm Government of British Columbia (n.d.). Stroke and transient ischemic attack- acute and long- term management. Retrieved from https://www2.gov.bc.ca/gov/content/health/practitioner-
professional-resources/bc-guidelines/stroke-tia#Risk%20Factors%20&%20Primary %20Prevention Government of Canada (2019, December 9). Stroke in Canada: Highlights from the Canadian chronic disease surveillance system. Retrieved from https://www.canada.ca/en/public- health/services/publications/diseases-conditions/stroke-canada-fact-sheet.html Healthwise Staff (2019, November 20). Epilepsy. HealthLinkBC. Retrieved from https://www.healthlinkbc.ca/health-topics/hw108148#show-all MacDonald, J.P., Ward, V., Halseth, R. (2018). Alzheimer’s disease and related dementias in Indigenous populations in Canada: Prevalence and risk factors. National Collaborating Centre for Aboriginal Health. Retrieved from https://www.nccih.ca/docs/emerging/RPT-Alzheimer- Dementia-MacDonald-Ward-Halseth-EN.pdf Szaflarski, M. (2014). Social determinants of health in epilepsy. Epilepsy & Behavior, 41, 283-289.
Retrieved from https://doi.org/10.1016/j.yebeh.2014.06.013
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