Patients who have suffered a stroke may experience a variety of limitations and complications that can hinder optimal recovery. The most common after-effects are:

Physical after-effects

These include all injuries or complications that affect the patient’s body. The most common are related to motor deficits, sensory or language disorders and urinary incontinence:

• Patients who have suffered a stroke should work to strengthen their muscles and train their balance, as they have a higher risk of falls.
• Patients will see speech therapists in the case of language disorders such as:
  • Misunderstanding or problems using language (aphasia).
  • Speech disorders that manifest in difficulty articulating words (dysarthria).
  • Inability to pronounce words (mutism).
• Stroke sufferers can also suffer changes to senses on the side where they have mobility problems, such as tingling, unpleasant sensations or a lack of touch. Special care must be taken to prevent injuries or burns as the patient may not notice them.
• Spasticity, or permanent contraction of certain muscles, can cause stiffness, pain, contractures and difficulty in some movements. The specialist will recommend the most appropriate treatment.
• Pain in the shoulder of the paralysed arm will need rehabilitation and is the most common complication in people with hemiplegia.

Although less common, other injuries such as problems with sight, central pain, or infections can also occur.

• Problems with sight are related to the loss of vision of half of the visual field (hemianopsia). However, the patient is not always aware of this and should be reminded to look at the affected corner as recovery will require training.
• In case of difficulty swallowing (dysphagia), changes to diet and safe-eating techniques will need to be used. In more severe cases, it may be necessary to resort to a nasogastric tube or, if it is going to be used for a long period of time, a gastrostomy.
• Central pain is a burning or stinging sensation that worsens on touch, in water, or during movements. 
• Urinary incontinence is usually temporary, although it may persist in patients with significant after-effects.

Alterations in mood

During recovery, rehabilitation, or later on, mood swings may be noticed. These usually occur in the first three months after a stroke, although there are cases where they occur later. Symptoms are similar to other depressions: problems sleeping, difficulty concentrating, and reduced appetite.
The most common psychological problems are depression and anxiety. Depression usually occurs in one in three patients, and is more common in women and patients with previous problems with depression, psychiatric disorders or social isolation or poor family structure.
Emotional instability, apathy, irritability, and lack of awareness can also occur following a stroke. 

Cognitive impairments

In this case, the most common cognitive impairment occurs in the form of dementia, attention deficit, and decreased memory. There are also patients who present with problems relating to orientation, difficulty in planning, and organising tasks.

Guidelines for caregivers

All of these factors have an impact on the patient’s family. In 60% of cases, the person who assumes the role of caregiver suffers from overload and anxiety at discharge. It is important:

• To ask for help and use social and community resources.
• To plan activities and find time for the caregiver.
• Not to abandon relationships with friends.
• To express thoughts and emotions without judging one’s own feelings.
• To set boundaries and not self-medicate.
• To participate in family associations and support groups, and in family respite programmes.

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Symptoms of stroke

• Ask the person to lift both arms at once to check if there is anything unusual. If the person is unable to lift one or the other arm due to lack of strength, this may be a symptom of a stroke. If they feel weakness in the legs, ask them to sit up and lift both feet at the same time.
• Make them smile to check whether the corner of their lips is twisted to one side (crooked mouth). Facial paralysis is often related to stroke, and may be accompanied by a tingling sensation. Sometimes vision loss can also occur.
• Ask specific things such as pointing at an object and asking what it is, or what is happening around them. The goal is to see if they change the order of the syllables or mispronounce the name of the object; see if they change the order of syllables, and if they respond with interspersed or incoherent words, as well as seeing if there is difficulty speaking and understanding speech. 

First aid 

Every minute, 1.9 million neurons and 14 trillion neural connections are lost: one hour means 3.6 years of brain aging and a loss of 120 million neurons. If you suspect a person may be having a stroke, call 112 quickly. Before medical services arrive:

• Keep the patient calm and still. 
• If possible, have them lie down to improve cerebral perfusion.
• If they are unconscious and breathing, place them in a safe position on their side.
• Do not lift the head (unless vomiting or breathing poorly).
• Do not administer drugs not prescribed by a medical authority.
• Call the emergency services number to check the most appropriate hospital and they will notify the hospital you are on your way so they can prepare.
• Avoid intermediate levels (health centre, family doctor, etc.) so as not to delay the start of emergency treatment.

Modifiable risk factors

• Proper monitoring of tension lowers the chances of suffering a stroke and other cardiovascular diseases. Hypertension is, in fact, the main risk factor for stroke after age (it is estimated to be the cause in between 25 and 50% of cases). 
• Follow a healthy diet, limiting salt and fats, processed meats, and industrial pastries . The Mediterranean diet is a good choice because, as well as being balanced and providing the necessary nutrients, it has a low content of saturated fatty acids, is rich in antioxidants and reduces the possibility of obesity, bad cholesterol (a risk factor for stroke) and diabetes. It is also advisable to eat fish, legumes, fibre, fruit and vegetables on a regular basis.
• Doingsport on a regular basis helps avoid obesity and diabetes and prevents cardiovascular disease. Everyone is advised, where possible, to do 30-60 minutes of moderate (walking quickly) or intense (running) aerobic physical exercise five days a week.
• Proper monitoring and treatment of diseases such as diabetes may decrease the risk of stroke and other vascular diseases. While chronic microvascular complications involved in diabetes (retinopathy, nephropathy, and neuropathy) are associated with poor long-term glycaemic control, macrovascular complications (ischemic heart disease and stroke) are determined mainly by other cardiovascular risk factors. We also need to monitor weight and obesity, which promotes high blood pressure, dyslipidaemia and diabetes.
• Nicotine causes cholesterol plaques in the arteries and can cause them to clog, so it is recommended to give up smoking. 
• Excessive alcohol consumption is also harmful: it causes hypertension and cardiovascular disease. This is why you are also advised to limit alcoholic beverages.
• Controlling heart disease, specifically atrial fibrillation: changes in heart rate, as is the case in atrial fibrillation, may cause thromboembolism in the brain (a type of stroke) or in other organs.
• Take your pulse is a campaign run by the Department for Health of the Generalitat de Catalunya, la Fundació Ictus (Stroke Foundation) and the Consell de Col·legis de Farmacèutics de Catalunya (Council of Associations of Pharmacists of Catalonia). If you feel strong, rapid palpitations without having done any previous physical activity, you are recommended to go to the doctor.

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Recommendations and treatment for relatives and carers

Communication

• Speak naturally, using simple words and short sentences, without shouting.
• In the first phase after a stroke, ask short, yes/no questions.
• Promote conversations about every-day life and familiar situations to stimulate the patient’s language.
• If necessary, accompany conversations with gestures to facilitate understanding.
• Items such as the radio or television should be turned off to avoid distractions.
• Respect the response time: avoid showing impatience or cutting off the patient.
• In serious cases, you can use alternative means of communication, such as boards with everyday images on them. There are also mobile apps that can help.

Movement

• Do the exercises recommended by the physiotherapist.
• Move joints and avoid incorrect positions.
• When moving a patient, never touch the affected side.
• It is important that the patient be out of bed for as long as possible.
• Pillows should be used to protect zones of friction and position should be changed every four hours.
• Before the patient drives again, a specialist should be consulted.

Sleep and rest

• It is recommended to sleep seven or eight hours a day.
• Provide a quiet environment and provide a point of light so the patient can orient themselves during the night.
• Create a day atmosphere (more active, bright) and a different, night atmosphere (quieter, darker). This helps in understanding the sleep pattern.
• Avoid letting them sleep during the day, except for a short afternoon nap.
• After a stroke, the patient may find themself more tired for a while. It is important to become more active but without forcing it.

Hygiene

• Encourage the patient to collaborate in their personal hygiene.
• Whenever possible, use a shower, instead of the bathtub, with a chair inside and a handle on the wall.
• The soap should be neutral and free of alcohol, as this can dry the skin.
• The skin should be dried properly, taking special care with folds. It should then be hydrated and protected.
• Maintain proper oral hygiene.
• Watch bony prominences to prevent pressure sores.

Getting dressed

• Wear comfortable clothes that are easy to put on and take off, such as sportswear with elastic and no buttons.
• Start dressing the patient on the affected side and undressing them on the side that is not affected. It is preferable to be seated.
• To put on trousers (pants), especially if the patient is in bed, it is easier to gather up the trousers, insert one leg at a time and then pull them up.
• Shoes should be closed, with no laces and non-slip soles, which fit the foot well. Shoehorns can make it easier to put on shoes.
• The patient feels the same degree of cold and heat as the carer, so do not give them too many layers.

 Physical obstacles

• Remove obstacles such as carpets or chairs to avoid tripping.
• Adapt the home to the new situation: install bars, a taller toilet or shower, etc.
• Adapt the home to improve patient autonomy and prevent falls. For example: have a high bed (70 cm) to make it easier for the patient to get up and down comfortably.

Leisure and recreational activities

• Maintaining social life and hobbies, while respecting the limitations of the patient, improves self-esteem and avoids isolation.
• Incorporate leisure activities gradually, according to the degree of autonomy and in consensus with the patient.

Sex

• Immediately after a stroke, sexual desire may decrease, but it will gradually recover. If in doubt, consult a doctor.
• Paralysis may make sex trickier, but not impossible.
• Fear of suffering another stroke during sex is generally unfounded.
• It is important to talk to your partner about any fears or worries that may arise.

Return to work

• The return to work must be planned, together with the company, so it is gradual, both in terms of demands and time.
• After re-joining the workplace, the situation should be re-evaluated in case changes or adaptations need to be made to improve patient performance and ability.

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