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Dr. Majersik: Hi, I'm Dr. Jennifer Majersik. I'm a stroke neurologist at the University of Utah Health Care and the Director of the Stroke Center. My guest today is Dr. Alex Terrill. She's a rehabilitation psychologist in the Division of Occupational Therapy at the University of Utah Health Care. So, Alex, I've been very excited about this topic since I take care of stroke patients and when patients come in, I find we talk all about their high blood pressure and whether they're taking aspirin.

But actually, it's difficult for us to talk about the partnership between the two of them and I can see, although I'm not experienced to this, I can see that there's maybe difficulties between them, but I don't always know how to deal with that with the partners. What have you seen that are some of the problems that happen between couples?

Dr. Terrill: They follow and there are some different broader categories. I'm going to focus more on the psychology or emotion-based problems because that's my area of expertise. But one of the big changes for a certain are changes in mood. So post-stroke depression or apathy is extremely common. It occurs in about a third of stroke survivors. But it's also extremely common and some suggest that it's actually more common in caregivers, up to about 50% of caregivers who experienced depression after stroke. And so these changes in mood, they not only affect the individual but it's been shown that there's a reciprocal effect.

So it's very interconnected. When one person isn't doing well emotionally, the other person isn't doing as well either. And so, for example, if you have a caregiver who is depressed, they will have a harder time doing some of the caregiving, having hard taking care of themselves on their own needs and this can actually increase the likelihood that the person who had the stroke will be hospitalized.

Dr. Majersik: I've also seen data saying that the caregivers health themselves is compromised and I somewhat assume that this is because they stopped going to appointments for a breast cancer screening or to get their own cholesterol checked and they're not out socializing as much.

Dr. Terrill: Yes.

Dr. Majersik: Sometimes, I do talk to my patients' spouses about that. "Are you taking care of yourself?" because I worry and I can tell that they probably aren't.

Dr. Terrill: That's great, yeah. We see that all the time and it's something that the message that we are trying to spread is that, again, the caregiver kind of . . . everything focuses on the patient and, of course, they are too and they want to help. Sometimes they don't know what to do, but it's exhausting and they often neglect their own needs in terms of taking care of their health. Just socializing, getting some social support and we believe that that also contributes to depression is that their social circle shrinks because they're not able to get out or will not get out.

Dr. Majersik: So if a spouse is looking for more help in trying to understand his or her new role, where should they go? Should they go to the usual caregiving sources of support or is there something else that they should do?

Dr. Terrill: That's a good question and I think it's very individually based. I mean, certainly, getting resources for caregivers in general could help with some of the more general issues that come up. How do you find time to do some stress management or take care of yourself? And there are some resources out there. There are caregiver support groups specifically. But there's relatively little that's out there for stroke caregivers, per se, and one of the things that is unique or there are actually several things that are very unique to caregivers for stroke survivors that might not be the case in other things like old-timers or spinal cord injury, for example, along with maybe some physical changes that might happen after stroke.

You do have kind of that emotional piece, the emotional component, changes in cognitions. So the way that you're thinking changes the way that you communicate. And if you think about couples talking to each other, and if one of those partners in the couple isn't able to communicate effectively, how difficult that is. And that's a fairly unique thing, I would say, to partners of stroke survivors.

The other thing is that it does happen very suddenly and, often times, I would argue that practically no one is prepared for something like that when it does happen. And so you have that sudden transition to where you're taking on that role and whereas initially, you might have people rallying in helping you, social support at the hospital, once you're back out there, there's few and far between. Things drop off and it's good to know where to go.

Dr. Majersik: What are you doing now to try to help the situation? It sounds like an area that you're obviously very interested in and I'm hoping we're going to learn more in the next few years about how to help spouses and caregivers.

Dr. Terrill: Yes, so one of the things that I'm working on is actually creating an intervention that is done by both partners in the couple. And rather than just focusing on kind of educational pieces for a caregiver, which is something that's more traditionally done, we actually have them both participating in activities on their own and the activities that they do together. So we like for them to have that shared experience and we have them do positive psychology-based activity. So things like expressing gratitude, working on relationships, acts of kindness, savoring. I mean there are all kinds of things that they can work on. And it really kind of helps to give that structure to ways that they can interact and share some positive moments, make that time.

And that's something that we're hearing quite a bit is that after stroke happens, you kind of flail. You just survive and you want to help each other, but you don't know how and you stop interacting altogether. So and that's really a shame because your partner can be one of your biggest sources of strength and resilience and that's mutual, for both the person who have the stroke and the caregiver.

updated: July 29, 2020
originally published: January 20, 2016

Interviewer: Your ability to recognize strokes symptoms can make all the difference if a loved one has a stroke, especially for their quality life afterward. We'll talk about that next, on The Scope.

You know, there are some things that everybody should be able to do, CPR, first aid and recognizing signs of a stroke. Dr. Jennifer Majersik is the Director of the University of Utah Stroke Center and a stroke specialist. And unlike the other conditions, the faster you realize that somebody has a stroke and the faster you get them help, really affects the rest of their life in a way that like no other disease really does.

Dr. Majersik: That's right because stroke has such a powerful impact on our lives both from a disability perspective and a quality of life perspective. And we actually have treatment. If you can treat a stroke early then you're less likely to have disability later.

Interviewer: I've heard time is brain.

Dr. Majersik: Right. I think that was coined about two decades ago right around the time that TPA was introduced which is the medicine for acute stroke. And if you are one of the very few people in the United States who receives TPA, you have 30% better chance or higher chance of having a better outcome. And that better outcome really matters. It's like walking out of the hospital going back to work, taking care of your family, not just wiggling your pinky or something that may not just critical to you, but things that really affect how you are able to take care of yourself and to live a full life.

Interviewer: So really as humans and members of the human race, all of us should be able to recognize when somebody we know or love is having a stroke because it really, truly could make you a super hero.

Dr. Majersik: That's what I call my patients who do recognize the signs of stroke or their family members. I've had numerous patients who they themselves didn't even know they are having a stroke, but their child or their neighbor, or their co-worker, even people at the gym, grocery store people, any passerby recognizes that someone is having a stroke and they make that decision to call 911. I've numerous times told me patients, "Please go back and find that person and thank them because they really made a difference."

Interviewer: Do people know a stroke when they see it?

Dr. Majersik: Sometimes and sometimes not.

Interviewer: Yeah, it's not like a rattle snake rattle where you hear that, you know.

Dr. Majersik: No.

Interviewer: Okay.

Dr. Majersik: So that most common signs of stroke, we use the acronym FAST. So FAST stands for face, arm, speech, and time, so the F is for face. So we ask people to smile and you see if their face is dripping on one side or the other.

Interviewer: So droopy face is a sure sign of a stroke?

Dr. Majersik: Well, not always. That's the trouble with anything neurologic.

Interviewer: This is tricky.

Dr. Majersik: It could be Bell's palsy. So I see a lot of patients who are coming in with, "My face is drooping. Is it Bell's palsy or stroke?" But the truth is that they should come in anyway.

Interviewer: If the face is drooping, call 911.

Dr. Majersik: You are not going to figure it out at home.

Interviewer: Okay. All right.

Dr. Majersik: It's going to take a specialist. Arms, we have people raise both arms and see if one doesn't raise or doesn't raise as high or drifts down after it goes up.

Interviewer: Okay.

Dr. Majersik: And then the last is speech. Speech is the most prominent symptom. So you look for someone who can't make speech or can't understand speech. So the speech could be slurred as if someone is drunk, but they aren't drunk. Or it could be misusing words or missing words up, they're backward. Sometimes it truly sounds like someone just took a whole bunch of words like confetti and threw them into the air and just randomly grabbed them out. They just don't make any sense at all. I've tried to imitate it for my medical students and I actually can't.

Interviewer: Okay.

Dr. Majersik: And the last is you talk to them or ask them to do something and they don't understand you. They can't make any sense of what you're saying. Their reception, their ability to receive speech is altered.

Interviewer: So let's pretend here for a moment we are sitting here and you have a stroke. Are you going to convulse, are you going to shake? What am I looking for? I know you told me FAST acronym.

Dr. Majersik: So unlike heart attack, which hurts in most people, particularly men but most people, stroke doesn't hurt and it doesn't look no one shakes and people typically don't call out as if having a seizure. It's very quiet. So you could be in a meeting and have a stroke and someone wouldn't notice except that they notice that you're not using your arm or maybe you notice you're not using your arm. I think for that reason, it's a bit of a quiet disease so it is very sudden onset, but it's not noisy and no one clutches their chest in pain. So they may say, "My arm feels funny. It's not moving right," but they're not going to be someone that everyone would notice on the street corner.

Interviewer: I understand that sometimes after a person has a stroke, they don't really know that they had a stroke or they don't even think they had a stroke. Explain how that's possible.

Dr. Majersik: There are some stroke syndromes, particularly in the right side of the brain, that involve recognition of your own body and of the disease processes that are going on. And so when your right side of your brain is having a stroke, you may be in complete denial that anything is wrong. I've had patients in the ER who can't move their left side and they are telling me they're going to go home. And I say, "You can't. You can't move your left side." And they say, "I'm still going home." They just don't get it. Patients who have a stroke on the other side of the brain typically do recognize it. So it just depends on which side that is hit because the brain is so specialized in all of its functions and locations.

Interviewer: Are there some common things that you hear your patients or family members say when they come to the hospital? Like, for example, "I thought it would just go away. I didn't actually think I was having a stroke. I just laid down for a second."

Dr. Majersik: Yeah, it's the bane of my existence really.

Interviewer: Yeah.

Dr. Majersik: So many, many patients ignore their symptoms. So the most common thing I hear is, "I just thought I'd take a nap. My arm was numb so I thought I'd take a nap." Or, "I was having slurred speech," or, "I couldn't see out the right side, but I kept driving because I had a really important appointment."

Interviewer: So those things, under no circumstances, are normal?

Dr. Majersik: It's not normal to not be able to see out of one side of your vision.

Interviewer: And you should do something about them immediately.

Dr. Majersik: Yeah. The best thing to do it to call 911. So, first of all, you shouldn't be operating a vehicle. I know that seems really obvious, but just in clinic yesterday, I had a guy tell how he just kept driving. It, again, kind of goes to that element of people not really recognizing how really serious something is. But if you call 911, the advantage rather than driving yourself, for example, is that ambulance, A, can keep you safe while you are in route. So they make sure your oxygen is okay and your blood pressure because a lot is going on when you're having a stroke.

And, second, they call the hospital ahead of time and they take you to a stroke center. They won't just take you to an ER that isn't just ready to take care of a stroke. They will take you to one that is ready. And they will call the hospital ahead of time and get the stroke team there in place. We were talking earlier about how time is brain. We only have three hours from the beginning of the stroke to the time when I'm no longer allowed to give that medicine, that TPA. And that includes from the very beginning of the stroke so it takes us a while in the hospital, up to an hour to get your head imaging, your labs and all that stuff. So you don't have a lot of time to waste. So we really want people to come via ambulance if at all possible.

Interviewer: Tell me if I'm right. The take away here is if you're experiencing any symptom of a stroke, which is you feel your face or somebody notices your face is dripping, if you can't raise your arm or put your arm up and it starts to drift down or your speech is slurred or jumbled words are coming out of your mouth, call 911 immediately.

Dr. Majersik: You got it.

Interviewer: Don't hesitate.

Dr. Majersik: You passed the test.

Interviewer: I passed the test. And the other thing I think that's important to take away is that strokes don't cause pain and there's no real other physical manifestation of it.

Dr. Majersik: That's right. It's a silent killer.

Dr. Majersik: There are other additional signs of stroke that aren't in the FAST acronym, such as the vision loss or having trouble walking, being off-balance. And we focus on those main three, face, arm and speech because they're so common. But sometimes I've actually had people say, "Well, I've had those other symptoms, but I wasn't sure if they were related." Anything where you've lost function in your body suddenly, sudden onset, be concerned.

Interviewer: For no apparent reason, yeah.

Dr. Majersik: Right. So, if something has been very slow over the years or weeks or months, that's a little different. But if something was normal one minute and five minutes later it's abnormal that's when you should be concerned and be calling 911.

updated: September 29, 2021
originally published: August 19, 2015

Interviewer: Somebody you know or love is having a stroke, you need to call 9-1-1 immediately. We'll tell you exactly why, coming up next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Dr. Jennifer Majersik is the director of the University of Utah Stroke Center and a stroke specialist. And this is the message that I hear you say all the time, "If you think you or somebody you know is having a stroke, call 9-1-1 immediately." Why is it so important that you call 9-1-1 so immediately?

Dr. Majersik: Yes, this is the heart of what I do is to try to get patients to understand just how important it is. In this country, there are about 800,000 strokes a year. And about 650,000 of them are ischemic strokes, maybe a few more, and only maybe 5% of them get acute treatment for stroke. The other 95% do not. And the vast majority do not because they do not get to the hospital fast enough. So we have two major types of treatment now that we can give quickly. One is intravenous, so via an IV, as it's usually called, it's a medicine called TPA and we can give that out to about three hours, sometimes four and a half hours.

Interviewer: And it makes a huge difference in the person's life afterwards.

Dr. Majersik: Yeah, it reduces disability, it makes patients walk again, talk again, go back to their lives, work, play, etc., all the things that are important. Some of the patients who are having a really severe stroke, so the kind that will land you in a nursing home if it doesn't get better or perhaps hurt you to the point of not surviving, those strokes we now have very effective treatment for as well.

2014 and '15 were landmark years for new trials that came out showing the efficacy, so the ability to work, for large-artery strokes, so these are the big ones. Nowadays we have physicians who are known as neuro-interventionalists and they can take a catheter and go into your leg and go on up to the brain and be able to pull clot out and, again, give you back that function so that the stroke is no longer affecting you like it was.

Interviewer: So it seems like a no-brainer, bad pun not intended but it just kind of came out. Why don't people call 9-1-1 after a stroke then?

Dr. Majersik: They are afraid. Some people think that the ambulance will come, will embarrass them. They don't want their neighbors knowing about it. To that fear, I usually say, "Call 9-1-1 anyway, it doesn't matter what the neighbors think, and if you're really that concerned, tell them to not run their sirens and nobody will know."

Interviewer: And this is stuff actual people have told you after they've come in for stroke that blows my mind.

Dr. Majersik: Absolutely people tell me that. Also, there's been studies on it, people-- we've asked, "Why didn't you call 9-1-1 or why wouldn't you call 9-1-1 in this situation?" And these are the kinds of things people tell us. So they're afraid of embarrassment. They're also afraid of being wrong, so what if I'm not actually having a stroke, I'm whatever, having a migraine or Bell's Palsy. And I think it's really hard as a layperson, and sometimes even as a physician, to sort those out. And so I don't think it's worth the risk. I think our lives are too important to be worrying about those kinds of fears. And I think we should do the best thing, which is to call 9-1-1 and get to the hospital and let the professionals sort it out.

And then the last thing. But it's just that people don't even recognize that they're having a stroke. Which we've talked about before, but again goes back to recognizing the signs and symptoms of a stroke.

Interviewer: And sometimes it's not like a heart attack where somebody grabs their head like, "Oh, I'm having a stroke," it's a very quiet thing with very subtle signs that I think all of us, as humans, should know because time is brain.

Dr. Majersik: Right. So the stroke patient doesn't call out, they don't say they're in pain, they just lose function. So the function that they lose could be vision, or it could be arm strength, or face strength, leg strength, sensory, or balance, or speech. I almost forgot speech, the most important one, perhaps.

Interviewer: And the acronym you use is FAST.

Dr. Majersik: Right, so we always use FAST. "F" for face, "A" for arm, "S" for speech. And so if the face is drooping, or the arm won't hold up when you ask someone to hold it up, or speech, if they can't make or understand speech. And all of these should start suddenly. These aren't signs or symptoms that come on slowly, they should come on over just a couple of minutes.

Interviewer: So of all the medical conditions, if you believe that you're having any sort of symptom of a stroke, don't go to the computer and Google and figure it out, don't waste any time whatsoever. The first, and only, thing you should do is dial 9-1-1. And what happens if the person's wrong?

Dr. Majersik: If the person's wrong, they'll come and find out they're having a migraine, perhaps, and hopefully they'll feel better and we'll send them home. Or maybe something else is going on, but I think it's still the most appropriate thing to do. We certainly, on the physician end or the nursing end, we're not upset that you came to the ER. We're not annoyed by extra patients. This is what we do every day and we really enjoy our job. And so whether someone's having a stroke, or if they're not having a stroke I have the joy of telling them, "You're going to be okay."

Interviewer: I guess, you know, we go to the ER for a broken arm, so the repercussions are a lot less worse than the potential repercussions of a stroke, so why would you hesitate?

Dr. Majersik: Right. Absolutely.

Interviewer: What's your takeaway? What's the final thought here?

Dr. Majersik: I think the final thought is that stroke used to be a field that we thought there were no treatments. And I think that still pervades in our communities, that if you're having a stroke just curl up and don't worry about it. But we actually have great treatments now. You just have to get to the hospital fast to receive them.

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