Awareness of stroke risk and symptoms in diabetes patients
BACKGROUND: Stroke is responsible for approximately 15% of deaths in people with type 2 diabetes but the baseline knowledge level of stroke warning symptoms, risk factors, and treatment options is unknown in the UK.
METHOD: This survey was conducted with hospitalised patients aged over 18 with type 2 diabetes, who consented to a personal interview. The questionnaire was adapted from a previous study and modified to suit local practice. Information about demographics, awareness of stroke warning symptoms, risk factors, and treatment options were collected.
RESULTS: The mean age of the 100 patients interviewed was 69 years; 53% were male. Forty of the patients claimed an annual income of 10,000–20,000 and 52% had a secondary level of education. When asked which organ of the body was affected by stroke, 41% said the brain, 21% did not know, 18% said heart, 14% said the whole body and the remaining 6% named other organs. When asked about stroke warning symptoms, respondents named a total of 20 different ones, with the two most common being sudden paralysis of one side of the body and sudden speech difficulty. Fifty-two per cent of respondents did not know what happened inside the brain when a stroke occurred. The median number of risk factors known by patients was two (range 0–6). Twenty-four per cent identified diabetes as a risk factor for stroke, with 26% recalling being told by a doctor that diabetes was a risk factor. The most common treatment for stroke that respondents were aware of was aspirin (28%).
CONCLUSION: More and different types of health promotion activities are needed with patients to increase their knowledge of stroke warning symptoms, risk factors and treatment options.
Hinkle, J. et al (2008) Awareness of stroke risk and symptoms in diabetes patients. This is an extended version of the article published in Nursing Times; 104: 31, 32-33.
Janice Hinkle, PhD, CNRN, RN, is senior research fellow, Oxford Brookes University and Acute Stroke Programme; Rabindranath Chanda, MRCP, is specialist registrar, geriatrics; Alastair Buchan, DSc, FmedSci, is professor of clinical gerontology and honorary consultant neurologist, Acute Stroke Programme; all at John Radcliffe Hospital; Aravindakshan Manoj, MD is consultant physician, Royal Liverpool and Broadgreen Hospital.
Stroke is the third most common cause of death in the UK and the largest single cause of severe disability in older people. Each year between 130,000 and 150,000 people in England have a stroke. The cost of stroke care to the NHS has been estimated at 15,306 per patient over five years. When informal care costs are included this increases to 29,405 (based on 2001-2002 prices) (Youman et al, 2003).
A study of more than 7,000 British adults over the age of 60 found that more than a fifth had undiagnosed type 2 diabetes according to new World Health Organization criteria (Thomas et al, 2005). Another study found the risk of stroke to be more than double the rate for the general population within five years of treatment for type 2 diabetes (Jeerakathil et al, 2007). There are many complications of type 2 diabetes including cardiovascular and renal disorders but as the researchers are part of an acute stroke team our interest was to explore the risk factor of stroke.
Stroke is responsible for approximately 15% of deaths in people with type 2 diabetes. Studies have reported that diabetes is the strongest risk factor for death from stroke among both men and women (Ho et al, 2003). Alteplase (Actilyse) is recommended for the treatment of acute ischaemic stroke within three hours of onset of the stroke symptoms (NICE, 2007). Decreasing the time from stroke onset to hospital presentation and risk reduction is in part dependent on the knowledge of stroke that patients, their carers and their family members possess. Self-awareness of increased risk of stroke is essential for success of educational programmes and campaigns. These programmes should target patients at high risk of stroke. Planning effective future programmes relies on an accurate assessment of prior knowledge of stroke.
This article describes a prospective descriptive study of 100 hospitalised patients with type 2 diabetes. The baseline knowledge level of stroke warning symptoms, risk factors and treatment options are reported and discussed. Implications for nursing practice are highlighted.
The main aim of this prospective study was to determine baseline knowledge about the warning symptoms, risk factors, and treatment options available for stroke in patients with type 2 diabetes. A secondary aim was to describe information resources to a UK-based group.
With the advent of time-dependent therapies for ischaemic stroke, it is important to understand the factors that delay hospital admission for patients with stroke. One group of researchers conducted a prospective study of all patients admitted with stroke over a 12-month period in Leicestershire (Harper et al, 1992). Factors assessed included age, sex, time of stroke onset, stroke severity, home circumstances, and routes of admission. The mean age of the 374 patients included was 75 years, 54% were female, and educational level was not assessed. The patient’s knowledge of stroke and interpretation of symptoms were not assessed but these factors have been found to influence the time to presentation at the hospital when stroke occurs (Williams et al, 1997).
Alteplase (Actilyse) has been recommended as the only fibrinolytic treatment of acute ischaemic stroke. Treatment must be started within three hours of onset of symptoms and after prior exclusion of intracranial haemorrhage by means of appropriate imaging techniques (NICE, 2007). Decreasing the time from stroke onset to presentation to hospital and imaging time depends partially on patients’, carers’ and family members’ knowledge of stroke symptoms. Poor knowledge of stroke warning signs limits effective intervention (Schneider et al, 2003; Williams et al, 1997).
Guidelines emphasise the importance of patients’ rapid recognition of, and reaction to, stroke warning signs in emergency care (Hack et al, 2003). FAST (Face, Arm, Speech Test) is advocated by the Stroke Association for use with the public (Harbison et al, 2003).
The test is performed by assessing the following:
Facial movements: Ask the patient to smile or show teeth. Look for new lack of symmetry;
Arm movements: Ask the patient to lift the arms together and hold. Look to see if one arm drifts or falls down;
Speech: If the patient attempts a conversation, look for new disturbance of speech;
Test all three: If one or more is abnormal, suspect stroke.
There were no UK population-based surveys identified in the literature that assessed the knowledge level of stroke warning symptoms, risk factors, and treatment options. However, population-based surveys in other countries have been conducted, for example a hospital-based survey assessed the public awareness of warning symptoms, risk factors and treatment of stroke in Northwest India (Pandian et al, 2005).
Pandian et al (2005) found that knowledge regarding the organ involved, etiology and treatment of stroke was lacking in the 942 participants (56% men, mean age 40 years). Education was categorised as primary, secondary, or college. Those interviewed were outpatients at the hospital and those who had had a stroke were excluded. No information about the number of patients with diabetes was included in the report. Forty-five per cent of participants could not name the organ affected and the most common warning symptom was paralysis of one side of the body in 62% of participants (Pandian et al, 2005). A higher knowledge about the organ involved was associated with both higher income and educational levels.
Another group of researchers assessed the baseline knowledge among 554 outpatients with increased risk of stroke in Oman (Al Shafaee et al, 2006). The educational level of the participants was reported as 42% illiterate, 39% elementary, 7% secondary and 12% college. Questions about symptoms of stroke, risk factors, treatment options, and sources of information revealed that participants were largely unaware of their increased risk for stroke. Thirty-five per cent of participants indicated the brain was the organ affected in stroke and 57% could not name the affected organ. The most common warning symptom named was paralysis of one side of the body in 65% of participants.
A group of US researchers looked at the knowledge of risk among 1,253 patients known to be at increased risk for stroke (Samsa et al, 1997). Less than half (41%) were aware of their increased risk and 27% recalled being informed of this by a physician. Being informed by their physician of an increased risk was strongly related to the patient’s awareness of stroke risk.
Another group conducted a population-based survey with 28,090 participants in the US, Europe, Korea and Australia; 34% had an educational level of tenth grade or higher. This group reported that 60–76% of respondents could name more than one or one correct stroke risk factor (MNordhorn et al, 2006). An increased knowledge of stroke risk factors was significantly associated with a higher educational level. The study conducted in Northwest India reported 51% of those surveyed could name one or more risk factors for stroke (Pandian et al, 2005).
In summary, researchers in North India, Oman, US, Europe, Korea and Australia have concluded that more health education is needed to improve the knowledge level of stroke warning symptoms, risk factors, and treatment options. High levels of knowledge are needed to increase the number of patients presenting early to hospital (Schneider et al, 2003; Williams et al, 1997) and for efficacy of secondary stroke prevention (MNordhorn et al, 2006; Samsa et al, 1997). This is the case in particular among the most vulnerable groups – those known to be at high risk of stroke. However, no studies of the baseline knowledge of stroke warning symptoms, risk factors, and treatment options in the UK were identified.
This study used a prospective survey methodology to study patients over the age of 18 years admitted to Oxford Radcliffe Hospitals NHS Trust and being treated with anti-diabetic tablets or insulin for type 2 diabetes. Exclusion criteria included those who were aphasic, delirious, confused, unconscious or severely ill, had a diagnosis of dementia or a learning disability and those who refused to participate in the study.
Once ethical and other approvals had been received, potential participants were identified by the diabetic nurses or the medical team responsible for the individual patient’s care while in the hospital. Those who gave consent were interviewed personally by one of three medical personnel who had undergone an orientation to the questionnaire. The interviewer only interrupted to clarify a response if required and made no attempt to prompt the respondents.
The survey questionnaire was adapted from previous studies and modified to suit local practice (Pandian et al, 2005). The first section gathered demographic information. Sections 2 and 3 asked about patient awareness of stroke warning symptoms, risk factors and treatment. All questions were open-ended with options for multiple responses. The questionnaire had not been used in the UK and therefore it was pre-tested on a sample of 25 patients.
Data was coded and entered into the statistical package for the social sciences (SPSS), version 14 (SPSS, 2005) for analysis. Descriptive summary statistics were used to provide a description of the baseline knowledge of stroke warning symptoms, risk factors, and treatment options in patients with diabetes.
Table 1 shows the main demographic characteristics of the participants. The mean age was 69 years (range 16–92) and 53% were male. The majority (79%) reported a primary or secondary level of education only. Forty claimed an annual income of 11,000–20,000 but it is worth noting that 39% of participants declined to answer this question. The majority reported smoking and a minority reported regular alcohol use.
Table 1. Demographic characteristics of patients
|Regular alcohol user|
When asked which organ of the body was affected by stroke, 41% indicated the brain, 21% did not know, 18% named the heart, 14% indicated the whole body and the remaining 6% named other organs. When asked about stroke warning symptoms a total of 20 symptoms were named, the median number named was two (range 0-5). The three mentioned most commonly were:
Sudden paralysis of one side of the body in 28%;
Sudden difficulty in speaking in 17%;
Sudden blurred or double vision in 10%.
Fifty-two per cent of respondents did not know what happened inside the brain when a stroke occurred. Other explanations were blood vessels or arteries in the brain become blocked (clot; 23%), the blood vessels or arteries in the brain ruptured (haemorrhage; 14%), and other explanations (fluid collection, swelling, clot and bleed, etc; 11%).
The median number of risk factors for stroke known by patients was two (range 0-6), 24% identified diabetes, and 26% recalled being told by a doctor that diabetes was a risk factor for stroke. If participants knew about stroke their knowledge came from 13 different sources, the most common being mass media and the least common the internet. Table 2 summarises where participants’ additional knowledge of stroke came from.
Table 2. Sources of additional knowledge
(TV, Newspapers, Magazines, Radio)
(Doctors, work in hospital/medical books)
(Other, personal experience, pamphlets)
Patients gave a wide variety of answers when asked what they would do first if they or one of their close relatives or a friend had symptoms of stroke. Fifty-seven per cent reported they would dial 999 for an ambulance, 27% said they would ring the GP, 11% responded they did not know what they would do and 5% said they would wait and see what happened.
The most common treatment for stroke that respondents were aware of was aspirin (28%). The treatments named by participants are listed in Table 3. Only one person knew of the availability of alteplase, the only ‘clot-busting’ for acute ischaemic stroke.
Table 3. What are the treatments for stroke? (n=56)
|Blood thinning agents||14% (8)|
|BP control||5% (3)|
|Cholesterol control||5% (3)|
|Clot buster||4% (2)|
|GTN spray||2% (1)|
This study found a fairly high level of awareness of stroke being something that affects the brain. When asked which organ of the body was affected 41% of participants in this study indicated the brain. Other researchers have reported 33% (Pandian et al, 2005) and 35% (Al Shafaee et al, 2006) of participants indicating the brain was the organ affected. It has been reported that 45% (Pandian et al, 2005) and 57% (Al Shafaee et al, 2006) could not name the organ of the body affected by stroke whereas 21% of those in the current study reported not knowing which organ was affected.
The most common warning symptom reported in this study was paralysis of one side of the body (28% of respondents); other studies have also reported the similar findings (Al Shafaee et al, 2006; Pandian et al, 2005). Clearly, healthcare professionals need to spend more time and effort teaching patients with diabetes the warning symptoms of stroke in order for them to present to the hospital in time for newer treatments options. Printed materials and a video on the FAST test are available from the Stroke Association for teaching purposes (The Stroke Association, 2008). Patients need to know to call 999 when warning symptoms occur as stroke is a medical emergency.
In this study 23% of participants reported that a blood vessel in the brain became blocked when a stroke occurred and 14% reported a blood vessel ruptured. Pandian et al (2005) reported 31% of participants stated that a blood vessel in the brain became blocked and 14% said a blood vessel ruptured. Al Shafaee et al (2006) reported that 25% of participants identified that a blood vessel in the brain became blocked or ruptured when a stroke occurred.
The percentage of those who identified diabetes as a risk factor for stroke (24%) in this study is similar to Al Shafaee et al’s (2006) study, in which 23% reported this as a risk factor. This is much higher than the 8% (MNordhorn et al, 2006) and 11 % (Pandian et al, 2005) reported by others. Also in this study, a low number (26%) recalled being told by a doctor that diabetes was a risk factor for stroke. Other researchers have reported similar findings of 27% of patients recalling being informed of this increased risk by a physician (Samsa et al, 1997). It is important that high-risk patients know that diabetes is a risk factor for stroke and physicians inform patients with diabetes of their stroke risk. Both of these need further emphasis in education for those caring for patients with diabetes.
Level of education is an important factor to consider when assessing the knowledge base of those with type 2 diabetes in relation to potential risks to their health. In our study, the majority of participants (79%) reported primary or secondary level education. This is similar to studies in other countries, which reported 66% (MNordhorn et al, 2006) and 88% (Al Shafaee et al, 2006). Other studies have noted the significant association of a college education with a higher knowledge of stroke symptoms (Pandian et al, 2005) and risk factors (MNordhorn et al, 2006). Due to the small sample size of our study we were unable to investigate the association between education and baseline knowledge level of stroke warning symptoms, risk factors and treatment options.
The high rate of smoking (58%) among these patients is cause for concern. In the UK the rate of smoking in those 16 years of age or older is 27% (Health Development Agency UK, 2004). Clearly, this is a group to target for smoking cessation and an inpatient hospital stay is an ideal time for nurses to approach smokers (Rice, 2006). Patients with diabetes need to be made aware that smoking further increases their risk of stroke, already elevated due to their diabetes.
A positive finding in this study was that more than half of respondents would ring 999 for an ambulance if they, a family member or a friend had symptoms of a stroke. Increased public education on using the FAST score is needed to further increase the number of people who know to ring 999 immediately following the onset of stroke symptoms and not delay by calling the GP or waiting to see what will happen.
This study does have some limitations. It had a relatively small sample, and has a sampling bias as it included only hospital inpatients, who may have been stressed and distracted by their current illness. The study needs to be repeated in an outpatient setting where patients may have different levels of awareness of stroke warning symptoms, risk factors and treatment.
This study contributes to the understanding of several factors for patients with type 2 diabetes in the UK. It demonstrates poor knowledge of stroke warning symptoms, risk factors, and treatment options among a sample of patients with type 2 diabetes. This is the first report documenting poor knowledge in patients in the UK. The findings are not surprising as other studies of patients from Oman (Al Shafaee et al, 2006), those in Northwest India (Pandian et al, 2005) and the US (MNordhorn et al, 2006; Samsa et al, 1997) have documented similar findings.
Implications for nursing practice
This study has several important implications for nursing practice. First, more research is needed in this area. There is a need to extend the study to other trusts and a larger population in order to obtain results that apply more generally. This is an ideal topic for nursing research.
Second, nurses need to be aware that more and different types of health promotion activities are needed with patients with diabetes to increase their knowledge of stroke warning symptoms, risk factors, and treatment options. Those with diabetes need to know the warning symptoms of stroke in order for them to present to hospital in time for the administration of new drugs if their stroke is ischaemic in nature.
Finally nurses are in an ideal position to initiate smoking cessation with patients with diabetes. Smoking compounds these patients’ already high risk of stroke and therefore should be a group targeted for smoking cessation efforts.
Al Shafaee, M.A. et al (2006) Perception of stroke and knowledge of potential risk factors among Omani patients at increased risk for stroke. BMC Neurology; 20: 6, 38.
Hack, W. et al (2003) European stroke initiative recommendations for stroke management - update 2003. Cerebrovascular Diseases; 16: 4, 311–337.
Harbison, J. et al (2003) Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Stroke; 34: 71-76.
Harper, G. D. et al (1992). Factors delaying hospital admission after stroke in Leicestershire. Stroke; 23: 835-838.
Health Development Agency UK (2004) Trends in Smoking in the UK. www.medicalnewstoday.com
Ho, J. et al (2003) Is diabetes mellitus a cardiovascular disease risk equivalent for fatal stroke in women? Data from the Women’s Pooling Project. Stroke; 34: 12, 2812-2816.
Jeerakathil, T. et al (2007) Short-term risk for stroke is doubled in persons with newly treated type 2 diabetes compared with persons without diabetes. Stroke; 38: 6, 1739-1743.
MNordhorn, J. et al (2006) Knowledge about risk factors for stroke: A population-based survey with 28,090 participants. Stroke; 37: 4, 946-950.
NICE (2007) Alteplase for the Treatment of Acute Ischaemic Stroke. www.nice.org.uk
Pandian, J.D. et al (2005) Public awareness of warning symptoms, risk factors, and treatment of stroke in northwest India. Stroke; 36: 3, 644-648.
Rice, V.H. (2006) Nursing intervention and smoking cessation: Meta-analysis update. Heart and Lung; 35: 3, 147-163.
Samsa, G.P. et al (1997) Knowledge of risk among patients at increased risk for stroke. Stroke; 28: 5, 916-921.
Schneider, A.T. et al (2003) Trends in community knowledge of the warning signs and risk factors for stroke. Journal of the American Medical Association; 289: 3, 343-346.
SPSS (2005) Statistical Package for the Social Sciences: SPSS Base Version 14 for Windows. Chicago: SPSS INC.
The Stroke Association (2008) Recognizing Stroke with the FAST Test. www.stroke.org.uk
Thomas, M.C. et al (2005) Prevalence of undiagnosed Type 2 diabetes and impaired fasting glucose in older British men and women. Diabetic Medicine; 22: 6, 789-793.
Williams, L.S. et al (1997) Stroke patients’ knowledge of stroke: Influence on time to presentation. Stroke; 28: 5, 912-915.
Youman, P. et al (2003) The economic burden of stroke in the United Kingdom. Pharmacoeconomics; 21(Suppl 1), 43-50.