Opening Ceremony of the 9th Singapore Stroke Conference

01 Sep 2007

By Prof Satku

Venue: DBS Auditorium

Dr N V Ramani

Chairman

Organising Committee 9th Singapore Stroke Conference

Distinguished Guests, Colleagues

Ladies and Gentlemen,

It gives me great pleasure to join you this afternoon for the opening of the 9th Singapore Stroke Conference, organised by the National Neuroscience Institute.

Let me begin by congratulating the Organising Committee for putting together such an impressive scientific programme and for simultaneously hosting the Annual Meeting of the Asian Chapter of the World Federation of Neurology’s Neuro-sonology Research Group.

PREVALENCE OF STROKE AND ITS IMPLICATIONS 

Over the years, with improvements in healthcare and increasing life expectancy the patterns of disease have shifted towards chronic complex diseases. Among these diseases is stroke. 

The incidence of stroke is declining in many developed countries, due to better control of hypertension and decreased levels of smoking. However, the absolute number of stroke cases continues to rise because of the ageing population. 

According to WHO data, the global burden of stroke is projected to almost double from around 38 million lost years of healthy life (or Disability Adjusted Life Years or DALYs in technical terms) in 1990 to 61 million in 2020. 

Globally, stroke is responsible for about 5% of the total years of healthy life lost from disease and injury in adult men and women. 

Singapore is fortunate because the risk of losing years of healthy life in the population due to stroke is about 0.3%, comparable to Australia, US, Canada and UK. Countries like China, India and South Africa experience a much higher burden of disease, with the risk ranging from 0.8% to 1.2%. 

However, as we are all aware, stroke is one of the leading causes of mortality in Singapore today.

Most will agree that stroke is a disease that consumes considerable resources. The treatment and care for major strokes are often prolonged and protracted as they include the management of complications as well as rehabilitation. Costs will continue after hospital discharge. 

After a stroke, about 10 to 15% die within the year and of the remaining, the majority live with disability thereafter. 

For some, their first stroke may not be their last. Once a stroke has occurred, the risk of another averages 10% a year.  About 20% of stroke survivors are able to recover fully and return to their previous level of independent functioning. But even that may take many months.

PRIMARY PREVENTION OF STROKE

There is much more we can do to manage stroke expeditiously to improve outcome. We can also reduce complications, delay a second vascular event, and improve quality of life and independence. The brain, while to some extent still plastic, is almost never the same after a stroke.  With this understanding, we should also invest in preventive measures while we continue to develop capabilities for the treatment of stroke.

Scientific evidence suggests that stroke risk can be reduced by managing the major vascular risk factors such as hypertension, diabetes and hyperlipidemia. Singapore has already begun the implementation of a nationwide programme in chronic disease management. 

This, if combined with lifestyle changes including weight reduction, regular exercise and a healthy lifestyle would reduce the risk of stroke significantly.   I would like to take this opportunity to recognise the efforts our Health Promotion Board has put into promoting a healthy lifestyle. It is heartening to know that the percentage of Singaporeans who exercise regularly has increased from 17% in 1998 to 25% three years ago. 

The age standardised prevalence of Singaporeans suffering from diabetes, hypertension and hyperlipidaemia are also much lower now than in the last decade. But much more can be done.  The medical profession is a willing partner in a joint quest for better health for all and as such we should encourage our patients to go regularly for screening for these well known risk factors and to follow medical advice closely.

ACUTE INTERVENTION OF STROKE

Despite the best efforts at primary prevention, some will still develop stroke. The percentage of individuals who will achieve complete to near complete recovery from stroke can be improved from the current 20% to 38% if they receive recombinant Tissue Plasminogen Activator (or rTPA) within 3 hours. This is according to a study conducted by the National Institute of Neurological Disorders and Stroke in the U.S. 

Locally, our experience, although limited, is just as promising.  I am pleased to inform you today that a National Thrombolysis Programme for early stroke intervention is in the pipeline. This will involve stroke specialists, radiologists, intensivists and emergency medicine physicians from all our major restructured hospitals. 

There are plans to enable all RHs as primary stroke centres capable of IV thrombolysis therapy through telemedicine. It is proposed that stroke specialists at NNI and NUH review patients and view CT or MRI images via 2 way teleconferencing. They will discuss treatment options including IV thrombolysis with the Emergency Medicine specialists and Intensivists. 

This will reduce the burden of disability and months of painful rehab for many patients in the years to come. I am encouraged that such evidence-based acute interventions were discussed in great depth this morning.

STROKE REHABILITATION

The role of rehabilitation is a critical one in post-stroke care. Survivors of stroke experience many changes resulting from their illness. Most people are aware of the physical changes that occur following stroke, for example paralysis or weakness on one side of the body, or difficulty with speech. 

The Ministry of Health will continue to invest heavily to increase our rehabilitation facilities through building more day rehab centres, strengthening the rehab units in acute and community hospitals and recruitment and training of allied healthcare professionals equipped with skills for rehab care. 

Patients themselves will also be empowered through home physiotherapy programmes and more focused patient education. These measures will reduce life years lost to disability.

MENTAL HEALTH IN THE POST-STROKE PATIENT  

Apart from the physical aspects mentioned earlier, the post-stroke patient is also at risk of cognitive impairment from vascular dementia and almost 40% of all survivors of stroke will experience some degree of depression and or anxiety. 

While vascular dementia is irreversible, depression and anxiety can be treated. However many people suffering from depression or anxiety are unaware that they are unwell and do not ask for help and may not receive treatment as a consequence. 

Recognising and providing treatment for depression following stroke is just as important as it affects the patient’s quality of life and his or her rehab potential. Recovery in stroke may be impeded if these issues do not receive the attention that they deserve.

CURRENT EFFORTS  IN PLACE (FOR REHAB AND MENTAL HEALTH)

Stroke is a major chronic disease and requires a multidisciplinary and holistic approach. I am encouraged that we have begun to take small steps in this direction. 

We are developing a National Community Psychogeriatric Programme aimed at training staff from Eldercare agencies so as to enhance early detection, intervention and treatment of mental health problems including post-stroke depression in the elderly. 

I am also told that the National Stroke Association plays an important role in providing support for patients as well as their caregivers as it is not uncommon for the caregivers to also suffer from burn-out and depression as well. 

I am pleased to announce that the Ministry of Health will support the Stroke Outcomes Prevention Programme proposed by NHG. This is a collaborative programme aimed at reducing the adverse outcomes among stroke survivors, with a focus on both rehabilitation and managing depression.  

It provides for co-ordinated post-discharge management across the entire spectrum of healthcare, from the acute hospital to the community hospital, GP or polyclinic, day rehab centre and integrated care service.

Each patient would have a stroke nurse following his or her progress closely to monitor his condition across these levels of care. It is important that rehabilitation professionals and doctors in the community be more knowledgeable about such issues that are beyond the physical aspects in stroke care and also understand the importance of rehabilitation. I am certainly glad to see that these often neglected issues will be discussed in tomorrow’s symposia. 

CONCLUSION

From prevention and early intervention to post-stroke care including rehabilitation and management of mental health, we have achieved much in the management of stroke. I wish to acknowledge the dedication and achievements of all the professionals involved in the management of stroke and look forward to their continued contributions.

I am sure all would agree that despite novel technology and rapid advances in management of stroke, the patient, once afflicted, is never completely free from the disease. Primary prevention brings the greatest benefit because then one never has to suffer from a stroke at all . 

This should be our goal.  On this note, I wish all participants a most enjoyable weekend of learning. 

Thank you.

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