Yves here. While this is not the cheeriest “news you can use,” knowing when to go to the emergency room is important. This article explains how ministrokes, aka transient ischemic attacks or TIAs, are serious events and warrant prompt treatment. It is a little disconcerting to see the authors point out that a ministroke produces the same average decline in cognitive performance as a stroke, and not have any suggestions about what if anything to do (other than prevent more of the same).
Most assume strokes are an affliction of the aged, but that is becoming less and less true. Stroke incidence has risen markedly among younger age groups. It has risen by nearly 15% among 18-44 year olds since 2020 accelerating a long-term trend. People under 50 now account for 10-15% of all strokes.
It is n of only 1, but my mother did have a full bore stroke and immediately got aspirin into her system before going to the ER (a potentially fatal move if she had had a hemorrhagic stroke). Her mental ability was fine until her early 90s (as in >15 years later). Even then, I attribute her decline to giving up on her habit of reading a book a day (she refused to get cataract surgery and also rejected large print books and other reading aids beyond glasses). One of the head nurses at a home health care agency confirmed that view: she said when old people started watching TV all day, the fall in cognition was marked.
Hopefully IM Doc and others with medical expertise or patient anecdata will chime in.
By Paula Span. Originally published at KFF Health News
Kristin Kramer woke up early on a Tuesday morning 10 years ago because one of her dogs needed to go out. Then, a couple of odd things happened.
When she tried to call her other dog, “I couldn’t speak,” she said. As she walked downstairs to let them into the yard, “I noticed that my right hand wasn’t working.”
But she went back to bed, “which was totally stupid,” said Kramer, now 54, an office manager in Muncie, Indiana. “It didn’t register that something major was happening,” especially because, reawakening an hour later, “I was perfectly fine.”
So she “just kind of blew it off” and went to work.
It’s a common response to the neurological symptoms that signal a TIA, a transient ischemic attack or ministroke. At least 240,000 Americans experience one each year, with the incidence increasing sharply with age.
Because the symptoms disappear quickly, usually within minutes, people don’t seek immediate treatment, putting them at high risk for a bigger stroke.
Kramer felt some arm tingling over the next couple of days and saw her doctor, who found nothing alarming on a CT scan. But then she started “jumbling” her words and finally had a relative drive her to an emergency room.
By then, she could not sign her name. After an MRI, she recalled, “my doctor came in and said, ‘You’ve had a small stroke.’”
Did those early-morning aberrations constitute a TIA? Might a 911 call and an earlier start on anticlotting drugs have prevented her stroke? “We don’t know,” Kramer said. She’s doing well now, but faced with such symptoms again, “I would seek medical attention.”
Now, a large epidemiological study by researchers at the University of Alabama-Birmingham and the University of Cincinnati, published in JAMA Neurology, points to another reason to take TIAs seriously: Over five years, study participants’ performance on cognitive tests after a TIA drops as steeply as it does among victims of a full-on stroke.
“If you have one stroke or one TIA, with no other event over time and no other change in your medical status, the rate of cognitive decline is the same,” said Victor Del Bene, a neuropsychologist and lead author of the study.
An accompanying editorial by Eric Smith, a neurologist at the University of Calgary, was pointedly headlined “Transient Ischemic Attack — Not So Transient After All!”
The study showed that even if the symptoms resolve — typically within 15 minutes to an hour — TIAs set people on a different cognitive slope later in life, Smith said in an interview: “a long-lasting change in people’s cognitive ability, possibly leading to dementia.”
The study, analyzing findings from data on more than 30,000 participants, followed three groups of adults age 45 or older with no history of stroke or TIA. “It’s been a hard group to study because you lack the baseline data of how they were functioning prior to the TIA or stroke,” Del Bene said.
With this longitudinal study, however, researchers could separate those who went on to have a TIA from a group who went on to suffer a stroke and also from an asymptomatic control group. The team adjusted their findings for a host of demographic variables and health conditions.
Immediately after a TIA, “we don’t see an abrupt change in cognition,” as measured by cognitive tests administered every other year, Del Bene said. The stroke group showed a steep decline, but the TIA and control group participants “were more or less neck and neck.”
Five years later, the picture was different. People who had experienced TIAs were cognitively better off than those who had suffered strokes. But both groups were experiencing cognitive decline, and at equally steep rates.
After accounting for various possible causes, the researchers concluded that the cognitive drop reflected not demographic factors, chronic illnesses, or normal aging, but the TIA itself.
“It’s not dementia,” Del Bene said of the decline after a TIA. “It may not even be mild cognitive impairment. But it’s an altered trajectory.”
Of course, most older adults do have other illnesses and risk factors, like heart disease, diabetes, or smoking. “These things together work synergistically to increase the risk for cognitive decline and dementia over time,” he said.
The findings reinforce long-standing concerns that people experiencing TIAs don’t respond quickly enough to the incident. “These events are serious, acute, and dangerous,” said Claiborne Johnston, a neurologist and chief medical officer of Harbor Health in Austin, Texas.
After a TIA, neurologists put the risk of a subsequent stroke within 90 days at 5% to 20%, with half that risk occurring in the first 48 hours.
“Feeling back to normal doesn’t mean you can ignore this, or delay and discuss it with your primary care doctor at your next visit,” Johnston said. The symptoms should prompt a 911 call and an emergency room evaluation.
How to recognize a TIA? Tracy Madsen, an epidemiologist and emergency medicine specialist at the University of Vermont, promotes the BE FAST acronym: balance loss, eyesight changes, facial drooping, arm weakness, speech problems. The “T” is for time, as in don’t waste any.
“We know a lot more about how to prevent a stroke, as long as people get to a hospital,” said Madsen, vice chair of an American Heart Association committee that, in 2023, revised recommendations for TIAs.
The statement called for more comprehensive and aggressive testing and treatment, including imaging, risk assessment, anticlotting and other drugs, and counseling about lifestyle changes that reduce stroke risk.
Unlike other urgent conditions, a TIA may not look dramatic or even be visible; patients themselves have to figure out how to respond.
Karen Howze, 74, a retired lawyer and journalist in Reno, Nevada, didn’t realize that she’d had several TIAs until after a doctor noticed weakness on her right side and ordered an MRI. Years later, she still notices some effect on “my ability to recall words.”
Perhaps “transient ischemic attack” is too reassuring a label, Johnston and a co-author argued in a 2022 editorial in JAMA. They suggested that giving a TIA a scarier name, like “minor ischemic stroke,” would more likely prompt a 911 call.
The experts interviewed for this column all endorsed the idea of a name that includes the word “stroke.”
Changing medical practice is “frustratingly slow,” Johnston acknowledged. But whatever the nomenclature, keeping BE FAST in mind could lead to more examples like Wanda Mercer, who shared her experience in a previous column.
In 2018, she donated at the bloodmobile outside her office in Austin, where she was a systems administrator for the University of Texas, then walked two blocks to a restaurant for lunch. “Waiting in line, I remember feeling a little lightheaded,” she said. “I woke up on the floor.”
Reviving, she assured the worried restaurant manager that she had merely fainted after giving blood. But the manager had already called an ambulance — this was smart move No. 1.
The ER doctors ran tests, saw no problems, gave Mercer intravenous fluids, and discharged her. “I began to tell my colleagues, ‘Guess what happened to me at lunch!’” she recalled. But, she said, she had lost her words: “I couldn’t articulate what I wanted to say.”
Smart move No. 2: Co-workers, suspecting a stroke, called the EMTs for the second time. “I was reluctant to go,” Mercer said. “But they were right.” This time, emergency room doctors diagnosed a minor stroke.
Mercer has had no recurrences. She takes a statin and a baby aspirin daily and sees her primary care doctor annually. Otherwise, at 73, she has retired to an active life of travel, pickleball, running, weightlifting, and book groups.
“I’m very grateful,” she said, “that I have a happy story to tell.”
Mum had TIA in about 2013 (can’t remember exactly but I do know it was was when I running big course in SIngapore around then).
Pretty sure it is worse than “traditional TIA.”. Dr instantly put her on Donepezil. I can’t say more for fear of getting into trouble but it I know what is going on.
I just have to live with the consequences. And yeah, I’d rather be dead than this state of affairs which is purgatory.
chronic consumption of baby aspirin is not risk-free; it’s trading one set of risks for another—which at the macro level is a (theoretical) net positive
The trade-off may work for you, it may not. think it through and monitor
It also reduces the odds of getting colon cancer….after taking it for quite a few years.
I gave me unpredictable, almost projectile diarrhea. Took a while to sort that out. Stopping the aspirin fixed it.
Odd, i know.
“One of the head nurses at a home health care agency confirmed that view: she said when old people started watching TV all day, the fall in cognition was marked.”
Anecdata: Both mother and grandmother were avid readers. But in later years both would just kick back in front of the TV while their books just gathered dust. Cognitive decline followed.
It’s one thing to hear about cognitive decline in others. It’s entirely different to have your own grandmother, who pretty much raised you, completely forget about you. :-(
Thzt is mum. Unfortunately……and I have to pick up the pieces.
So when I go quiet……you can guess why
Oh I am so so sorry. My mother was still very much herself except she was too often asking the same question she’d asked ten minutes ago.
Pretty sure mum is on verge of major stroke……hence my interrupted responses.
Dad gives impression life would easier without her…..which it probably would….but I can’t wish that.
I’m WEARY with long COVID. so hopefully people understand the horrid things I have to choose beteen. I’ll admit I’m pretty sad :(
my mom is doing that…for the last 2 years, really.
repeats herself, often not 5 minutes later.
she’ll be 83 in november.
as ive said, i avoid her, due to the whole covert narcissism thing…never know when she’ll fly into a psychotic rage….but i still see her more than anyone else on the planet(she’s alienated everyone)
plus…maybe 20+ years ago, she and i were loading up barbadoe sheeps(she insisted on being in the chute), and one of the big rams, with the large curly horns, jumped up and beaned her in the forehead.
knocked her out cold. I let the animals loose…and carried her into the house and was fixin to call 911, when she roused and started chewing me out,lol.
(she hates HCP’s…telling her what to do/thats she’s wrong/etc)
turns out, a lesion on the prefrontal cortex, where that ram got her, causes exactly the sort of symptoms one sees with covert narcissism…except worse..plus dementia, like i’m seeing, now.
i intend to beg for a post-mortem ct scan or something…because i feel i hafta know.
it would explain a lot of weird ass behavior over the last 20 or so years.
(ex: the 8year prowler problem. dude was really sneaking around(i found abundant evidence), but he wasnt fllying through the air, or slithering up the wall like a snake, or projecting holograms that only she could see….but due to the Cov Narcissism, no one wanted to challenge her…especially me…bc she’d fly into a violent rage if contradicted)
great granma(died at 99) had TIA’s all the time for her last 10 years(when she was up here, so mom and i could take care of her(mostly me. for mom, it was some weird status thing(munchausen by proxy or just simple martyrdom))…she’d just stop…walking, talking, whatever…for 2-10 minutes…and then just pick up where she left off. home health nurses and doctors said there wasnt much they could do by that point. she raised me, so it was hard to watch her slowly go away like that.
So sorry to hear that.
It kinda resonates. I’ve been chatting with Yves about a key topic. It scares me that papers I’d had at my fingertips were no longer “there”…….I had to look them up. It made me question everything about my career. All I ever had was good brain and inituition………and now I’m losing them…..perhaps coindedentally with number of COVID infections ….. but perhaps not.
Don’t know if you’ll see this, as your post was over 24 hours ago. Whatever…
Same thing happening to me, at 75. Long career as a reasonably successful lawyer, in areas requiring good brain and intuition. Had to retire, as mistakes due to failure of memory and narrowing of perceptions began to occur.
I’ve learned that good brain and intuition was *not* all I had. Not even close. What I had (not enough of) was caring for other people, which I’m trying to foster and which gives me a measure of peace (in spite of everything). You have that. It’s what matters.
Blessings to you.
Yes, the “ask the same question she asked ten minutes ago” was common for us. We’d just answer, regardless of how many times she’d asked.
“Did anyone get the paper?” (that she’d just finished reading)
“Yes, Mom, it’s right there on the table.”
LOTS of problems keeping track of meds…
Out on a limb here…… but perhaps the asking the same questions concept, could be a cultural thing. I’ve dealt with many elderly Americans, and many of them do ask those same questions. Some other cultures don’t feel it’s imperative to keep a conversation going. Americans are not comfortable just sitting with a freind and not saying much. When returning to the US after living elsewhere, where people felt comfortable “not being chatty”, I found it interesting that Americans can’t just sit with a friend without saying “So, how is”… or “So tomorrow we’re going over to Bill’s house, right?”
No,
My mother was extremely introverted and mainly did not talk to her children, to the degree that when I was not living there and merely visiting, she’d talk to me for about a half hour and then stop talking, leading me to wonder why I had bothered visiting, since she didn’t seem to value my company.
After I moved down to take care of her, I was usually working when in the room with her, so interaction would be an intrusion.
Her questions were of the “What we are doing for dinner?” sort, as in requests for specific information that I had already provided.
This was absolutely a cognitive decline, as confirmed on tests.
Re TV vs reading, I don’t think the causality goes in only one direction. I’m sure my father’s switch from reading to TV was an effect of his cognitive decline, not a cause. Reading just became too difficult and confusing for him.
This is very useful for me and my friends, as I’m sharing it. I had no idea a ‘short weird happening’ could be so serious.
My dad had had MS for some seven years (probably more before diagnosis and retiring, during which time I moved back out of Detroit within ten miles of them to help out) when he had a stroke. I remember clearly the day, when sitting down to supper, that my mom called saying he was on the floor saying he had had a stroke. I got up and rushed over. The two of us picked him up (no small feat) and took him to the nearest hospital. But that hospital (just a community unit, later closed, sold) said they couldn’t treat him, so we took him to the next facility, where he stayed for a month. So he didn’t get much (enough?) immediate intervention (why didn’t we call an ambulance, I don’t know). The MS had affected one side more than the other but the stroke took care of that imbalance. His mobility, speech and cognition were negatively impacted, though he did improve temporarily in the next year. I kept my place 10 miles away but I was rarely there as I, with my mom, maintained his care at home. He lasted another seven years, but the final six months crushed us all. My mom was out of service in the last year, worn out and with her own health problems. I only managed with home health aids whom I cherish to this day.
Many of us who’ve had parents of a certain age have stories about strokes that reflect the consequences of not having the benefits of current best practices. Small strokes can be life altering with complications such as dysphasia being extremely debilitating over time. Prompt and continuing monitoring and rehab treatment of complications of stroke are essential.
As for dementia, I like the Mayo Clinic’s definition of dementia as the impairment of two or more cognitive functions. By implication much cognitive function remains. My experience is that to receive a diagnosis of dementia is dangerous. Health providers tend not to appreciate the degrees of dementia and appreciate the value and quality of life of many whose dementia is much less than those who are severely disabled. They can be incurious, and lump dementias od different causes together as Alzheimer’s disease. In my mother’s case (vascular not Alzheimer’s dementia), they chose not to consider that the inability to clearly verbalize her thoughts (expressive aphasia) was that she was unaware when a little patient questioning would have shown that she knew what was going on. After one encounter, I asked her what she thought of the new doctor. Her correct observation and response were that he dyed his hair.
The result of implied bias (ageism) is neglect rising to abuse by medical professionals. My mother’s skilled nursing facility doctor who was also at the time the facility’s medical director inadvertently gave it away when he said that “Places like W.H. are filled with old ladies.”
I am a bit surprised that they don’t mention mental fatigue. As I understand it, stroke is the classic case of mental fatigue because the difference is so marked before and after. It wouldn’t be surprising if TIAs give mental fatigue but more gradually. You can see similar symtoms in long term pain sufferers.
One way to think of mental fatigue is a bucket. It is the bucket of much input you can stand before getting mentally tired. When you get mental fatigue, the bucket shrinks. The bucket model is used to explain how you need to regularly take breaks before you get tired, to let it pour out. And also how you can ease mental fatigue by limiting input (inflow into the bucket) by for example sunglasses and sound cancelling headphones. If you overextend yourself, next day you may still be mentally tired. The self care advice is mostly about finding your own limits and staying within them, as frustrating as it may seem if you used to be very active.
I am not a doctor, I just have had reason to interview a leading expert on mental fatigue.
All neurological injuries are immensely tiring to recover from. This is a good point about TIA’s.
Another point that is gloomier is that TIA’s are often collateral to other diseases like lung cancer (circulating mini thrombi) and brain metastases. So another reason not to ignore them, there nay be something going on that needs attention.
I wonder if the dog didn’t need to go out, but was telling her she was indeed having a mini-stroke.