Exercise and dementia; life after cancer; female stroke risk: Upstate Medical University's HealthLink on Air for Sunday, Dec. 11, 2022

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an exercise physiologist discusses how physical activity is good for the brain.

Carol Sames, PhD: ... Clearly, I think the research is demonstrating that physical activity is a strong risk factor reducer, and there's other components to that beyond physical activity or cognitive activity or social activity. ...

Host Amber Smith: An oncology nurse talks about what cancer survivorship means.

Nurse Susan Tiffany: ... A big part of survivorship is also talking about health promotion going forward and making sure that also, there's good communication between the patient and their primary care doctors. ...

Host Amber Smith: And a nurse from the stroke team goes over how stroke affects women.

Michelle Vallelunga: ... Some higher stroke risk may occur in the younger ages of women due to some unique risk factors. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, we'll talk about the meaning of cancer survivorship. Then, a nurse from the stroke team explains stroke risks and warning signs that are unique to women. But first, studies are showing that physical exercise can stave off cognitive decline.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Several research studies have shown that vigorous exercise, walking, even household chores, have positive effects on the brain. Can this reduce our risk of developing dementia as we age? I'm talking about this with Upstate exercise physiologist Carol Sames. Welcome back to "HealthLink on Air," Dr. Sames.

Carol Sames, PhD: Thank you so much, Amber. Glad to be here.

Host Amber Smith: We've talked before about the benefits of exercise, not only to the whole body, but specifically to the brain. But now I understand there are three major long-term studies involving hundreds of thousands of people over the course of years, that get fairly specific about the types of exercise, the intensity, duration, that provide protection against dementia. Can you tell us about them?

Carol Sames, PhD: Absolutely. So the first study is coming out of the UK, and they had about 500,000 individuals. And what they did was they recruited them between like 2006, 2010, and they started following them one year after recruitment and then followed them until the end of 2019. So, you're looking at between eight and 12 years. And basically what they did initially is they collected information about their activity. They used questionnaires, what type of activity, what type of more vigorous activities, so more sports type activities -- hiking, running, biking, more vigorous types of activities. But they also included household activities, job-related activities, if anybody was using biking or walking to work, or were they doing any type of transportation for others.

They also collected some what we call mental activity, so looking at social contacts, uses of electronic devices. They also wanted to look at educational levels. And what made this study kind of unique is that they had data, blood data, and they were able to look at some genetic markers of dementia. And, they also asked about family history, since we know that there are certain types of dementia that do have a genetic component. And so what they found out was that individuals who had been engaged in the more vigorous type of physical activity reduced their risk of all-cause dementia, Alzheimer's dementia and vascular dementia by 35% compared to the lowest level of physical activity. But then they also found that people that were engaged in household activity reduced their risk by 21%. And generally household is more of a moderate level of exercise intensity. So it doesn't have to be things that are highly vigorous.

Host Amber Smith: So vacuuming, dusting, those sorts of just ... movement?

Carol Sames, PhD: Exactly. Mowing the lawn, probably all the things that we don't necessarily enjoy doing. But the point is, the body is moving. They are physical activity. They don't require us to become out of breath and to be sweating profusely. And so I think that's a big, really important finding in this study because I think many people, when they think of physical activity, they think it has to be something that is arduous. And then, how many people want to do arduous activity?

Host Amber Smith: That was a study out of the United Kingdom, correct?

Carol Sames, PhD: Yes. Mm-hmm.

Host Amber Smith: So what else has been found since then?

Carol Sames, PhD: So another study, also that just got published in August (2022) was what we call a systematic review and a meta-analysis. And so what they did was they took 38 articles, and when you add articles together like that, you really increase your sample size. And, so what they had was 2 million people that were in these 38 studies. They followed them for three years. And these individuals started without dementia, and then they followed them for three years to see, like, a combination of all of these studies. They also looked at leisure activities, things that spanned from what we would call more vigorous to less vigorous activity. They also looked at cognitive outcomes, things like reading books, magazines, newspapers, watching television, writing, playing cards or checkers or board games. And then they also include listening to music or painting. And then they also include what they called social activities. So, you know, being around friends or family or volunteering or being in any type of social club. And so the results were that when you controlled for age, education and gender, this huge variety of physical activity had a 17% lower risk of developing dementia than those that were inactive. So again, we're getting these results from large sample sizes following people, looking at the individuals who develop dementia and finding out that they tend to have higher physical activity levels. And in the example that I just gave in the meta-analysis, they also had more social activity. But here's the conundrum. People that have more social activity tend to be engaged more in cognitive activities and physical activities. So, you know, that's a little tough to tease out.

Host Amber Smith: Well, when we talk about a risk reduction of 17% or 21%, or even, I think you said 33% on the high end, those sound like small numbers, but the, those are really huge differences, right?

Carol Sames, PhD: They really are. Because think about, this is the sample size we're looking at. So we're not talking about looking at 20 people, right? You're talking at looking at 500,000 in the first study, 2 million in the second study. That's an impressive risk reduction, understanding that when we talk about the human body, there's not one factor that impacts an outcome. There's multiple risk factors. So, clearly, I think the research is demonstrating that physical activity is a strong risk factor reducer, and there's other, also, components to that beyond physical activity or cognitive activity or social activity.

Host Amber Smith: Now, a third study published in August 2022 in the Journal of Science and Medicine in Sport focused on children. Can you tell us about that?

Carol Sames, PhD: Super unique study. So they had children that were between the ages of 7 and 15 years old in 1985. And it just so happens they were participating in a study, and they collected data on their cardiovascular fitness, their muscle strength, their muscle power and then their waist to hip ratio. And then they followed up from 2017 to 2019 these same children, which were clearly now middle adults, they were now 39 to 50 years old, and they wanted to see, were there any differences?

Not surprising, the adults, when they were children, if they had higher levels of fitness strength and lower waist-hip ratios, they had a reduced risk of developing dementia than the adults who, when they were children, had poor fitness, poor strength and greater waist-to-hip ratios.

Host Amber Smith: This is Upstate's "HealthLink on Air." Our guest is Dr. Carol Sames. She's an exercise physiologist at Upstate, and we're talking about how physical activity can work to protect people against the development of dementia.

So let's get a bit more firm definition of what counts as vigorous exercise. Is this another word for aerobic?

Carol Sames, PhD: So when we talk about aerobic or cardiovascular activity, we have a continuum of intensity. So we can have intensity that's moderate. Moderate-level intensity is being able to carry on a conversation. So if I go out and walk with my friend, you know at a nice easy pace, doing some household activity, generally that's moderate intensity. Vigorous intensity is those activities where you notice an increase in your breathing. You're really not carrying on a conversation, maybe saying yes or no. You'll really notice that your heart is elevated. You can tell you're doing something that is definitely more challenging than a moderate type of intensity.

But here's what we know, in terms of the guidelines, the guidelines for aerobic or cardiovascular activity is 150 minutes a week of moderate-intensity activity, or 75 minutes a week of what we call more vigorous activity. Or a combination of both. So, if you think about 150 minutes -- and that's the goal; people might not start there. People might start with 10 minutes in a week, and that's fine because the new guidelines are emphasizing the importance of reducing sedentary behavior, so that even if I get my 150 minutes of moderate activity in, in a week, but I sit for long portions of the day, I actually negate some of the benefits that you get from cardiovascular activity. So we want to move more, sit less, and aim for that 150 or 75 minutes a week of either moderate or vigorous activity.

I also have to say that the guidelines for adults and older adults are strength training, and we are definitely highlighting the importance of strength training. In fact, for older adults, strength training and what we call power training is even more important. So why is strength important for adults and older adults? Well, simply put, you need muscle to move. And if you don't have muscle, you're not moving, you're not going to complete that cardiovascular activity. We need muscle functionally, just to do all the functional things that we need to exist in our world, whether it be going up and down stairs, whether it be making a bed, doing a wash, just all of those activities. We need strength.

As we get older, what happens is that we start to lose what we call our fast-twitch muscle fibers. They're our power fibers. And a lot of times people say, "Well, who cares? Older adults don't need power. That's more of a younger adult or athletic population," to which we say, "Absolutely not. You need power to get out of your chair. You need power to take the first step. If you have stairs, that's all about power. We need power as we get older." And so power training with older adults, sometimes that's our first line. We won't even start cardiovascular activity if people are really weak. We'll start with strength training and power training first.

Host Amber Smith: So these recommendations for physical activity, if we also want to keep our brains healthy, are the exercises for our brain health on top of the physical recommendations, or do we get the benefit of the brain health while we're working out to keep our bodies healthy?

Carol Sames, PhD: Well, certainly there probably is some carryover there, right? That it's difficult to tease those out. But the research is still suggesting that we need to be engaged cognitively. And that is just such a wide spectrum of activities. You know how people say I don't really like to read? And it's like, fine, you don't need to read to be engaged. Do you enjoy listening to music? Do you enjoy looking at art? I don't do crossword puzzles because I'm terrible at them, but do you enjoy something along the lines of that? There's some question about television. So the research is suggesting it's not just like television to be on in the background, but that I am engaged with whatever is on the TV, so that there's an actual engagement. Carrying on a conversation, that is cognitive. There's all different levels of cognition that you choose from, just like with activity. There's not one best physical activity, and there's not one best cognitive activity.

Host Amber Smith: Can physical activity be cognitively protective for people with a family history of dementia who may be at high risk themselves? Or the studies that we just spoke about, were they more meant to apply to people of average risk?

Carol Sames, PhD: No. So here's what's impressive, is that even in individuals that have a family history, being active is reducing the risk. So I mean, again, that is really powerful, when we talk about the impact of being active. Certainly, as I usually tell my students, you can't choose your parents, right? We don't know how to do that yet. So, I'm born with these genetics, and so what can I do? So I have a mother who has very severe dementia, and hopefully my lifetime of activity, and my lifetime of enjoyment of reading can help to reduce my risk. It doesn't mean it's going to be eliminated. Genetics is genetics, but we know study after study, when you control for family history, or in the example of that UK article, they actually controlled for the biomarkers and the family history. There still was protection with physical activity.

Host Amber Smith: Well, Dr. Sames, I appreciate you making time for this interview.

Carol Sames, PhD: My pleasure.

Host Amber Smith: My guest has been Dr. Carol Sames. She's an exercise physiologist at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air".

What cancer survivorship means -- next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Some people who are treated for cancer believe their life will be different after cancer. Today I'll be talking about life after cancer with Susan Tiffany. She's a registered nurse, certified in oncology nursing.

Welcome to "HealthLink on Air," Ms. Tiffany,

Nurse Susan Tiffany: Thank you so much. Thank you for having me.

Host Amber Smith: From time to time we hear about how many people are diagnosed with cancer or who die from cancer. Do you have numbers for how many people who are diagnosed with cancer actually survive the disease?

Nurse Susan Tiffany: I can talk about survivorship in general, but it really depends on a lot of variables: what type of cancer, when they were diagnosed. Breast cancer for a five-year survival, we have 90%. Colon has gone way up, to 87%. And even lung cancer, if diagnosed in early stages, people are surviving 50% for five years.

Host Amber Smith: So it sounds like more people are surviving cancer now than ever before.

Nurse Susan Tiffany: Oh, absolutely. Just for some statistics, in 1971, there was 3 million survivors. In '22, we have 18 million survivors, and I think it's projected for 2030, 26 million people. So yes, many people are surviving cancer, much longer periods of time.

Host Amber Smith: At what point do you consider a patient is in survivorship? Because I wonder, is it when treatment concludes, ordoes it start when they're in treatment, or does it start a certain number of years after treatment ends?

Nurse Susan Tiffany: Survivorship, definition of survivorship from the National Cancer Institute, is Stage Zero, time of diagnosis, to the end of their life.

Host Amber Smith: Is that how things work at the Upstate Cancer Center as well? Is someone considered in survivorship from Day One?

Nurse Susan Tiffany: That is the definition. Our survivorship program typically is for curative intent, and so people are referred to me, and then I call them, and we go over a multitude of things, including diagnosis, their treatment, late-term, long-term side effects, surveillance, cancer screening and surveillance for the cancer they've been diagnosed with.

And then a big part of survivorship is also talking about health promotion going forward and making sure that also, there's good communication between the patient and their primary care doctors.

Host Amber Smith: Now during this survivorship, I understand a medical team will be checking on physical aspects or medical aspects over the years. Is that right?

Nurse Susan Tiffany: Absolutely. Absolutely. Patients are followed by the specialist for approximately five years. It depends on the interval and what they're being treated with, but then eventually they are reunited with their primary care doctor. And that communication is extremely important to make sure that the follow-up continues, to make sure that the patient feels safe and that they're continuing to be followed.

Host Amber Smith: Let me ask you a little about some of the emotional and mental aspects of survivorship. I wonder, is relief a universal feeling for people who have survived cancer, or is that relief mixed with a constant fear that the cancer's going to come back?

Nurse Susan Tiffany: A constant fear. I think a lot of people have that constant fear.

In fact, they've given it a name, "scanxiety." When they come in to have their scans done, it causes a lot of fear and anxiety, so helping those people through that is part of what we do. They can have trouble sleeping, they can feel irritable, trouble eating. And so what we try and do is explain to them that it's a normal response that they're feeling, try and get them to name the physical response that they're feeling in their chest, what kind of stress release they're having, response. Meditation and mindfulness are two practices that can help with that.

Host Amber Smith: Do you see people who are more anxious about their overall health after cancer treatment than they ever were before?

Nurse Susan Tiffany: Absolutely. And that can bring a lot of positive changes, and that's the part with health promotion that we can do. I think there's a time for that post-traumatic, positive improvement.

Host Amber Smith: Now, what about survivor's guilt? Have you ever helped people who successfully survived cancer and feel survivor's guilt?

Nurse Susan Tiffany: Yes, yes I have. Many people have survivor's guilt.

It's the same type of guilt that our military (and) survivors of 9/11 have had. Somebody has passed with the same diagnosis that they have and they have this feeling with, "Why me? Why didn't it happen to me?" So that can be very hard. It's different degrees for different people. We try and tell them that that's very normal. It means they're compassionate. However, if it does interfere with their activities of daily life, then we do suggest that they get some professional help, and I'll make a referral to our psychosocial oncology program.

Host Amber Smith: How might a person's relationships change during or after cancer treatment? I'm thinking about with family members, with friends, with romantic partners.

Nurse Susan Tiffany: That's hard. It's different for everybody, but I see a lot of people who have been diagnosed with cancer, and it's very difficult for them to talk to their family members about their fears. Family members have their own fears.

And I think that's where the nursing staff comes in, the doctors, the nursing staff, comes in at Upstate, is allowing those patients to express their fears and anxiety that they're having because family members are just too close. Another aspect of that is feeling as though they're a burden. They need transportation, they're a little more needy than they were before the diagnosis.

Women have a hard time with that. It's also a time that they can try and learn how to let go and let somebody take care of them.

Host Amber Smith: It's one thing to let your family and your close friends know that you have cancer. How do you advise people, they have work friends that they're really not that close to: Do they need to know that the person has cancer?

Nurse Susan Tiffany: They do not need to know that. Absolutely not. That's up to the individual, how much they want to share and how much they feel comfortable sharing. So, no, that's not something that is often expressed to people. And, in fact, a lot of people don't want to share that information. They don't want people to feel sorry for them.

They don't want people to know that they have a diagnosis. They don't want to feel outcast. They don't want to feel different. They don't want to feel as though they're getting privileges that maybe somebody else didn't have.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Susan Tiffany from the Upstate Cancer Center. She's a registered nurse, certified in oncology nursing.

How long is a person considered in survivorship, and I wonder if that works the same for a person who was diagnosed with childhood cancer versus a person with cancer that they developed in their 50s or 60s?

Nurse Susan Tiffany: It should be all the same. Survivorship starts with diagnosis and goes to end of life. Now, the difference with children Is the cancer treatment that they received. We want to keep a close eye on it. There's some cancer treatments that could cause problems later in life with lungs and the heart. And so we keep a close eye on that.

Host Amber Smith: Do you find people who are not interested in survivorship, they just want to put their cancer behind them? Or do you find people that see value years, decades later, in staying active in survivorship programs?

Nurse Susan Tiffany: Absolutely, Amber. There is some folks that do not want to talk about survivorship. They don't want to be called a survivor. They don't want to talk about their cancer at all. They don't participate in any of the fundraisers, or they just want ... their diagnosis is over. When their treatment ended, that's it, they don't want to know anything else.

Then there's folks that are so grateful that they finish their treatment, they want to help other people. They want to be mentors. They participate, volunteer at fundraisers. They want to be part of the program.

Host Amber Smith: it sounds like you meet a variety of people. Do they ever talk with you about personal growth that they've experienced because of or tied to a cancer diagnosis?

Nurse Susan Tiffany: They have. And that is one of the aspects of the survivorship program that I feel very fortunate about, is to help bring out these positive changes in people.

Actually, it's called "post-traumatic growth." That's what it is. And it describes the changes that people develop. As a result of this frightening experience, stressful experience, that they've gone through, oftentimes it deepens their connections with their families and their friends. They have more of an appreciation for life.

Often people have developed more of a spiritual practice, and also, their health becomes more important, and they want to know more about exercise and nutrition and stress reduction.

Host Amber Smith: So let me ask you, when you connect with people about survivorship and you talk with them, what sorts of resources do you make them aware of, and how do you go about connecting them?

Nurse Susan Tiffany: At Upstate, we have a lot of resources. We have a great program. Our psychosocial oncology program is a supportive service that we have, and they address the psychological, psychosocial, social, behavioral, emotional, issues that come up with a cancer diagnosis. And that's one resource.

But then we also have palliative care. We have pain management, we have social work services, financial counselors. Smoking cessation is important. And then we do have some support groups at Upstate. We do have the Pink Champions, which is a breast cancer support group. And then we have a support group for the head and neck folks, people who have been diagnosed with head and neck cancers.

And Men to Men is a support group for prostate (cancer) patients.

Host Amber Smith: Now you mentioned that some of the process of survivorship is for the patient to go back to their primary care doctor rather than seeing their oncologist all the time. Can you help someone who doesn't have a primary care doctor find one?

Nurse Susan Tiffany: Absolutely. So far, that hasn't been an issue. But if they didn't have a primary care, I would definitely help them find one. And then also I do send a letter to their primary care, letting them know, very brief letter, about their diagnosis and where they are in surveillance: When's the last time they had a colonoscopy? When did they have a pelvic exam? Mammograms. Immunizations, even.

Host Amber Smith: Even for the people that want to put cancer way behind them and forget that it ever happened, it is still part of their medical history for life, right?

Nurse Susan Tiffany: Correct. It is. It is.

Host Amber Smith: So how do you advise people to balance the importance of knowing about that cancer history and, like, always keeping it in the back of your head, but living your life without dwelling on it? How do you balance those two things?

Nurse Susan Tiffany: Education. That's the only thing we can do, is educate. It may be too stressful of an event that they can't discuss. They want to put it behind them. It's so individual, but the most important thing is education, explaining to them why it's important that they're followed, why other health care providers need to know about their diagnosis. And then also finding out what the fear is and possibly getting them help through our psychosocial oncology program, support groups. Online now, there are so many support groups and so much information that's out there. Even our Upstate Cancer Center, looking around the Upstate Cancer Center website support services, we have so much information on there and education for our patients.

Host Amber Smith: Ms. Tiffany, I really appreciate you making time for this interview.

Nurse Susan Tiffany: Thank you so much for having me.

Host Amber Smith: My guest has been Susan Tiffany. She's a registered nurse, certified in oncology nursing, at the Upstate Cancer Center.

I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air" -- stroke risks for women.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Stroke kills about twice as many women as breast cancer does every year. And yet, surveys show women are more afraid of a breast cancer diagnosis.

Here to discuss how stroke affects women is Michelle Vallelunga. She's a nurse at Upstate and also the Stroke Program data coordinator.

Welcome back to "HealthLink on Air," Ms. Vallelunga.

Michelle Vallelunga: Thanks for having me.

Host Amber Smith: Why do you think women are more concerned about breast cancer?

Michelle Vallelunga: In general, it's definitely, I think, more on the radar of people, out in the media. And stroke, I think, sometimes it's been linked to, like, heart disease in general. And so I feel like there's just a greater heightened awareness out there about breast cancer, as it should be, and the importance of screening for that, a little different public perception out there about stroke and, specifically, women's risk for stroke.

And that's why I wanted to talk today about this topic, to just raise some awareness for folks.

Host Amber Smith: Why do women face a higher risk of stroke overall?

Michelle Vallelunga: I think that in general, the simple way to look at this is that some higher stroke risk may occur in the younger ages of women due to some unique risk factors. And then, as specifically for women in the older ages, like over age 75, for example. So it's like those two potentially coming together for women kind of ups their risk.

And then you add to those unique risk factors, some more general risk factors that affect both men and women, things like high blood pressure in general, obesity, lack of exercise, those kinds of things.

So when you take all three of those components together, it can lead to a higher stroke risk for women.

Host Amber Smith: Do women have more strokes than men have?

Michelle Vallelunga: About 85,000 women a year die from a stroke. And it actually has been increased to the third leading cause of death for women overall. It used to be the fourth leading cause. We just pulled up some recent information from American Heart and American Stroke Association. So that's really going to be the key where we can get some of these statistics.

Host Amber Smith: So it sounds like the strokes for women may be becoming more deadly.

Michelle Vallelunga: Yes, it is. I think that women, again, just have some of these unique risk factors that come into play that would cause them to be a little bit more at risk.

Host Amber Smith: Well, let's talk more about the risk factors that women and men have, but women have some unique risk factors.

So let's go over those, if you would.

Michelle Vallelunga: Sure. So, women and high blood pressure: Certainly high blood pressure is a risk for men as well, but women are generally a little bit more likely to have high blood pressure. For women, it often comes after menopause and in high-risk populations like African American women, who are at greater risk for high blood pressure. For them, that also is a combined factor and can be unique to them.

But the good news for high blood pressure is that (controlling) it gives you the biggest bang for your buck in terms of lowering your stroke risk. So if you're very careful about monitoring your blood pressure, knowing what those numbers are, both men and women, if they take really good steps and get that blood pressure in the acceptable ranges, they can really hit their stroke risk by about 30 to 40%.

The second factor for women that is unique is pregnancy, just the state of pregnancy. When a woman is pregnant, there's more blood volume, and the blood tends to form clots more easily. It goes into sort of what we call a hypercoagulable state or, again, the ability to more easily form clots. And when those clots form, obviously, they can cause a blockage in the brain that then leads to stroke.

I just want to be clear that stroke after pregnancy is relatively rare. You're talking 25 to 35 for every, like, 100,000 deliveries. So it's kind of a rare thing, but I have seen it here in my career. And we've taken care of women who have had strokes post-pregnancy. But we're just trying to get the word (out) that these effects, the effect that pregnancy has and that rapid change after delivery, could make a perfect storm for a stroke.

Also related in pregnancy is something many of us have heard about, called preeclampsia, which is the state of high blood pressure during pregnancy. So you're probably picking up on a common theme here. We talked about high blood pressure normally now, high blood pressure during pregnancy. Many women have this condition, so we encourage them to really get monitored carefully during pregnancy and after, because if you have preeclampsia during pregnancy, later on in your life gives you a little bit higher risk for a stroke as well.

So those are unique to women.

Host Amber Smith: I've heard that oral contraceptive use can increase the risk of stroke, but can you tell us how that is and what can be done about it?

Michelle Vallelunga: Yes. The use of oral contraceptives, particularly combined with smoking -- so if a woman uses the oral contraceptive and smokes -- really increases their risk for stroke.

And the reason: The contraceptive action, again, is having an effect on those various clotting factors in the blood, and they just increase the body's ability to form clots. It increases those clotting factor activities and interestingly, though, that the clotting factors are actually, like, after pregnancy and when affected through the use of hormones is really almost like a protective, like the body's own protective barrier, for, like, postpartum bleeding or postpartum hemorrhages. So it's kind of a good thing, but in certain women under certain conditions, it can be a bad thing where the clots form and then leads to a stroke.

Host Amber Smith: So is there concern for postmenopausal hormone use? Does that affect a stroke risk, too?

Michelle Vallelunga: Yeah, it could in the same manner as oral contraceptives, having an effect on those clotting factors. So we just encourage women who are considering the postmenopausal hormones to really sort of look at their entire health history and, certainly, review that with their doctors and look at sort of the whole picture.

That's what we encourage.

Host Amber Smith: You're listening to Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with nurse Michelle Vallelunga. She's Upstate's Stroke Program data coordinator.

How big of a threat are stress and depression in leading to stroke? And I wonder if this is a bigger problem for women than for men?

Michelle Vallelunga: I'm not aware of a lot of statistics on this, but we do know, in general, both high stress levels and particularly depression are linked to risk factors for stroke for both men and women.

But in the case of women, we tend to report higher stress levels than men, sort of subjectively, and I think we are also a little bit more likely to experience depression and anxiety. And I think just in general, the stress on women as caregivers -- particularly, recently we read a lot about being caregivers for elderly parents, of other family members -- just in general can heighten that stress.

So I feel like they're in a little bit of a unique situation there to cause high stress levels.

Host Amber Smith: What about migraine headaches? Are those a risk factor for stroke?

Michelle Vallelunga: Yes, those are listed as a risk factor for women, and particularly migraine, the type of migraine, that has an aura precede it, so they have sort of symptoms coming on before the actual headache. This type of migraine is really more like vasculature, so it really is going to affect the arteries in the brain and could sort of cause them to spasm, very simply, in some cases.

And so this, over time, women are very likely to have migraines with aura, and also they say migraines with aura and smoking again, that "lovely" smoking is not great for you (chuckles). When combined with a lot of other things, can increase the risk for having stroke.

Host Amber Smith: Now, if I understand correctly, most strokes are caused by a blockage in a blood vessel, but some happen when a blood vessel bursts and blood escapes.

Do you see one type over the other affecting women more than men?

Michelle Vallelunga: No. I mean, I think just in general, ischemic strokes are more common, so the kind of stroke that you mentioned, where the blood clot is formed, versus the bleeding stroke. About 80% or so of all strokes are that ischemic type, that clot type.

And about 15% or so are the bleeding type. I don't really see, actually, not that I'm aware of, you know, an increase of one or the other of those type of strokes. But the, bleeding type of stroke is generally for women caused by long-standing, not treated, high blood pressure. That is probably the biggest factor. So we circle back to high blood pressure being a factor in so much of one's health, related to stroke.

Host Amber Smith: I'm curious about stroke treatment and how women compare with men. Do you know if the clot-busting medications, which have to be given very early in the stroke, are as effective in women as in men?

Michelle Vallelunga: They are as effective. Like you mentioned, the clot-busting medication that we use here at Upstate, which is called tenecteplase or TNK. It's a type of tPA (tissue plasminogen activator). I think many people know that term out there. It has to be given within three hours or up to four and a half hours of the patient last being well, or, usually, when their symptoms are first noticed, to be very effective, and this obviously can be effective for both men and women.

The other form of treatment that we offer is a clot retrieval or a clot removal procedure called a thrombectomy. And that can be done in some cases up to 24 hours of last (being) known well. Time is the key word here. If you feel as though you're having any stroke symptoms, whatsoever, the treatments are very time sensitive, as we've mentioned. So your best chances of getting the treatment, and ultimately your recovery, is to get here as quickly as possible.

Host Amber Smith: Well, stroke is the leading cause of adult disability. So I'd like to ask you to explain how this may impact women differently than men.

Michelle Vallelunga: I just think that with women being caregivers for, often, elderly parents, children, many, many other members of their family, I think that that can definitely have an impact. Because if a woman is disabled from a stroke or is suffering long-term effects from a stroke, the whole family unit is disrupted.

I think that that can really have a huge impact on the family and everything that takes place in that family.

Host Amber Smith: Is stroke something that is a concern, moreso for older people, older women and men, than for younger, and how common is it for you to see a younger woman in her 20s, 30s, 40s, 50s, with a stroke?

Michelle Vallelunga: It's definitely less common for a younger woman to have a stroke than in older women. I think obviously in general we see more strokes in older women, older women and men. but really the information that I'd like to get out there is that even though it's rare, and obviously much less prevalent out there, if you're at a gathering in the holidays and younger women start talking about different risk factors that they have having been pregnant, being on oral contraceptives and smoking, high stress levels in their lives, they have a history of migraines with auras. If younger women are talking about these kinds of things to you.

Hopefully this will never happen, but should you be in a situation with a younger woman who maybe has just delivered a baby or has some of these risk factors and starts developing stroke symptoms, and tells you they're having stroke symptoms, the goal of my lecture is to definitely get these people to say, "Oh, wait a second. Let me put these factors together, and perhaps I should encourage this person to call 911 and get help for the stroke." So that's kind of my ultimate thing, is to get people to start thinking about stroke can happen in younger women.

For older women, largely, their risk is tied to atrial fibrillation, and women, especially over age 75, are at higher risk for stroke due to atrial fibrillation (called A-fib for short).

Host Amber Smith: So let's explain that a little bit more. Atrial fibrillation is a specific heart rhythm, and you may not know you have it unless a doctor diagnoses it, right?

Michelle Vallelunga: Right. A-fib is an interruption of the electrical impulses of the heart that really causes your heart to beat irregularly. Some people are symptomatic, so they kind of feel their heart racing, they're a little bit short of breath, but other people, as you say, are not symptomatic at all and never know that they have A-fib.

So in general, we recommend that all women over 75 get at least screened for A-fib, through their primary provider or cardiologist, if they're seeing one. Certainly they can help screen you for A-fib. In the condition of A-fib, because the heart is not beating regularly, the blood tends to pool in the top of the heart, and clots have a greater tendency to form.

And so those clots can then be sent out of the heart and go up to the brain and then, cause a stroke. So that's the concern there with atrial fibrillation.

Host Amber Smith: So if a person knows they have that, but it's under control, either through a procedure or medications, that type of thing, does that remove their risk of stroke?

Michelle Vallelunga: Not entirely. Certainly it can still happen, but it's the best defense. The best defense is to definitely be in touch with your physician or your cardiologist about it and take the medications according to -- we see this all the time, where folks are not really taking the medications the way they're prescribed.

Or if you have symptoms, even though you're taking the medication, don't ignore the symptoms. Give your doctor a call, talk to them about those symptoms because you want to try to manage yourself, along with your doctor, the best way you can.

Host Amber Smith: Well, we've covered pretty well atrial fibrillation and high blood pressure, but I want to ask you about some of the other risk factors that might affect people's risk for stroke. Is diabetes a concern? If you have diabetes, are you at higher risk for stroke?

Michelle Vallelunga: It is, yes, it is. The overall presence of diabetes, really, in general, causes your vascular (system), your blood, to be at risk. Basically, it causes the blood vessels to be very stressed, along with high blood pressure for long periods of time, not diagnosed, and other factors related to diabetes, like obesity, lack of exercise.

Just in general, heart-healthy habits are also healthy habits for the brain. So we say heart-healthy habits are brain-healthy habits as well. So those are some of the general risk factors that people should pay attention to.

Host Amber Smith: What is it about smoking, or vaping, that increases a person's risk? What does the act of smoking do to your body?

Michelle Vallelunga: It's really, again, we keep circling back to the effect on the blood vessels. So anything that's going to either cause the blood vessels to spasm or cause it to constrict, where that normal blood flow is interrupted, through the use of like tobacco products and the effect that they have, is really what the concern is.

Over time, the effect on the blood vessels is what could cause a clot to become lodged, could cause the vessel to burst. So, we really obviously caution people certainly not to smoke -- lessen if you can, but certainly go towards not smoking.

Host Amber Smith: Do you have any dietary recommendations?

Michelle Vallelunga: I think that most of our stroke patients are recommended for a low-sodium diet. There's a lot of information out there on the low-sodium diet, which is in general a diet called the DASH diet (dietary approaches to stop hypertension), and people can look that up, but in general it's low sodium, higher intake of vegetables, fruit and just less red meat. I mean, just a general heart-healthy diet works for stroke as well.

Host Amber Smith: And what we are talking about applies to men as well as women, right?

Michelle Vallelunga: Yes.

Host Amber Smith: So before we wrap up, I want to go over the typical warning signs of stroke.

Michelle Vallelunga: So, to review the signs of stroke, we usually think of the acronym FAST-ED, and we've added a couple letters. Most people are very familiar with FAST, or at least I hope so, but to review them for everyone: FACE, so if you have like a droop, you see someone with a facial droop on one side or the other, that could be a sign of stroke. ARM weakness, either side. SPEECH, slurred speech. T is TIME , so time to call 911. And we've added a couple of others now that we like folks to be aware of.

And we work with our local EMS agencies, too, to talk to them about our newest ones that we've added:

E for EYES, eye deviation or vision problems. So if you see someone sort of looking to one side or the other, or they report that suddenly their vision has changed, either sudden blurred vision or sudden loss of vision in one section of what they can see.

The last letter is D, for DENIAL or DIZZINESS. The denial refers to someone who may not really be aware of one side of their body or the other. This happens a lot, in some large-vessel strokes that we see, or a dizziness. And a dizziness is pretty profound in folks that are having strokes, where it really may affect their ability to walk. They may be walking like they're drunk, in that sense, so they're very dizzy.

So we want to think FAST-ED for our stroke symptoms.

Host Amber Smith: Well, Michelle Vallelunga, I appreciate you making time for this interview.

Michelle Vallelunga: Thank you, Amber. It was a pleasure being here.

Host Amber Smith: My guest has been Michelle Vallelunga.

She's a nurse at Upstate and the Stroke Program data coordinator. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Poet Jennifer Wholey's poetry appears in Panoply, Stone Canoe and Smartish Pace. She was a 2018 AWP (Association of Writers and Writing Programs) mentee and a recent winner of the Silver Needle Press Poetry Prize. She sent us a beautiful villanelle, which also serves as an elegy and loving tribute to a friend. Here is "Two Arts":

I walk the path where all your pieces lay

down Risley's Gorge where you buried your art

just out of sight, your clay returned to clay.

You hid your sculptures off the trodden way;

I search, but I'm not quite sure where to start

along the path where all your pieces lay.

You'll dig them up when you come back, you say.

You just can't ship them, they will fall apart!

Just out of sight your clay returned to clay.

I hope you might have left one here today,

by accident? No, you were far too smart.

I walk the path where all your pieces lay.

You disinterred them when you came to stay.

I had no idea when you would depart

-- just out of sight -- your clay returned to clay.

For your memorial, we put them on display.

I spoke about you, but I did not have the heart

to walk the path where all your pieces lay,

just out of sight, your clay returned to clay.

Host Amber Smith: This has been Upstate's "HealthLink on Air" brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," all about cochlear implants.

If you missed any of today's show or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Bill Broeckel. This is your host, Amber Smith, thanking you for listening.

On "HealthLink on Air," an exercise physiologist discusses research showing how exercise can help stave off dementia. An oncology nurse talks about the meaning of cancer survivorship. And a nurse from the stroke team goes over how stroke affects women and the unique risks and warning signs it's important to know. Please join us for Upstate's "HealthLink on Air."