incidence and the results are contradictory. Since stroke rates increase greatly with age and the number of elderly people is increasing worldwide, the burden of stroke on individual families, and the health services is unlikely to fall rapidly. Malmgren et al estimated that between 1983 and 2023 there will be an absolute increase in the number of patients experiencing a first ever stroke of about 30%16 . There will be an increase in the number of deaths from stroke of about 40%, but there will only be an increase of 4-8% in the number of disabled long-term survivors. One can, therefore, anticipate an increase in the need for acute care and early rehabilitation services over this time period, but not an increase in longer term care. There has been a significant decrease in mortality from stroke over time and in the western world which started in the early 1900s and has British Medical Bulletin 2000,56 (No 2) 279 Downloaded from https://academic.oup.com/bmb/article/56/2/275/303250 by guest on 17 April 2022 Stroke accelerated during the past 30 years; this has been attributed by some to better control of hypertension, although this is far from clear1 . Data on trends in case-fatality rates based on epidemiological studies are scarce and contradictory. Peltonen and colleagues demonstrated marked improvements in short and long-term survival since 1985 in Sweden, equating to a 30% reduction in death rates which they attribute to improved management17 . Prevalence of stroke The prevalence is the number of stroke sufferers in the population. There have been very few prevalence surveys of stroke, the prevalence rates being estimated using the incidence and survival data from stroke registers. O'Mahony et al validated a simple self-completed questionnaire to screen for cases of stroke in the community and estimated that 10% of respondents reported a history of stroke. The question 'have you ever had a stroke?' had a sensitivity of 95% and a specificity of 96%xs . Geddes et al, in a study in the north of England, estimated the prevalence of stroke to be 46.8 per 10,000 {95% CI 42.5, 51.6). Cognitive impairment (33%), problems with lower limbs (30%) and speech difficulties (27%) were the most common residual impairments19 . Impairment, disability and handicap The World Health Organization definitions are used to classify the impact of stroke longer term. The classification is being revised to introduce the concept of 'contextual factors' which impact upon the manifestation of all diseases (social, physical, personal). The revised classification refers to 'activities' and 'participation' rather than 'disability' and 'handicap'4 . Impairment Impairment refers to abnormalities arising at the level of the organism. Impairments are usually the external manifestations of the pathology: the symptom and signs. Impairments are 'objective' and cover a wide range of states which carry no personal meaning to the patient: hemianopia, sensory loss, muscle weakness, spasticity, pain, etc (Tables 1 &C 2). Disability Disability refers to changes in the interactions between the patient and the environment. It is the behavioural consequences, which manifest 280 Bntrsh Medical Bulletin 2000;56 (No 2) Downloaded from by guest on 17 April 2022 The impact of stroke Table 1 Acute (0-7 days), three week and six month impairment/disability rates Phenomenon Impairments Initial loss/depression of consciousness Not oriented (or unable to talk) Marked communication problems (aphasia) Motor loss (partial or complete) Disabilities Incontinent of faeces Incontinent of urine Needs help grooming (teeth, face, hair) Needs help with toilet/commode Needs help with feeding Needs help moving from bed to chair Unable to walk independently indoors Needs help dressing Needs - 31 49 4 5 12 32 47 The 'acute' figures are of limited accuracy as many patients were not assessed within the first week, many of these were very ill and probably very dependent Consequently, the figures relating to acute disability are minimum estimates These data relate only to survivors and are summarised from Wade3 within the patient's environment, or the personally meaningful functions or activities which are no longer executed, or are altered. Altered behaviours stretch from continence and turning over in bed to dressing and bathing and gardening, interacting with other people and specific work skills. In practical terms, especially in relation to health and social services, disability manifests itself as an increasing dependence upon people and/or environmental adaptations. Some representative data of disability for the acute phase and 6 months are shown in Tables 1 and 2. The Oxford study estimated that, at 1 year, 65% of survivors were functionally independent. Handicap Handicap is the most difficult level to define and measure and is the change in social position which arises from illness; it also refers to the social, societal and personal consequences of the disease. It is the roles and expectations which are performed less readily, if at all. British by guest on 17 April 2022 Stroke Table 2 Epidemiology of stroke' the figures are per 100,000 population per year, where relevant General - SAH, TIAs, stroko - diagnosed Cases SAH per year 14 New cases TIA per year 42 - carotid territory TIAs 34 First strokes per year 200 All acute strokes per year 240 Stroke survivors alive in community 600