Psychological Considerations in Stroke David Gillespie ClinPsyD, PhD Clinical Neuropsychologist Lothian Stroke MCN

PRESENTATION OUTLINE Psychological morbidity after stroke Cognition Emotional and personality functioning Addressing psychological needs How do we identify those with problems? What type(s) of help may be required? Carer support Edinburgh Stroke Carers Support Group Had lectures on individual problem areas but here numbers presenting to a service, extent of problem and prevalence of problems

Detecting cognitive changes: MMSE screening will detect gross cognitive impairment Patel et al. (2003) n= 163, first-ever stroke MMSE <24 “impaired”; MMSE 24-30 “intact” Results: Patel et al. (2003) Natural history of cognitive impairment after stroke and factors associated with its recovery, Clinical Rehabilitation, 17, 158-166

Detecting cognitive changes: But most patients require more detailed screening tests Important when: Deficits are less obvious The patient is of above average intellectual ability They’ve recovered well physically (with only short LOS expected) Rasquin et al. (2004) n= 196 Full cognitive test battery, 1mo, 6 mo, 12 mo post-stroke Results: Rasquin et al. (2004) Cognitive functioning after stroke: a one year follow-up study. Journal of Dementia and Geriatric Cognitive Disorders, 18, 138-144

Rasquin et al. (2004) Cognitive functioning after stroke: a one year follow-up study. Journal of Dementia and Geriatric Cognitive Disorders, 18, 138-144

Post-stroke dementia The prevalence of dementia after stroke is high More common in individuals with poor pre-stroke cognitive functioning

What should be offered? Routine cognitive screening of all patients (MMSE, ACE-R) Follow-up assessments to monitor progress Advice and support to patients and their families On wards: Important to increase individuals’ awareness of their cognitive losses And teach systematic approaches to address them Post-hospital discharge: More detailed assessment may be required (e.g. Clinical Neuropsychology service) Individual taught long-term (i.e. sustainable) cognitive compensations (e.g. Community Rehab teams, outpatient OT, Day Centre staff, etc) Vocational issues should be considered

Cognitive screening protocol ACE-R (at a minimum) Other assessments (if necessary) *Other assessments (if necessary) Stroke Early home discharge Extended stay in acute setting MMSE (at a minimum) ACE-R (if possible) Relatives’ assessment (IQ-CODE) *Other assessments (as necessary) Home Nursing home Stay in rehabilitation setting Allows comparison

Detecting emotional changes: Psychological/psychiatric problems are very common O’Rourke et al. (2000) n= 105 hospital-referred patients, 6 mo after stroke onset 30/105 (29%) had a psychiatric diagnosis Hackett et al. (2005) Systematic review of studies of post-stroke depression Mean proportion depressed across studies 33%

Other types of emotional problems exist too Anxiety might be as common as depression Fure et al. (2006) n= 178 patients in stroke unit setting (Norway) 14% > HADS cut-off for depression (associated with physical disability) 26% > HADS cut-off for anxiety (associated with cognitive impairment) PTSD-like problems more common than once thought Bruggimann et al. (2006) 15/49 (31%) of individuals with mild strokes met criteria for PTSD Lack of emotional responsiveness can have as big an impact Some individuals display unconcern and this carries long-term psychosocial difficulties (e.g. Prigatano, 2003) Personality changes are important to consider too Families commonly report aspects of character change (Stone et al., 2004)

What should be offered? Routine mood screening of all patients (SAD-Q, GDS, HADS) Follow-up assessments to monitor progress On wards: Think about non-pharmacological as well as drug approaches Allow the person to discuss their experiences (in a private setting) If treatment is initiated think about how you’ll know it’s helped E.g. Re-administration of mood scales at regular intervals Post-hospital discharge: Keep mood under review Transition between (or discharge from) services are often “trigger points” Encourage effective problem-solving and realistic goal-setting Specialist help or intervention might be required E.g. Clinical Neuropsychology