Clinical Neuropsychology

1
Clinical Neuropsychology Stroke MCNs an
introduction

• Dr Marion Murray
• Clinical Neuropsychologist
• Lothian Stroke MCN
• marion.murray_at_lpct.scot.nhs.uk
• 22 September 2006

2
Background to MCNs

• Scottish Executive HDL (2002) on development of
  Managed Clinical Networks
• Linked groups of health professionals and
  organisations from primary and secondary and
  tertiary care, working in a co-ordinated manner,
  unconstrained by existing professional and Health
  Board boundaries, to ensure equitable provision
  of high quality clinically effective services
  throughout Scotland
• Set out 12 core principles

3
MCN Core Principles

• Clear management arrangements
• Defined structure
• Clear statement of the specific and service
  improvements patients can expect
• Documented evidence base (e.g., SIGN guidelines)
  a commitment to ongoing research
• Multidisciplinary focus with clarity on the roles
  of professionals
• Clear policy on the dissemination of information
  to patients

4
MCN Core Principles cont.

• Agreement of all professionals involved to work
  within an evidence base and to the principles of
  the MCN
• A quality assurance programme acceptable to NHS
  Quality Improvement Scotland
• Commitment to exploiting education potential to
  the full, in partnership with others where
  appropriate
• A commitment to ongoing audit
• Appropriate continuing professional development
  programmes for all staff
• A commitment to pursuing value for money
• Ultimate aim to improve patient care with
  standards set for patient journey.

5
Stroke

• Scotland has very high rates of stroke
• SIGN 64 Guidelines indicate 70 000 people living
  with stroke and 15 000 new stroke events each
  year in Scotland
• In 2002 2003, Lothian had an estimated
  population of 783 600 and the stroke rate was
  3.76 per 1000 (about 2946 strokes. First
  incidence lies at about 1300)
• 3rd major cause of death main cause of serious
  disability
• 30 of stroke patients die within the first year
• ½ survivors left dependent

6
Prevalence of psychological problems post stroke

• At least 35 of survivors have permanent
  intellectual impairment.
• (50 75 have affected cognitive functioning
  Haring, 2002)
• Approx 16 will reach criteria for dementia
• 20 80 of people will reach criteria for
  depression after stroke
• Wide variation within the literature due to
  timing of assessment and criteria used
• Other mood disorders prevalent
• Anxiety (Astrom, 1996 Gillespie, 1997)
• Emotionalism
• PTSD? (Sembi et al., 1998)

7
Importance of Psychological Intervention

• Mood related to mortality rates (House et al.
  2001)
• Depression, fatigue and cognitive problems 1 year
  post stroke were predictors of mobility decline
  (van de Port et al., 2006)
• Cognitive problems and depression lead to reduced
  health related quality of life.
• Carers find cognitive difficulties
  personality change most difficult to deal with
• Link between mental health of carers and person
  who has had stroke
• As acute care improves there is an increase in
  longer term disability

8
SIGN guidelines key elements of a clinical
psychologist

• Direct work
• Detailed neuropsychological assessment
  (assessment of cognitive emotional effects of
  stroke)
• Neuro-rehabilitation (both direct suggesting
  strategies to others)
• Skilled therapeutic intervention for mental
  health problems
• Use appropriate techniques to manage difficult
  behaviour
• Services to carers professionals
• Work within MDT to use results of assessments to
  develop care programmes
• Training, supervising, consultation
• Working with families on adjusting and
  understanding cognitive deficits

9
SIGN guidelines key elements of a clinical
psychologist cont.

• Services to purchasers planners
• Designing service evaluation and audit projects
  to identify psychological needs and provide
  information about service use and outcome
• Research
• Improving understanding of psychological problems
  and efficacy of assessment and treatment methods.
  

10
Current Status

• Increased psychology staffing for stroke services
  across Scotland.
• But not all geographic areas have input.
• Challenges
• Trying to marry SIGN guidelines/BPS guidelines
  with MCN principles
• Working with staff unaccustomed to psychology
• Some staff isolated with no B Grade for support

11
Stroke Psychology Services

• Health Boards with specific Stroke MCN
  psychological input
• Argyll Clyde, Ayrshire Arran, Dumfries
  Galloway, Fife, Grampian, Greater Glasgow,
  Highland, Lothian
• Health Boards without (to my knowledge) specific
  Stroke MCN psychological input
• Borders, Forth Valley, Lanarkshire, Tayside,
  Orkney, Shetland, Western Isles