Psychological aspects of stroke

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Psychological aspects of stroke

• Dr Aileen Thomson
• Dr Andy Champion
• Clinical Psychologists
• Health Psychology Dept, Gloucestershire Hospitals
  NHS Foundation Trust

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Aims and objectives

• To understand the main emotional reactions to
  stroke
• To be aware of possible cognitive consequences
• To have improved understanding of the impact of
  stroke on family/carers
• To have an awareness of the possible role of
  psychologists

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Overview

• Role of psychologist after stroke
• Case example
• Emotional consequences of stroke
• Cognitive impairment
• Impact on family and carers
• Psychology in action

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Where/if does psychology come in?

• The NSF for Older People recommends that clinical
  psychologists should be members of specialist
  stroke services
• All stroke survivors may require emotional
  support, and pts with mood disorder may require
  treatment by staff skilled in psychological
  approaches (RCP, 2000)

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Where/if does psychology come in?

• Despite high rates of psychological problems, the
  majority of stroke patients do not have
  specialist psychological assessment
• BPS recommendation - 2 wte clinical psychologists
  and 1 wte assistant psychologist working in
  stroke for an average general hospital (500
  000)
• Division of Neuropsychology (2004) recommendation
  that there should be at least one full-time
  clinical psychologist for every 10 - 12
  neuro-rehab inpatients

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Cost effectiveness of psychological input in
stroke

• Mood disorders are associated with worse outcomes
  in the longer term, including longer hospital
  stay, increased morbidity and mortality
• Long-term effects of cognitive impairment are as
  or more significant than physical impairments in
  re-establishing family and social activities
• Standard rehab outcome measures are insensitive
  to subtle cognitive impairment

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The role psychology can play

• Assessment
• Psychological formulation
• Direct treatment/intervention

• Consultation
• Teaching
• Training
• Research and development

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The role psychology can play

• Cognitive impairment
• Psychological adjustment post stroke
• Mood disorders

• Needs of carers
• Contribution to rehab- lifestyle changes,
  treatment adherence etc (inc groups)

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Role of psychology

• Assessment to identify not only impairments but
  strengths
• Inform rehabilitation approaches
• Information provision to all concerned
• Input re functional compensatory strategies to
  minimise effects on activities of daily living
• Discharge planning

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Margery
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Emotional reactions

• Adjustment
• Assessment of mood
• Emotionalism
• Depression
• Anxiety

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Depression

• Estimates of 20-50 prev of depression following
  a stroke
• Linked with poor prognosis - longer hospital
  stay, impedes rehab, increased mortality
• It is not, however, inevitable

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Depression

• Diagnosing depression post stroke can be
  difficult.
• Overlapping symptoms makes assessment probelmatic
  
• concentration difficulties
• fatigue
• emotional lability
• irritability
• sleep/appetite disturbance

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Depression

• Risk factors
• female gt 60 yrs
• history of depression
• dysphasia
• social isolation
• extent of impairment
• not location of stroke

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Anxiety

• Uncertainty regarding extent of recovery and
  timescale
• Fear of having another stroke
• Fear of falling
• Worry about effects on family
• Practical concerns

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Anxiety

• 17-36 of patients clinically anxious after
  stroke
• often accompanies depression
• often associated with social isolation and
  dysphagia

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Margery
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Cognition

• Memory
• Concentration
• Language
• Perception
• Planning movement
• Executive function

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Cognitive impairment after stroke

• 1/3 people surviving stroke present with
  persisting cognitive impairment
• Subsequent impact upon quality of life
• Cognitive impairment can slow rehab, increasing
  length of stay in hospital
• Cognitive/behavioural changes most distressing
  aspect for carers

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Memory

• 50 impaired at 7 months post-stroke
• Most common difficulty is learning new
  information
• Memory is not a single skill different aspects
  can be affected selectively
• Recognition vs. recall
• Verbal vs. non-verbal

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Attention

• Concentration difficulties slow rehab
• SUSTAINED (staying on track)
• SELECTIVE (filtering out distraction)
• DIVIDED (doing 2 things at once)
• Impact upon other skills e.g. personal care,
  communication safety concerns
• Speed of information processing

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Attention 2

• Visual attention
• Inefficient scanning of the environment
• Finding/noticing things
• Picking up social cues
• Unilateral neglect
• As if selectively ignoring half of space
• Poor prognostic factor for functional recovery
• safety

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Language

• Expressive vs. receptive
• Non-literal use of language
• Metaphor, prosody, humour
• Impact on communication of other cognitive
  factors
• e.g. attention, disinhibition, speed of
  information processing

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Perceptual skills

• WHAT things are
• Object perception
• WHERE things are
• Spatial perception
• Depth perception, figure-ground discrimination,
  relative positions of objects (judging distances,
  angles, shadows), visual closure
• Visuo-spatial construction
• Impact upon ADLs e.g. dressing

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Planning Movements

• 40 patients 1 month post-stroke
• May coexist with dysphasia
• A) incorrect timing and sequencing of movements ,
  i.e. overall goal intact but elements disrupted
  (ideomotor)
• B) concept/content errors e.g. shaving with
  toothbrush (ideational)

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Executive Function 1

• Often linked with frontal lobes
• Roles of a chief executive
• Planning
• Implementing
• Monitoring
• Problem-solving, prioritising, adjusting
• Can have marked effects on behaviour

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Executive Function 2

• Initiation
• Impulsivity
• Sequencing
• Perseveration
• Disinhibition
• Emotional lability
• insight

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Impact on family and carers

• Premorbid relationships crucial in determining
  subsequent coping
• Need information given in accessible form
• Anxiety/depression/guilt
• Most difficult aspects are not physical but
  behavioural or personality changes