Psychological aspects of stroke

1. Psychological aspects of stroke Dr Aileen Thomson Dr Andy Champion Clinical Psychologists Health Psychology Dept, Gloucestershire Hospitals NHS Foundation Trust

2. 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

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

4. 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) Where/if does psychology come in?

5. 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 Where/if does psychology come in?

6. 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

7. Assessment Psychological formulation Direct treatment/intervention Consultation Teaching Training Research and development The role psychology can play

8. Cognitive impairment Psychological adjustment post stroke Mood disorders Needs of carers Contribution to rehab- lifestyle changes, treatment adherence etc (inc groups) The role psychology can play

9. 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

10. Margery

11. Emotional reactions • Adjustment • Assessment of mood • Emotionalism • Depression • Anxiety

12. 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

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

14. Depression Risk factors • female > 60 yrs • history of depression • dysphasia • social isolation • extent of impairment • not location of stroke

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

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

17. Margery

18. Cognition • Memory • Concentration • Language • Perception • Planning movement • Executive function

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. 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

27. Executive Function 2 • Initiation • Impulsivity • Sequencing • Perseveration • Disinhibition • Emotional lability • insight

28. 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