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

2. 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

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

4. 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,

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

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

7. 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

10. 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

11. 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%

12. 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)

14. 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