Stroke and Rehab

Question 1

What is a stroke?

Answer 1

Sudden disruption of flow of blood in the CNS that causes tissue death, damage and loss of function.
Greatest cause of death after CHD
Also called CVD or CVA

Question 2

What is the role of psychologists in post-acute stroke care?

Answer 2

Ax of cognitive functioning
Ax, Dx, Mgmt of PSD, anxiety, FOF, adjustment disorders
Tailoring of MDT tx
Behavioural interventions
Carer assistance

Question 3

Why assess cognitive functioning in post-acute stroke care?

Answer 3

Predicts stroke survival
Impacts upon
- insight
- ability to engage and benefit from rehabilitation
- predicts onset of PSD
- linked to anxiety and QofL
- domain specific neuropsych ax linked to Functional Independence Measure
- impacts upon ability to ax and tx above

Question 4

What do you use as a neuropsychological screen?

Answer 4

• RBANS
• Cognistat
• Screening Instrument for Neuropsychological Impairments in Stroke (SINS)
  Then do a clinical neuropsychological domain-specific assessment.

Question 5

What do you need to know to do a clinical neuropsychological domain-specific assessment?

Answer 5

• Stroke knowledge (types, time course, risk factors)
• Neuroanatomy (to know likely deficits with lesions, helps with targeting testing, advice to MDT)
• Neurological/neuropsychological syndromes
• Clinical/health psychology
• Evidence base for interventions and what options might be if evidence is limited

Question 6

What is PSD prevalence and impact?

Answer 6

15-40% experience depressive sx few months post-stroke, 33% prevalence
Average duration 12 months
Linked to higher morbidity and mortality
Reduces ability to engage in rehab/success of rehab
Impacts on carers

Question 7

How can psychologists help with PSD?

Answer 7

Ax, prevention and treatment
Ax: use standardardised, validated scales. Special scales for people with dysphasia.
Prevention: through preventative psychotherapy
Intervention (evidence-based):
- ax appropriateness for therapy
- provide MI or problem-solving therapy
- monitoring and assessing of outcomes, provision of case management.

Question 8

What predicts the severity of PSD symptoms and predictors of reduced QofL?

Answer 8

• baseline domain specific functioning
• baseline depressive sx
  DM
  female
  hx of TIA

QofL:
Cognitive impairment, age, functional impairment

Question 9

What are some typical psychological problems in rehabilitation?

Answer 9

'Loss of control'
Anxiety
Depression
Adjustment disorders
Grief
Stress related to psychosocial stressors
Cognitive decline (ST and LT)
Acute or chronic pain

Question 10

Anxiety and PSD

Answer 10

Risk factor of PSD
Tends to be persistent (some studies 3 yrs)
Limited research on prevalence and intervention 
Carers become anxious e.g. 33% reported anxiety sx
Possible anxious concerns:
- FOF
- cognitive deficits
- rehabilitation process
- loss of control
- sense of being a burden
- being able to be independent
- re-occurrence of stroke
- where will I like?

Question 11

FOF

Answer 11

Limited psychological intervention evidence (same for adjustment)
Associated with activity avoidance, loss of SE around ADLS, reduced QofL
Risk factors - hx of falls, female, no. medications

Question 12

What are some factors influencing delivery of therapy?

Answer 12

Cognition
Length of admission
Medical and psychiatric history, ‘frequent flyer’
Age ranges
Medical complications (discharge and readmission)
MDT goals may conflict with client’s goals
May need to advocate for client
Consider demographics (e.g. education, SES)

Question 13

What should you consider in working with rehab patients?

Answer 13

Intervention will continue to occur long after discharge
Often referrals come at end of stay
Non-adherence to MDT plan may be reason for referral
- Factors influencing delivery of therapy
- Intervention tips

Question 14

What are some tips in delivering interventions to rehabilitation clients?

Answer 14

• Provide therapy that assists client to engage in rehab to facilitate discharge (psych problems often resolve post-discharge).
• Psychoeducation of client and carers. Handouts helpful
• Goals and values need to be client-determined. SMART goals
• Use MDT and carers to generalise reinforce therapy e.g. PT and behavioural activation
• Teach positive reinforcement to MDT and carers
• Empathic, flexible
• Post discharge services to support continuity of care and reduce client anxiety about how they will cope on their own. Some problems only apparent after discharge.

Question 15

What are the pros of working in a stroke rehab MDT?

Answer 15

• Easy to refer to other disciplines
• Use of case conferencing potentially leading to more client-focused care
• Better discharge planning
• Increased team communication so better chance of more evidence-based Tx
• Opportunity for joint ax and Tx
• Stroke pts do better with MDT

Question 16

What are the cons of the MDT in the stroke rehab environment?

Answer 16

• Psychologists not typically part of team so less likely to be considered essential
• Role conflict and overlap leading to tension
• APS guidelines encourage two charts (administration and tx)

Question 17

What disciplines are involved in stroke rehab setting?

Answer 17

• Rehab physician
• nurses
• physio
• OT
• speechies
• dietitian
• pharmacist
• SW
• diversional therapist