Neuropsychological Rehab of Stroke Flashcards
What is stroke?
Interruption/loss of blood suply to the brain leading to cell damage
What is an ischemic stroke?
Cerebral blood flow obstruction (plaque, blood clot) that can originate at the site of occlusion (thrombus) or at a distance from the occlusion (embolus)
Most common (88% of all cases)
What is a hemorrhagic stroke
Bleeding within the brain; most commonly caused by hypertension (50%) / in younger adults most commonly due to aneurysm or arteriovenous malformation (AVM)
12% of all cases
Name me 2 types of ischemic strokes
- Left Middle Cerebral Artery Stroke
- Right Middle Cerebral Artery Stroke
What are the symptoms of Left Middle Cerebral Artery stroke?
- Right hemianopia/neglect
- Right hemiplegia/paresis
- Left right confusion
- Apraxia
- Impaired Verbal Memory
- Impaired speech-aphasia
- Slow performance
- Awareness of deficits-depression/anxiety
Symptoms of Right Middle Cerebral Artery Stroke:
- Impaired Judgement
- Impulsive/safety problems
- Left neglect
- Left Hemianopia
- Short attention span
- Denies problems, insight difficulties
- Spatial-perceptual deficits
- Visual memory difficulties
- Personality/ social cognition changes
What is the Hyper-acute stroke unit (HASU) for?
Immediate response to stroke
When can patient be transferred to local stroke unit (SU)?
When medically stable within 72h or earlier if appropriate.
What care does patient receive at the local stroke unit?
Multidisciplinary specialist rehabilitation & ongoing medical monitoring.
What happens after rehabilitation at the stroke unit?
1) discharged home with community rehabilitation and social care (as required)
2) transferred to post-acute rehab unit
3) transferred to residential or nursing home
Neuropsychological impairments of Attention and information processing speed post-stroke
1) Focused Attention
2) Divided Attention
3) Sustained Attention
4) Speed of processing information
Interventions for Attention and Speed of information processing:
1) Compensatory strategies, like time pressure management (setting timers/alarms, breaking tasks into smaller steps, using calendars, establishing routines & predictability, seeking assitance and deligating tasks)
2) Enivornmental modification (e.g. reduced distractions, have written plan, organised work area)
The cogntive strategy behind Time Pressure Management (TPM) - Main objectives
! To recognise time pressure in the task at hand
! To prevent as much time pressure as possible
! Dealing with time pressure as quicky and effectively as possible
! Urging the patient to monitor himself while using the TPM
Executive functions inpairment domains post-stroke:
- Planning and executive tasks
- Inhibition automatic impulses
- Regulating emotional responses
- Reasoning about risk and weighing up information
Which tests assess executive tasks?
Behavioural Assessment of Dysexecutive Syndrome (BADS)
Trail making tests
Delis-Kaplan Executive Functioning System (DKEFS)
Hayling & Brixton Tests
Interventions for executive functions
- Compensatory techniques-Meta-cognitive strategies –Mental checklist
- Stop-Think
- Goal Management Training
- Goal setting and feedback on functional tasks
- External strategies (e.g. written checklists, electonic reminders)
Goal Management Framework (GMF) for executive function
- What is my goal? (What am I trying to achieve?)
- Identify the possible solutions. (Think outside the box!)
- Weigh up the pro and cons.
- Make a decision and plan the steps.
- DO IT!
- Review it and evaluate.
Domains of memory impairment post-stroke
- Attention
- Encoding, analysis/processing of information
- Storage
- Retrieval, searching/activating existing memory traces
Types of memory:
- Explicit
- Implicit
- Semantic
- Episodic
- Declarative
- Procedural
Assessement of Memory includes?
-Assess verbal and non-verbal memory
- Possible test are Wechsler Memory scales, Rivermead behavioural memory test (RBMT)
Interventions for memory impairment
- Training and use of stragies (e.g.. spaced retrieval, deep encoding of material, errorless learning)
- External aids (electronic reminders, written checklists)
what is ideational apraxia?
the loss of concept of an action
Which assessment tool is used for apraxia? And which rehab help to offer?
Test of Upper Limb Apraxia (TULIA)
Offer compensatory techniques
Rehabilitation techniques for Spatial Neglect
- Scanning training (e. g. Lighthouse strategy, Eye Search and Readright -UCL online therapy)
- Alerting techniques (e.g. arm band, auditory alert)
- Prism lenses
Communiation aids for stroke survivors:
- 1/3 stroke pateints have communication difficulties
- cards stating “I have had a stroke…”
- Careful assessement using Yes/No questions and technology/visual aids
Help with NotFAST (Nottingham Fatigue After Stroke)
! Resting does not relief fatigue
- CBT
- Pharmacological approaches
Pain post-stroke causes?
- may be neuropathic
- musculo-skeletal
- shoulder pain
Sleep disturbance post stroke interventions
! Assess if not part of a mood disorder
- sleep hygiene management
- pharmacological management
Behavioural changes may require functional anaylsis of…
- Disinhibition
- Impulsivity
- Agitation/Aggression
- Not eating
- Not sleeping
How to address findings from functional anaylsis of behavioural changes?
- environmental modification
- reduction of triggers
- support guidelines for the team
Neuropsychological evaluation post-stroke:
- Mood and cognitive functioning should be screened within 6 weeks of stroke = identify those with presenting emotional/ cognitive change or those vulnerable to mood disturbances
What is a holistic rehab approach in stroke
-Functional, goal orientated treatment to release impact on daily life tasks
- goals are specific, relevant to patients, time limited, ambitious and incremental
- include family and friends, voluntary agencies, social care and health care
Stroke “Stepped Care Model” Levels
Level 3: Severe & Persistent mood/anx/behaviour = May need direct intervention from psychologist, RISK assessment, follow up
Level 2: Mild/Moderate anxiety or behaviour issue that interferes with rehab = May need specific recommendations from psychologist, support provided by specialist ward staff
Level 1: Emotional Distress - transitory worries, feeling low, frustrated = Support from peers and ward staff
Interventions for Emontional functioning post-stroke (Depression, Anxiety, Distress)
- Direct psychological interventions
- Couple/Family work
- Behavioural Activation - Increase social interaction, exercise, psychoeducation groups
- Medication review after 4 months
- Stepped/matched pathway approach
Interventions for Emontional functioning post-stroke (emotionalism/pseudobulbar affect)
- Psychoeducation for person and signficant others
- Self-distraction strategies
-Antidepressant medication and other medications now being trialled
