Older Adults Stroke

Question 1

What is the watershed effect?

Answer 1

Areas of the brain which are furthest away from the damage are more effected as there is less blood supply

Question 2

What is a cerebrovasuclar accident?

Answer 2

Any sudden episode where the blood systems of the brain are damaged or stop working

Question 3

The general public have a poor awareness of stroke

Answer 3

Stroke association (2011):
42% did not know what a stroke is
Low awareness of risk factors -39% blood pressure, 9% diet
FAST campaign

Question 4

Fast campaign

Answer 4

Facial weakness
Arm weakness
Slurred speech
Time to call

Question 5

What is ischemia/infarction?

Answer 5

Loss of blood flow around the brain (clot)

Also accounts for loss of important things contained in the blood eg diabetic stroke

Question 6

What is a Haemorrhage?

Answer 6

Leakage of blood from the vessels (bleed).

Burst pipe analogy, Central heating high water pressure

Question 7

Epidemiology WHO (2011)

Answer 7

Second most common cause of death after CVD

Most common cause of severe neurological disability

130,000 people per year
60,000 die

Question 8

What are the 8 common causes and mechanisms of ischemia / infarction?

Answer 8

1. Atherosclerosis
2. Thrombus
3. Embolism
4. Hypoglycaemia
5. Tachycardia
6. Hypotension
7. Blood vessel compression
8. Atriovenous malformation

Question 9

1. Atherosclerosis

Answer 9

Plaques building up within the vessel wall, like a dam

Question 10

Thrombus

Answer 10

Blood clot within the brain

Question 11

Embolism

Answer 11

Blood clot travels into the brain, common following heart surgery, angina

Question 12

Hypoglycaemia

Answer 12

Low blood glucose

Question 13

Tachycardia

Answer 13

Fast resting heart beat

Question 14

Hypotension

Answer 14

Low blood pressure, Blood coagulates,

Question 15

Blood vessel compression

Answer 15

Vessels are squeezed common in young stroke - car accident, weight lifting

Question 16

Arteriovenous malformations

Answer 16

Problems in construction of blood vessels

Question 17

What is the treatment for ischemia / infarction

Answer 17

If within 41/2 hours can be treated with thrombolysis to break down the clot and allow blood flow to resume

Question 18

9 common causes of haemorrhage..

Answer 18

1. Hypertension damage to blood vessels (50%)
2. Cerebral amyloid angiopathy - build up of plaques in walls of arteries (10%)
3. Excessive cerebral blood flow
4. Aneurysm rupture (vessels can expand and restrict also may have a ballon due to this if the wall is weakened, can rupture completed)
5. Arteriovenous malformations eg weak walls
6. Tumour
7. Infection
8. Trauma
9. Obstruction to veins leaving the brain

Question 19

Risk factors include ( anything that damages or interferes with blood supply)

Answer 19

Hypertension
Hypercholesterolemia - fatty deposits reduce elasticity making ruptures more likely, embolism less likely to pass through…
Obesity - more vessels heart working harder
Smoking -hardening vessels
Alcohol - neurotoxin
Sodium intake
Genetics

Question 20

How long do symptoms last for in a transient ischeamic attack?

Answer 20

24hrs

Question 21

What are the main components of the cerebrovascular system?

Answer 21

Middle cerebral artery
Anterior cerebral artery
Posterior cerebral artery

Question 22

What is the middle cerebral artery?

Answer 22

The largest brain artery, feeds the outer sides of the brain and the sensory motor cortex and language centres

Question 23

What is the anterior cerebral artery?

Answer 23

The second most largest artery. It feeds the inner sides of the brain and the frontal lobes responsible for higher level functioning

Question 24

What is the posterior cerebral artery?

Answer 24

The third largest cerebral artery. Feeds the rear parts of the brain. Responsible for vision and brain stem functioning e.g balance

Question 25

What is vascular dementia?

Answer 25

Continued strokes that result in a stepwise progression in neurological functioning. Political issue, no clear cut distinction

Question 26

What are the 5 year survival rates for vascular dementia compared with age-matched controls?

Answer 26

Fitzpatrick et al (2005) 39% vs 75%

Question 27

What are the benefits of having a diagnosis of vascular dementia vs multiple strokes

Answer 27

May have better access to cpns, services But may be age limited

Question 28

What are the general outcomes following stroke?

Answer 28

``` McKevitt et al (2004) 1/2 admitted 1/3 die 1/3 significant impairment 1/3 little or no impairment (TIA) ```

Question 29

What are some common factors an individual may rely on nursing staff for?

Answer 29

``` 33% lose consciousness 10% talking/ swallowing 10% moving Incontinence Bedsores ```

Question 30

For which type of stroke do outcomes tend to be better?

Answer 30

Ischemic / infarction rather than haemorrhage,

Question 31

Common psychological effects of stroke: (x9)

Answer 31

1. Cognitive difficulties 75% (RCP, 2008) 2. Sig distress 30-50% (kneebone & Lincoln, 2012) 3. Depression 33% (Hackett et al. 2005) 4 anx disorder 25% (burvill et al., 1995) 5. Emotion regulation 25% (Calvert et al., 1998) 6. Anger 25% (aybek et al., 2005) 7. PTSD 20% (bruggimann et al., 2006) 8. 2x increased risk for completed suicide (Teasdale & engberg, 2001) 9. Relationship breakdown 30-50%

Question 32

What is emotionalism / emotional lability / emotional dysregulation?

Answer 32

25%, difficulty regulating emotions. | Exhibit short lived, sudden, disproportionate emotional reactions, sometimes no obvious trigger

Question 33

What type of stroke does emotionalism tend to result from?

Answer 33

More severe strokes, can be almost any brain region. | NTC premorbid personality, pathology or normal distress reactions

Question 34

What can be done to help with emotional dysregulation?

Answer 34

Poses distress to survivor and their system. Can be an obstacle to rehabilitation. Psychoeducation can reduce distress and prevent relationship breakdown. Alleviates worry that they are "making things worse" by visiting Small dose antidepressants can help as it is a psychomotor problem.

Question 35

Greatest natural recovery occurs during...

Answer 35

The first month

Question 36

Natural functional recovery includes:

Answer 36

1. Reduced swelling/ oedema repair 2. Cerebral reperfusion / return of blood supply 3. Stabilise surviving cells - viable heal, dying die 4. Blood is reabsorbed, toxicity removed 5. Masking - create new connections to learn repost skills

Question 37

Common difficulties experienced on discharge include : (4)

Answer 37

1. Previous routines / ADLs 2. Adaptation finding, what works, what do they have problems with 3. Sick role behaviour, learned helplessness 4. Depression related to inactivity

Question 38

Stress appraisal model

Answer 38

Lazarus & folk man (1984)

Question 39

Describe Lazarus and folkman's (1984) stress appraisal model.

Answer 39

1. Primary stressor - the stroke, needs, impairments and behaviours as a result. 2. Primary appraisal 3. Secondary appraisal with resources (eg family, profs, skills...) 4. Problem focused coping Emotion focused coping 5. Secondary stressors - arise from coping, may feed back into primary appraisal (e.g physio pain - not going to recover) 6. Outcome

Question 40

Health beliefs

Answer 40

Janz & Becker (1984)

Question 41

What does the health beliefs model consider?

Answer 41

1. Demographics 2. Perceived susceptibility 3. Perceived severity 4. Health motivation 5. Perceived benefits 6. Perceived barriers/costs 7. Cues to action 8. Preventative action

Question 42

Describe sensory motor impairment

Answer 42

Paralysis is usually one sided, contralateral to damage

Question 43

What are the outcomes of sensory-motor impairment?

Answer 43

1/3 no recovery 1/3 need aids 1/3 recover walking

Question 44

What is the general hierarchy of recover of sensory motor functioning

Answer 44

1. Legs 2. Arms 3. Fingers

Question 45

What are dyspraxia and apraxia, and what area of impairment are they associated with?

Answer 45

Sensory motor, | Difficulties planning motor sequences

Question 46

What are important predicates of damage in strokes affecting the sensory motor cortex

Answer 46

Size of damage and connectivity

Question 47

what percentage rely on unpaid family / carers for help with personal care and ADLs?

Answer 47

Wilkinson et al. (1997) 40-50%

Question 48

What are some common activities individuals are reliant on carers for following stroke?

Answer 48

``` Warlow et al. (2011) Bathing (33%) Walking outdoors Stairs Dressing Feeding Bladder Walking indoors Transfers Toileting Grooming (11%) NTC individual difficulties and their impact e.g makeup in women and self esteem ```

Question 49

When does the focus move from spontaneous recovery to compensatory strategies?

Answer 49

6-12 months post stroke. | Coincides with reduction of support

Question 50

How can the brain develop adaptive strategies and skills? (4)

Answer 50

1. Can recover functioning 2. Existing neurons can create new connections 3. Adjacent brain areas can take over some functioning - > evidence base evolving

Question 51

Some themes of depression in stroke: (10)

Answer 51

1. Actual loss 2. Perceived progression 3. Proximity to premorbid self 4. Level of disability 5. Identity - role changes and adaptations 6. Hope for future 7. Current relationships, bidirectional influence 8. Isolation, abandonment - attachment styles, anxious more difficult 9. Access to resources 10. Burden/guilt

Question 52

Common themes in anxiety

Answer 52

1. Threat of loss 2. Stigma 3. Confidence in abilities -falls, ADLs, visual recognition, acalcula, continence, communication 4. Another stroke 5. Trauma of stroke/hospital 6. Guilty, worry about others

Question 53

What are the quality of life factors that are important to consider (12)

Answer 53

1. Finance 2. Health 3. Personal growth 4. Achievements 5. Work/career 6. Friendship 7. Security 8. Energy 9. Self-esteem 10. Fun & recreation 11. Home & family 12. Relationships

Question 54

Obstacles to recovery

Answer 54

Stroke association (2011) Not given info and support on emotional coping (80%) Emotional needs not looked after as well as physical (66%) Anxiety (67%) Depression (59%) Family breakdown (50%) No one to talk to (34%)

Question 55

Family and carer difficulties

Answer 55

``` Stroke association (2012) Frustration, anger (burnout, arguments, neglect, abuse) 85% Anxiety (79%) Emotional impact is hardest 64% Knowledge not respected or valued 60% Depression 59% ```

Question 56

What percentage of stroke services have access to actinic am psychologist?

Answer 56

20%

Question 57

Factors in mood problems

Answer 57

``` Acceptance of loss of functioning Adapting to changes Fear of falling Uncertainty of future and present Emotional dysregulation Loss of roles and identities Guilt and shame Existential challenges ```

Question 58

The carers act 2014 states

Answer 58

That we should provide carers with the tools and support that they need. This can be difficult in the NHS- not geared towards it eg note taking separately not manageable

Question 59

Predictors of distress in carers (6)

Answer 59

Low et al 1999 1. Poor information provision 2. Lack of appreciation of emotional needs 3. Poor preparation for role 4. Social isolation 5. Reduced self care 6. Financial strain

Question 60

What is associated with aphasia in carers?

Answer 60

``` Ross & Morris (1998) 1, poorer adjustment 2. Greater role changes 3. Depression 4. Loneliness 5. Rel difficulties ```

Question 61

Name predictors of carers who adapt well

Answer 61

Greenwood et al (2009) 1. One day at a time 2. Routine 3. Asking for help / information 4. Being patient 5. Satisfaction with healthcare services

Question 62

What percentage return to work after stroke

Answer 62

10%, but this is mostly voluntary. | Odd- 1/3 have no significant problems

Question 63

Personal predictors of return to work

Answer 63

1. Disability severity 2. Psychological problems 3. Personality 4. Gender 5. Age

Question 64

Systemic predictors of return to work

Answer 64

1. Social demographic 2. Economic demographic 3. Employers attitudes