Older Adults Stroke Flashcards
What is the watershed effect?
Areas of the brain which are furthest away from the damage are more effected as there is less blood supply
What is a cerebrovasuclar accident?
Any sudden episode where the blood systems of the brain are damaged or stop working
The general public have a poor awareness of stroke
Stroke association (2011):
42% did not know what a stroke is
Low awareness of risk factors -39% blood pressure, 9% diet
FAST campaign
Fast campaign
Facial weakness
Arm weakness
Slurred speech
Time to call
What is ischemia/infarction?
Loss of blood flow around the brain (clot)
Also accounts for loss of important things contained in the blood eg diabetic stroke
What is a Haemorrhage?
Leakage of blood from the vessels (bleed).
Burst pipe analogy, Central heating high water pressure
Epidemiology WHO (2011)
Second most common cause of death after CVD
Most common cause of severe neurological disability
130,000 people per year
60,000 die
What are the 8 common causes and mechanisms of ischemia / infarction?
- Atherosclerosis
- Thrombus
- Embolism
- Hypoglycaemia
- Tachycardia
- Hypotension
- Blood vessel compression
- Atriovenous malformation
- Atherosclerosis
Plaques building up within the vessel wall, like a dam
Thrombus
Blood clot within the brain
Embolism
Blood clot travels into the brain, common following heart surgery, angina
Hypoglycaemia
Low blood glucose
Tachycardia
Fast resting heart beat
Hypotension
Low blood pressure, Blood coagulates,
Blood vessel compression
Vessels are squeezed common in young stroke - car accident, weight lifting
Arteriovenous malformations
Problems in construction of blood vessels
What is the treatment for ischemia / infarction
If within 41/2 hours can be treated with thrombolysis to break down the clot and allow blood flow to resume
9 common causes of haemorrhage..
- Hypertension damage to blood vessels (50%)
- Cerebral amyloid angiopathy - build up of plaques in walls of arteries (10%)
- Excessive cerebral blood flow
- Aneurysm rupture (vessels can expand and restrict also may have a ballon due to this if the wall is weakened, can rupture completed)
- Arteriovenous malformations eg weak walls
- Tumour
- Infection
- Trauma
- Obstruction to veins leaving the brain
Risk factors include ( anything that damages or interferes with blood supply)
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
How long do symptoms last for in a transient ischeamic attack?
24hrs
What are the main components of the cerebrovascular system?
Middle cerebral artery
Anterior cerebral artery
Posterior cerebral artery
What is the middle cerebral artery?
The largest brain artery, feeds the outer sides of the brain and the sensory motor cortex and language centres
What is the anterior cerebral artery?
The second most largest artery. It feeds the inner sides of the brain and the frontal lobes responsible for higher level functioning
What is the posterior cerebral artery?
The third largest cerebral artery. Feeds the rear parts of the brain. Responsible for vision and brain stem functioning e.g balance
What is vascular dementia?
Continued strokes that result in a stepwise progression in neurological functioning.
Political issue, no clear cut distinction
What are the 5 year survival rates for vascular dementia compared with age-matched controls?
Fitzpatrick et al (2005) 39% vs 75%
What are the benefits of having a diagnosis of vascular dementia vs multiple strokes
May have better access to cpns, services
But may be age limited
What are the general outcomes following stroke?
McKevitt et al (2004) 1/2 admitted 1/3 die 1/3 significant impairment 1/3 little or no impairment (TIA)
What are some common factors an individual may rely on nursing staff for?
33% lose consciousness 10% talking/ swallowing 10% moving Incontinence Bedsores
For which type of stroke do outcomes tend to be better?
Ischemic / infarction rather than haemorrhage,
Common psychological effects of stroke: (x9)
- Cognitive difficulties 75% (RCP, 2008)
- Sig distress 30-50% (kneebone & Lincoln, 2012)
- Depression 33% (Hackett et al. 2005)
4 anx disorder 25% (burvill et al., 1995) - Emotion regulation 25% (Calvert et al., 1998)
- Anger 25% (aybek et al., 2005)
- PTSD 20% (bruggimann et al., 2006)
- 2x increased risk for completed suicide (Teasdale & engberg, 2001)
- Relationship breakdown 30-50%
What is emotionalism / emotional lability / emotional dysregulation?
25%, difficulty regulating emotions.
Exhibit short lived, sudden, disproportionate emotional reactions, sometimes no obvious trigger
What type of stroke does emotionalism tend to result from?
More severe strokes, can be almost any brain region.
NTC premorbid personality, pathology or normal distress reactions
What can be done to help with emotional dysregulation?
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.
Greatest natural recovery occurs during…
The first month
Natural functional recovery includes:
- Reduced swelling/ oedema repair
- Cerebral reperfusion / return of blood supply
- Stabilise surviving cells - viable heal, dying die
- Blood is reabsorbed, toxicity removed
- Masking - create new connections to learn repost skills
Common difficulties experienced on discharge include : (4)
- Previous routines / ADLs
- Adaptation finding, what works, what do they have problems with
- Sick role behaviour, learned helplessness
- Depression related to inactivity
Stress appraisal model
Lazarus & folk man (1984)
Describe Lazarus and folkman’s (1984) stress appraisal model.
- Primary stressor - the stroke, needs, impairments and behaviours as a result.
- Primary appraisal
- Secondary appraisal with resources (eg family, profs, skills…)
- Problem focused coping
Emotion focused coping - Secondary stressors - arise from coping, may feed back into primary appraisal (e.g physio pain - not going to recover)
- Outcome
Health beliefs
Janz & Becker (1984)
What does the health beliefs model consider?
- Demographics
- Perceived susceptibility
- Perceived severity
- Health motivation
- Perceived benefits
- Perceived barriers/costs
- Cues to action
- Preventative action
Describe sensory motor impairment
Paralysis is usually one sided, contralateral to damage
What are the outcomes of sensory-motor impairment?
1/3 no recovery
1/3 need aids
1/3 recover walking
What is the general hierarchy of recover of sensory motor functioning
- Legs
- Arms
- Fingers
What are dyspraxia and apraxia, and what area of impairment are they associated with?
Sensory motor,
Difficulties planning motor sequences
What are important predicates of damage in strokes affecting the sensory motor cortex
Size of damage and connectivity
what percentage rely on unpaid family / carers for help with personal care and ADLs?
Wilkinson et al. (1997) 40-50%
What are some common activities individuals are reliant on carers for following stroke?
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
When does the focus move from spontaneous recovery to compensatory strategies?
6-12 months post stroke.
Coincides with reduction of support
How can the brain develop adaptive strategies and skills? (4)
- Can recover functioning
- Existing neurons can create new connections
- Adjacent brain areas can take over some functioning
- > evidence base evolving
Some themes of depression in stroke: (10)
- Actual loss
- Perceived progression
- Proximity to premorbid self
- Level of disability
- Identity - role changes and adaptations
- Hope for future
- Current relationships, bidirectional influence
- Isolation, abandonment - attachment styles, anxious more difficult
- Access to resources
- Burden/guilt
Common themes in anxiety
- Threat of loss
- Stigma
- Confidence in abilities -falls, ADLs, visual recognition, acalcula, continence, communication
- Another stroke
- Trauma of stroke/hospital
- Guilty, worry about others
What are the quality of life factors that are important to consider (12)
- Finance
- Health
- Personal growth
- Achievements
- Work/career
- Friendship
- Security
- Energy
- Self-esteem
- Fun & recreation
- Home & family
- Relationships
Obstacles to recovery
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%)
Family and carer difficulties
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%
What percentage of stroke services have access to actinic am psychologist?
20%
Factors in mood problems
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
The carers act 2014 states
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
Predictors of distress in carers (6)
Low et al 1999
- Poor information provision
- Lack of appreciation of emotional needs
- Poor preparation for role
- Social isolation
- Reduced self care
- Financial strain
What is associated with aphasia in carers?
Ross & Morris (1998) 1, poorer adjustment 2. Greater role changes 3. Depression 4. Loneliness 5. Rel difficulties
Name predictors of carers who adapt well
Greenwood et al (2009)
- One day at a time
- Routine
- Asking for help / information
- Being patient
- Satisfaction with healthcare services
What percentage return to work after stroke
10%, but this is mostly voluntary.
Odd- 1/3 have no significant problems
Personal predictors of return to work
- Disability severity
- Psychological problems
- Personality
- Gender
- Age
Systemic predictors of return to work
- Social demographic
- Economic demographic
- Employers attitudes
