Psychological impact of a stroke and rehabilitation

Question 1

Challenges of illness

Answer 1

• Treatment and hospitalisation
• Disruption to daily living
• Uncertainty, threat to future
• Burden of ongoing self-care, lifestyle changes

Question 2

Psychosocial challenges in a stroke

Answer 2

• Cognitive impairment
• Perceptual impairment (psychological process of taking in information and using that to make decisions about our actions)
• Limitations to communication
• Participation in activities
• Psychological functioning
• Leads to anxiety/depression/emotionalism

Question 3

Emotional and cognitive responses to stroke

Answer 3

• Emotional impact is a key feature of some conditions and increasingly recognized in others
• Common emotional responses include emotionalism/anxiety/depression, frustration and anger
• Emotionalism: lessening of control over emotions, increased tendency to cry or laugh
• Emotionalism can be embarrassing and may interfere with treatment, affects 20-25% of patients in first 6m of stroke
• Symptoms of emotionalism generally get better with time

Question 4

Frustrated response to stroke

Answer 4

• Frustration e.g. about not being able to do normal things is normal and understandble
• Can escalate into anger and be directed at others
• Can complicate relationships, focus concerns away from illness and lead to reactance
• Common post-stroke and may affect longer term adherence to rehab

Question 5

Anxious responses to stroke

Answer 5

• Re: consequences of illness/treatment, unavoidable
• Re: procedures, can be reduced with good clinical care
• Results in disturbing beliefs, increased attention to symptoms, alters perception, interpretation of information and memory recall
• Initially can be positive as it motivates, helps patients overcome initial adjustment but problematic if prolonged/disproportionate and linked to depression
• Affects 25-33% of stroke patients

Question 6

Depressed responses to stroke

Answer 6

• Common reaction indicated by persistent low mood, loss of interest or pleasure in normal activities
• Can have huge negative effects: suicide, poor adherence, lack of motivation, alienation of others
• 1 in 3 stroke patients will experience
• Largest effect on worsening health

Question 7

When will depressed responses be more common?

Answer 7

• Life threatening or chronic illness, unpleasant or demanding treatment, low social support/adverse social circumstances, history of depression/alcohol or drug abuse

Question 8

Why is it important to address depressive responses to a stroke?

Answer 8

• Reduced survival
• Increased risk of further acute events and complications
• Increased symptoms, disability and reduced quality of life
• Prolonged recovery, poorer outcomes from treatment
• Increased costs of care

Question 9

What are illness cognitions?

Answer 9

A patient’s own implicit common sense beliefs about their illness

• Mental representation for recognising symptoms and responding to illness experience
• Developed through own and others’ experiences, media, education etc
• Qualitative and quantitative research to investigate

Question 10

Dimensions of illness cognitions

Answer 10

• Identity: label, signs, symptoms
• Cause: biological, psychological, multi-factorial
• Timeline: duration, pattern
• Consequences: short and long term effects on life
• Curability/controllability: by themselves/others
• Links to wider beliefs about body and medicine

Question 11

What are stressors?

Answer 11

Physical, psychological threat to well being, placing demands that require adaptation, leading to stress response

Question 12

What is a stress response?

Answer 12

Biological and psychological (behavioral, cognitive, emotional) response associated with internal state of strain/tension/arousal

Question 13

What is stress?

Answer 13

An interaction between stressor and response perceived as discrepancy between demands vs resources and ability to cope

Question 14

What does the self-regulatory model do?

Answer 14

Suggests how illness beliefs interact with emotional response to influence actions

Question 15

Aspects of self-regulatory model

Answer 15

• Interpretation: understanding problem/stressor
• Coping: address problem to re-establish normality
• Appraisal: assessing success of coping
• Re-interpretation: additional coping as necessary

Question 16

What does coping mean?

Answer 16

Constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding resources

Question 17

Stages of adjustment

Answer 17

Major event 
Shock and denial 
Anger
Depression
Coming to terms
Acceptance
Moving on

Question 18

Social support

Answer 18

• Positive social support provides emotional and practical assistance to enhance effective coping and adjustment
• Presence of support alone not enough: carers may not be coping themselves, burdens associated with relationships (guilt, protection, expectations)
• Clinicians have key role in forming supportive relationship by providing opportunities for disclosure, effective listening, ensuring continuity and follow up
• Clinicians can facilitate support outside clinical context by involving carers and support groups
• ‘Take into consideration the impact of the stroke on the person’s family, friends and/or carers and, if appropriate, identify sources of support’

Question 19

What is a stroke rehabilitation service?

Answer 19

Comprises a multidisciplinary team of people who work together towards goals for each patient, involve and educate the patient and family and have relevant knowledge and skills to help address most common problems faced by their patients

Question 20

Cycle of rehabilitation

Answer 20

• Multi-disciplinary assessment to identify/measure patients’ difficulties and needs
• Goal setting for long/medium/short term improvements
• Interventions to support change and assist in achievement of goals
• Evaluation of re-assessment to assess progress against agreed goals

Question 21

Stages of stroke rehabilitation

Answer 21

• Inpatient stage: stroke unit with multi-disciplinary team (e.g. drs, nurses, physios, OTs, SLTs, psychologists, social worker etc) plus access to other services (e.g. continence, psychiatry) as needed. Focus on mobilization, education
• Early post discharge: multi-disciplinary stroke team in community with links to GP and social care where necessary, plus ongoing training and support for carers with daily activities (OTs)
• Ongoing: structures exercise training with educational and psychological support and advice based on goal setting with stroke patient and family/carers. Initially 45 min 5 days per week, later tailored to needs/ability

Question 22

Characteristics of goals in stroke rehabilitation

Answer 22

• Meaningful and relevant to individual
• Focus on activity and participation
• Challenging but achievable
• Both short and long term
• Communicated, understood and supported
• Reviewed regularly
• Part of a broader, individual rehab plan

Question 23

Cognitive support for stroke victims

Answer 23

• Visual neglect affecting functions such as mobility, dressing, eating
• Memory (e.g. using associations, mnemonics, encoding, aids)
• Attention (e.g. attention training)