the invisible effects of stroke - londonscn.nhs.uk · the invisible effects of stroke 1. overview 2...
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Nicole Walmsley
The Invisible Effects of Stroke
1
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Overview
2
The objective is to:
1. identify four common invisible effects of a stroke
2. demonstrate how nursing staff can identify these on an
acute stroke unit
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Introduction
3
Invisible symptoms
Cognition
Visual perception
Emotion
Fatigue
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Consider the Difference
4
Hospital Home
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Cognition and Post Stroke Cognitive Deficits
5
The
majorityexperience
cognitive
impairment
(RCP 2016)
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Cognition and Post Stroke Cognitive Deficits
6
(XXX)
• VIDEO
• https://www.youtube.com/watch?v=6Y67e69YlZc
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Definition
• Cognition refers to the
brain functions for
perceiving, thinking,
remembering and
applying knowledge in
the right way
Cognition and Post Stroke Cognitive Deficits
7
Causes
• Localised damage due to stroke
• Infection/ delirium
• Pre-morbid disease e.g. dementia
• Mood disturbance
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SEVERE
• Independent
• Orientated
• “Self caring” ward
environment
Spectrum of Cognition
8
• 1:1
• Disorientated
MILD
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Why Is Assessing Cognitive Impairment Important?
9
Associated with:
• Poorer rehab outcomes
• Increased length of stay
• Poorer physical functioning at discharge (RCP 2012)
• Higher mortality 1 year following stroke (Leys et al. 2005, Hinkle 2006,
Zinn et al 2004)
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Post Stroke Cognitive Deficits
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1. Basic cognitive impairments
• Information Processing:
Slow speed of thinking
• Attention:
Impaired focused, sustained, divide, alternating attention.
• Memory:
Impaired ability to store and retrieve visual and verbal information
(short term and long term)
• Apraxia:
Unable to cognitively plan movements (ideational, ideomotor)
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Post Stroke Cognitive Deficits
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2. High level cognitive impairments
• Executive dysfunction:
Plan, organise, realistically goal set, insight, manage non-routine
• Anasognosia:
Loss of awareness of their deficits
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Neuroanatomy of Cognition
ACA
• Memory
• Abulic
symptoms
• Apathy
• Frontal
executive
impairment
• Abstract
thinking
• Inhibition
• Apraxia
Right MCA
• Neglect
PCA
• Agnosia
• Cortical
blindness.
• Severe
memory
impairments.
Left MCA
• Apraxia
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Hemispheres
Right hemisphere
• Visual spatial deficits
• Emotional problems
• Left sided neglect
Left hemisphere
• Apraxia
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Post Stroke Cognitive Impairments
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• Don’t initiate going to the bathroom
• Go to the bathroom but forget all their belongings
• Not recalling your name yet you have looked after them many times
before.
• Using their toothpaste as their toothbrush.
• Doesn’t appear to be concerned about their stroke
• Takes a long time to do tasks such as eat their dinner yet have no
physical impairment
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Post Stroke Visual Perceptual Impairments
15
92%have visual
impairment
(ROWE, 2009)
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Neuroanatomy of Visual Perceptual Impairments
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Post Stroke Visual Perceptual Impairments
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Vision Loss
• Homonymous hemianopia
• Homonymous quandranopia
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Post Stroke Visual Perceptual Impairments
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Cortical blindness
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Post Stroke Visual Perceptual Impairments
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Visual perception
• Spatial impairments:
• Hemi-spatial neglect*
• Depth perception
• Figure ground
* Most common
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Post Stroke Visual Perceptual Impairments
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Visual perception
• Agnosia:
Failure to recognise stimuli despite
adequate primary visual function
• Prosopagnosia:
Difficulty recognising differences in
faces.
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Common Signs of Visual Perceptual Impairments
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• Wearing clothes inside out
• Spilling hot drinks
• Eating half of their dinner
• Bumping into doorways/ people/ obstacles
• Not being able to recognise objects
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Importance of Cognitive Screens
22
Cognition screen
• Visual spatial
• Attention
• Language
• Executive dysfunction
• Memory
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Rehabilitation of Cognition and Visual perception
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1. Educate and build insight
2. Teach strategies
• Use of a diary
• Use of a timetable
• Visual scanning
• Use of prompt cards
• Use of alarms
3. Functional task practice
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The Nurses Role
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• Assist with intensity and repetition- provide 24 hour approach
• Give feedback to patients.
• Support use of aids- diaries, alarms, prompt sheets.
• Feedback to the ward
• Observe
.
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Tips
• Consider written information to assist with slow, processing, attention,
memory
• Consider the business of the ward- could you give information in a
quiet place?
• Prepare patients for home… encourage independence.. challenge.
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Post Stroke Fatigue
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50%experience
fatigue
(Mckivitt, 2001 )
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Post Stroke Fatigue
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Definition
• Not relieved by rest.
• Mental or physical
• Causes unknown
• Impact on cognition
Factors associated with fatigue
• Depression
• Side effects of medication
• Disturbed sleep
• Pain
• Anxiety
• Respiratory problems
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Management Strategies
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• Information and education
• Identification of strategies – triggers, re-energisers
• Environmental modifications
• Lifestyle change
• Scheduling and pacing
• Cognitive strategies to reduce mental effort
• Psychological support to address mood, stress and adjustment
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Post Stroke Emotional Changes
29
1/3 experience
depression
25%experience
anxiety (RCP 2016)
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Post Stroke Emotional Changes
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Definition
• Anger
• Frustration
• Anxiety
• Sadness
• Fear
• Hopelessness
• Emotionalism
Causes
• Reaction to sudden effect of life
changing
• Damage to the brain
• Genetic
• Social factors
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Emotional Changes
31
Treatment
• Medication
• Cognitive behavioral therapy
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Key Takeaways
32
• Stroke is a brain condition with many non-motor deficits.
• The ‘Invisible’ affects can be very disabling for patients
• Nurses have a key role in identifying and helping patients manage these
problems.
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Questions?
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References
• Blake et al (2002) An evaluation of screening measures for cognitive impairment after stroke. Age and ageing 31 (6):451-456
• Doyle (2002) Measuring health outcomes in stroke survivors. Achieves of physical medicine and rehabilitation. Supplement 2, pages
S39-S43
• Intercollegiate Stroke Working Party (2016) ‘National clinical guideline for stroke’. Royal College of Physicians
• McKevitt, C., Fudge, N., Redfern, J., Sheldenkar, A., Crichton, S., Rudd, A. R., Forster, A., Young, J., Nazareth, I., Silver, L. E., Rothwell, P. M. and Wolfe, C. D. A. (2011) ‘Self-reported long-term needs after stroke’, Stroke, 42(5), pp. 1398–1403. doi: 10.1161/STROKEAHA.110.598839.
• Rowe, F., Brand, D., Jackson, C. A., Price, A., Walker, L., Harrison, S., Eccleston, C., Scott, C., Akerman, N., Dodridge, C., Howard, C., Shipman, T., Sperring, U., Macdiarmid, S. and Freeman, C. (2009) ‘Visual impairment following stroke: Do stroke patients require vision assessment?’, Age and Ageing, 38(2), pp. 188–193. doi: 10.1093/ageing/afn230.
• Stroke Association (2015) Life after stroke: Depression and emotional changes. Information leaflet
• Stroke Association (2015) Life after stroke: Fatigue after stroke. Information leaflet
• Stroke Association (2015) Life after stroke: A complete guide to cognitive problems after stroke. Information leaflet
• Stroke Association (2015) Life after stroke: Visual problems after stroke. Information leaflet