2012_Vocaturo

Psychological Adjustment following Stroke:

Improving Outcomes & Quality of Life

Loran C. Vocaturo, EdD, ABPP Vice President of Program Development & Education

Select Medical Inpatient Rehabilitation Division [email protected]

2012

Disclosure

Dr. Loran Vocaturo has no industry relationships to disclose

Dr. Loran Vocaturo will not discuss any products or product usage

Which discipline do you represent?

1 2 3 4 5 6

17% 17% 17%17%17%17%

1. Physician 2. Nurse 3. Therapist (PT,OT, SLP) 4. Psychologist or

Counselor 5. Social Worker/Case

Manager 6. Administrator

Pre-Test Questions

What percentage of stroke survivors are affected by post-stroke depression?

1 2 3 4

25% 25%25%25%1. 2% 2. 5-10% 3. 10-20% 4. 40-60%

Post-stroke depression is a left hemisphere syndrome

1 2

50%50%1. True 2. False

Symptoms of post-stroke depression are easy to identify and assess?

1 2


Overall, male stroke survivors have better outcomes than female

survivors.

1 2


Post-stroke anxiety is more common but less disabling than depression.

1 2


Objectives Identify post-stroke depression and other common

emotional reactions Discuss prevalence and implications on rehabilitation

outcomes Discuss the importance of early and accurate

diagnosis Describe differential diagnosis, characteristics and

process of assessment Discuss treatment options to improve adjustment

and QOL

Introduction Post-stroke depression is a common and seriously disabling condition Stroke survivors are more predisposed to PSD compared to physically ill patients with similar levels of disability, even quite a long time after the stroke, regardless of other risk factors.

Prevalence of Psychological & Neuropsychological Symptoms

Post-Stroke Depression (PSD) 40-60%* Anxiety 20-30% Emotional Instability 10-25% Crisis Reaction 20% Cognitive Impairment 50-75%

39% Executive Dysfunction 38% Visual perceptual/Constructional deficits

Importance of the Problem Impact of post-stroke depression

Prolonged hospitalization Limit ultimate level of functional recovery Compromise social integration Higher mortality rate

PSD - 3.4X greater than non-depressed CVA patients

Decreased self-care Less attention to health-related issues General de-conditioning Increased suicide risk

Predictors of PSD

Stroke-related Factors Physical changes (physical limitations, ADL, pain/

spasticity, bladder/sexual dysfunction, driving). Fatigue*

Reduced initiative and fatigue 50-70% Emotional reactions* Communication difficulties* Cognitive impairment* Visual-spatial/visual perceptual impairment*

Individual Risk Factors Psychiatric History (e.g. depression) Pre-morbid personality & coping styles

Self-esteem Self-efficacy Coping style Locus of control Perception of health status Resilience

Age, education/employment status

Individual Risk Factors Habits and lifestyle

Substance Abuse May be cause of stroke, particularly in young

stroke patients abusing stimulants May be consequence or ongoing risk of future

stroke (alcohol and prescription medications) Culture, family structure & social support

Quality of Life: Age Younger stroke patients (age 18-55) *Depression: 50% report general life dissatisfaction Cognitive impairment Fatigue Ability to return to school/work Having a significant other Older stroke patients (>55) *Depression Affected by social support Fatigue Uncertainly about future Caregiving needs

Quality of Life: Gender Male stroke survivors impacted by

Depression * Cognitive impairment Inability to return to work Life partner/support

Women stroke survivors report more dissatisfaction with life in general than men

Depression* Cognitive impairment Coping styles Social Support

*Women have poorer functional recovery after controlling for age and stroke severity *Suggest need for age and gender specific interventions

PSD Etiology

Despite high incidence of post-stroke depression there is limited agreement on etiology and few studies focus on effective treatment and prognosis

PSD Etiology

Structural alterations to the brain Patients response to sudden and disabling

illness Reactive depression: occurs with increased

awareness of functional limitations Implication stroke sequelae has on independence

and community re-integration

*Biological and psychosocial factors play significant roles in the development of this disability disease {depression}.

Structural Changes

Previous studies have suggested that PSD more likely associated with left hemisphere stroke; especially left anterior lesions or basal ganglia involvement.

Recent studies have found less support for specific

hemisphere involvement. Acute depression believed to be secondary to biological

factors and location of lesions. Neurochemical processes may play some role in the

pathophysiology of this condition (e.g depletion of norephinephrine and serotonin)

Identification & Treatment Early identification & treatment benefit patients and their families by

Identifying need for psychological & pharmacological treatment

Containing/reducing sx and related sequelae Improving treatment investment & functional performance Improving staff and patient awareness of safety

concerns Providing platform for patient/family education Improving long-term adjustment & QOL

DSM-IV: Symptoms of Depression Challenges for Assessment & Dx

Affective Somatic Cognitive

Depressed mood; loss of interest/pleasure

Sleep disturbance Reduced attention or concentration

Guilt, Worthlessness Fatigue Indecisiveness

Flattening affect, apathy

Appetite disturbance Suicidal ideation; recurrent thoughts of death

Tearfulness Psychomotor agitation or retardation

Psychosis

PSD Assessment Clinical Interview Beck Depression Inventory II Geriatric Depression Scale KIR admission screening (Cully, et al, 2005 ) Evidence suggests that affective information from stroke

patients is unreliable due to fatigue, confusion, reduced arousal, cognitive impairment, reduced awareness leading to impaired perception of emotional state.

Sole use of standard measures has lead to PSD being

underreported.

Multimodal Approach for PSD Dx

Standardized self and observer report instruments Interview patient and family Behavioral observations by multiple staff in multiple

contexts: * Look for: poor, erratic participation,

noncompliance with treatment, deterioration from previous level of functioning

Treatment for PSD

Multimodal approach most effective Motivation Enhancement Therapy Psychotherapy Pharmacology

Motivational Enhancement

Early intervention program that can be modified for use by non-mental health professionals

Facilitate discussion of and provide support around adjustment to CVA (physical, functional, social support, etc.)

Identify goals for recovery; perceived barriers to progress

Reinforce optimism and positive self-efficacy

Psychotherapy

Cognitive-Behavioral Strategies Improving self-efficacy & problem-focused

coping Reducing cognitive distortions related to

perceived health status Improving management of fatigue and

communication difficulties Improving treatment investment and initiation

of daily activities Providing compensatory strategies for

cognitive deficits

Pharmacological Intervention * Tricyclic antidepressants nortryptiline, imipramine *potential side-effects * SSRI sertraline *fluoxetine paroxetine *escitalopram venlafaxine (SSNRI) * Psychostimulants *methylphenidate

dextroamphetine *modafinil armodafinil

Antidepressant Treatment

Use of antidepressants among patients with a diagnosis of PSD has been associated with improvement in depressive symptoms

Efficacy of sertraline, citalopram and nortriptyline to treat post-stroke depression.

Longer duration of antidepressant treatment may be associated with greater reduction in depressive symptoms

(Chen Y, et al, 2006; Starkstein SE, et al, 2008)

Antidepressant Prophylaxis

May also be helpful in preventing post-stroke depression

Antidepressant prophylaxis was associated with a significant reduction in the occurrence rate of newly developed post-stroke depression

Suggests antidepressants may be considered along with other vascular preventive strategies in the management of stroke patients

(Chen Y, et al, 2007)

Combination Treatment

Escitalopram and problem-solving therapy for prevention of post-stroke depression

Combination therapy - interpersonal psychotherapy plus antidepressant medication

Resulted in a significantly lower incidence of depression over 12 months of treatment

(Robinson RG, et al 2008)

Apathy

Indifference reaction, lack of initiation, motivation caused by organic, neurological factors.

Has been associated more often with right

hemisphere lesions and posterior portion of the internal capsule.

50% patients with subcortical infarctions

demonstrate apathy; 40% of those patients also meet criteria for depression.

Apathy

Apathetic patients tend to be more cognitively impaired and more functionally disabled. Tend to have reduced awareness of deficits.

May also be due to bilateral frontal and anterior temporal hypoactivity as measured by cerebral bloodflow.

May be the result of cortical serotonergic deficits that may improve with dopominergic and serotonergic agents (e.g. psychostimulants).

Depression vs. Apathy

DEPRESSION Is the indifference reaction a

result of the mood disorder? Is the mood disorder

congruent with concerns over implications of CVA?

Do other symptoms of depression exist?

Has the indifference subsided when depression is successfully treated?

APATHY Is apathy the result of

organic factors or neurological etiology?

Does the indifference reaction occur in the absence of other symptoms of depression?

Does the patient demonstrate little concern over the implications of CVA on current or future goals?

Does apathy exist despite treatment of depression?

Assessment of Apathy

Assessment Clinical Observation Family Report Apathy Scale Executive functioning tests

Treatment of Apathy

Psychopharmacological Intervention (antidepressants, psychostimulants)

Improving awareness of symptoms and implications on daily life (CRP)

Behavioral strategies to improve initiation, motivation and participation in daily activities (CRP)

Family counseling, support and behavioral strategies

Pharmacological Treatment

When added to antidepressant treatment, psychostimulants have been found to be effective in treating depression in the general population.

The potential benefits of psychostimulants alone or in combination with antidepressant medication in the stroke population is limited but has received more attention

Impact on rehabilitation outcomes is limited

Effectiveness of Psychostimulants

Stimulant medications can enhance motor recovery, activities of daily living (ADL), mood and cognition in stroke rehabilitation, but human clinical trial results are inconclusive

Psychostimulant Treatment

Methylphenidate (Ritalin) has been advocated in patients with traumatic brain injury and stroke for a variety of cognitive, attention, and behavioral problems.

Rapid effects of methylphenidate may be especially useful to speed recovery from post-stroke depression so that patients can participate more fully in rehabilitation programs

Pharmacological Treatment

Modafinil (Provigil) Possible benefits include improved

wakefulness as well as antidepressant properties to improve motivation and participation in rehabilitation.

Fewer side-effects and potential for abuse than other psychostimulants.

Combination Therapy: Antidepressants + Psychostimulants

Limited information on the role of combination

therapy (antidepressants/psychostimulants)

Several trials have shown evidence that the older, as well as newer antidepressants and psychostimulants may reduce/prevent depressive symptoms after stroke.

Pharmacological Treatment & Rehabilitation Outcomes

Impact of psychostimulants on rehabilitation outcomes (LOS, motor recovery, cognitive recovery, discharge destination) is unclear. Much research needs to be completed before clinicians know precisely whether and how rehabilitation therapies and medications interact to assist in functional recovery. (Zorowitz RD, et al, 2005).

The Future for PSD

Vocaturo, LC, Frisina, P, Martin, RT, Hedeman, R, Pagan, N

Retrospective analysis of N stroke patients admitted to KIR 2011.

Review screening for positive identification of PSD on admission

Review outcomes of depressed patients treated with psychotherapy and/or pharmacological intervention (antidepressants, psychostimulants)

Outcomes include participation in therapy, LOS, FIM change, discharge disposition.

Anxiety

Driven by fear: Fear of recurrent stroke, falling, being stranded away from home may lead to reduced activities or Agoraphobia (most common subtype)

24 % of CVA patients manifest Generalized

Anxiety symptoms (majority of those patients are also depressed)

Treatment for Anxiety

Avoid or limit use of anxiolytics because of sedating and potential anticholinergic effects

SSRI antidepressants may be a better choice Cognitive-behavioral strategies

Problem-focused coping Decatastrophizing Improving self-efficacy Relaxation training

Psychoeducation of stroke & anxiety

Summary A CVA is a traumatic event in the lives of patients and their families

Psychological and neuropsychological sequelae after stroke is

common, but complex and requires comprehensive assessment and treatment

Early identification and treatment can have positive impact on rehabilitation outcomes and quality of life

Combination therapy (antidepressant, psychostimulants and psychotherapy) may be the most effective approach to treating PSD and other psychological syndromes following stroke

While treatment options and approaches may be similar, early and accurate diagnosis plays an important role in patient/family education, course of treatment and prognosis.

Post-Test Questions

A 51-year old male SP Right CVA presented with post-stroke depression, apathy and executive dysfunction. Which of the following likely contributed to his depressive symptomology?

1 2 3 4

25% 25%25%25%1. Fatigue 2. Inability to return to work 3. Pre-morbid alcohol use 4. All of the above

A 51-year old male SP Right CVA presented with post-stroke depression, apathy and executive dysfunction.

How likely would you be to recommend the following treatment for this patient?

Antidepressant Therapy

1 2 3 4

25% 25%25%25%

1. Very Unlikely 2. Unlikely 3. Likely 4. Very Likely



Psychostimulants

1 2 3 4

25% 25%25%25%




Psychotherapy

1 2 3 4

25% 25%25%25%




Cognitive Remediation

1 2 3 4

25% 25%25%25%


References Berkowitz HL. Modafinil in poststroke depression. Psychosomatics. 2005 Jan-

Feb;46(1):93; author reply 93-4. Carlsson, GE, Moller, A, Blomstrand, C. Managing an everyday life of uncertainty

a qualitative study of coping in persons with mild stroke. Disability Rehabilitation. 31(10):773-782. 2009

Carod-Artal, FJ, Egido, JA. Quality of life after stroke: the importance of good recovery. Cerebrovascular Dis. 27: 204-214. 2009

Chen Y, Guo JJ, Zhan S, Patel NC. Treatment effects of antidepressants in patients with post-stroke depression: a meta-analysis. Ann Pharmacother. 40(12):2115-22. 2006

Chen Y, Patel NC, Guo JJ, Zhan S. Antidepressant prophylaxis for poststroke depression: a meta-analysis. Int Clin Psychopharmacol. 2007 May;22(3):159-66

Darlington, AS, Dippel, DW, Ribbers, GM, van Balen, R, Passchier, J, Busschbach, JJ. A prospective study on coping strategies and quality of life in patients after stroke, assessing prognostic relationships and estimates of cost effectiveness. Journal of Rehabilitation Medicine. 41(4):237-241. 2009

References Hakim AM Depression, strokes and dementia: new biological insights into

an unfortunate pathway. Cardiovasc Psychiatry Neurol. 2011;2011:649629 Haley WE, Roth DL, Kissela B, Perkins M, Howard G. Quality of life after

stroke: a prospective longitudinal study.Life Res. 2011 Aug;20(6):799-806 Kajs-Wyllie M. J Ritalin revisited: does it really help in neurological injury?

Neurosci Nurs. 2002 Dec;34(6):303-13. Leach MJ, Gall SL, Dewey HM, Macdonell RA, Thrift AG. Factors associated

with quality of life in 7-year survivors of stroke. J Neurol Neurosurg Psychiatry. 2011 Dec;82(12):1365-71

Lenzi GL, Altieri M, Maestrini I. Post-stroke depression. Rev Neurol Oct;164(10):837-40. Epub 2008 Sep 3.

Lerdal A, Bakken LN, Kouwenhoven SE, Pedersen G, Kirkevold M, Finset A, Kim HS. Poststroke fatigue--a review. J Pain Symptom Manage. 2009 Dec;38(6):928-49

References Masand P, Murray GB, Pickett P.J Psychostimulants in post-stroke

depression.Neuropsychiatry Clin Neurosci. 1991 Winter;3(1):23-7. Ostwald, SK., Bernal, MP, Cron, SG, Godwin, KM. Stress experienced by

stroke survivors and spousal caregivers during the first year after discharge from inpatient rehabilitation. Top Stroke Rehabilitation. 16(2): 93-104. 2009

Paolucci S. Epidemiology and treatment of post-stroke depression. Neuropsychiatr Dis Treat. 2008 Feb;4(1):145-54.

Perlesz, A, Kinsella, G, Crowe, S. Psychological distress and family satisfaction following traumatic brain injury: injured individuals and their primary, secondary, and tertiary carers. 15(3): 909-929. 2000

Robinson RG, Jorge RE, Moser DJ, Acion L, Solodkin A, Small SL, Fonzetti P, Hegel M, Arndt S. Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial. JAMA. 2008 May 28;299(20):2391-400.

References Starkstein SE, Mizrahi R, Power BD. Antidepressant therapy in post-stroke

depression. Expert Opin Pharmacother. Jun;9(8):1291-8. 2008 Sugden SG, Bourgeois JA. Modafinil monotherapy in poststroke

depression. Psychosomatics. 2004 Jan-Feb;45(1):80-1. Tharwani HM, Yerramsetty P, Mannelli P, Patkar A, Masand P. Recent

advances in poststroke depression. Curr Psychiatry Rep. 2007 Jun;9(3):225-31.

Vanhook, P. The domains of stroke recovery: a synopsis of the literature. Journal of Neuroscience Nursing. 41(1): 6-17. 2009

Vickery, CD, Evans, CC, Sepehri, A, Jabeen, LN, Gayden, M. Self-esteem stability and depressive symptoms in acute stroke rehabilitation: Methodological and conceptual expansion. Rehabilitation Psychology. 54(3): 332-42. 2009

Psychological Adjustmentfollowing Stroke: Improving Outcomes & Quality of LifeDisclosureWhich discipline do you represent?Pre-Test QuestionsWhat percentage of stroke survivors are affected by post-stroke depression?Post-stroke depression is a left hemisphere syndromeSymptoms of post-stroke depression are easy to identify and assess? Overall, male stroke survivors have better outcomes than female survivors.Post-stroke anxiety is more common but less disabling than depression.ObjectivesIntroductionPrevalence of Psychological & Neuropsychological SymptomsImportance of the ProblemPredictors of PSDIndividual Risk FactorsIndividual Risk FactorsQuality of Life: AgeQuality of Life: GenderPSD EtiologyPSD EtiologyStructural Changes Identification & TreatmentDSM-IV: Symptoms of DepressionChallenges for Assessment & Dx PSD AssessmentMultimodal Approach for PSD DxTreatment for PSDMotivational EnhancementPsychotherapyPharmacological Intervention Antidepressant TreatmentAntidepressant ProphylaxisCombination TreatmentApathyApathyDepression vs. ApathyAssessment of ApathyTreatment of ApathyPharmacological TreatmentEffectiveness of PsychostimulantsPsychostimulant TreatmentPharmacological TreatmentCombination Therapy: Antidepressants + PsychostimulantsPharmacological Treatment & Rehabilitation OutcomesThe Future for PSDAnxietyTreatment for AnxietySummaryPost-Test QuestionsA 51-year old male SP Right CVA presented with post-stroke depression, apathy and executive dysfunction. Which of the following likely contributed to his depressive symptomology?A 51-year old male SP Right CVA presented with post-stroke depression, apathy and executive dysfunction. How likely would you be to recommend the following treatment for this patient?Antidepressant TherapyA 51-year old male SP Right CVA presented with post-stroke depression, apathy and executive dysfunction. How likely would you be to recommend the following treatment for this patient?PsychostimulantsA 51-year old male SP Right CVA presented with post-stroke depression, apathy and executive dysfunction. How likely would you be to recommend the following treatment for this patient?PsychotherapyA 51-year old male SP Right CVA presented with post-stroke depression, apathy and executive dysfunction. How likely would you be to recommend the following treatment for this patient?Cognitive RemediationReferencesReferencesReferencesReferences

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2012_Vocaturo