Nicole Walmsley

The Invisible Effects of Stroke

1

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

Introduction

3

Invisible symptoms

Cognition

Visual perception

Emotion

Fatigue

Consider the Difference

4

Hospital Home

Cognition and Post Stroke Cognitive Deficits

5

The

majorityexperience

cognitive

impairment

(RCP 2016)

Cognition and Post Stroke Cognitive Deficits

6

(XXX)

• VIDEO

• https://www.youtube.com/watch?v=6Y67e69YlZc

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

SEVERE

• Independent

• Orientated

• “Self caring” ward

environment

Spectrum of Cognition

8

• 1:1

• Disorientated

MILD

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)

Post Stroke Cognitive Deficits

10

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)

Post Stroke Cognitive Deficits

11

2. High level cognitive impairments

• Executive dysfunction:

Plan, organise, realistically goal set, insight, manage non-routine

• Anasognosia:

Loss of awareness of their deficits

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

Hemispheres

Right hemisphere

• Visual spatial deficits

• Emotional problems

• Left sided neglect

Left hemisphere

• Apraxia

Post Stroke Cognitive Impairments

14

• 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

Post Stroke Visual Perceptual Impairments

15

92%have visual

impairment

(ROWE, 2009)

Neuroanatomy of Visual Perceptual Impairments

16

Post Stroke Visual Perceptual Impairments

17

Vision Loss

• Homonymous hemianopia

• Homonymous quandranopia

Post Stroke Visual Perceptual Impairments

18

Cortical blindness

Post Stroke Visual Perceptual Impairments

19

Visual perception

• Spatial impairments:

• Hemi-spatial neglect*

• Depth perception

• Figure ground

* Most common

Post Stroke Visual Perceptual Impairments

20

Visual perception

• Agnosia:

Failure to recognise stimuli despite

adequate primary visual function

• Prosopagnosia:

Difficulty recognising differences in

faces.

Common Signs of Visual Perceptual Impairments

21

• Wearing clothes inside out

• Spilling hot drinks

• Eating half of their dinner

• Bumping into doorways/ people/ obstacles

• Not being able to recognise objects

Importance of Cognitive Screens

22

Cognition screen

• Visual spatial

• Attention

• Language

• Executive dysfunction

• Memory

Rehabilitation of Cognition and Visual perception

23

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

The Nurses Role

24

• 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

.

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.

25

Post Stroke Fatigue

26

50%experience

fatigue

(Mckivitt, 2001 )

Post Stroke Fatigue

27

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

Management Strategies

28

• 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

Post Stroke Emotional Changes

29

1/3 experience

depression

25%experience

anxiety (RCP 2016)

Post Stroke Emotional Changes

30

Definition

• Anger

• Frustration

• Anxiety

• Sadness

• Fear

• Hopelessness

• Emotionalism

Causes

• Reaction to sudden effect of life

changing

• Damage to the brain

• Genetic

• Social factors

Emotional Changes

31

Treatment

• Medication

• Cognitive behavioral therapy

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.

Questions?

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