448 - Post Stroke Psychosocial Issues Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC Executive Director: AllCEUs Podcast Host: Counselor Toolbox, Case Management Toolbox, NCMHCE Exam Review

Objectives • Examine the prevalence of and risk factors for stroke • Identify Post-Stroke Psychosocial Issues Intro • Many of our clients are at high risk of stroke • People with anxiety disorders have a 33% higher risk of stroke partly due to HBP and lifestyle factors such as smoking • Mood stabilizers were collectively associated with a significantly increased risk for stroke in participants with bipolar disorder • Benzodiazepine use is associated with a 20% higher risk of stroke • Almost 40% received 1 or a combination of drugs hypothesized to impair recovery during the first 30 days after stroke.(e.g. clonidine which reduces NE levels, atypical antipsychotics, benzodiazepines) Risk for Stroke • Smokers are 2-4x as likely to have a stroke • Make blood sticky and more likely to clot, which can block blood flow to the heart and brain • Damage cells that line the blood vessels • Increase the buildup of plaque (fat, cholesterol, calcium, and other substances) in blood vessels • Cause thickening and narrowing of blood vessels • Alcohol increases stroke risk by 38% • Causing A-Fib • Development of atherosclerosis, or the hardening and narrowing of arteries • Liver damage impairing blood clotting • HBP during detoxification Risk for Stroke • Stimulant abuse increasing blood pressure • High blood pressure • Sleep apnea • Non-sleep-apnea sleep disorders • Age • Diabetes doubles the risk of stroke • Use of nonsteroidal anti-inflammatory drugs (NSAIDs), but not aspirin, may increase the risk of heart attack or stroke, particularly in patients who have had a heart attack Mini-Strokes • The signs and symptoms of a TIA resemble those found early in a stroke and may include sudden onset of: • Weakness, numbness or paralysis in your face, arm or leg, typically on one side of your body • Slurred or garbled speech or difficulty understanding others • Blindness in one or both eyes or double vision • Dizziness or loss of balance or coordination • Sudden, severe headache with no known cause • 70% reported that their TIA had long-term effects including memory loss, poor mobility, problems with speech and difficulty in understanding. 60% of people stated that their TIA had affected them emotionally

Assessments • When • Just before discharge • One month after stroke • Three months after stroke • Six months after discharge • What to look for • Cognitive functioning • Depression • Anxiety • Social withdrawal • Changes in physical presentation Impacts of Stroke • General Physical Issues • Reduced mobility / independence • Vision problems • Difficulty with ADLs • Difficulty swallowing • Sleep problems (36%) • Chronic headaches • Pneumonia • Pain

Impacts of Stroke • Difficulty understanding or expressing emotions • Post-stroke depression (PSD) (67%) • Post-stroke depression may remit as the person regains function • Correlated with hospitalization, functional loss and particular areas of the brain being damaged • Post-stroke anxiety (25%) • Post-stroke emotional incontinence (PSEI) uncontrollable outbursts of involuntary laughing or crying for no apparent reason (34%) • Functional status, serotonin polymorphisms, and low social support were related to PSEI at three months post-stroke • SSRIs are often effective

Impact • Post-stroke anger proneness (PSAP) • serotonergic dysfunction seems to play a role in the development of PSAP • Post-stroke fatigue (PSF) (50%-86%) • Depression • Neurological deficits • Antidepressants • Sleep disturbances • Post-stroke pain • Changes to thinking, memory and perception after stroke can impact how the person sees, hears and feels the world. This can affect how they feel about themselves and others

Impact • Cognitive skills can be affected by emotional state or tiredness, but brain damage caused by stroke can also cause difficulties with • Ability to learn new skills • Ability to plan • Ability to problem solve • Attention – being able to concentrate and focus • Orientation – knowing the day and time • Short-term memory – knowing what happened recently • Changes in working memory • Intellectual fulfillment

Attention and Memory Intervention • Minimum of 1 hour a day of actively listening to music showed recovery in both verbal memory and focused attention, as early as 3 months after a stroke Impact • Personality changes • Repetitive behavior • Disinhibition – tendency to say and do things that are socially inappropriate • Impulsivity including sudden and socially inappropriate actions.

Impact • Perception is the term that describes how you see, hear and feel the world. After a stroke, your perception can include changes to: • Feeling contact, pain, heat or cold on the side of your body affected by stroke • Judging distance • Performing certain movements even without physical disability (apraxia) • Recognising shapes and objects, or even your own body • Seeing or feeling things only on one side – which can cause you to bump into things • Watching TV or reading – can become difficult • Vision – some people lose half their vision in each eye (hemianopia).

Impact • Communication after stroke • Difficulty in finding the right words or understanding what others are saying (aphasia or dysphasia) • Weakness in the muscles that help speech (dysarthria) • Dysfunction of the nerve connection between your brain and mouth, making speaking difficult (dyspraxia) • Reading and writing problems caused by a weak writing hand or problems thinking or seeing.

Impact • Physical changes after stroke • Difficulty with gripping or holding things • Fatigue or tiredness • Incontinence – many types of incontinence can occur, but it can be caused by medication, muscle weakness, changes in sensations, thinking and memory • Pain – can be caused by actual or potential damage to tissues (nociceptive pain) or by damage to nerves that then send incorrect messages to the brain (neuropathic pain) • Restricted ability to perform physical activities or exercise • Swallowing issues • Vision problems • Weakness or paralysis of limbs on one side of the body.

Impact • Aphasia • Affects about one third of the stroke population and 40% continues to have significant language impairment at 18 months post-stroke • Persons with aphasia (PWA) are especially prone to psychosocial problems, such as • Anxiety and depression • Threatened identity • Changes in interpersonal relationships • Reduced social networks • Unemployment • Abandonment of leisure activities Post Stroke Grief • Losses • Independence • Function/hobbies/employment • Home (if moved to an ALC) • Self-Esteem • Appearance Post-Stroke Guilt • Not being able to do things with kids/family/friends that they used to • Needing assistance from caregivers/feeling like a burden

Post-Stroke Interpersonal Issues • Social life • Personality changes, anger, depression, fatigue may inhibit relationships • Emotional Incontinence may cause social withdrawal • Financial challenges • Loss of employment • Need for an ALC • Need for PT/OT Post-Stroke Caregiver Needs • Caregivers should be assessed for their ability to provide care • Regularly assess caregiver wellbeing • Caregiver Strain Index • Caregiver Burden Scale • Support caregivers in balancing personal needs and caregiving responsibilities by providing community programs, respite care, and educational opportunities Summary • Stroke impacts people physically, affectively, cognitively, and interpersonally. • It is important to explore the causes of mood or cognitive issues to identify the best interventions • Brain damage • Sleep dysfunction • Cognitive issues • Life changes