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Improving Psychological Care After Stroke

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Improving Psychological Care After Stroke Dr Steve Margison Consultant Clinical Neuropsychologist South Devon Healthcare NHS Foundation Trust How do we know who to be ... – PowerPoint PPT presentation

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Title: Improving Psychological Care After Stroke


1
Improving Psychological Care After Stroke
  • Dr Steve Margison
  • Consultant Clinical Neuropsychologist
  • South Devon Healthcare NHS Foundation Trust

2
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3
Accelerated Stroke Improvement (ASI)
Joining Up Prevention
Implementing Best Practice in Acute Care
Improving Post Hospital and Long Term Care.
Domains
  • Early Supported Discharge
  • Joint Care Plans using Single Assessment Process
  • 6/12 review
  • Psychological Support

Key Areas of Focus
  • Direct Admission to a Stroke Unit
  • Timely Brain Scan
  • (1 Hour and 24 Hour)
  • AF Detection and Treatment
  • Timely and effective management of TIA

4
ASI 6 Timely Access to Psychological Support
5
Psychological Services for Stroke Survivors and
their Families
  • Key Recommendation
  • Psychological Screening for both cognitive
    impairment and mood disorder should become
    routine within all hospitals admitting stroke
    patients
  • Also provides recommendations on Service
    Specifications, structure and staffing

January 2010 Edition
6
How do we know who to be concerned about?
  • West et al (Stroke, 2010, 41, 1723-1727)
  • Investigated trajectory of psychological symptoms
    and their impact on functional recovery.
  • 444 patient assessed at 2-6 weeks, then followed
    up at 9, 13, 26 52 weeks.
  • Used GHQ to look at psychological symptoms and
    modified Barthel Index for function.

7
West et al (2010)
  • Strong association between trajectory of
    psychological symptoms and functional outcome.
  • Four classes or groups of patients identified
    based on GHQ.
  • Groups show a gradual decrease in psychological
    distress over time.
  • Cluster 37 scored above the WHO threshold for
    1st 3 months and continued to have problems.

8
West et al (2010)
  • Cluster 37 had more pre-morbid depression.
  • Higher dep. lt-gt poorer Barthel scores but there
    was wide variation in this group.
  • One high score does not predict poorer outcome
    but trajectory does seem to.
  • Poorer functional outcome actually associated
    with
  • Psychological symptoms
  • More severe disability early on
  • Age

9
How to assess?
  • Depression and distress are not the same.
  • Measures of depression are similar in content -
    dont produce different results.
  • Ask questions as well as doing questionnaires
    e.g. previous problems?
  • It matters more that we ask and do something with
    the results.

10
What should we do with patients who are
depressed? - On a Stroke Unit or Ward
  • Keep relevant notes
  • Watchful waiting
  • Refer to mental health professional e.g.
    psychiatric liaison.
  • Consider anti-depressant medication
  • (Kneebone et al, British Journal of Occupational
    Therapy, February 2010)
  • Pass on your concerns on discharge.

11
What should we do with patients who are depressed?
  • Stepped care suggests interventions based on need
    not one size fits all.
  • Sub-threshold problems are everyones
    responsibility - all staff and peer support?
  • Mild-moderate problems should be dealt with by
    designated staff - Stroke Ward, Rehab,
    Re-Ablement etc.
  • Severe or persistent problems need to be managed
    by specialist services - Mental Health
    professionals.

12
What should we do with patients who are depressed?
  • Cochrane review
  • Anti-depressants are most effective if used for
    people who are moderately to severely depressed
    (15).
  • Cognitive behaviour therapy isnt useful.
  • BUT there is significant criticism of the
    Cochrane review which points out that it was
    based on a study with poor protocols for doing
    CBT.
  • In reality IAPT services will be important.

13
What could we do in Stroke Services.
  • Brief interventions that are strong on engagement
    and acceptability are important.
  • Activity Scheduling
  • Problem Solving
  • Active Listening
  • Motivational Interviewing?
  • Staff need supervision and training.

14
South Devon
  • Devising a stepped care model.
  • Engaging the stakeholders.
  • Working with resources we have.
  • Training as many staff as possible to be aware of
    psychological issues.
  • Agreeing which assessment, when, by whom.
  • Exploring referral pathways.

15
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16
Some things to remember.
  • Not all psychological disorder post stroke arises
    from the stroke. At least half of all depression
    post-stroke arises from depression before stroke
    (Prof. Allan House, Liaison Psychiatrist).
  • Mental and physical health needs should be of
    equal importance.
  • Targeting interventions isnt possible without
    on-going monitoring.
  • Do something to get started.
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