The Role of Rehabilitation Professionals in Mental Health Disorders Following Stroke

Original Editor - User Name

Top Contributors - Stacy Schiurring, Jess Bell, Kim Jackson and Matt Huey  

• Mental Health Disorders following stroke.
  • Introduction
  • Highlighting the most important risk factors that the rehab professional can take note of (briefly discussed)
  • Assessment - this focus would be to emphasise the importance of considering this in the assessment and to .  this portion may include rehab assessment too in order to develop a rehab plan... like occupational profile, pain assessment etc.  History taking. Occupational Therapy creates the occupational profile into mental health, previous experiences and family members with it.  What is meaningful to the person, enjoy previous to the stroke.  Pain Assessment always part of it. Cognitive assessment.  (Look at articles)
    • Management for each it relates to rehabilitation.  
      • Occupational Therapy covers mental health in undergrad.  Scope of practice more mental health focus.  
      • CBT - Trained professionals in your team.  
      • Physical Activity - PT programme, OT motivation and in routine, team can encourage physical activity and check therapists what is good for this person.  
      • Speech Therapy does cognitive training and communication.
      • Talk the team to find out who is trained.  

Introduction

Always have a detailed assessment of the mental health aspect. And because this more or less affects the rehabilitation outcome, be it any rehabilitation protocol, it can be speech, it can be physiotherapy, it can be occupational therapy. So, these psychological problems following stroke should be very carefully assessed. Also by the medium of this course, that whenever you are seeing a patient, either in an inpatient or outpatient setting, with quite a lot of affection in their mental health it is important to remember that it is not that only one rehabilitation professional can deal with it. So we require a team of rehabilitation professionals from different disciplines so that we can give the patient a better clinical outcome. So, identifying the features and the disciplines which are expert in dealing with them.

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So as we know that stroke, or cerebrovascular accident, is particularly characterised by sensory and motor difficulties and which presents as hemiplegia or hemiparesis, leading to difficulty in balance, gait, activities of ADL. (Activities of Daily Living) So now what happens is that we address all of these difficulties, but the mental health aspect remains overlooked. So, as a result of which, what happens that the patient performs poorly in all of these other interventions. And it is very important to identify that this poor performance is because some psychological issues are present which are not been assessed or treated. So psychiatric disorders are very common complications following stroke and which are associated with low quality of life, worsening of treatment outcomes, also increasing the burden on the caregivers, and deterioration of the functional status of the patient.

So neuropsychiatric disorders following stroke also increase the mortality. In this course, I will be talking about three major neuropsychiatric disorders or mental health issues following stroke: post-stroke depression, post-stroke anxiety, and post-traumatic stress disorder. (PTSD) In addition to this some rare disorders, which are not that prevalent, are psychosis and mania. And it can be present in combination of any of these.

Assessment

Now, we are going to understand the assessment of these mental health disorders in general. The first is history of present illness. So it is very important. And now I want to repeat this again, as we are going through this section of assessment, you will see that the format is very simple as we take the neurological examination. So my aim here is that you should incorporate these aspects in your regular assessment. Even if it is better to screen the patient, even if the patient does not present with any obvious signs. Because you are not going to find this any obvious signs initially. So, history of present illness. It is important to screen for any psychological symptoms in the initial phases of stroke. Then, history of onset of symptoms, along with characteristic severity psychological symptoms and somatic symptoms which are associated with this. So, this is correlated to, as we just discussed about the features or physiological features associated with anxiety. Dizziness and increase in heart rate. So all of this has to be taken. Also, the detailed history of stroke. Why? Because, what happened? How it happened. What was the cause? How was inpatient programme? How was the situation when the patient got discharged? Because all of these is associated with PTSD.

Now, past history. It is important to know if there were any previous episodes of stroke, even TIA, that is transient ischaemic attack. Previous history of any psychological disorder such as depression, anxiety, anything. Also, treatment outcomes for any of the previous conditions should be assessed, if the patient was on certain medications for a longer duration of time, anything. Also, it is very important to assess for vascular risk factors such as angina pectoris, hypertension, because they're independent predictors of post-stroke depression. Personal and family history, how much support the patient is getting from the family. First, because this is very much coordinated with the outcomes. Secondly, age of the patient. As we have just discussed, that patients, younger patients, less than 65 years of age are more prone to develop the psychological issues. Gender. It has been documented that in certain psychological issues the female gender is more prominent. Family income, because this is going to affect how the patient has access to these rehabilitation services. Personal and social support. Also, it is very important to document any family history of psychological illness because some of these are genetically mediated. Right.

One of the important things here is occupational therapy assessment. This is done by a specialised team of occupational therapists. So if you feel that the patient is having some of these clinical features and in your initial assessment if you find that they're very much prone, it is very much important to refer them to an occupational therapist who is specialised in assessing and also has a very important role to play in the rehabilitation as well. So what does occupational therapy assessment, include? It is the name and the type of assessment, with results. Very basic. State if the procedure is standardised, and source of referral. Where the patient was referred to, from whom, and why the person is seeking services. What are the areas of occupation the patient is successful, and which one of those are causing problems, such as, it can be anything, education, work, play, social participation, motor skills, process skills, communication skills, interaction skills, habits and routines. So all of this has to be assessed that how the patient is able to do it, that is how much successful the patient is, and where the patient is facing the problems. What is hindering the performance of the patient? And what is promoting the performance of the patient? Occupational performance history, very much important. And an individual's priorities and what are the target outcomes for that particular patient. How like every patient has a different lifestyle, so what the patient is expecting. That has to be documented. Occupational therapists are specialised professionals who utilise journal writing as an expressive media, a psychological tool. And, apart from this, there are different scales. The details of the scales, any of the scales, which I'm going to talk, will be available on the Physiopedia pages. So kindly go through them.

Then the scales for occupational therapists are Performance Assessment of Self-Care, Comprehensive Occupational Therapy Evaluation, Community Adaptive Planning Assessment, vocational assessments used in mental health. And these tools are used. Apart from this Worker Role Interview, Work Environment Impact Scale, The Bay Area Functional Performance Evaluation, The Assessment of Occupational Functioning. These are the behavioural assessment tools. OT (occupational therapist) professionals also use a 'kawa' model, which uses, as a metaphor to describe, it gives the patient the word as a tool and how the river moves, the patient has to explain in form of that. And it is useful to support the exploration of oneself, life events, and the environment, and which is used for interpretation of the thoughts. The next is orientation and alertness. It is very important to check orientation of time, including date, day, month, and year. Orientation to person which includes date of birth, home address, body orientation, orientation to place, orientation to recent news or personal events such as the Prime Minister or the President, or anything from the current affairs. The scales which are used here are Bachelor's Memory scale, three. Right? And it is important to screen for orientation and alertness as patients who are not oriented are going to perform poorly in the psychological assessment. And this is very important to rule out dementia also.

Now, there are specific assessment tools which are very important to assess for pre-morbid intellectual functioning, how the patient was before the attack or something like that. So pre-morbid intellectual functioning can be tested by reading tests, such as National Adult Reading Test 2, and Bachelor's Test for Adult Reading, which is used to test for language impairments, visual inattention, and dysarthria. These tests are going to include the patient to read out irregular words and look for the accuracy of the pronunciation. And it is used to estimate the pre-morbid intelligence of the patient. How was a pre-morbid stage of intelligence? Spot-the-Word test is also used. Now, what happens is sometimes a patient is not able to take any of these formal tests. So what to do in that case? You need to check for the highest qualification of the patient and occupational achievement of the patient as being taken into consideration. Also, there are specialised skills to check for general intellectual functioning, language, visual neglect, or inattention, visual-spatial and visual-perceptual functioning, attention, and memory. All of these details are present in the Physiopedia pages. Kindly refer, the list of scales will be provided.

The motor function should be assessed on NIHS, that is National Institute of Health Stroke Scale. Very simple. Barthel index, or ranking scale, or modified ranking scale. Anything can be used. Now, apart from this, there are specific scales for depression, anxiety, and PTSD. So assessment scales for depression are Montogometry-Asberg's Depression Rating Scale, Hamilton Depression Rating Scale, Hospital Anxiety and Depression Rating Scale, and Becks Depression Inventory. It is very much important that if you suspect the patient is going towards PSD, it is mandatory to have an objective assessment using these scales.

Scales for anxiety include Hamilton Anxiety Scale, Hospital Anxiety and Depression Scale, the anxiety version. Or the subscale. For PTSD, clinician-administered PTSD scale, Impact of Event Scale, the revised one, the revised version. Post-Traumatic Stress Diagnostic Scale, and Acute Stress Disorder Scale.

Management

(Second half of video)

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