Disability as a result of Stroke
By: Dr. Michael Kirby
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Disability as a result of Stroke By: Dr. Michael Kirby |
The disability resulting from stoke is frequently a combination of physical and mental problems. Each set of problems impacts on the other and cannot be treated in isolation. Physical disability is obviously a major factor in the mental problems but mental problems can aggravate physical disability by impeding rehabilitation.
Physical Disability and Mental Problems.
There are a number of factors which can militate against the diagnosis, treatment and full appreciation of mental problems following a stroke. The physical disability - such as paralysis - is the most impressive and obvious problem and takes most of our attention. Consequently, mental or psychological issues are often unrecognised or at least underestimated. Psychological difficulties are considered "understandable" following a stroke and resultant physical disability and therefore they may not be fully treated. The mental problems following a stroke may be due directly to the brain damage sustained. They may also, of course, represent the individual's reaction to the handicaps imposed on him/her more or less vulnerable to the development of psychological problems.
The previously independent and self sufficient individual may react more adversely to physical handicap and the resultant increased dependence on others. The person who lives alone with little social support may experience greater psychological difficulties and indeed stroke often occurs at the time of life when social supports have markedly decreased, through bereavement of family and friends and family moving away. The person who has suffered depression in the past may be more prone to a further episode after a stroke. The common mental disorders following stroke are intellectual deficits, depression and personality change. It is important to remember that these problems impinge not only on the patient but on the carer and family also.
Defect in Intellect
Defect in intellect following stroke results directly from the brain damage incurred and the particular defect depends on the site of damage within the brain. It may take some time following the stroke for these deficits to emerge clearly as there is often initial acute confusion at the time of the stroke which reduces after a time.
The common deficits are speech and language problems, difficulties performing motor actions such as gait problems (not specifically related to the paralysis) and body image disturbance such as denial or disowning of a paralysed limb.
Disturbances of language accompany between one half and two thirds of cases with paralysis of the right side of the body. Language disturbance consists of impaired comprehension or impaired expression or a combination of both. Patients with loss of expression but good comprehension will in general make better adjustment than when understanding is faulty. Improvement over time in these specific deficits will generally occur, with most improvement being expected within the first six months but wide variation is seen.
Additional help for specific deficits, such as occupational and speech therapy, can also aid recovery or improvement. In the case of language impairment it is important to remember that the individual has not only lost his ability to speak but also his primary means of relating with those around him. Initially emotional contact must be established with the person, by means of whatever channels of communication are available. Pictures may be used with which he can indicate requests, even though he cannot read or speak. Cards with words or short phrases may be useful at a later time. Every attempt must be made to avoid withdrawal after early failures, to keep the patient involved and to stimulate a continued desire to communicate. This approach can be taken at home in addition to any formal speech therapy.
Dementia
Generalised intellectual impairment of "dementia" can occur following multiple strokes. Each episode is accompanied by some further loss of mental ability, leading over time in a step-like fashion to a generalised deterioration of memory, intellect and personality. This may be referred to as as a "multi-infarct dementia" and is the next commonest type of dementia after Alzheimer's disease. Management concentrates on limiting further strokes(with medication such as aspirin) and social support in the form of home help, day centre attendance and respite admissions where indicated. Memory impairment is most prominent for recent events with relative preservation of distant memory. Provision of props and supports by way of notes and written instructions (telephone numbers in large writing over the phone, written reminders to turn off fires) can help.
Depression
Depression occurs in between 30% and 50% of individuals who have suffered a stroke with the peak occurrence at six months to two years following the stroke. When we refer to depression we do not merely mean transient sadness or unhappiness but a collection of symptoms. The person has depressed mood most of the time, little interest in things, disturbed by sleep and appetite, little energy or motivation, possibly feelings of guilt, despondency, death wish and, maybe, ideas of suicide. All of these features need not, of course, be present in every depressed person. It is scarcely surprising that depressive reactions are common in those who have suffered a stroke. There are many factors which may act as an initial focus for the development of a depressive episode - the frustrations of physical handicaps and communication difficulties, the enforced dependency and invalid role and the uncertainty about the prospects of resolution of these disabilities.
The concept of "loss" is frequently referred to in the discussion of depression in general and applies to a considerable degree in depression following stroke. There may be a physical loss in terms of ability to work, loss of job, participation in sport or hobbies and a psychological loss in terms of perceived decrease in self esteem and increased dependency. In addition to these understandable factors in the development of depression, there is evidence of a specific relationship between stroke and depression, depending at least in part on the actual brain damage and its site. Stroke patients have been found to suffer from depression more frequently than patients with other brain injury despite equivalent disability. Strokes affecting the left front part of the brain result in depression more often than when other sites are affected. As I mentioned earlier, depression may be ignored due to the "understandability" factor and the fact that it is a less visible disability. It is important that this doesn't happen as it can be treated in a large proportion of cases.
Treatment
Treatment of depression is on an individual basis but, in general the approach would be to acknowledge with the patient that he is depressed (this may be a new experience he doesn't understand), give support, possibly further help with specific difficulties and, in many cases antidepressant medication. The fact that there is an obvious cause does not mean that antidepressants are not warranted or not effective. A complication of stroke that can be very distressing for both patient and carer is where episodic brief bouts of crying or laughing occur, often unprovoked. This is not unusual in multi-infarct dementia but can also occur after a single stroke and is not necessarily related to the person feeling sad. It frequently responds to a type of antidepressant drug (a"tricyclic antidepressant") even in the absence of depression itself.
Personality Changes
Personality changes following stroke are among the most troublesome of post stroke events and result from the brain damage incurred. The change varies from the mild to the severe. The patient may have difficulty adjusting to anything different and small matters make him anxious, irritable or depressed. He may avoid new experiences and restrict himself to an unvarying routine. This can make rehabilitation, with its inherent need for adjustment and change, difficult. Previous personality features may become accentuated - a previously lonely and with drawn person may become suspicious and paranoid. The patient may be unmoved by the interests of others, including those close to him, but react severely to a threat to his own security. In more severe cases with significant damage to the front of the brain a person can become disinhibited, with a disregard for previous standards and social norms. It is important for the carer to realise that these changes are, generally, the result of the brain damage as this, at least, gives some logic for the carer who experiences a possibly bewildering change in a previously close relationship. Medication may occasionally be required for more severe personality and behavioural change.
Physical, Psychological and Psychiatric Problems
The physical, psychological and psychiatric problems resulting from stroke place a very large burden on the patient's carer. This burden can similarly result in the carer developing physical and psychological difficulties. Not unlike the situation where psychological problems in the stroke victim may be ignored due to comparison with the more obvious physical disabilities, carer problems may, also, be ignored as they are less obvious than the problems of the stroke victim. Support for the primary carer is essential and comes both from family and community services (home helps for example). Family organised rotas and time off for the primary carer can help considerably. Depression can similarly affect the carer and should not be ignored or accepted as "understandable" with the implication that it can be alleviated. Psychiatric problems following stroke are common and the cause of considerable distress for patient and carer. The fact that they occur against the background of a major stress does not lessen the need for attention and treatment. Both physical and psychological difficulties impinge on each other, contribute to the total disability and affect eventual rehabilitation.