Abstract
It is never too early to begin to educate the patient and family about lifestyle changes and medical treatments to prevent another stroke. These need to be reinforced throughout the hospital and rehabilitation stay, and in the outpatient stroke clinic.
After a major stroke, both the family and the patient go through a grief reaction that at first includes denial and disbelief, and sometimes anger. In particular, the need to insert a PEG is often a crisis point when the family finally comes to terms with the severe disability and prolonged recovery that lies ahead. At this stage, which is usually when the patient is in the acute stroke unit, mainly supportive measures are indicated.
Psychosocial Evaluation
It is never too early to begin to educate the patient and family about lifestyle changes and medical treatments to prevent another stroke. These need to be reinforced throughout the hospital and rehabilitation stay, and in the outpatient stroke clinic.
After a major stroke, both the family and the patient go through a grief reaction that at first includes denial and disbelief, and sometimes anger. In particular, the need to insert a PEG is often a crisis point when the family finally comes to terms with the severe disability and prolonged recovery that lies ahead. At this stage, which is usually when the patient is in the acute stroke unit, mainly supportive measures are indicated. More detailed teaching and coping with the consequences of the disability usually wait until after the acute stroke stay, when the realities of the impairment become clearer, and the shock, disorientation, and confusion have worn off. Even in patients fully recovering from their stroke, the threat of another event and the realization of vulnerability usually cause significant emotional consequences.
All members of the multidisciplinary stroke team should be involved in assisting the stroke patient and the family through this major life event. Having a dedicated transitions-of-care coordinator, with a nursing or social-work background, is exceptionally helpful in transitioning from the hospital to the community setting.
Stroke Prevention Clinics
Ensuring close follow-up in an outpatient stroke clinic may help ease the transition to the community setting and address the challenges that inevitably arise, as stroke is a major life event. The most common post-stroke sequelae that we see in our stroke clinics are depression, cognitive impairment, and fatigue. A nurse-practitioner-led early stroke clinic follow-up program in North Carolina has been associated with lower 30-day readmissions.1 Care in stroke prevention clinics in Ontario was more likely to be guideline-based and demonstrated a 26% decreased risk of mortality.2
Common Post-Stroke Sequelae
Depression
Cognitive impairment
Fatigue
Depression
Depression in the patient and caregiver is common after stroke. At least 30% of stroke patients suffer from depression within the first year, with a cumulative incidence of 50% at 5 years.3,4 Incontinence is an important contributor to depression and dependence, in addition to the obvious other causes (paralysis, inability to talk, and pain). Premorbid depressive tendencies are often amplified after a stroke, so that even patients with little disability may become depressed. Stroke location may also play a role, with more depression reported in non-dominant frontal lesions. Post-stroke depression (PSD) is associated with higher morbidity and risk of stroke recurrence. SSRIs may be helpful in the prevention and treatment of PSD to reduce morbidity and mortality.5
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