Post Stroke Depression

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Post Stroke Depression

• Lana Richardson BSW, RSWSocial work
  consultantMaureen McDermidJill Rita- Patey

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DEPRESSION

• Depression is not a normal consequence of aging
  any more than it is a natural part of any life
  stage.depression is caused in part, by certain
  life goals which become unfeasible, but which a
  person cannot abandon, resulting in reflection on
  lost goals. To gradually abandon these goals and
  work towards other goals is to overcome
  depression.

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STROKE AND DEPRESSION

• Depression can affect anyone, but people who have
  a serious illness such as stroke may be at
  greater risk
• Now recognized as a frequent consequence to
  stroke
• Estimated that between 40 50 of stroke
  patients have Post Stroke Depression (PSD)

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Depression and Stroke Survivors

• Stroke survivors are most likely to suffer from
  depression within the first three months
  post-stroke, after multiple TIAs and within the
  first four months after placement in a
  residential care setting.
• Sometimes this is delayed in onset up to 2 years
  post stroke

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CONTRIBUTING FACTORS

• Location of lesion - left frontal lobe
  significantly at risk
• Previous or family history of depression - 20
  of PSD have prior history
• Bereavement - those over age 70 who recently
  lost a spouse were 9x more at risk
• High pre-stroke alcohol intake

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• Major functional impairment - especially in
  stroke survivors who have lost the capacity to
  care for their own needs
• Helplessness and hopelessness - due to losses of
  social roles and control
• Pain - frequently not recognized and under
  treated

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Physiological Side Effects

• Depression is often accompanied by
• - a change in sleep pattern
• - weight gain or loss
• - a change in appetite
• Other effects are
• - flat affect
• - increased sensitivity to pain and
  discomfort
• - lack of self care

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Emotional Side Effects

• Sad
• Angry
• Flat or blah
• Unmotivated
• Uncaring
• Self-centered

• Frustration
• Feeling inadequate
• Feeling unworthy
• Discouraged
• Grumpy
• Helpless

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Cognitive Side Effects

• People who have clinical depression often have
• a negative outlook
• poor concentration
• a feeling of confusion or living in a fog
• short term memory loss
• self-focus
• difficulty relating with others

They are also easily overwhelmed by information
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Consequences of PSD

• Associated with increased rate of mortality
• Major barrier to full physical and mental
  recovery from stroke
• May limit energy to fully participate in rehab
  and ADLs
• May increase the severity of cognitive impairment
• May increase irritability and the appearance of
  personality changes

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• People suffering from depression are 4x more
  likely to have a heart attack
• Known link between hopelessness and
  arteriosclerosis
• Having a depression is the same as smoking a pack
  of cigarettes a day

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SUICIDE IN LTC

• Large study shows not uncommon but lower than
  elderly in community
• Depression a major factor
• Factors - losses of spouse,child or
  pet - loss of physical function often as
  a result of a stroke -
  helplessness and hopelessness -
  feelings of rejection and abandonment

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• Most used passive means such as refusing food,
  drink and medicationOther means were -
  jumping out of windows - hanging with bed
  sheets - asphyxiation - highest percentage of
  violent attempts were wrist slashing

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Treatment for PSD

• PSD symptoms are often mild and resolve without
  treatment
• Treatment should be initiated for patients with
  persistent and disabling symptoms
• Treatment includes
• Antidepressants start low and go slow,
  especially in geriatric population
• Psychological therapies to assist the patient and
  family adjust to the loss of function and
  compromised self-image and self-esteem

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Who Does What?

• Who assesses and/or screens for depression? -
  all can assess
• Who diagnoses depression? - psychiatrists,
  physicians, Seniors Mental Health
• Who treats depression? - medications are
  prescribed by physicians - psychotherapy can be
  offered by various therapists
• Who provides support to the treatment? - all

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What is Your Role?

• Assessment - Do your Own Fact Finding
• Depression in the elderly is often untreated
  and under-diagnosed due to the stigma of
  psychiatric illness and the complexity of
  multiple medical problems.
• Reynolds, CF III. Recognition and differentiation
  of elderly depression in the clinical setting.
  Geriatrics, 1995.

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Ask?

• Has this person ever been depressed before or
  received treatment for depression or anxiety?
• What worked before? How did this person cope?
  What did family members do to help them?
• Now that this person has had a stroke and is
  living in residential care, what strategies can
  be used to help them cope now?

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In the Stroke Survivor It Is Important to

• Differentiate from being emotionally labile
• Make sure that a flat affect is not due to a
  medical condition like Parkinson Disease
• See if there is a rational reason for a low mood,
  such as reduced independence

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Caregiver Stress

• Spouse
• Financial
• Time management
• Energy conservation
• Health problems
• Loss
• Guilt/control
• Changes in role responsibilities

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Adult Children as Primary Caregivers

• More burnout than spouses
• Role Reversal
• Sandwich Generation
• More financial loss
• Time taken from spouse and children

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Tips for Working with an Overstressed Family
Member

• Be clear and consistent in communication.
• Be prepared to listen to the same thing over and
  over again.
• Empathize with feelings. You dont have to agree
  with them.
• Offer hope and caring.
• Try not to get caught up in who said what. Talk
  about how we can work to make the situation
  better for everyone.

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Tips for Working with the Stroke Survivor and
their Family

• Stay positive
• Empathize
• Communicate Caring and Hope
• Use the past or the present
• Watch for non-verbal cues

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• Be aware of own biases and attitudes
• Remember the elderly and stroke survivors are the
  experts in their experiences of aging and
  illness
• Educate yourself

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Great Resources

• The Stroke Recovery Network
• www.strokerecoverycanada.com
• Caregiver Network Inc.
• www.caregiver.on.ca
• The Heart and Stroke Foundation of Canada
• www.heartandstroke.ca
• Mental Health Service Information Ontario
• www.mhsio.on.ca
• Canadian Stroke Network
• www.canadianstrokenetwork.ca

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REFERENCES

• Ainsworth Patricia Understanding Depression
  2000
• Grant B Lipman A Osgood N. Suicide Among the
  Elderly in Long Term Care Facilities 1991
• Burwell Peter Journal of Geriatric Psychiatry
  1997
• Ellison James Verma S. Depression in Later
  Life A Multidisciplinary Psychiatric Approach
  2003

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• Kinney H. Dupuis M. Fast FAQs for Stroke
  Nurses, South East Toronto Regional Stroke
  Network, 2004
• Narushima K Robinson R. Stroke-related
  Depression Cardiovascular Disease and Stroke 2002
  4 296-303
• Heart and Stroke Foundation of Ontario RNAO.
  Stroke Assessment Across the Continuum of Care,
  2004

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• The End
• Thank you