class=E-Title2>4.3. Treatment of Anger after Stroke

Treatment of anger after stroke remains largely uninvestigated. Glancy and Knott [51] have broadly suggested medications for the treatment of anger. Meta-analyses have supported the use of psychological interventions to treat anger in adults, though none specific to those who have had a stroke. DeVecchio and O’Leary [52] concluded that for non-institutionalised adults CBT is useful for driving anger, anger suppression and trait anger. They recommend relaxation therapy for state anger.

4.4. Treatment of Behavioural Problems

The literature on interventions for behavioural problems after stroke is highly limited, however it is considered that behavioural management strategies involving functional analysis of the behaviour of concern may be effective [28]. As with other populations, the use of medications to manage challenging behavioural problems after stroke remains unproven.

4.5. Prevention of Emotional Problems after Stroke

There is no evidence of any benefit of anti-depressants in preventing the onset of depression after stroke [53]. However, there is some evidence to support the provision of psychological treatments [53]. Motivational interviewing and problem solving therapy appear to offer preventative effects in this regard after stroke. Other psychological interventions such as distress management, group support and music therapy have been provided, but the evidence is limited [28]. However, the provision of information to patients and carers, and planned follow ups do improve patients’ mood [54].

5. Cognitive Impairments after Stroke

Cognitive impairments affect about 80% of stroke patients [55,56]. They are more common in the acute phase but many problems persist over time. Cognitive impairments are important because they are associated with rehabilitation outcome [56-59]. Impairments occur in cognitive domains, including attention, memory, language, visuospatial abilities, executive functions and praxis. In addition, there may be loss of awareness of deficits (anosognosia). Further, some patients have a dementia after stroke, usually vascular, which produces a progressive decline in cognitive abilities over time.

6. Screening for Cognitive Impairments after Stroke

Cognitive screening measures are used for two purposes, one is to detect post-stroke dementia and the other is to determine the pattern of cognitive impairments following stroke. Brief screening measures, derived from those used for the detection of Alzheimer’s dementia have been shown to be poor at detecting post stroke dementia [28]. Some widely used measures, such as the Mini Mental State Examination-MMSE [60] do not perform any better than chance [61]. Others, such as the Montreal Cognitive Assessment-MOCATEST [62], include more tests of executive abilities, which tend to be the most frequently impaired in vascular dementias, and are more sensitive. However, there are few validation studies [63].

Screening measures have also been used to detect cognitive impairment after stroke. The application of screening batteries developed for people with dementia, such as the Middlesex Elderly Assessment of Mental State—MEAMS [64], have rarely been supported [65]. However, they were useful in a stepped screening model as they were more sensitive than the brief bedside measures. An alternative strategy to detect cognitive impairment after stroke seems to be to screen in specific cognitive domains. Tests have been identified to detect language impairment such as the Frenchay Aphasia Screening Test-FAST [66], and The Sheffield Screening Test for Acquired Language Disorders-SSTALD [67]. Visual inattention can be assessed using Star Cancellation [68] and visuospatial impairment using the Rey Figure Copy [69] and Ravens Matrices [70]. There are also valid tests for apraxia [71]. However, there is little evidence to support screening measures to detect impairments of memory and executive abilities after stroke. Screening measures should be used to identify people who need further evaluation as the challenge is to correctly identify those without cognitive problems rather than those with them. The suggestion is therefore that all patients are screened with a brief bedside screening during the acute phase. If there are concerns about whether patients have capacity, further evaluation may be needed [72]. Those with no detectable problems on these bedside screening measures should be further evaluated using more sensitive tests. Those who have no detectable problems on these may need further evaluation if they wish to return to cognitively demanding activities, such as work [73], and driving a car [74-76]. These patients will require a comprehensive or specialist neuropsychological assessment, usually once they have been discharged from hospital to the community. There is some evidence to suggest that cognitive assessment can reduce stress in carers [77].

7. Cognitive Rehabilitation

Cognitive rehabilitation is provided to reduce cognitive impairments after stroke and improve functional outcomes. Narrative reviews have suggested there is evidence to support the effectiveness of cognitive rehabilitation [78,79]. However, Cochrane reviews have identified a dearth of high quality studies. There is evidence that cognitive rehabilitation can reduce some cognitive impairments, such as visual inattention [80] after stroke but there is a lack of evidence for an effect on functional outcome. In addition, there is little evidence to support or refute the effectiveness of rehabilitation of memory [81], attention [82], or apraxia after stroke [83,84]. However, lack of evidence does not mean such procedures are ineffective, and there are ample single case experimental design studies to support the provision of cognitive rehabilitation. Therefore it is important that visual inattention is treated as part of a rehabilitation programme. Other cognitive problems will also need an individualised treatment plan, based on expert guidelines rather than strong research evidence.

8. Research Needs

Research is needed to identify better measures to screen for anxiety problems after stroke, in both those with and without communication/cognitive problems. The investigation for psychological means to both prevent and treat emotional problems after stroke is in its infancy, and much needs to be done. There are few randomised controlled trials of individual or group psychological interventions after stroke, despite the evidence of the effectiveness of these in the non-stroke population. The provision of information is one means of supporting mood. The nature, prevalence and best means for managing challenging behaviours after stroke should be documented.

Cognitive assessments need to be developed to identify people with impairment of memory and executive abilities after stroke. In particular screening measures need to be developed which are sensitive to vascular dementia. Cognitive rehabilitation programmes have been shown to improve outcomes in individual patients, but more evidence is needed to indicate the generalisability of these findings.

9. Acknowledgements

Andrew Bateman, Louise Clark, Sarah Gillham, and Allan House are all to be thanked for their helpful comments. This article is based on a paper commissioned by the NHS Stroke Improvement Programme, who financially supported open access publication.

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NOTES

*Corresponding author.

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