Psychosocial Issues After a Stroke | Comprehensive Case Management Certification

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you I'd like to welcome everybody to today's presentation on post stroke psychosocial issues. I AM your host, Dr. Donnelly Snipes. Over the next hour, we're just going to examine the prevalence of and risk factors for stroke so we can kind of understand why this is an issue that we need to know about and identify post stroke psychosocial issues. Many of our clients are at high risk of stroke, and it's important for us to recognize that, you know, many of our clients have had strokes, maybe not even realizing it, and, you know, a lot of others are at high risk. So it's not uncommon for us to be working with a client who does have a stroke. And we need to be aware of the issues that may face them after that. People with anxiety disorders have a 33% higher risk of stroke. This is partly due, they think, hypothesizing partly due to high blood pressure and lifestyle factors that people who tend to have anxiety engage in in order to cope with their anxiety, such as drinking and smoking. People who are on mood stabilizers. So people who are bipolar were collectively associated with significantly increased risk for stroke when they were on mood stabilizers. Another one that's a little interesting, and you may not have thought about it, is benzodiazepines. Now, benzos are your Valiums, your Xanax, your antianxiety medications. So you would think that somebody taking a benzo would be at a reduced risk of stroke, but in reality they're at a 20% higher risk of stroke. And if you've ever taken benzos or if you've ever talked to a client who's taken benzos, especially the short duration benzodiazepines, those go into your system really fast and leave your system really fast. And a lot of times it leaves their system before they can take another dose. So they have what some people have referred to as rebound anxiety. And when that anxiety goes up, a lot of times their blood pressure goes up and, or they may engage in other compensatory behaviors until they can take more benzos. So that's, it's just something interesting to look at. People with benzos obviously probably have an anxiety disorder. And if you want to look at it that way, then with anxiety disorders, they have a 33% risk and those on benzos only have a 20% higher risk. So the benzos may be helping some people, you know, just depending on how you want to look at it. But we do. The take home message is people with underlying anxiety do have a higher risk of stroke. Another fact which is frustrating is that right after a stroke, research has found that almost 40% of people received one or more drugs hypothesized to actually impair recovery during that first 30 day period right after their stroke. And when we look at the drugs that potentially impair recovery, you might start understanding why. Clonidine, which is associated with reducing blood pressure and it also reduces norepinephrine levels. Atypical antipsychotics and benzodiazepines, both of those are often used to address agitation issues in people who have had stroke. However, the mechanism of action of those particular medications can actually impair stroke recovery. Smokers are two to four times as likely to have a stroke. Why? Well, a lot of our clients are going to ask us, why are we even addressing this? Smoking makes blood sticky and more likely to clot, which can block blood flow to the heart and brain, causing a stroke. Smoking also damages cells that line the blood vessels. It increases the buildup of plaque, which is fat, cholesterol, calcium and other stuff. Think about your pipes at home. You know, and where we live, we have really bad hard water and every six months or so we actually have to disassemble the faucets and clean out all of the calcium deposits or we end up with drippy faucets. The same sort of thing happens in our body when cholesterol, calcium and other stuff, just as it's going through, kind of gets picked up along those blood vessels. When that happens, the space in the vessel for the blood to go through narrows, which can increase blood pressure as well as contribute to blockages. And smoking also causes thickening and narrowing of blood vessels in and of themselves. Without even considering the plaque, it causes those blood vessels to narrow. This is not just people who smoke cigarettes or cigars or pipes. It's also people who are vaping. And I know vaping has got a lot of bad press lately and there's an uproar and yada yada, people are still going to continue to vape. As long as it's legal, they're going to continue to do it. We just want them to recognize the potential impacts of it and then they can make an educated decision. Alcohol increases stroke risk by 38%. And here's a little soapbox. I will warn you, I'm going off on it. When People are detoxing from alcohol, it can create a life threatening emergency because their blood pressure can go up and they can stroke out. Unlike detoxing from opiates where people have really bad flu like symptoms and they may get dehydrated. But typically, you know, opioid detox is not a life threatening event as is, whereas alcohol detoxification can be. It really frightens me when people decide that they're going to try to self detox for that reason. Alcohol, when you drink, it can cause atrial fibrillation, which can lead to a stroke. Alcohol causes the development of atherosclerosis or the hardening and narrowing of arteries. So smoking plus alcohol, which a lot of people do together, both really make those blood vessels narrow and get less flexible and increase blood pressure. Liver damage can impair blood clotting. Now where smoking causes the blood to become more likely to clot because it stickier when there's liver damage, the blood may not clot well enough, which can lead to a brain bleed, which can lead to a stroke. And as I mentioned, high blood pressure during detoxification. I can't talk today, y'. All, I'm sorry. Can also increase stroke risk. We want to be aware of this when we are working with clients, when we are working with clients who are binge drinkers. And this, some of this stuff can happen when you have one drink and it becomes intensified the more you drink. And when people binge drink, obviously they are raising their blood alcohol way high, which means it's going to drop substantially and there's going to be alterations. So they're at much higher risk of this. Even if they're not drinking heavily every single day or more most days. If they are binge drinking, they are also at a much higher risk of stroke risk than even the person who just moderately drinks alcohol on a daily basis. Stimulant abuse increases blood pressure. Stress and lifestyle factors and other things cause high blood pressure. Blood pressure is a really big thing when we're talking about stroke. We want to help people understand the impact of blood pressure on their whole cardiovascular system because that's where mindfulness activities and stress management activities, distress tolerance, emotion regulation, biofeedback, all of those things can come in handy. I'll give you a little anecdote. This morning I did a bad thing and I checked my work email before I went to the gym. So this was like five in the morning, you know, nothing was open. I couldn't do anything about anything. And I got some, an email from somebody that you Know, caused me a little bit of distress. And so my blood pressure went through the roof. You know, I was just like, freaking out. And thankfully my husband is the voice of reason and he can kind of talk me down. But initially, you know, after I sat down a little bit, we had just gotten a blood pressure cuff in for him, and he's like, let's take your blood pressure just to see how much energy you wasted getting upset. And I was just like, really shush. But I did it anyway. And sure enough, my blood pressure was high for me and I practiced some biofeedback, deep breathing, you know, the whole breathe in for four, hold for four, exhale for four, you know, distress tolerance skills, ride the wave, all that stuff. You know, I implemented some tools that I actually talk about, tested my blood pressure 20 minutes later, and it had actually gone down significantly, like 9 points on the systolic and 3 points on the diastolic or something. We can help clients learn to use biofeedback to reduce their blood pressure. Now, if they've got other health conditions, it's not going to be the panacea. Be all, end all. My point with that anecdote is that for the average person, we can help them at least stabilize their blood pressure down to what's normal or average for them. Sleep apnea increases the risk of stroke. When people have obstructive sleep apnea, they actually stop breathing. If you've ever held your breath for a while, you know how your face can start to get red when we stop breathing, even for a minute, it increases our blood pressure because when we stop breathing, it triggers that HPA axis, our stress response system, which then dumps norepinephrine and cortisol because it's like, okay, the person's not breathing, we've got to fight or flee. We got to wake them up. So sleep apnea, we know, increases risk of stroke. But interestingly, non sleep apnea related sleep disorders also significantly increases risk of stroke. So your circadian rhythm disorders, your shift work, sleep disorders, when people's circadian rhythms get out of whack, it actually does increase their risk of stroke and increase their risk of high blood pressure. But age, the older we get, no matter how healthy we try to live, even if you don't smoke or drink or whatever, the older we get, the more, the less flexible our vascular system becomes and the more at risk we are for stroke. The proportion of people, the prevalence of stroke is really not super huge. We're not talking 3, 4, 5% of the general population but it is important to recognize that the older you get, the easier it is for your body to have some kind of a problem that obstructs blood flow to your brain. Diabetes doubles your risk of stroke. And the use of non steroidal anti inflammatory drugs, your ibuprofens, your. What's the one that lasts 12 hours? I can't remember right now, but any of your anti inflammatories that you take over the counter, except for aspirin may increase the risk of heart attack or stroke, particularly in patients who have already had a heart attack. Now, Tylenol is not an nsaid and aspirin is specifically exempted. But when you're talking about some of the others that we take for our random aches and pains, especially consistent use, you know, use. Taking one or two doses doesn't seem to really be super strongly affiliated with having a stroke. But if somebody's taking it for weeks on end, especially at the maximum dose for weeks on end, it can increase risk of stroke. Why am I bringing this up? A lot of our patients have chronic pain. A lot of people with chronic pain medicate that pain. They may not want to take opioids or gabapentin or something else. They may be taking the over the counter anti inflammatories, just being aware that it is a risk factor. Mini strokes. I said earlier that some people may have had strokes and not even realized they had one. The signs and symptoms of a TIA or a mini stroke resemble those found in early stroke and may be a sudden onset of weakness, numbness or paralysis in their face, arm or leg. And it's typically on one side of the body. It may not last for very long, you know, a couple of minutes. It may not last for more than that. Slurred or garbled speech or difficulty understanding others. Blindness in one eye or double vision, dizziness or loss of balance or coordination, or a sudden severe headache with no known cause. Now those are sort of ambiguous symptoms. There are a lot of things that can cause these symptoms. As usual, I don't want people to freak out if all of a sudden they get dizzy or lose their balance and they think, oh my gosh, I had a stroke. No. You know, there's a lot of things that can cause that, from low blood sugar to, you know, just getting up too quickly. But it is important to be aware of the signs, the potential signs of stroke. 70% of people report that their mini stroke had long term effects, including memory loss, poor mobility, problems with speech and difficulty understanding other people and 60% said that their mini stroke affected them emotionally, made it more difficult for them to control their emotions. So we may be dealing. If you're working with somebody who has a fair amount of emotional dysregulation or some of the other problems we're getting ready to talk about, then you might want to consider, especially if they're an older adult, consider whether they may have had a mini stroke here or there, or if they're in recovery from alcoholism. That's another big risk factor. So when do we assess for issues related to stroke? When you're working with a patient who's had a stroke, just before discharge, one month after stroke, three months after stroke, and six months after discharge. It's important to look at these time frames to see if there's progression or regression in emotional, physical, or cognitive functioning. You want to look for cognitive functioning, signs of depression, anxiety, social withdrawal, or changes in physical presentation. And what I mean by physical presentation, if they are not dressing appropriately for the weather, for example, or. Or if it looks like they're not bathing or anything that you would see on a mental status exam and go, okay, there's something going on here. Impacts of stroke, general physical issues, reduced mobility and independence. If you've ever had surgery or been on bed rest for something, you got a little glimpse into how frustrating it can be not to be able to be independent, not to be able to get up and go to the bathroom when you want, or make your own food, or, you know, jump in the car and go to the grocery store or whatever it is that you do. It can get very frustrating, and you can feel trapped, if you will. And we don't want people to feel trapped. We want to look at what may be impairing their mobility and any interventions that we can help. If they have lost vision or the ability to drive after their stroke, that is definitely going to contribute to a loss of independence. So we want to look at ways we can help the person get some of that independence back. Maybe they can't drive to the store anymore, but maybe they can Uber, or maybe they can't go grocery shopping independently anymore, but they can have groceries delivered so they have good meals. We want to look at what aspects of their life have been impacted by this reduced mobility or independence, and how can we help them gain some of that back. Vision problems are not uncommon. Sometimes people lose vision in half of their field of vision, in both eyes sometimes. Sometimes they lose it completely in one eye or there's all kinds of permutations. This affects driving, it Affects reading. It affects a lot of things. If you're working with somebody who likes to see, they do things that involve vision, then we want to figure out how we can modify their environment. They may need monitors that can accommodate larger vision or larger letters and things on the screen. There are a lot of really great tools that you can use for people with reduced visual abilities. You just have to look and you can consult your local vocational rehabilitation agency to find out about different interventions that are out there for vision problems. Difficulty with activities of daily living. This can be one of the most frustrating, especially if you're an adult and you can't. I remember there was a few years back I dislocated my finger and I had to have it in a. In a splint. And you think it's a finger. What's the big whoop? Well, I couldn't get it wet and I couldn't. So I was trying to wash my hair and. And I couldn't wash my hair like a normal person. I'm like trying to wash my hair with one hand. And you know, for the guys in the room, if you've got shorter hair, you may not be able to really relate to that. But any of you who have longer hair know how hard it can be to get really good clean with only one hand. That's minor compared to what a lot of people face. But I can understand and empathize with their frustration When I've had different things happen that I haven't been able to do the things just that I normally do. We want to help people deal with those frustrations and again find accommodations that can help them. If they can't because their balance was messed up. If they can't get in and out of the tub by themselves anymore, maybe they need to look into a walk in tub or getting grab bars installed in order to assist them in taking a shower. Maybe they need to have a. Maybe they need to have a seat installed in their shower so they don't have to stand and risk falling on the slippery floor. We want to look at different accommodations. If for example, they live in a two story house and their bedroom's upstairs and they can't go up and down stairs anymore or not safely. May need to look at accommodations for that. And they have different accommodations for little elevator type things that can be installed on railings. Some people will have difficulty swallowing. This is going to affect their nutritional status. It also creates a high risk or a higher risk for the development of pneumonia after a stroke. If people have difficulty swallowing, they May swallow down the wrong pipe, aspirate food and develop pneumonia. But it's also again, really frustrating because you think not only do you swallow food and drink, but you swallow saliva. And it can make it very hard for them to feel comfortable in front of other people if they have difficulty swallowing even their own bodily secretions. That can contribute to self consciousness withdrawal, social isolation and other things. Sleep problems are prominent in 36% of people who've had a stroke. This can be because of pain due to the stroke. If, if you have one side of your body or part of your body that is not working the way it should, the other part will often compensate for it, which can create imbalances and create pain. Sometimes there's neurologic pain after a, after a stroke and other times people just. Their sleep schedule gets disrupted. We want to work with them on looking at sleep hygiene. And by that I mean not only turning off blue lights and creating an hour before bedtime and creating a sleep schedule, but also making sure that their sleep environment is ergonomically sound. Do they have an appropriate mattress for, for their needs? If they have paralysis on one side of their body, are there recommendations from the physical therapist or the doctor that they can implement in order to sleep more comfortably? How can we help them do this? People with chronic headaches. There can be a lot of reasons for chronic headaches with or without a stroke. But chronic headaches, you know, are going to impact your ability to see. Sometimes when you get a really bad headache and it's hard for you to focus, you have sensitivity to light, your head hurts, it's hard to concentrate, headaches are no fun. If people after a stroke have chronic headaches, it's going to impact their social relationships because you generally don't want to go out and do a bunch of stuff when you've got a bad headache, it's going to impact their activities of daily living, it's going to impact their mood, and if it persists into the night, it's going to impact their sleep. We want to make sure we refer out so they can have their vision assessed. Because after a stroke it can affect vision. And if their vision has been impacted, then that may be contributing to their headaches. We want to look at their posture. This is true for anybody, but especially if they have paralysis on one side of their body. If you sit in awkward positions, you can create neck tension and back tension, which can contribute to muscular neck tightness and headaches. Pneumonia. I mentioned that earlier. Because of the difficulty swallowing, people are at a higher Risk of pneumonia. That's not something we as counselors are really going to deal with. But we do want to make sure that clients understand that there may be a risk and if they're having difficulty swallowing, to encourage them to follow through with their occupational therapy appointments. And we already talked about pain to a certain extent. There are a lot of different causes of pain, but after someone has a stroke, if they do experience pain, we need to look at why. If it's because of a muscular imbalance, because after the, after the stroke, then they probably need a referral to a physical therapist or their primary care whomever, whichever way you want to go. In order to help them assess any kinesiology related, any physical related causes of their pain. We also may need to refer them to a neurologist if it doesn't seem like there are muscular reasons for their pain. Let's look and see if there are neurological reasons for their pain. And remember that pain perception goes down as serotonin goes down. And we also know that stroke does impact the neurotransmitter levels. People after a stroke may have difficulty identifying, understanding or expressing emotions. How frustrating is that? If you feel something but you can't express how you feel and you're not sure why, and you feel like you're kind of living in somebody else's body, you know, that has to be exasperating. Working with clients on emoticon sheets, you know, the little sheets that have the different feeling faces on them can help them. Sometimes they can't put a word to it, but they can put a emoticon to it. Sometimes colors will work. If you get a, one of those great big boxes of crayons or paint or cloth swatches or whatever in different colors, like red, black, blue, yellow, sometimes that is a good trigger for them because they can say, I'm, you know, I'm feeling green. And you can help them figure out what that means and put a label on it. Post stroke, depression is common in 67% of people after they have a stroke. Well, that makes sense, you know, when you think about it, after you have a stroke, especially if you have some ongoing physical or cognitive issues, you can feel kind of hopeless and helpless. Your body rebelled against you and you, you're not sure how much functioning you're going to be able to get back. Post stroke, depression may remit as the person regains function. It doesn't for everybody, but for a significant proportion of people, as they start to regain their functioning and regain their independence, their depression starts to remit. Intensity of post stroke depression is correlated with the duration of hospitalization, the degree of functional loss, and the amount of brain damage. If they only lose a little part of their brain, if only that little part of brain tissue dies, then a lot of times they have less post stroke depression than if significant areas of the brain were affected. 25% of people have post stroke anxiety. A lot of this anxiety revolves around fear that they're going to have another stroke or fear that their symptoms are going to get worse instead of better. A lot of that can be handled with cognitive behavioral interventions and distress tolerance activities to help them get into their rational mind, out of their emotional mind and learn more about the likelihood, you know, what's the likelihood that you're going to have another stroke? And separate that. Cognitive processing therapy can be super helpful with post stroke anxiety. Post stroke emotional incontinence, and I really hate that term, but I didn't come up with it. Post stroke emotional incontinence refers to uncontrollable outbursts of involuntary laughing or crying for no apparent reason. This can be caused by functional status, serotonin, what they call polymorphisms, or changes in the serotonin system, and low social support. All of those things have been related to post stroke emotional incontinence at three months post stroke. Well, let's think about what may be causing that. This could be a stress reaction. If they are having difficulty identifying and naming their feelings, they may just kind of express whatever's coming out at that point in time or, you know, kind of reach that point and where they've got to express something and get some sort of feedback, some sort of response from other people. But a lot of times when people have post stroke emotional incontinence, it ends up pushing away social supports, because social supports don't know how to deal with this. As clinicians, it's important for us to educate their caregivers and their loved ones about emotional incontinence so they understand what might be causing it, so they can start charting and looking for triggers. A lot of times you can find triggers just like you can find triggers when you're working with someone who's on the autism spectrum. Triggers for when they start stimming. Sometimes you can find triggers for emotional incontinence and it can be, you know, not getting enough sleep. It can when you start looking at those vulnerabilities. They have found, though, that SSRIs in many cases are very effective with helping to reduce the post stroke emotional incontinence, which again points to the fact that in people who develop this, there must be some sort of damage to their serotonin system. And the addition of SSRIs seems to ameliorate that, at least to a degree. Post stroke, anger proneness has also been associated with serotonin dysfunction, and SSRIs have also been found to be very useful. After a stroke, some people get depressed. You know, think, think about that grief process, denial, anger, bargaining, depression, acceptance. After a stroke, you generally lost something, whether it's temporary or permanent. But people often feel a sense of trauma after, after they have a stroke and they go through a grieving process. Some people stick in that anger period for a while, whereas others may move on to that depression. And some others may have both depression and anger. However, we want to look at triggers for the anger proneness. What things might trigger irritable outbursts in the person post stroke. If they are cognitively high functioning, it is much easier to get this information if they are not functioning cognitively very well. You may not know right after. Well, right before my mother passed, she had a stroke and she was just, I mean, generally she's really accommodating. And she was just given the nurses and doctors in the, in the hospital what for. They would come into the room to try to take her blood pressure and she would just start chewing them out for being rude and invasive. And I'm just like, oh my gosh. But, you know, and my, my stepfather would have to terminate the conversation and say, you know, I've got to go run, run interference because your mom's kind of giving him a challenge right now. She didn't understand cognitively, she was not there. And she wasn't intending to be mean, but she was very irritable. When people have a stroke, it is terrifying. Some people's response to terror is anger. And she was trying to protect herself. She was trying to reestablish some sort of normalcy, I think, in what was going on. Regardless, SSRIs tend to be helpful in people who have post stroke anger. Another thing that we can do is help caregivers and higher functioning stroke survivors anticipate and reduce irritants. Like I said, the cognitive abilities range from very limited to completely normal. In people who've had a stroke, the higher their cognitive functioning, the more able they are to participate in anticipating and reducing some of these vulnerabilities and irritants. We want to give the patient the opportunity to do this whenever possible. We don't want to do it for them. It's not our job to be paternalistic. We want to empower them to find their new normal. And post stroke fatigue impacts 50 to 86% of people after a stroke and often is persistent even six months and years after a stroke. We want to look at what's causing that. Post stroke fatigue is not a particular diagnosis, but it is a symptom. It can be caused by post stroke depression, which we've already talked about. We want to look at, you know, what causes depression. Let's think about this. Sleeping changes can impact mood. Eating changes can impact mood. Cognitions. A feeling of hopelessness and helplessness can impact mood brain changes. You know, actual brain trauma as a result of the stroke can affect serotonin, norepinephrine and dopamine systems and actually cause depression. We need to help the person figure out what thing or things are contributing to these depressive symptoms and which ones can we mitigate, which ones may you have to deal with? You know, some things may not be mitigatable. It is important to address that because that fatigue is going to be persistent. And you know, when somebody tends to be fatigued for days on end or weeks on end, it also can contribute to development of depression because they can't do the things that they used to do. They can't do the things they want to do. They may start feeling guilty because they can't do the things that they did before their stroke. And it takes a big toll on their self esteem, their sense of self, as I mentioned, guilt. Lots of stuff we need to explore with them and help them reinterpret instead of focusing on the things they can't do, looking at the things they still can do and figuring out how to mitigate the problems with the other things. If you don't have the energy to go to your kids, your grandkids ball games anymore because that's just three hours is too long. Maybe you can go for an hour or maybe mom or dad can go and video record the ball game and you can watch it or they can facetime it in real time so you can be there in real time or but you're actually still able to sit at home. You know, there are different, especially with technology, there are a lot of different options to help people. If they can't walk the dog and clean the house like they used to, there are options. Maybe they can get a one of those little robotic vacuums that can help out or whatever. But you want to brainstorm what things about your current situation are contributing to your sense of powerlessness and depression and how can we fix that? You know, what can we do? Neurological deficits can contribute to post stroke fatigue. For some people, if they have problems with proprioception or movement, it may take a whole lot more energy to get from the couch to the kitchen or wherever than it did before their stroke. And that can be exhausting. Sometimes we can't help with that. Other times, the little motorized wheelchairs that you can get for inside the house, if you can get Medicare to pay for it, can, can be helpful. But looking for different reasonable accommodations to help them not use so much energy on particular things, we want to help them maintain their independence because that gives us a sense of self empowerment and it contributes to our mood. Antidepressants, interestingly, if you know, if you're not familiar, can contribute to fatigue. Certain antidepressants like Prozac are typically known to give people a little bit more energy. Other antidepressants like Zoloft tend to be more neutral. And other antidepressants like Paxil tend to be very sedating. They all work on serotonin, the serotonin system in a slightly different way. It's possible that the antidepressants may be contributing to fatigue. If it is, then the person can try taking the antidepressant at dinner so you know it has gotten into their system and is starting to wear off by morning. If that doesn't work, they may need to talk with their doctor about looking at alternatives to that particular antidepressant that may not have the side effects. And one of the doctors I worked with one time called them, quote, unacceptable side effects. There's acceptable ones, you can live with them, not a big deal. But unacceptable ones are the ones that negatively impact your quality of life and might contribute to treatment, non compliance. So I thought that was a really interesting way to look at it, encouraging patients to advocate for themselves regarding unacceptable side effects. Sleep disturbances can cause post stroke fatigue. We need to help people figure out what's keeping them up, whether it is. And sometimes it can be emotional because they're afraid if they go to sleep, they may have another stroke. There's a lot of reasons for sleep disturbances. There are doctors that specialize, psychiatrists that specialize in sleep disturbances. So if it's not any of the obvious things like they're staying up until at 2 in the morning watching Netflix, then a referral may be in order. And we've already talked about post stroke pain and one of the Newton's laws. Remember, a body in motion tends to stay in motion and a body at Rest tends to stay at rest. When you don't move because you've got pain, you tend to feel heavier and your body tends to stiffen up, which makes it even more arduous to get out of the chair to move around to do those sorts of things. Post stroke, pain, not only does it impact mood, but it also can contribute to needing to use more energy just to move your body. And kind of a non sequitur here. Going back to other interventions for helping people maintain their independence. Those chairs, those, you know, the big easy chairs that actually tilt up to sort of tip you out of your chair now so you don't have to raise yourself from a sitting position, are super helpful for a lot of people post stroke to help them, you know, get to their feet. Also really helpful if you're like eight months pregnant. But that's a whole different topic. Stroke can impact thinking, memory and perception the way, and it depends on what areas of the brain the stroke affected, but it can actually impact how people see the world. It can change their vision. It can make things seem wobbly, it can make things, you know, distort your field of vision, it can distort how you hear. It can make certain sounds a whole lot more poor, poignant and painful, or it can do the opposite and make it harder for you to hear certain sounds. And it can affect your proprioceptive sensors in your skin. So things that didn't used to bother you may be intolerable. You may put on a wool sweater and it just feels like your skin's being scraped off with sandpaper. We want to encourage people to identify and articulate what's going on so we can help them modify their environment so they're comfortable. If they're not comfortable, that HPA axis is going to be going off like crazy. And it's going to keep them stressed, it's going to keep them from getting quality sleep, because you don't sleep well when that HPA axis is activated and it's going to start causing other health problems. And we don't want to do that. We want to help people add tools for bolstering their memory, such as alarms on their phone or to get up reminder apps that remind them to take their medicine or to take a shower and encourage them if they have the cognitive ability to write things down, if they don't have a great memory right now. Okay, so what do you do when you don't have a great memory, when you've got 17 things going and you can't possibly remember them all, even before your stroke, how did you help yourself remember things? Let's start doing more of that when short term memory is impacted. Encourage staff that work with clients to wear a tag with their name and occupation. If you're going for a home visit or you're working in a clinic or whatever the case may be, make sure staff has a tag that says their name and that they are a physical therapist or a mental health counselor or whatever it is, because the person may be in the middle of a session with you and not remember, wait a minute, who are you? Why are you here? Again, use written schedules. Post them throughout the person's home so they can remember what they're supposed to do at different times a day if needed. Again, it depends on the person's level of cognitive disruption. Adapt the environment for perceptual changes. Like I mentioned before, if their vision is impaired, you may need to increase the wattage on bulbs in their house. They may be exceptionally sensitive to fluorescent lights or other things. Sometimes it's trial and error to figure out what is comfortable for that person, what won't contribute to distress, pain, headaches, that kind of thing. And get the person evaluated for visual or hearing aids. If they need glasses now, or if their hearing was disrupted in some way, the ophthalmologist or audiologist may be able to provide them assistive devices that can again, help them regulate their environment so they are not uncomfortable, so they are not in pain or stressed out all the time. Cognitive skills can be affected by emotional state or tiredness. It may not be brain damage, but brain damage caused by stroke can also cause difficulties with the ability to learn new skills. When you're teaching people new skills after they've had a stroke, whether it's how to brush their teeth again, or, you know, cognitive behavioral interventions, whatever it is you're teaching them, go slowly. Don't assume that they are going to pick it up at the same pace that somebody who hadn't had a stroke will. And use scaffolding. When you're teaching, teach them the concept and then have them show you the concept. Think about tying your shoes. You know, I can show my son when he was little, I showed him how to tie his shoes and had him watch me. And we had a little rhyme for it. And then I said, okay, now you do it. And he would get to the point that he could remember how to do it, and then when he got stuck, I would help him the rest of the way. And then the next time I would encourage him, I would give him little prompts to kind of remind him what the next step was. And eventually he got to the point where he remembered all the steps. That's all scaffolding is being there when the person needs you, but not until the person needs you. Their ability to plan may be disrupted. Their times, their sense of time may disrupt, be disrupted. Have them write things down, write down a schedule for them or with them ideally. That way they know what's going on. They can plan for when the CNA is coming in or they can plan for when they have to go shopping. There's a lot of different things we plan for. We don't even realize it's going to be important. You know, generally this falls within the rubric of a case manager. It's going to be important to do an assessment of the person's psychosocial and environmental needs to figure out what they need help with. They may not know, they may not remember what they need help with. And ideally, if we can figure this out ahead of time or if they're, you know, if they have a caregiver because they are not able to live independently right now, if their caregiver can start figuring out where they need plans, that will be helpful. Their ability to problem solve may be non existent at this point or impaired to some degree. They're getting up, it is 32 degrees today and they thought it was going to be 50. And the outfit that they plan to wear is not appropriate. And now they don't know what to do. They may not be able to think through, okay, maybe I need to put a sweatshirt on top of this so I'm not so cold. Instead of telling the person what to do, we want to encourage and educate caregivers to provide options. Alright, so what are your options here? It's cold outside, you know, you could wear a jacket or maybe you could wear your brown pants or, you know, whatever the other option is. Try to give them some options so they can choose. That gives them a sense of personal power. Their ability to focus and maintain attention may be impaired. Eliminate distractions whenever possible. And that can include the dogs, you know, even if it's a really sweet doggie, sometimes it may be too distracting, sometimes it may help, you know, if the dog just sits nicely on their lap or something. But eliminate any unnecessary distractions and then chunk it. A lot of people post stroke will not be able to endure an hour or an hour and a half assessment or session or group or anything. That's just way too long. Think five to ten minutes. What can we accomplish in five to ten minutes here. And as they recover, you can extend those periods. So it's, you know, 15 minutes, maybe 20 minutes. Think about yourself, you know, how hard is it to sustain your attention for more than 15 or 20 minutes without kind of wandering off mentally? They may have difficulty with orientation, knowing the day and time calendars help with this. You know, sometimes I have difficulty remembering what day it is because, you know, if I work all weekend or something, I may have challenges with that. That one is less problematic a lot of times, unless they have appointments that they've got to get to. And with short term memory, we've talked about, touched on this a little bit already, they may not remember what happened recently. Did you take your medicine? Did you brush your teeth? Did you eat breakfast? Have them write it down and review it when possible. Encourage the use of checklists. People tend to be much more compliant if all they've got to do is put a check mark as opposed to writing something longhand. Changes in working memory can also be impacted their ability to manage a bunch of things going on in their mind at the same time. So simplify and eliminate distractions. If you're trying to help the person cook, you don't want to have them try to be baking bread and making a main dish and figuring getting all the dishes on the table at the same time or whatever. Simplify. They need to focus on one thing, what is it that they're doing right now? So it's going to be more serial than concurrent intellectual fulfillment. Some people may not be able to do the things they used to because their short term memory, their energy levels, their vision, whatever it is, is impairing them from being able to do that. I've talked before about my grandfather, how he used to make little dollhouse furniture miniatures. And when his Parkinson's got bad, he couldn't hold the things steady enough in order to do the fine cuts. As his vision got bad, he wasn't able to see well enough to make these tiny, tiny little pieces of furniture. Those were things that he did for intellectual fulfillment. And when he couldn't do those anymore and he didn't like to read, he was kind of stuck. He's like, well, what do I do all day long? I hate watching tv. We want to help people figure out, what are your options. Again, looking for assistive technologies is really important. Interestingly, a minimum of one hour a day of actively listening to music, people showed recovery in both verbal memory and focused attention as early as three months after stroke. So that's one of those interventions that can't hurt to try, you know, not probably not going to have any negative effects from that. Personality changes can occur. You can start seeing people after a stroke engage in repetitive behavior. It can be stimming, but a lot of times it's more like washing their hands repeatedly or doing other things that look more like obsessive compulsive disorder, but it's not. We want to identify and mitigate triggers. What is causing this person to do this over and over again? Or what's the function of the behavior? Why is this person doing that? If they start tapping, you know, on the table constantly, what's the function for that? What are they trying to do? Are they self soothing or are they trying to get your attention? What's going on? Disinhibition kind of goes along with that emotional incontinence, but not quite. It's when people basically don't have a filter, they have a tendency to say and do things that are just socially inappropriate. And oh gosh, I can't think of the television show right now. But there was a perfect example. On one of the television shows that was popular about 10 years ago and the grandmother was living with them and she would just randomly walk out of her bedroom without a top on and you know, she had a bra on or whatever, didn't even phase her. She didn't notice that that wasn't appropriate at that point. Disinhibition can generally be addressed with behavioral interventions. Again, you want to look at, are there things that make this worse? If the person's not getting enough sleep, if they're not taking certain meds, what things may contribute to making it worse and what can we do to what works to encourage it to not happen? And impulsivity, including sudden and socially inappropriate actions. Again, I sound like a broken record here. Explore the triggers and the function of the behavior. If they suddenly start yelling or running or hitting something, where did that come from? How is that in some way functional for them? Because behavior is communication. The person may have gotten bored and not be able to express that. They may be stressed in pain. Hard to say. Perception is also altered. They may have difficulty feeling contact, pain, heat or cold on the side of the body affected by the stroke. They may have difficulty judging distance, performing certain movements. Even without a physical disability. They may have difficulty recognizing different shapes and objects, including watches. I've shared with you guys before that my mother used to be an avid bird watcher. And after her stroke she couldn't recognize a hawk. She didn't. I pointed it out it was outside of her window one day, and she said, you know, that's a word I just learned this week, Hawk. And he. And she repeated it, like, three times and like she was trying to remember it. And. We want to give people after a stroke the benefit of the doubt. We don't know what they don't know, and they don't know what they don't know until they encounter a situation where you identify there's a deficit. People after a stroke may see or feel things only on one side, which can cause them to bump into things. We want to help them adjust their environment. We want to adjust our offices to make sure that they are not at risk of trips and falls or injury. Watching TV or reading can become difficult because of visual disturbances. And as I said, some people can lose half their vision in each eye, which I imagine can be really distressing. We want to help them figure out how to make the best of what they can perceive. Communication after stroke, people may have difficulty finding the right words or understanding what others are saying. Aphasia and dysphagia are often used interchangeably. Sometimes aphasia is perceived to be worse than dysphagia. Whatever. Either way, it means the person is having difficulty understanding or communicating. Use active listening and teach caregivers how to do this. So repeat back. You know your basic level. Paraphrasing. In order to make sure that you're understanding. Try not to cut the person off and assume you know what they're gonna say. Be patient. Allow them time to try to find the word. If they start getting frustrated or agitated, then start offering suggestions. You know, are you talking about, you know, this? Ask it in a question instead of stating it like you know what they're thinking. Weakness in the muscles that help speech can also make communication difficult. They may slur their words or have hard time articulating so people can't understand them. Imagine how frustrating that is. You know, if you've ever had your wisdom teeth out until that stuff wears off, until the numbing wears off hard for you to actually talk. Well, imagine living like that for days, weeks, months, years. Having difficulty communicating to other people. Your wants and needs. That would have to be exasperating and frustrating. The dysfunction of the nerve connection between their brain and their mouth can also make speaking difficult. And reading and writing problems can be caused by the weak writing hand or. Or problems thinking or seeing. Think about how many home activities we give our clients that involve reading or writing. We have to figure out ways to adjust those. One of the best things is to have them use a voice recorder on a mobile device and record what they want to say, and then you can work with it from there. Physical changes can include difficulty with gripping or holding things, fatigue, incontinence. It's important to remember that many types of incontinence can occur, but it can be caused by medication, muscle weakness, changes in sensations or thinking and memory. They may not notice or being paying attention to the fact that they've got to go to the bathroom. They may have muscle weaknesses that can be strengthened or they may be taking other medications like diuretics that cause them to have to suddenly go to the bathroom. Encourage them to work with their doctor on incontinence issues because a lot of times it can be at least mitigated, if not completely ameliorated. Pain can be caused by nerve damage or damage to the tissues after the stroke. There can be restricted ability to perform physical activities or exercise, swallowing issues, vision problems, and weakness or paralysis on one side of the body. We've already covered those. Aphasia affects about 1/3 of the stroke population and 40% continue to have significant language impairment. At 18 months post stroke, it can manifest as either a partial or complete inability to speak or comprehend. People with aphasia are especially prone to problems such as anxiety or depression, threatened identity, changes in interpersonal relationships, reduced social networks, unemployment, and abandonment of leisure activities. We do want to find ways to help people communicate, whether it be through using pictures or even asking simple yes and no questions. If they have hard time finding the words but they can understand speech, then sometimes yes and no can be much easier for them. After a stroke, a lot of people experience losses of independence. They may lose the ability to engage in their hobbies. They may actually lose their job because of their fatigue or their physical ability loss. They may lose their home if they have to move to an assisted living community. They have losses of self esteem because they can't do things that they used to. They may feel guilty about other things. They may grieve the loss of their appearance, especially if the stroke impacted part of their facial musculature. They may have to adapt to that and there may be a grieving process associated. They may feel guilty because they can't do things with kids, family and friends that they used to. So work to identify modifications. Like we talked about. If you can't be there, maybe have somebody else who's there. FaceTime, it's so you can be there. Virtually focus on things they can do and work with the family to celebrate strengths and adjust to losses without making the person feel guilty. Some people may also feel guilt because they need assistance from caregivers and feel like a burden. Let's do what we can to maximize their independence and process their feelings interpersonally. Their personality changes and emotional incontinence may impact their social life. We talked about ways to address some of that and Financially because of loss of employment, they may need to have financial challenges. Look for options for supportive employment, Social Security disability, snap, any other benefits they can get. If they need to go to an assisted living facility and they have a high deductible or high coinsurance insurance plan, they could have some financial challenges that need to be mitigated. Same thing if they have a lot of therapy appointments they have to go to. We want to look for options for payment of those costs. Caregivers should be assessed for their ability to provide care. Are they physically able to meet the needs of this person right now? Are they emotionally, financially and environmentally able? Do they have room in their house for grandma and do they have the time? If somebody can't live independently, it's not like you can move them in and forget about them. It does put a drain on caregivers time. Regularly assess caregiver well being using the Caregiver Strain Index or the Caregiver Burden Scale and support caregivers in balancing personal needs and caregiving responsibilities by providing linkages to community programs, respite care, and educational opportunities. Stroke impacts people physically, affectively, cognitively and interpersonally. It's important to explore the causes of mood or cognitive issues to help identify the best interventions because these things can be caused by brain damage, sleep dysfunction, cognitive issues, or just plain old stress from life changes. I appreciate y' all sticking with me. I know we ran a couple minutes over. Are there any questions? It's likely most of us are going to either work with somebody who has had a stroke or who is a caregiver for someone who has had a stroke. So some of these things may come into play for us again. Remember, you're not expected to know all of the assistive technologies out there. Vocational rehabilitation is available and provides a lot of really good information. The Job Accommodation Network, otherwise known as JAN Online, can also provide options or suggestions for different ways to accommodate or mitigate problems people are having. Between writing notes, filing insurance claims, and scheduling with clients, it can be hard to stay organized. That's why I recommend TherapyNotes. Their easy to use platform lets you manage your practice securely and efficiently. Visit therapynotes.com to get two free months of therapy notes by just using the promo code CEU when you sign up for a free trial at therapynotes.com. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allceus.com podcastceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allce.com sponsor. Thank you.