Working Together with Stroke Survivors and their Caregivers to Achieve Optimal Outcomes is an imperative within the areas of mood, cognition and fatigue following stroke. The occurrence of post-stroke depression and changes to cognition (vascular cognitive impairment), even if subtle, affect up to 30% to 60% of patients who have experienced a stroke within the first year after onset. Of equal concern is the large number of family members and informal caregivers who also may experience depressive symptoms in the post-stroke recovery phase, and the timing of symptoms may vary from within a few weeks to a year or more after the stroke has occurred.
The primary underpinnings of this chapter on cognitive and mood changes after stroke require individuals with stroke, their families and healthcare team members to work together to identify risk areas, agree on goals for treatment and recovery, and implement appropriate management strategies. This theme applies across the system of care, and emphasizes the participation of individuals with stroke, their families and caregivers, healthcare providers, and the broader community.
The first steps for healthcare professionals in Working Together for mood and cognition are to understand the frequency of occurrence and build screening for the symptoms of depression, vascular cognitive impairment, and post-stroke fatigue into regular workflows. Achieving optimal outcomes for stroke survivors and their families requires ongoing screening and assessment for mood and cognitive changes. Screening should occur through all stages and settings following a stroke, including in acute care, rehabilitation, prevention clinics and outpatient community settings (including primary care, home care and long-term care).
Working Together involves healthcare providers, policy makers, individuals with stroke, their families and caregivers, and the public. It should ensure timely access to clinicians with expertise in treating these issues, and ongoing monitoring of the effects of treatment and goal attainment. Ideally, when screening is suggestive of a mood or cognition issue, patients and families should be referred to these clinical experts without delay to facilitate access to appropriate in-depth assessment and management, and to receive support and education for coping and self-management. Continuity of care and strong communication among healthcare professionals, and between members of the healthcare team and the patient and their family are critical to smooth transitions between care settings and for ensuring that issues related to mood, cognition and fatigue do not fall through the cracks.
Recent reports on the quality of stroke services across Canada and within specific provinces have shown that there is inconsistent screening and monitoring of patients for post-stroke depression and vascular cognitive functioning issues, in both urban and rural settings. Delays in comprehensive assessment and management of mood and cognition issues may result in poor outcomes and slower recovery.
The 2015 update of the Canadian Stroke Best Practice Recommendations Mood, Cognition and Fatigue module reinforces the growing and changing body of research evidence available to guide screening, assessment and management of these conditions following stroke. A coordinated and organized approach to screening and assessment as well as appropriate management is emphasized throughout this chapter.
In some areas, the research evidence is weaker or just starting to emerge. For some of these topics, the writing group was able to provide preliminary guidance based on expert opinion and current clinical practices.
Highlights of the moderate and significant updates as well as new additions to the Mood, Cognition and Fatigue module recommendations for 2015 include:
- Updated recommendations on the timing of screening for depression and VCI
- New literature incorporated which suggests that prophylactic antidepressant medication can be effective in some stroke patients.
- New comparison table of selected antidepressants for management of post-stroke depression;
- New information on cognitive rehabilitation strategies for patients with vascular cognitive impairment;
- Updated comparison table of assessment tools for screening for vascular cognitive impairment
- Addition of post-stroke fatigue recommendations to this module (previously included in Transitions of Care following Stroke module)
Guideline Development Methodology:
The detailed methodology and explanations for each of these steps in the development and dissemination of the Canadian Stroke Best Practice Recommendations is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual available on the Canadian stroke best practices website.
Citing the Mood, Cognition and Fatigue following Stroke 2015 Module
Eskes G, Lanctot K on behalf of the Mood, Cognition and Fatigue following Stroke Writing Group. Mood, Cognition and Fatigue following Stroke Module 2015. In Lindsay MP, Gubitz G, Bayley M, and Smith EE (Editors), on behalf of the Canadian Stroke Best Practices and Advisory Committee. Canadian Stroke Best Practice Recommendations, 2015; Ottawa, Ontario Canada: Heart and Stroke Foundation.
We invite comments, suggestions, and inquiries on the development and application of the Canadian Stroke Best Practice Recommendations.
Please forward comments to the Heart and Stroke Foundation’s Stroke Team at firstname.lastname@example.org
- Mood, Cognition and Fatigue Following Stroke guideline publication in the International Journal of Stroke
- Writing Group Members and External Reviewers; Declaration of Conflicts of Interest
- Section 1: Post Stroke Depression
- Table 1A: Selected Validated Screening and Assessment Tools for Post-Stroke Depression
- Table 1B: Summary Table for Selected Pharmacotherapy for Post-Stroke Depression
- Evidence Table 1A Post stroke Depression Screening and Assessment
- Evidence Table 1B Non-pharmacological Interventions
- Evidence Table 1C Pharmacotherapy and Combined Treatment
- Section 2: Vascular Cognitive Impairment
- Definition of Vascular Cognitive Impairment
- Table 2A: Diagnostic Criteria for Vascular Cognitive Impairment and Dementia (Gorelick et al, 2011)
- Table 2B: Summary of Select Screening and Initial Assessment tools for vascular cognitive impairment in stroke patients (Updated 2014)
- Evidence Table 2A Vascular Cognitive Impairment: Screening and Assessment
- Evidence Table 2B Vascular Cognitive Impairment: Cognitive Rehabilitation
- Evidence Table 2C Vascular Cognitive Impairment: Pharmacological Therapy
- Section 3: Post Stroke Fatigue