Nurses play a key role in helping patients manage emotional and social health issues, or psychosocial health, after stroke. Improved screening and assessment of psychosocial needs are essential for optimal patient care. These findings are highlighted in a new statement from the American Stroke Association, a division of the American Heart Association, titled “The Role of Nursing in Psychosocial Health Management After Stroke,” published today in the association’s peer-reviewed scientific journal. stroke.
Although there have been significant advances in stroke prevention and treatment, stroke remains the second leading cause of death and a leading cause of disability worldwide. Current research shows that 16 to 85 percent of stroke survivors experience psychosocial symptoms such as depression, anxiety, stress, fatigue and/or reduced quality of life during their recovery.
“Discussions about psychosocial health are often associated with stigma, so it is critical for nurses and all health care professionals to create a safe and therapeutic environment for patients and provide hope and comprehensive education on this topic,” said scientific statement author group chair Patricia A. Zrelak, Ph.D., RN, FAHA, a regional quality care advisor for stroke programs at Kaiser Permanente Northern California and a member of the American Heart Association’s Council on Cardiovascular and Stroke Nursing.
The scientific statement provides a comprehensive review of the latest evidence from 2018 to 2023 on the mental health of patients who have had a stroke. The statement addresses the impact, underlying causes, screening, diagnosis and treatment of five key emotional and social determinants of health, including depression, stress, anxiety, fatigue and quality of life. The scientific statement aims to provide guidance for care during a patient’s recovery from a stroke, from preventing negative psychosocial health conditions to identifying and managing symptoms.
Emotional, cognitive, behavioral and/or personality changes may occur following a stroke. These conditions may occur immediately after a stroke or may be delayed, sometimes more than a year later, and their intensity may fluctuate over time. In addition, psychosocial symptoms are interrelated, and patients who experience any of these symptoms are at higher risk of developing other mental health conditions. Effective and regular screening is essential for early detection and treatment.”
Patricia A. Zrelak, Ph.D., RN, FAHA, nurse consultant for regional stroke programs at Kaiser Permanente Northern California
depression
About 30% of stroke survivors experience depression, particularly in the first three months after a stroke. Symptoms of depression may include persistent sadness, feelings of anxiety or a “empty” mood, restlessness and irritability, loss of interest or enjoyment in hobbies and activities, difficulty concentrating and thinking, increased or decreased sleep, changes in appetite, and weight gain or loss. Depression after a stroke worsens cognitive and functional recovery and increases the risk of death and/or another stroke.
The AHA/ASA guidelines for early management of patients with acute ischemic stroke recommend routine depression screening for all patients after stroke. Caregivers can educate stroke patients and their families about symptom recognition, prevention, and treatment options such as medication management and/or cognitive behavioral therapy.
stress
A 2022 study found that about one in six (about 16.5%) stroke survivors experience post-stroke stress and post-traumatic stress disorder (PTSD). These conditions can increase the risk of additional health problems, including anxiety and poor medication adherence. Screening of stroke patients for stress and PTSD should occur during hospitalization and continue during rehabilitation and at outpatient visits after hospital discharge.
Nursing interventions that can help reduce patient distress include stroke education and self-management strategies such as mindfulness and meditation. Nurses can also consider stroke patients’ coping styles. People with a high-anxious coping style are at significantly higher risk of developing PTSD after a stroke than people with a low-anxious coping style.
Fear
The prevalence of anxiety is 20 to 25 percent in the first few months after a stroke and increases to 32 percent over the course of the year, with a five-year prevalence of 34 percent. Factors such as younger age at the time of stroke, lower income, inability to work, social isolation, previous mental illness, and/or the severity of the stroke are factors that increase the risk of developing anxiety. Anxiety is also associated with a higher risk and severity of depression.
Standard anxiety screening and early diagnosis can lead to early treatment, greater patient engagement, and improved recovery in stroke patients. Although there are established clinical guidelines for treating general anxiety, more research is needed on anxiety interventions following different types of stroke.
fatigue
Fatigue after a stroke can occur at any time, but it is most common in the first six months after a stroke. Symptoms of fatigue may include decreased physical and mental energy levels that interfere with daily activities, as well as problems with self-control, emotions, and memory. Women and people with depression, sleep problems, anxiety, and/or multiple health conditions are at higher risk of experiencing fatigue after a stroke.
Further research is needed to develop effective treatment strategies for post-stroke fatigue, as there are currently no proven treatments. However, interventions aimed at improving overall physical fitness may help prevent, reduce, or treat post-stroke fatigue and other aspects of psychosocial health.
Quality of life
After a stroke, regaining the quality of life one is accustomed to is challenging, especially after a severe stroke. Physical strength, speech, depression, anxiety, and the ability to return to work and social activities are all factors that contribute to a stroke survivor’s quality of life. However, conditions such as chronic pain can negatively impact recovery and the return to independent living.
Physical activities that include interpersonal contact, such as yoga and tai chi, have been shown to improve patients’ quality of life. Caregivers can help stroke survivors improve their quality of life after stroke by connecting patients with social services in their area, such as stroke support groups and community-based organizations.
“Mental and emotional well-being is critical to recovery and caregivers play an important role in caring for patients after a stroke,” Zrelak said. “It is important to engage stroke patients and their caregivers so they are aware of these psychosocial conditions and know how to help. Early recognition of symptoms and early treatment can improve recovery after a stroke.”
The statement also highlights existing research showing that the outcomes of stroke vary considerably among people of different racial and ethnic groups. Social determinants of health, such as structural racism, socioeconomic status, inadequate housing, and/or limited access to health care, including mental health services, can all influence a stroke survivor’s recovery.
Zrelak added: “The stroke care team is critical to addressing these health inequalities, using targeted interventions and tailored treatments to improve mental health support and overall care coordination for those most at risk. More research is needed to understand how we can best support the psychosocial wellbeing of people after a stroke so they are better able to return to their everyday activities and have a better quality of life.”
This scientific statement was prepared by the volunteer writing group on behalf of the Council on Cardiovascular and Stroke Nursing and the Council on Lifestyle and Cardiometabolic Health of the American Heart Association. The American Heart Association’s scientific statements promote awareness of cardiovascular disease and stroke issues and assist in health care decision making. Scientific statements provide an overview of what is currently known about a topic and areas in which additional research is needed. Although scientific statements are used to develop guidelines, they do not provide treatment recommendations. The American Heart Association guidelines contain the association’s official recommendations for clinical practice.
Source:
American Heart Association
Journal reference:
Zrelak, P.A., et al. (2024) The role of nursing in psychosocial health management after stroke: A scientific statement from the American Heart Association. stroke. doi.org/10.1161/STROKEAHA.123.044719.
