Mood, Cognition and Fatigue following Stroke

Partnerships and Collaborations 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, are reported to affect up to 30% to 60% of people in the first year after experiencing a stroke.  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. Experiencing any of these sequelae of stroke may make it more challenging to actively participate in rehabilitation and recovery, slow progress, and potentially lead to worse outcomes for people who have experienced a stroke, including increased mortality and lower quality of life.  Each of these conditions are complex, they may have similar symptoms and it can be a challenge to sort out underlying mechanisms.  In addition, people may experience more than one of these issues.  In current practice, people who have experienced a stroke are not consistently screened for these conditions, and the most appropriate timing to screen lacks evidence and consensus.  People who have experienced a stroke often report that their symptoms get misinterpreted, for example reporting symptoms of post-stroke fatigue may be presumed to be a symptom of depression, rather than an issue unto itself.  We also now understand that these conditions are not severity-dependent; any of these conditions may appear even after a seemingly mild stroke. Understanding each of these conditions, their overlap and interplay, and current best evidence in screening, assessment, and management will lead to improved person-oriented outcomes and enable people to be more likely reach their recovery goals.

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 in partnership to identify risk areas, agree on goals for treatment and recovery, and implement appropriate management strategies. This theme applies across the continuum of care, and emphasizes the participation of individuals with stroke, their families and caregivers, healthcare providers, and the broader community.  People experiencing any of these issues following a stroke often report they feel stigmatized, first by the stroke itself, and more so if it is accompanied by any or all these conditions.

Partnerships and Collaboration involves healthcare providers, policy makers, individuals with stroke, their families and caregivers, and the public.  Together, they should ensure timely access to clinicians with expertise in treating these issues, and ongoing monitoring of the effects of treatment and goal attainment. The first steps for healthcare professionals in Collaboration for mood, cognition and fatigue 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. 

Ideally, when screening is suggestive of a mood or cognition issue, people who have experienced a stroke 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 person who experienced a stroke 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. Frequent ‘checking in’ and ongoing education with people post stroke and their families is important as these areas can be missed if they do not appear until later stages of recovery. 

Recent reports on the quality of stroke services across Canada and within specific provinces have shown that there is inconsistent screening and monitoring of people who have experienced a stroke for post-stroke depression, fatigue 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.

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 2019 Module:

Lanctôt KL, Swartz RH, on behalf of the Mood, Cognition and Fatigue following Stroke Writing Group.  Mood, Cognition and Fatigue following Stroke Module 2019. In Lindsay MP, Mountain A, Gubitz G, Dowlatshahi D, Casaubon L, and Smith EE (Editors), on behalf of the Canadian Stroke Best Practices and Quality Advisory Committee.  Canadian Stroke Best Practice Recommendations Sixth Edition, 2019; Toronto, Ontario Canada: Heart and Stroke Foundation.

Comments:

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 strokebestpractices@heartandstroke.ca

The 2019 update of the CSBPR Mood, Cognition and Fatigue following Stroke 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 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 Sixth Edition of the Mood, Cognition and Fatigue following Stroke module 2019 include:

• New clinical considerations have been added to each section, acknowledging emerging therapies and consensus-based practices.
• New literature incorporated which suggests that prophylactic antidepressant medication can be effective in some people who have experienced a stroke.
• New information on cognitive rehabilitation strategies for people with vascular cognitive impairment.
• Updated comparison table of assessment tools for screening for vascular cognitive impairment.
• Updated information on management of post-stroke fatigue.

• 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
  • Table 1C: Summary of 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
  • 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 People who have Experienced a Stroke
  • 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 
  • Box 3: Examples of Specific Energy Conservation Strategies
  • Table 3A: Summary of Selected Assessment Tools for Post-Stroke Fatigue
  • Evidence Table 3 Post-Stroke Fatigue