What now, after a stroke?
A stroke can be a devastating life event. Even a minor stroke can leave people with challenges that are physical, mental and emotional.
A new study done at the Cleveland Clinic showed that the three main areas where stroke survivors find the most impact on the quality of their life is physical function, cognitive abilities (especially their ability to think through things) and their satisfaction with their role in life.
The study followed 1,195 people who had suffered an ischemic stroke, which is the type of stroke where blood flow to part of the brain is blocked by a clot. Most of the people in the study had what was considered a minor stroke. Even so, 63 percent reported greater physical challenges and 46 percent reported having increased difficulty with thinking and reasoning. The majority, 58 percent, reported greater dissatisfaction with their role in life, which had changed.
The findings parallel what inpatient occupational therapist Mary Ellen Nelson, OT/L sees on a regular basis at Cape Cod Hospital.
“It’s so important to assess the patient for their cognitive deficits while they are here in the hospital, because once they leave here, if they are really high-level functioning, things slip through the cracks,” she said. “We do a cognitive assessment here called the MoCA (Montreal Cognitive Assessment). It’s a very quick test that we do with people and it can tease out areas, such as the planning and sequencing, problem-solving and more executive functions.”
The test allows occupational therapists to see what areas the patients are struggling with. They aren’t always things that are easy to notice if you aren’t trained to assess them. For example, some people with mild strokes can carry on a conversation, but if you ask more challenging questions such as attempting calculations, or observe their ability to sequence a task, it may reveal a loss of executive function that will cause them difficulty down the road, Nelson said. Perhaps they will have errors with banking, or difficulty following directions when driving, or preparing a meal.
Other people might be walking and talking, but banging into things on the right because they can’t see out of the right side of their eye. In that case, Nelson would recommend home occupational therapy to help learn compensatory strategies, or suggest environmental modifications. She may even recommend sight loss services.
Other patients may have communication issues, which can be very isolation, so a speech pathologist is referred.
“Our primary concern in the hospital is can they take care of themselves safely?” she said. “If their dominant arm is weak or coordination is lost, how are they going to feed themselves, dress themselves? The mild strokes are the ones that are riskier for safety because subtle deficits can go unnoticed.”
Roadblocks In The Brain
In addition to MoCA, occupational therapists spend a significant amount of time during evaluation assessing self-care and can pick up deficits that may go unnoticed. For example, if the therapist asks a patient to brush her hair and she picks up a toothbrush, this demonstrates apraxia, which is the term for those who know what they are supposed to do, but aren’t quite sure how to do it, said Nelson.
“There are roadblocks in their brain now and they have to learn a new route to get the job done,” she said. “When we re-train with specific tasks, you can set new pathways. That’s why it’s called cognitive re-training because you’ve got a blockage there that you can’t go through anymore. Your brain has to find a new way to get the message across and the more you do it, the easier it becomes.”
If a patient is savvy with a tablet, Nelson recommends downloading memory and sequencing games. They are fun to do and come with little rewards like bells, whistles and blinking signs of “congratulations.” That positive feedback makes people feel good, so they want to continue. In the beginning, it’s important to start slowly and limit distractions like the television. She recommends that family members not distract the person trying to play these games.
They need their full concentration to succeed, especially at first. As they improve, more stimuli can be added or they can be encouraged to do the game in a shorter amount of time to increase their speed with processing, she said.
“You’re going to learn better if you enjoy what you’re doing, so OTs really try to find out what it is that they’re interested in and then build the or the therapy around that,” Nelson said.
An example is a woman who loves to knit but might now have trouble holding small needles and small yarn. A first step would be to try finger knitting. Next that patient could move on to knitting with large needles and fatter yarn. As she progresses, she can move down in size.
It is impossible to assess everything while the patient is in the hospital because it’s much different than their home environment. Once a patient is discharged, Nelson recommends they continue occupational therapy in their own home.
“It’s hard in the hospital environment because you are not putting them through all the paces of their daily routine. So it’s really important to get a therapist in to see them at home and witness that and work with the family,” she said.
Services In The Community
Part of the occupational therapist’s job is finding resources in the community to help. Nelson recommends Elder Services of Cape Cod & the Islands, which can provide a lifeline button, equipment and a homemaker to come in for a few hours a week to do some of the higher-level meal prep or household chores. She also recommends a stroke survivor support group through the Visiting Nurse Association of Cape Cod. There are often caretaker support groups, as well.
Senior Centers are also a lifeline for many people and many provide vans for transportation. Elder Services can also provide rides for those who can’t drive because their cognitive or visual deficits make it unsafe.
“It’s really important for people to know that depression is very normal after a stroke because you do lose a lot,” Nelson said. “Minor cognitive deficits can be even more devastating than minor physical deficits because people lose their purpose and sense of identity.”
Depression usually sets in about a month after a stroke, she said. That’s when patients become frustrated with how slow their recovery is proceeding. They are often exhausted from doing activities they used to take for granted. Everything is slower and harder and it’s easy to become depressed about the things that you’ve lost like the independence that comes with driving or your role as the caregiver in the family.
Signs of depression include:
- Loss of appetite
- Not motivated to get out of bed
- Not feeling any joy in life
- Frustration to the point of not coping well
- Feeling hopeless
If a stroke survivor has any of these symptoms, it’s important for them or a family member to inform their doctor because medication can help. It’s also important to establish a routine of activities that gets the patient out of the house. Structure gives them something to look forward to.
“Typically, you will know within three months how well you’re going to recover, but you can still be showing progress three and five years out,” Nelson said. “The key to recovering from a stroke is getting the most intense therapy and putting in the most effort you can manage in the beginning.”