Conflict of interest: Dr. Gail A. Eskes (primary author): no conflicts of interest; Dr. Krista Lanctôt (co-primary author): research/travel support – AbbVie, Lundbeck, Pfizer, Hoffman-La Roche Ltd. Consultation fees – AbbVie; Dr. Richard Swartz: Heart and Stroke Foundation of Canada New Investigator Award and Henry Barnett Scholarship; Research support – CIHR, Heart and Stroke, Sunnybrook HSC AFP and Department of Medicine, Hoffman-LaRoche Canada; Speaker: BMS Pfizer; Dr. Nathan Herrmann: research support – Lundbeck, Pfizer, Roche, Transition Therapeutics. Consultation fees – AbbVie, Eli Lilly; Dr. Mark Bayley: no conflicts of interest; Laurie Bouvier: no conflicts of interest; Dr. Deirdre Dawson: no conflicts of interest; Sandra Egi: no conflicts of interest; Dr. Elizabeth Gilchrist: no conflicts of interest; Dr. Theresa Green: no conflicts of interest; Dr. Gord Gubitz: Bayer, speaker; Boehringer Ingleheim, speaker; BMS Pfizer, speaker; Dr. Michael D. Hill: Heart and Stroke Foundation of Alberta Board Chair, salary award holder; Institute for Circulatory and Respiratory Health of CIHR Advisory Board member; Vernalis Group Ltd and Merck Ltd Consultant; Hoffmann-LaRoche Canada, provided drug for clinical trial, consultancy and CME lecturer; Coviden, research grant holder; Servier Canada, CME lecturer (funds donated to charity); BMS Canada, consultancy (funds donated to charity); Alberta Innovates Health Solutions, salary award; Dr. Tammy Hopper: no conflicts of interest; Aisha Khan: no conflicts of interest; Andrea King: no conflicts of interest; Dr. Adam Kirton: no conflicts of interest; Dr. Paige Moorhouse: no conflicts of interest; Dr. Eric E. Smith: no conflicts of interest; Janet Green, no conflicts of interest; Norine Foley: no conflicts of interest; Katherine Salter: no conflicts of interest; Dr. Patrice Lindsay (corresponding author): no conflicts of interest.
Funding: The development of the Canadian Stroke Best Practice Recommendations is funded in their entirety by the Heart and Stroke Foundation, Canada. No funds for the development of these guidelines come from commercial interests, including pharmaceutical companies. All members of the recommendation writing groups and external reviewers are volunteers and do not receive any remuneration for participation in guideline development, updates, and reviews. All participants complete a conflict of interest declaration prior to participation.
Specific references related to the best practice recommendations can be accessed online at www.strokebestpractices.ca.
Abstract
Every year, approximately 62 000 people with stroke and transient ischemic attack are treated in Canadian hospitals, and the evidence suggests one-third or more will experience vascular-cognitive impairment, and/or intractable fatigue, either alone or in combination. The 2015 update of the Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue Module guideline is a comprehensive summary of current evidence-based recommendations for clinicians in a range of settings, who provide care to patients following stroke. The three consequences of stroke that are the focus of the this guideline (poststroke depression, vascular cognitive impairment, and fatigue) have high incidence rates and significant impact on the lives of people who have had a stroke, impede recovery, and result in worse long-term outcomes. Significant practice variations and gaps in the research evidence have been reported for initial screening and in-depth assessment of stroke patients for these conditions. Also of concern, an increased number of family members and informal caregivers may also experience depressive symptoms in the poststroke recovery phase which further impact patient recovery. These factors emphasize the need for a system of care that ensures screening occurs as a standard and consistent component of clinical practice across settings as stroke patients transition from acute care to active rehabilitation and reintegration into their community. Additionally, building system capacity to ensure access to appropriate specialists for treatment and ongoing management of stroke survivors with these conditions is another great challenge.
Every year, approximately 62 000 people with stroke and transient ischemic attack (TIA) are treated in Canadian hospitals [1]. The annual cost of stroke is approximately $3·6 billion, taking into account both healthcare costs and lost economic output [2]. Moreover, it is estimated that for each symptomatic stroke, there are nine ‘silent’ strokes that result in subtle changes in cognitive function and processes [3], and these are often not counted in incidence rate estimates. Three common consequences of stroke, including poststroke depression (PSD), vascular cognitive impairment (VCI), and poststroke fatigue (PSF) all have significant impact on the lives of people who have had a stroke, impede recovery, and result in worse long-term outcomes [4, 5]. A recent survey of Canadian stroke programs revealed significant practice variations in screening and more detailed assessment of stroke patients for these conditions [1] These variations may be further confounded by a lack of evidence regarding the appropriate time to start screening stroke patients, and questions regarding the validity of screening during the acute phase of stroke, as it may be too soon to detect clinically meaningful changes. Also of concern, an increased number of family members and informal caregivers may also experience depressive symptoms in the poststroke recovery phase which further impact recovery. These factors emphasize the need for a system of care that ensures screening occurs as a standard and consistent component of clinical practice across settings as stroke patients transition from acute care to active rehabilitation and reintegration into their community.
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. These guidelines focus on management of people who have experienced a stroke or TIA. A coordinated and organized multidisciplinary approach to screening and assessment as well as appropriate management is emphasized throughout this module. The evidence related to screening, assessment, and management of these three clinical conditions following stroke has been reviewed, and a comprehensive set of clinical practice guidelines has been developed and updated by the Canadian Stroke Best Practices Mood, Cognition and Fatigue Following Stroke expert writing group. This is the fifth update of these recommendations. Additional supporting information may be found at www.strokebestpractices.ca.
Guideline development methodology
The Canadian Stroke Best Practice Recommendations development and update process follows a rigorous framework adapted from the Practice Guideline Evaluation and Adaptation Cycle [6]. An interprofessional group of mood, cognition, and fatigue experts was convened to participate in reviewing, drafting, and revising all recommendation statements. Members who were selected have extensive experience in the topic area, are considered leaders and experts in their field, have been involved in clinical trials or publications on the topics addressed in this module, and have experience appraising the quality of research evidence. People who have experienced a stroke or their family members are also included as group members and/or external reviewers. The interprofessional writing group included stroke neurologists, psychiatrists, a clinical pharmacologist, neuropsychologists, occupational therapists, a speech language pathologist, family physicians, nurses, stroke survivors, and education experts. This interprofessional approach ensures that the perspectives and nuances of all relevant health disciplines are considered in the development of the recommendations, and mitigates the risk of potential or real conflicts of interest from individual members. Other experts outside the writing group were consulted for very specific issues such as sleep apnea.
A systematic literature search was conducted to identify research evidence for each topic area addressed in the Mood, Cognition, and Fatigue following Stroke module. All literature searches are conducted by individuals with expertise performing systematic literature reviews that are not directly involved in active research or the writing group to ensure objective selection of evidence. Literature searches include set time frames which overlap the previous search time frame by six-months to ensure high catchment of key articles within that time frame.
The writing group was provided with comprehensive evidence tables that include summaries of all high-quality evidence identified through the literature searches. The writing group discusses and debates the value of the evidence and through consensus develops a final set of proposed recommendations. Through their discussions, additional research may be identified and added to the evidence tables if consensus on the value of the research is achieved. All recommendations are assigned a level of evidence ranging from A to C, according to the criteria defined in Table 1. When developing and including ‘C-Level’ recommendations, consensus is obtained among the writing group and validated through the internal and external review process. This level of evidence is used cautiously, and only when there is a lack of stronger evidence for topics considered important system drivers for stroke care (e.g. transport using ambulance services or some screening practices). Recommendations with this level of evidence may also be made in response to requests from a range of healthcare professionals who seek guidance and direction from the experts in the absence of strong evidence on certain topics that are faced on a regular basis. In some sections, the expert writing group felt there was additional information that should be included within the documentation, but these statements did not meet the criteria to be stated as recommendations; therefore, these were included as clinical considerations, with the goal of providing additional guidance or clarity in the absence of evidence.
Table 1. Summary of criteria for levels of evidence reported in the CanadianBestPracticeRecommendations forStrokeCare (Update 2015)
Evidence from a meta-analysis of randomized controlled trials or consistent findings from two or more randomized controlled trials. Desirable effects clearly outweigh undesirable effects, or undesirable effects clearly outweigh desirable effects.
B
Evidence from a single randomized controlled trial or consistent findings from two or more well-designed nonrandomized and/or noncontrolled trials, and large observational studies. Desirable effects outweigh or are closely balanced with undesirable effects or undesirable effects outweigh or are closely balanced with desirable effects.
C
Writing group consensus and/or supported by limited research evidence. Desirable effects outweigh or are closely balanced with undesirable effects or undesirable effects outweigh or are closely balanced with desirable effects, as determined by writing group consensus. Recommendations assigned a Level C evidence may be key system drivers supporting other recommendations, and some may be expert opinion based on common, new, or emerging evidence or practice patterns.
After completion of the draft update to the recommendations, the mood, cognition, and fatigue module underwent an internal review by the Canadian Stroke Best Practices Advisory Committee, and an external review by 13 Canadian and international experts in mood, cognition, and/or fatigue following stroke who were not involved in any aspects of the guideline development. All feedback was reviewed and addressed by the writing group members and the advisory committee to ensure a balanced approach to addressing suggested edits. All recommendations are accompanied by additional supporting information, including a rationale for inclusion of the topics, system implications to ensure the structural elements and resources are available to achieve the recommended levels of care, performance measures to monitor care delivery and patient outcomes, as well as implementation resources and a summary of the evidence to which the recommendations were based. The evidence tables are available as well. This additional supporting information for the recommendations included in this publication can be found at http://www.strokebestpractices.ca/index.php/cognition-mood/.
For a more detailed description of the methodology on the development and dissemination of the Canadian Stroke Best Practice Recommendations, please refer to the Canadian Stroke Best Practice Recommendations Overview and Methodology documentation available on the Canadian stroke best practices website at http://www.strokebestpractices.ca/wp-content/uploads/2014/08/CSBPR2014_Overview_Methodology_ENG.pdf [8].
Canadian Stroke Best Practice Recommendations: Mood, Cognition, and Fatigue Following Stroke update 2015
This section provides detailed recommendations for screening, assessment, and management of PSD and other mood issues, VCI, and fatigue following stroke or TIA. All recommendations are assigned a level of evidence which reflects the strength and quality of the evidence available to support the recommendations. For more details on the rationale for the recommendations, health system implications, suggested performance measures, implementation resources, and detailed evidence summaries and evidence tables, please visit http://www.strokebestpractices.ca/index.php/cognition-mood/. For full French translation of this manuscript and the recommendations, refer to Appendix S1.
Section 1: mood and stroke
PSD is a common sequelae of stroke. The occurrence of PSD has been reported as high as 30–60% of patients who have experienced a stroke within the first year after onset [9-11]. In a systematic review of 51 prospective, observational studies of PSD conducted in hospital-, rehabilitation-, and population-based settings, Hackett et al. estimated that approximately one-third of all individuals who experience stroke exhibit depressive symptoms at some point following the event (i.e., at acute, subacute, or long-term follow-up) [9]. The authors suggest that this proportion is likely an underestimation of prevalence, given possible under-reporting of unusual mood, difficulty in the assessment of depression within the stroke population, and the variability in the methods used to assess and define cases of depression within the literature [9]. The best time to screen formally for the possible presence of PSD is not certain, and incident rates of PSD are not stable over time. Although incident rates decline over time and a general trend toward improvement in depressive symptomatology is evident in the first year poststroke, PSD may prove to be persistent for a longer duration for a significant proportion of individuals identified as depressed [10, 11]. Once diagnosed, treatment by pharmacotherapy has been associated with a reduction of depressive symptomatology [12, 13]. In addition, talk-based therapy used in combination with pharmacotherapy has been demonstrated to be an effective means to reduce the symptoms of depression and improve mood [14-16].
What's new for mood and stroke in update 2015
Treatment of depression poststroke with antidepressants remains strongly supported by RCT evidence (section 1.5), and guidelines recommending screening and outlining the care pathway subsequent to a positive screen have been updated (sections 1.1–1.3). To help support treatment recommendations, a comparison table of selected antidepressants for management of PSD has been added and is available at www.strokebestpractices.ca. The goal of this table is to highlight the antidepressants with stroke-specific evidence for their efficacy. Consistent with the recognition of the negative impact of PSD on patient outcomes and quality of life, there is now new literature evaluating the prophylactic use of antidepressants poststroke. Data from randomized placebo-controlled trials now exist and suggest a significant decrease in emergence of depression, and mortality in those treated with antidepressants [14, 15]. Despite the high-quality evidence, the expert writing group did not recommend all stroke survivors be treated prophylactically with antidepressants. Optimal timing and duration of interventions remain to be elucidated, and benefits may not outweigh risks in those who are not at increased risk for depression. Instead, careful monitoring particularly for those considered at increased risk for depression and individualized treatment was felt to be reasonable at this time.
Mood and stroke best practice recommendations 2015
1.0All patients with stroke should be considered to be at high risk for PSD, which can occur at any stage of recovery (Evidence Level A).
1.1Screening for PSDSide note: Common risk factors associated with PSD include increasing stroke severity, functional dependence, presence of cognitive impairment, and history of previous depression. Increased functional dependence (e.g. requiring help with activities of daily living) and having a history of prestroke depression may be the two most salient risk factors for the development of PSD. Communication deficits and social isolation may also be considered as possible risk factors for depression. Refer to Transitions of Care Module (available at www.strokebestpractices.ca) for information on depression in family and informal caregivers of people with stroke.
All patients with stroke should be screened for depressive symptoms, given the high prevalence of depression poststroke, the need for screening to detect depression, and the strong evidence for treating symptomatic depression poststroke (Evidence Level B).
Screening should be undertaken using a validated tool to maximize detection of depression (Evidence Level B); table1A – a summary of suggested validated tools – is available atwww.strokebestpractices.ca.
Stroke patient assessments should include evaluation of risk factors for depression, particularly a history of depression (Evidence Level C).
For patients who experience some degree of communication challenge or deficits following stroke, appropriate strategies for screening of possible PSD should be implemented to ensure adequate assessment and access to appropriate treatment (Evidence Level C).
1.2Timing of screening for PSD
Screening for PSD may take place at various stages throughout the continuum of stroke care, particularly at transition points (Evidence Level C). Repeated screening may be required since the ideal timing for screening for PSD is unclear.
Screening for depressive symptoms could be considered during acute care stay in patients at high risk for depression, particularly if evidence of depression or mood changes is noted. Stroke patients who are identified as at risk could be screened before discharge from acute care (Evidence Level C).
Screening for depressive symptoms should be considered during transition points in care, such as from an inpatient acute setting to an inpatient rehabilitation setting, and or before return to the community (Evidence Level C).
Screening for depressive symptoms should be considered following discharge to the community, at stroke prevention clinic assessments, during follow-up appointments, and during periodic health assessments with primary care practitioners and consulting specialists (Evidence Level C).
1.3Assessment for PSD
Patients identified with a high probability of clinically significant PSD during screening should be assessed in a timely manner by a healthcare professional with expertise in diagnosis, management, and follow-up of depression in patients following stroke (Evidence Level C).
1.4Nonpharmacological management of PSD
There is a lack of evidence to support use of psychotherapy as a monotherapy in the treatment of PSD (Evidence Level C). However, it is reasonable to consider these therapies (either cognitive behavioral therapy or interpersonal therapy) as one of the first line treatments for acute major depressive disorders poststroke, given their demonstrated efficacy in primary depressive disorders (Evidence Level A).
Treatment for PSD may include psychotherapy as an adjunct in combination with antidepressants (Evidence Level B), as appropriate to the patients' health state and other deficits (e.g. communication and other cognitive deficits).
Treatment should be provided with the goal of preventing relapse (Evidence Level B).
Other approaches to adjunctive treatment of PSD are emerging, but these require more research. These include physical exercise, music, mindfulness, acupuncture, deep breathing, meditation, visualization, and repetitive transcranial magnetic stimulation. These could be considered on an individual basis at the discretion of the treating healthcare professional in consultation with the patient (Evidence Level C).
1.5Pharmacotherapy for PSD*Note: Watchful waiting is defined as a period of time when the patient who displays mild depressive symptoms is monitored closely without additional therapeutic interventions to determine whether the mild depressive symptoms will improve. The timeframe for watchful waiting varies in the literature somewhere between two and four-weeks. It is often described as including suggestions to the patient for self-help strategies and participation in physical exercise and other strategies noted in Section 1.4 above.
Patients with mild depressive symptoms or those diagnosed with minor depression may initially be managed by ‘watchful waiting'* (Evidence Level B). See note below for definition.
Pharmacological treatment should be considered/started if the depression is persistent and interferes with day-to-day functioning and recovery goals, or worsens (Evidence Level B).
Patients diagnosed with a depressive disorder following formal assessment should be considered for a trial of antidepressant medication (Evidence Level A).
No one drug or drug class has been found to be superior for PSD treatment. Side effect profiles, however, suggest that some selective serotonin reuptake inhibitors may be favored in this patient population (Evidence Level A). Refer to table1B for a summary of suggested pharmacotherapy agents for the treatment of PSD (available atwww.strokebestpractices.ca).
Choice of an antidepressant medication will depend upon symptoms of depression, potential known side effects of the medication, particularly in the child or older adult, drug interactions with other current medications, and underlying disease conditions.
Response to treatment should be monitored regularly by a health professional. Monitoring should include evaluation of any changes in the severity of depression, review of potential side effects, and update of ongoing management plans (Evidence Level C).
If a good response is achieved, treatment should be continued for a minimum of 6–12 months (Evidence Level C).
Examples of a ‘good response’ may be indicated by positive changes in thoughts and self-perceptions (e.g., hopelessness, worthlessness, guilt), emotional symptoms (e.g. sadness, tearfulness), neurovegetative symptoms (e.g. sleep, appetite), and improved motivation to carry out daily activities.
If the patient's mood has not improved two to four-weeks after initiating treatment, check that the patient is taking the medicine as prescribed. If yes, then consider increasing the dose or changing to another antidepressant (Evidence Level B).
Following the initial course of treatment, maintenance therapy could be considered on an individual basis (consider previous history and risk factors for recurrence of depression) (Evidence Level C).
If a decision is made to discontinue an antidepressant, it should be tapered over one to two-months (Evidence level C).
Following initial treatment for PSD, patients should continue to be monitored for recurrence of depressive symptoms, as part of ongoing comprehensive stroke management (Evidence Level C). The involvement and feedback of patients, family, and caregivers can be an important component of ongoing monitoring.
Pseudobulbar affect: In cases of severe, persistent, or troublesome tearfulness (emotional incontinence or lability), patients may be given a trial of antidepressant medication (Evidence Level A). Side effect profiles suggest that some selective serotonin reuptake inhibitors may be preferred over others for this patient population. There is no evidence for nonpharmacotherapy for this condition. Refer to table1B for a summary of suggested pharmacotherapy agents for the treatment of PSD (available atwww.strokebestpractices.ca).
1.6Prophylactic treatment for PSD
At this time, the routine use of prophylactic antidepressants for all stroke patients is not recommended as the risk – benefit has not been clearly established (Evidence Level B).
Emerging data on the use of pharmacotherapy to prevent PSD suggests that pharmacotherapy may be reasonable for some patients (Evidence Level A).
Further research is required to define at risk patients, choice of antidepressant agents, optimal timing, and duration of intervention (Evidence Level C).
1.7Other mood states (anxiety and apathy)
Anxiety frequently co-exists with depression following stroke or may appear in patients not clinically depressed. For patients with marked anxiety with or without clinical depression, it is reasonable to offer psychotherapy (Evidence level C).
Although evidence is limited in stroke patients, psychotherapy may be considered as an adjunct to pharmacotherapy (Evidence Level C).
Apathy frequently co-exists with depression following stroke or may appear in patients not clinically depressed. For patients with marked apathy, with or without clinical depression, it is reasonable to offer psychotherapy (Evidence level C).
1.8Ongoing monitoring, support, and educationNote: Additional materials available on the Stroke Best Practices website (www.strokebestpractices.ca/depression) include a table summarizing the psychometric properties of a selected set of screening and assessment tools that have been validated for use with stroke patients, or frequently reported in the stroke literature, and a table summarizing the pharmacotherapeutic properties, side effects, drug interactions, and other important information on selected classes of medications available for use in Canada and more commonly recommended for PSD.
Patients and families should be given information and education about the potential impact of stroke on their mood and that of family and caregivers; patients and families should be provided with the opportunity to talk about the impact of stroke on their lives at all stages of care (Evidence level C).
Patients and their caregivers should have their psychosocial and support needs assessed as part of ongoing stroke management (Evidence level C).
Section 2: cognition following stroke
VCI refers to cognitive impairment due to all forms of cerebral vascular disease, including stroke, with severity that ranges from mild cognitive impairment to dementia [17, 18]. However, in individuals who have experienced stroke, reported VCI prevalence rates tend to be much greater, depending upon time poststroke, number of strokes and method of assessment, with values ranging from 61% in the acute phase [19] to 21–66% from three-months to 14 years [20-22]. While the risk for cognitive impairment is greater following stroke and, certainly, not all individuals with cognitive impairment have dementia, poststroke cognitive impairment is associated with an increased risk for dementia.
Pendlebury and Rothwell conducted a systematic review and meta-analysis of 73 published studies examining prevalence and predictors of dementia in individuals with stroke. Overall, pooled prevalence of prestroke dementia was 14·4% in hospital-based cohorts (n = 22) and 9·1% in community-based studies (n = 8) [23]. Prevalence of poststroke dementia ranged from 7·4% in population-based studies of individuals with first-ever stroke and no existing dementia to 41.3% in hospital-based studies of individuals with recurrent stroke (both with and without existing dementia). Rates of dementia were at least doubled following recurrent stroke when compared with first-ever stroke and were higher in hospital-based than in community-based studies. At three to six-months, poststroke incidence of dementia was approximately 20%; this increased linearly at a rate of 3·0% per year in hospital-based studies of either first or recurrent stroke. Incidence rates were lower in population-based studies of first-ever stroke and when cases with recurrent stroke were excluded.
What is new in cognition and stroke in update 2015
There is a growing recognition of the effect of stroke on cognitive function (VCI), and standardized screening and assessment are recommended for those at risk of cognitive deficits and/or for those identified with cognitive deficits through screening. To this end, an updated comparison table of screening and assessment tools is now provided (available at www.strokebestpractices.ca); no single tool was recommended as screening and assessment needs will vary depending upon the patient population, stage of care, needs of the patients and families, as well as the resources available. Thus, the table highlights the particular strengths and limitations of each tool in order to provide healthcare professionals with the evidence needed to make informed choices. The heterogeneity of VCI presents a challenge for identifying an efficient screening tool, and development of more evidence-based screening tools is needed. The need for routine screening at each stage was debated among the group; given the lack of strong evidence for clear benefit of routine screening, it was decided not to recommend this for all stroke patients at this time. The question of whom and when to screen is clearly an area that needs more research and further development, however.
Management of VCI is further developed in the current guidelines, although the evidence for effectiveness is still limited and needs expansion. Both remediation and functional (strategy-based) approaches for certain cognitive deficits are identified as having enough evidence to warrant consideration by appropriate clinicians. Issues such as the best approach (e.g. remediation vs. strategy training), the need for evidence of benefit in daily activities, and the need for more targeted interventions to manage the range of deficits seen in VCI were recognized as areas requiring further research. Given the impact and chronicity of cognitive deficits on functional independence and quality of life, the need for system changes to optimize outcomes for patients and families as highlighted here is critical.
Cognition and stroke best practice recommendations 2015
2.0All patients with clinically evident stroke or TIA should be considered at risk for VCI (Evidence Level A).
2.1Screening and assessment for VCIRefer to www.strokebestpractices.ca for a summary of suggested VCI screening and assessment tools, and their psychometric properties, which may help to guide decision making about the appropriate tool for individual patients.
Patients with stroke and TIA should be considered for screening for VCI (Evidence Level C).
Patients with other significant risk factors for vascular disease and VCI poststroke, such as neuroimaging findings of covert stroke or white matter disease, hypertension, diabetes, atrial fibrillation, other cardiac disease, and/or sleep apnea, should be considered for screening for VCI, particularly those patients with cognitive, perceptual, or functional changes that are clinically evident or reported during history taking (Evidence Level C).
Screening for VCI should be conducted using a validated screening tool, such as the Montreal Cognitive Assessment test (MoCA) [24] (Evidence Level C).
2.2Assessment for VCI*Note: Experts in neurocognitive assessment may include neuropsychologist, psychologist, occupational therapist, speech language pathologist, clinical nurse specialist, psychiatrist, physiatrist, geriatrician, neurologist, memory specialists, and developmental pediatricians. Experts require specific qualifications to administer many of the identified assessments.
Patients who demonstrate cognitive impairments in the screening process should be managed by healthcare professionals with expertise in the assessment and management of neurocognitive functioning.* If required, a referral could be made to an appropriate cognitive specialist (Evidence Level C).
VCI is associated with a range of potential deficits; thus, a detailed cognitive screen and/or assessment could address arousal, alertness, sensorimotor function, attention, orientation, memory, language, agnosia, visual-spatial/perceptual function, praxis, and executive function (Evidence Level B).
Executive function assessment may include assessment of initiation, inhibition, shifting, insight, planning and organization, judgment, problem solving, abstract reasoning, and social cognition (Evidence Level B).
Additional assessments could be undertaken to determine the nature and severity of cognitive impairments, as well as the presence of remaining cognitive abilities and strengths (Evidence Level C).
The impact of deficits on function and safety in activities of daily living and instrumental activities of daily living, and occupational and school functioning should also be assessed (e.g., driving, home safety) (Evidence Level C).
The results of these assessments should be used to guide selection and implementation of appropriate remedial, compensatory, and/or adaptive intervention strategies according to client-centered goals and current or anticipated living environment (e.g. to help with discharge planning) (Evidence Level B). Refer to Sections 2.3 and 2.4 for more information on management of patients with stroke and VCI.
2.3Other considerations related to screening and assessmentsNote: Additional materials available on the Stroke Best Practices website (www.strokebestpractices.ca) includes a table summarizing the psychometric properties of a selected set of screening and assessment tools for VCI that have been validated for use with stroke patients, or frequently reported in the stroke literature.
Comorbidities
Screening for VCI should take into account any immediate factors that may impact assessment results, such as communication and sensorimotor deficits (speech and language, vision, hearing), delirium, hypoarousal, and other medical conditions that may have temporary impact on cognition (Evidence Level B).
Poststroke patients with suspected cognitive impairment should also be screened for depression, given that depression has been found to contribute to VCI (Evidence Level A). Refer to Recommendation 1.0 on Post Stroke Depression for additional information.
Timing
The impact and presentation of VCI evolves over time. All patients considered at risk for cognitive impairment should be screened and/or assessed periodically to detect changes over time in cognition, perceptual deficits, depression, and/or changes in function (Evidence Level C).
Screening and assessment could occur at different stages of care as indicated by the severity of clinical presentation, history, and/or imaging abnormalities (Evidence Level C).
Age
Effects of age or developmental stage must also be considered when deciding when and what to assess (Evidence Level C).
For example, in children with stroke, outcomes will evolve in parallel with development, and deficits may not be fully realized until many years later (Evidence Level C).
In young adults, decisions about what to assess should take into consideration age-specific goals such as educational and vocational needs (Evidence Level C).
Multiple assessments
Although screening or conducting assessments at different stages of care is important for guiding diagnosis and management, it is also important to be aware of the potential impact of multiple assessments on both the validity of the results as well as on the patient (e.g. practice effects, test fatigue) (Evidence Level B). Thus, use of different equivalent assessment forms is recommended when available (e.g. MoCA has three versions).
2.4Management of VCI following stroke
Vascular risk factors (e.g. hypertension, diabetes) should be managed aggressively to achieve maximum risk reduction for future strokes (Evidence Level B).
Treatment of hypertension reduces cognitive decline, even in the absence of stroke events, and should be addressed for all patients with stroke and elevated blood pressure (Evidence Level A).
The benefits of vascular risk reduction on cognitive decline in older populations suggest extrapolation to individuals poststroke is warranted and should be addressed (Evidence Level B).
Interventions for cognitive impairment should be tailored according to the following considerations
Goals should be patient centered and sensitive to the values and expectations of patient, family, and caregivers (Evidence Level B).
Goals and interventions should take into account the strengths and weaknesses of the cognitive profile and communication abilities (Evidence Level C).
Patients with communication or cognitive issues may require additional support (e.g. family involvement) to optimize patient participation in goal setting and/or engagement in rehabilitation (Evidence Level C).
Interventions should be individualized, based on best available evidence, and have the long-term aim to facilitate resumption of desired activities and participation (e.g., self-care, home and financial management, leisure, driving, return to work) (Evidence Level C).
Severity of impairments: If the level of impairment has reached the moderate dementia stage, it is reasonable for interventions to be more focused on providing education and support for the caregiver in addition to, or in lieu of, cognitive rehabilitation with the patient (Evidence Level C).
Note: Issues such as intensity and dose of therapy, stage of treatment, and impact of severity of deficits can modify effectiveness of therapy and require more research.
Interventions with the patient can be broadly classified as either compensation strategies training or direct remediation/cognitive skill training. These approaches are not mutually exclusive, and, depending upon the impairments, activity limitations and goals may be offered together.
Compensation strategy training should focus on teaching strategies to manage impairments and is often directed at specific activity limitations to promote independence. It can include environmental changes or changing the way one performs an activity (Evidence Level B).
Direct remediation/cognitive skill training should focus on providing intensive specific training to directly improve the impaired cognitive domain. It can include drill and practice exercises, mnemonic strategies (ex: acronyms, songs), or computer-based tools directed at specific deficits (Evidence Level B).
It is reasonable to treat attention impairments with computerized skill training under the supervision of a therapist aimed at specific aspects of attention (Evidence Level B).
Evidence for impact on activity or participation limitations is limited, however, and requires more research (Evidence Level C).
Memory impairments may be treated with compensation using external strategies (e.g. assistive electronic and nonelectronic devices) and using internal strategies (e.g. encoding and retrieval strategies, self-efficacy training), with some evidence for benefits to activity limitations (Evidence Level B).
Executive function deficits may be treated with computerized skill training under the supervision of a therapist and/or compensation strategies, depending upon the specific impairment. There is some evidence for benefits to activity limitations (Evidence Level B).
Targeted computerized skill training directed by a therapist may be considered for working memory deficits (Evidence Level B)
Internal strategy training may be considered and includes strategies to improve goal management, problem solving, time pressure management, and metacognitive reasoning (Evidence Level B).
Aerobic exercise can be considered for treatment of cognitive impairments including attention, memory, and executive function (Evidence Level B), although evidence for benefits to physical activity and/or participation limitations is limited.
Exercise may be considered to slow cognitive decline in those with vascular disease without presence of stroke (Evidence Level B)
New developments in cognitive intervention that may be of potential benefit include repetitive transcranial magnetic stimulation or direct stimulation, the use of virtual reality environments, and application of constraint-induced approaches for the impaired cognitive domain. These strategies require more research before recommendations can be developed on their use (Evidence Level C).
Patients with cognitive impairment and evidence of changes in mood (e.g. depression, anxiety) or other behavioral changes on screening could be referred and managed by an appropriate mental healthcare professional (Evidence Level B). Refer to Recommendation 1 on Post Stroke Depression for additional information.
2.5Pharmacotherapy for VCI following stroke
Cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) and the NMDA receptor antagonist memantine may be considered in individual stroke patients with vascular dementia, based on randomized trials showing small magnitude benefits in cognitive outcomes. However, the clinical relevance of these benefits remains controversial; therefore, the use of these medications should be based on clinical judgment that small improvements in cognition would have a meaningful impact on the patient's quality of life (Evidence level B).
For patients with evidence of VCI, a referral to a healthcare professional or team with expertise in VCI should be considered for further assessment and recommendations regarding pharmacotherapy (Evidence Level C).
Clinical considerations for cognition and stroke
It should be noted that most of the available evidence is based on people who meet the criteria for vascular dementia or mixed dementia. Thus, evidence for pharmacological treatment effects in VCI-ND is limited at this time.
Severity should be taken into account in decisions for pharmacological management.
VCI patients may be susceptible to adverse events given the frequent medical comorbidities and concomitant medications.
Stages of care across the continuum may include:
during presentation to emergency when cognitive, perceptual, or functional concerns are noted
during acute care stay, particularly if cognitive, perceptual, or functional concerns, in the absence of delirium is noted
during rehabilitation within inpatient, outpatient, and home-based settings, according to client progress, and
following hospital discharge from the emergency department or inpatient setting to an outpatient or community-based healthcare setting.
Note: These medications are currently approved by Health Canada for the treatment of Alzheimer's disease. They have not yet received approval for the indication of VCI.
Section 3: Poststroke fatigue
PSF occurs frequently, has been associated with mood disorders and pain, and negatively impacts recovery after stroke. Estimates of incidence and prevalence also vary depending on the point at which fatigue is assessed within the recovery process and the assessment tool used [25, 26]. A systematic review by Moran et al., including the results from three studies, reported that the percentages of participants who experienced fatigue following minor stroke or TIA were 23% (assessed at 4–26 weeks), 31–53% (26 weeks), and 34% (52 weeks) [26]. In a study that assessed PSF following minor stroke at two assessment points, the prevalence of fatigue was 35% at two-months poststroke and 33% at 18 months [27]. Independent predictors of fatigue that have been identified include depression, low levels of physical functioning, and prestroke fatigue [25]. Both increasing and decreasing age have been reported as predictors of PSF [27, 28], as have female and male genders [29, 30]. Current management of PSF focuses on education and energy conservation strategies.
What is new in fatigue following stroke in update 2015
As fatigue negatively impacts rehabilitation and long-term outcomes, patients, health care teams, and families are more strongly encouraged to screen and monitor for this symptom in Update 2015. While there is insufficient evidence to recommend pharmacologic or nonpharmacologic interventions, stroke survivors who experience PSF should be screened for common and treatable poststroke co-morbidities and for medications that are associated with and/or exacerbate fatigue. Further research establishing efficacious treatments for PSF is encouraged.
Fatigue and stroke best practice recommendations 2015
3.0PSF is a common condition and can be experienced after TIA and stroke at any point during the recovery process. PSF is often under-recognized; thus, healthcare professionals should anticipate the possibility of PSF, and prepare patients and families to mitigate fatigue through assessment, education, and interventions at any point during the stroke recovery continuum.
3.1Screening and assessment
Stroke and TIA survivors should be routinely asked about PSF during healthcare visits (e.g. primary care, home care, and outpatient) following return to the community and at transition points (Evidence Level C).
Prior to discharge from hospital ward, stroke unit, or the emergency department, the stroke survivors, their families, and informal caregivers should be provided with basic information regarding the frequency and experience of PSF (Evidence Level B).
PSF experience includes
overwhelming tiredness and lack of energy to perform daily activities
abnormal need for extended sleep
more easily tired by activities than prestroke and abnormal need for naps or rest, and
unpredictable feelings of fatigue without apparent reason
Stroke survivors who experience PSF should be screened for common and treatable poststroke co-morbidities and for medications that are associated with and/or exacerbate fatigue (Evidence Level B), including
signs of depression or other mood-related conditions
sleep disorders or factors that decrease quality of sleep (e.g. sleep apnea, pain), and
other common poststroke medical conditions and medications that increase fatigue (e.g. systemic infection such as UTI, dehydration, sedating drugs, thyroid disorders, or other general medical problems).
3.2Management of poststroke fatigue
Management strategies for PSF can vary, and are not mutually exclusive, due to the potential multifactorial nature of PSF. In addition to education of both patient and caregivers about PSF, and treatment of any co-morbid condition that could cause/exacerbate fatigue (as above), strategies can include the following categories:
Strategies for energy conservation and fatigue management that take into account optimizing daily function in high priority activities (e.g. daily routines and modified tasks that anticipate energy needs and provide a balance of activity/rest) (Evidence Level C). Refer to box 3 for detailed examples of energy conservation techniques (available atwww.strokebestpractices.ca).
Engaging in planned exercise schedules with increasing physical demands appropriate to tolerance level to improve deconditioning and physical tolerance (Evidence Level C)
Education in, and establishment of, good sleep hygiene behaviors (Evidence Level B)
Communicating energy status and rest needs to family members, caregivers, employers, and social groups (Evidence Level C)
Stroke patients should be cared for by healthcare professionals who are knowledgeable in the symptoms of fatigue and its management (Evidence Level C).
There is insufficient evidence to recommend specific pharmacological treatment for PSF at this time (Evidence Level B).
Summary
The 2015 update of the Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue Module provides a common set of guiding principles for important aspects of poststroke care. There is a growing appreciation for the magnitude and impact of these three consequences of stroke, and a realization of how poorly they may be addressed across settings. Screening and assessment practices need to be integrated into existing stroke protocols, especially in the postacute stages of care such as rehabilitation, return to the community, and during ongoing primary care and prevention clinic surveillance of patients. Further, there needs to be increased capacity within the healthcare system to ensure stroke survivors have access to appropriate specialists to address issues of depression, cognitive impairment, and fatigue. One of the greatest challenges in effecting such system change is that the research evidence for these conditions is weaker than in other areas of stroke, or just starting to emerge. We have included a call for research directed at gaps that we identified while reviewing the current body of evidence and where clarity around clinical guidance is much needed. Innovations within these areas of stroke best practices will contribute to health system reform in Canada and internationally.
The Canadian Stroke Best Practice Recommendations are developed and presented within a continuous improvement model and are written for health system planners, funders, administrators, and healthcare professionals, all of whom have important roles in the optimization of stroke prevention and care and who are accountable for results. Several implementation tools are provided to facilitate uptake into practice (available at www.strokebestpractices.ca) and are used in combination with active professional development programs. By monitoring performance, the impact of adherence to best practices is assessed, and results were then used to direct ongoing improvement. Recent stroke quality monitoring activities have compelling results which continue to support the value of adopting evidence-based best practices in organizing and delivering stroke care in Canada.
The Canadian Stroke Best Practice Recommendations modules continue to be a work in progress and are regularly updated every two to three-years in order to integrate newly released data to help maximize patient outcomes from this disabling disease.
Acknowledgements
The authors wish to acknowledge and thank the many people who provided internal and external review and feedback on earlier drafts of the Mood, Cognition, and Fatigue following Stroke recommendations update 2015.: the stroke team and communications team at the Heart and Stroke Foundation, including Ian Joiner, Stephanie Lawrence, Ev Glasser, Mary Elizabeth Harriman, and Diego Marchese; members of the Canadian Stroke Best Practices Advisory Committee: Dr. Dariush Dowlatshahi, Dr. Alexandre Poppe, Dr. Sam Yip, Dr. Sean Dukelow, Dr. Eddy Lang, Katie Lafferty, Dr. Ian Graham Dr. Maureen Markle-Reid, Dr. Theresa Green, Dr. Michael Kelly, Barbara Ansley, Dr, Stephen Phillips, Dr. Moira Kapral, and Dr. Janusz Kaczorowski; external reviewers for the 2015 update of the Mood, Cognition, and Fatigue following Stroke recommendations: Dr. Sandra Black, Dr. Christian Bocti, Dr. Louise Clement; Dr. Nancy Cox; Dr. Phillip Gorelick; Dr. Brian Levine; and Beth Linkwich, Dr. Stewart Longman, Dr. Kevin McNeil, Dr. David Nyenhuis, Dr. Demitrios James Sahlas, Dr. Abraham Snaiderman, and Dr. Gael Wealleans.
Authors' contributions
Gail Eskes (first author) and Krista Lanctôt (co-primary author) are chairs of the Mood, Cognition, and Fatigue following Stroke expert writing group and lead authors contributing to all aspects of the development, data analysis, writing, editing, and final approval of this manuscript; M. Patrice Lindsay is corresponding author, senior editor of the guidelines and this manuscript, and writer of supplementary documentation. Richard Swartz is senior author, and he and Nathan Herrmann are senior clinical advisors and contributed significantly to the development of the recommendations and this manuscript. Laurie Bouvier, Deirdre Dawson, Sandra Egi, Elizabeth Gilchrist, Theresa Green, Tammy Hopper, Aisha Khan, Andrea King, Adam Kirton, and Paige Moorhouse are all members of the Cognition and Fatigue following Stroke expert writing group and contributed by reviewing, analyzing, and discussing the evidence and collectively finalizing the wording of all the recommendations; Gord Gubitz is senior advisor to the writing group and contributed significantly to the methodology and recommendation development and provided review and edits to the overall documents; Eric E. Smith, Michael D. Hill, and Mark Bayley provided extensive review and feedback for the recommendations and this manuscript; Norine Foley, Janet Green, and Katherine Salter conducted the evidence searches and completed the evidence tables and evidence summaries supporting this guideline update.
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