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Neuropsychological Interventions in Stroke Survivors: Implications for Evidence Based Psychological Practice

U.O. di Neuropsicologia, San Giacomo Ospedale Privato Accreditato UU.FF. Omnicomprensive di Medicina Riabilitativa, Ponte dell’Olio, Piacenza

Introduction

Cognitive impairment and emotional disorders are fre-quently detected in stroke survivors, linked with mor-bidity, disability and life dissatisfaction (1).

Measures of cognitive function quantify some of themost important aspects of brain function. Despite this cog-nitive measures generally have not been included in theroutinary assessment of cerebrovascular disease. Vascularcognitive impairment affects up to 60% of stroke sur-vivors and is associated with poor performances in basicand instrumental activities of daily living and poor func-tional outcome (2, 3).

It has been suggested that cognitive abilities are rele-vant to predict functional status at discharge. Individualscan recover from physical disability resulting from stroke,

Giornale Italiano di Medicina del Lavoro ed Ergonomia Supplemento A, Psicologia© PI-ME, Pavia 2011 2011; Vol. 33, N. 1: A29-A36http://gimle.fsm.it ISSN 1592-7830

ABSTRACT. Introduction. Stroke survivors should be consideredat high risk for cognitive impairment and emotional disorders,linked with disability, poor functional outcome and lifedissatisfaction. The aim is to provide indications about theneuropsychological interventions based on existing evidence,appropriateness and clinical effectiveness.Methods. Guidelines in stroke management, systematic reviewsand randomized controlled clinical trials about cognitive and emotional disorders, neuropsychological rehabilitation and psychological treatments in stroke survivors were used to provide good practices. They were searched with multiplesearch strategies and appropriate key words in CochraneCentral Register of Controlled Trials and in the Medline and PsychInfo databases.Results. Implications for psychological practice. There is a strong evidence and expert consensus to support the use of post stroke neuropsychological assessment, based on aconsiderable amount of studies. There is evidence of first gradeof benefit of cognitive rehabilitation in terms of improvement inscores on neuropsychological tests, but there is poor evidencefor increase in functional outcome and quality of life. Evidenceis emerging that some psychological treatments seems to beeffective in stroke survivors, but more evidence is required torecommend the routine use of psychotherapy after stroke. Toolsto examine executive functions, attention, memory, visuospatialdomains, neurobehavioral change and emotional distress arerecommended. A compilation of indications for cognitiverehabilitation and psychological treatment is suggested.Conclusion. Psychological treatment and neuropsychologicalrehabilitation needs to be developed in rehabilitation services to improve the quality of life of stroke survivors. General expertconsensus and validation of practices and protocols needs to be accomplished.

Key words: stroke, neuropsychological assessment, cognitiverehabilitation, psychological approach.

RIASSUNTO. INTERVENTI NEUROPSICOLOGICI NELL’ICTUS

CEREBRALE: PROCEDURE PSICOLOGICHE BASATE SULL’EVIDENZA.Introduzione. I pazienti colpiti da ictus cerebrale presentanofrequentemente disturbi cognitivi ed emotivi, correlati a disabilità, basso outcome funzionale ed insoddisfacentepercezione della qualità della vita.Scopo della pubblicazione è fornire indicazionisull’appropriatezza degli interventi neuropsicologici in basealle evidenze scientifiche disponibili.Metodo. Sono state consultate le linee guida esistenti sull’ictuscerebrale; le revisioni e gli studi di settore sui disturbipsicologici cognitivi ed emotivi conseguenti ad ictus; le revisioni sistematiche e gli studi clinici randomizzati recentisui trattamenti psicologici e sulla riabilitazione cognitiva dopoictus cerebrale.

Sono stati ricercati nella Cochrane Central Registerof Controlled Trials, nei database Medline e PsychInfo con parole chiave appropriate.Risultati. Implicazioni per la pratica psicologica. Ci sono fortievidenze e consenso a supporto della valutazioneneuropsicologica dopo l’ictus cerebrale nella fase post acuta,sostenuta da numerosi studi che confermano l’alta incidenzadi disturbi cognitivi ed emotivi. C’è una evidenza di primogrado del beneficio della riabilitazione cognitiva misurata con il miglioramento ai test neuropsicologici, ma sussisteancora una ridotta evidenza di un miglioramento dell’outcomefunzionale e della percezione della qualità della vita. Stannoemergendo alcune indicazioni di grado inferiore per alcunitrattamenti psicologici dopo l’ictus, ma non sono sufficientiper raccomandarne l’utilizzo come procedura di routine.Vengono proposti strumenti per esaminare le funzioniesecutive, attentive, mnesiche, visuospaziali, il disagio emotivo, le modificazioni del comportamento e raccomandazioni per la riabilitazione cognitiva e il trattamento psicologico.Conclusione. La riabilitazione neuropsicologica e l’assistenzapsicologica sono approcci che dovranno essere sviluppatiall’interno delle strutture riabilitative per migliorare le condizioni di vita dei pazienti colpiti da ictus. Dovrannoessere effettuati un consenso tra esperti ed ulteriori validazionidi procedure e protocolli diagnostici e riabilitativi.

Parole chiave: ictus, valutazione neurologica, riabilitazionecognitiva.

Silvia Toniolo

G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicolhttp://gimle.fsm.it

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but might be unable to return to their previous occupationsor independent life because of cognitive impairments.Cognitive impairment can be chronic and progressiveafter stroke (4). Post-stroke dementia is estimated to occurmore than a third of stroke patients. Cognitive impairmentincreases long-term dependence and is associated withhigher mortality (5).

Depressive and anxiety disorders are important se-quelae of stroke, occurring in at least one quarter of pa-tients, although there are differences between studies dueto varying definitions, heterogeneity of populations, ex-clusion criteria, and timing of assessments (6-8).

In last 10 years a number of meta-analyses on the ef-fectiveness of different therapy techniques in stroke neu-ropsychological rehabilitation were published, and pro-vided information on the validity of the various ap-proaches to cognitive rehabilitation (9-14).

The aim is to provide indications about the neuropsy-chological interventions based on existing evidence, ap-propriateness and clinical effectiveness, and similarly toprovide suggestions for psychological intervention instroke population.

Method

Guidelines in stroke management, systematic reviewsand randomized controlled clinical trials about cognitiveand emotional disorders, neuropsychological rehabilita-tion and psychological treatments in stroke survivors wereused to provide good practices.

Systematic reviews and randomized controlled trialswere searched with multiple search strategies in CochraneCentral Register of Controlled Trials, in the Medline andPsychInfo databases, using key words cognitive, neu-ropsychological, emotional, depression, psychologicaltherapy associated with stroke.

Type of supporting evidence is identified and gradedfrom systematic review or existing guidelines.

To determine as effective an intervention is requiredat least one randomized, controlled clinical trial or anadequately powered systematic review of prospectiverandomized controlled clinical trials with masked out-come assessment in stroke population, or at least twoprospective matched-group cohort study in a stroke pop-ulation with masked outcome assessment. To determineas possibly or probably effective an intervention is re-quired at least one prospective matched-group cohortstudy in stroke population with masked outcome assess-ment or all other controlled trials in a stroke population,where outcome assessment is independent by patienttreatment. The use of a rigorous single-case method-ology has been considered by some reviews as a sourceof acceptable evidence, as the randomised controlledtrial methodology is difficult to apply. Neuropsycholog-ical rehabilitation is made up of multiple components,and has the expressed goal of achieving multiple distincttargets that are not easily implemented, evaluated andinfluenced when measured using randomized controlledtrial methods.

Implications for Psychological Practice

Target Population: Stroke SurvivorsSetting: Rehabilitation UnitUsers: PsychologistAll stroke survivors should be considered at high risk

for cognitive impairment, emotional distress and low qual-ity of life (15-17).

ASSESSMENT

From existing evidence-based guidelines all strokesurvivors should be screened for cognitive impairment anemotional distress (18-22).

A interview about psycosocial and cognitive history,emotional distress, behavioural functioning, goals, and ex-pectations for community integration should be conductedwith all patients who can reliably respond to a verbal in-terview.

Cognitive FunctionsCognitive impairment after stroke may include all cog-

nitive domains, from focal deficits, resulting directly froman area of infarction or from hypoperfusion in adjacenttissue, to global cognitive dysfunction related to white-matter disease, but executive and attentional deficits morefrequently are detected, such as slowed information pro-cessing, impairments in the ability to shift from one taskto another, and deficits in the ability to hold and manipu-late information (23). Cognitive impairment of the vas-cular type includes a large range of cognitive disorders,from mild cognitive impairment to severe vascular de-mentia (24-26).

Criteria for Test SelectionNeuropsychological protocols must be sensitive to a

wide range of abilities and especially the assessment ofexecutive and attentional functions (23).

The use of simple brief mental status scales that under-represent frontal syndromes, as well as other syndromesrelated to secondary and tertiary association cortex (espe-cially in right-sided) are inadequate for documenting poststroke neuropsychological sequelae.

Screening TestsThe Mini Mental State Examination was found to be a

reliable, valid, and stable cognitive screening instrumentfor dementia, but can not considered sensitive to vascularcognitive impairment.

Screening to investigate cognitive status should ad-dress the following domains: arousal, attention, executivefunctions (such as insight, judgement, social cognition,problem- solving, abstract reasoning, initiation, planning)orientation, memory, language, visuospatial function, per-ceptual function, neglect, praxis.

It was recognized that there are no perfect tests. Thetests selected to be included in protocols met a preponder-ance of the follow criteria: quality of the italian standard-ization, psychometric qualities, brevity, domain speci-


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ficity, lack of ceiling and floor effects, previous use of thetest in stroke survivors samples:

Frontal Assessment Battery (27), Weigl Sorting Test(28), Trail Making Test A and B (29), Digit CancellationTest (30), Clock Test (31), Rey-Osterrieth Complex FigureCopy and Memory (32), Rivermead Behavioral MemoryTest (33), Animal Naming Semantic Fluency (34), FASPhonemic Fluency (35), Test of Apraxia (31). Screeningtests of neglect, visual naming, semantics and syntax,should be considered.

The Mini-Mental State Examination (36), would alsobe prudent if not already administered to all patients > 65years or dementia case ascertainment.

Most of these screening instruments have an highspecificity to detect cognitive disorders, but their sensi-tivity is poor. When cognitive impairment is not detectedon a screening test, the patient should receive additionalneuropsychological assessments. Patients who screenedpositive, based on a combination of screening tests, haveto be administered a diagnostic test battery.

Specific cognitive network assessmentThe cognitive tests battery have to included multiple

tests of many cognitive domains: prefrontal subcorticalnetwork for executive functions; hippocampal limbic net-work for memory and emotional disorders; left hemi-sphere network for aphasias, apraxias, Gerstmann syn-drome; right hemisphere network for anosognosias, ne-glect syndromes, visuospatial and aprosodias; occipi-totemporal network for complex visual processing such asalexias, simultanagnosia, achromatopsias, prosopagnosia,simultanagnosia, object agnosias, visual hallucinations, il-lusions and delusions; and network associations for dis-connection syndromes, dyscalculias, delusional misidenti-fication. The degree and type of cognitive problems de-pend on the extent and localisation of brain damage (37).Italian validate neuropsychological tests considered to besensitive to the principal domains can be found in Bianchipublications (38). In spite of the number and quality oftests, there are few studies that have used them in poststroke population.

Neglect AssessmentOne of the more common deficits detected after stroke

affecting the right hemisphere is hemispatial neglect.Hemispatial neglect is defined as a failure to explore, re-spond or orient towards stimuli presented on the contrale-sional side (39). Hemispatial neglect could be assessed byneglect battery (40) consisting of the following tests: linecancellation, letter cancellation, sentence reading, Wundt-Jastrow illusion. Cancellation tests, such as the bells testand letter cancellation, are more helpful tools to detectspatial neglect (41). Visuospatial deficits associated withneglect should be assessed asking the patient to copy afigure and draw figures from memory (42). Standardisa-tion on normal subjects is not required.

Anosognosia AssessmentAnosognosia will be found in about one third of stroke

survivors (43). The main dimensions to consider in the in-

vestigation of anosognosia are: awareness of deficit andrelated functional implications, modality specificity,causal attribution, expectations of recovery, implicitknowledge and differential diagnosis with psychologicaldenial. Time elapsed from stroke, aetiology, laterality,aphasia and clinical complications may influence all thesecharacteristics and must be taken into consideration (44).Although a number of reliable scales for the assessment ofanosognosia in stroke have been developed (interview,questionnaire or visual analogue scale), at present nosingle measure fully explores the multifaceted nature ofthe phenomenon (45).

Vascular cognitive impairment criteriaNo commonly agreed standards exist to determine the

severity of a vascular cognitive syndrome into mild, mod-erate, severe. Despite the high frequency of vascular cog-nitive syndromes, there are no shared standards for use incognitive impairments related to vascular factors. De-mentia criteria, based on the DSM-IV-R guidelines (46),focus on the late stages of cognitive impairment, and arestrongly biased toward the diagnosis of Alzheimer disease,while the memory disorder is not prevalent in stroke sur-vivors. Although the term vascular dementia was reportedfor several decades, it was redefined recently to encom-pass the more realistic spectrum of cognitive and behav-ioral disorders after stroke (47). The DSM-5 proposes thata new category of Neurocognitive Disorders, replace theDSM-IV Category of Delirium, Dementia, and AmnesticDisorders. The main characteristic of this category is de-fined by the fact that the core is represented by cognitionand that these deficits represent a decline from a previouslevel of cognitive functioning.

Emotional Distress AssessmentSystematic screening for emotional distress should be

considered in all stroke survivors, including screening fordepression, anxiety, irritability, emotional lability, apathy,disinhibition, delusional misidentification syndromes, so-matoparaphrenia, hallucinations (48-51).

Depression is a common yet often unrecognized neu-ropsychological consequence of stroke, having biological,psychological, and social dimensions (52). No consistentevidence was found that a specific localisation of the le-sion is associated with depression. The factors found to beassociated with depression include personal history of de-pression, living alone, family support, advanced age andcognitive impairment (53).

Depression and anxiety screening after stroke can becomplicated by cognitive and physical symptoms ofstroke that may introduce additional variability in assess-ment of depressive symptoms and diagnosis.

Although several depression screening instrumentshave been validated in stroke they can be burdensome tocomplete for patients (54). The Beck Depression Inven-tory (55), the Hamilton Rating Scale (56), the GeriatricDepression Scale (57), and the Zung Self-Rating Depres-sion Scale (58) are considered acceptable screening in-strument (59, 60) but their specificity is too low to providea basis for psychological assessment. For example, it may


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be difficult to establish whether symptoms such as in-somnia, loss of appetite, difficulties of attention, or painare secondary to an organic problem or due to the onset ofdepression. These tools may be less specific and thus lessreliable, so caution is needed using scales as screening in-struments in post stroke patients (54).

Hospital Anxiety Depression Scale (61) was specifi-cally designed for patients with physical illness, and theitems do not include somatic indicators of psychologicaldistress, such as headache, insomnia or weight loss, whichmight be due to the coexisting illness.

All these questionnaire do not takes into account a se-ries of emotional symptoms commonly observed in poststroke patients. Poststroke Depression Rating Scale (62) isa validated test (63) of a comprehensive array of knownemotional and behavioural syndromes including depres-sion, anxiety, irritability, emotional lability, apathy.

Screening for depression is therefore desirable, but ex-pert conclusion is that the isolated use can not replace amore thorough exploration of the psychological impact ofsevere disabilities in survivors. A single question aboutdepression, or a high score on a depression questionnaireit is unlikely to elicit important information about certainaspects of the patient’s cognition, such as a sense ofworthlessness or hopelessness or thoughts that life is notworth living (64). Poststroke cognitive impairment maylimit a patient’s ability to describe or express emotion andmay lead the patient to deny depressive signs that are ob-jectively observable.

In conclusion the diagnosis of Post Stoke Depression,because of the difficulties in assessment, depends pri-marily on psychological interview with the patient and be-havioural observation, supplemented by selected scalesand caregivers report.

Apathy often occurs after the stroke, sometimes coex-isting with depression but often appearing separately: thisimplies different treatment strategies (65). Stroke sur-vivors may not have the insight to recognize that they havethese feelings or behaviours. None of the available mea-sures of apathy can be considered optimal by psychome-tric standards.

Some patients with poststroke cortical lesions havegreat difficulty in inserting affective variation in theirspeech and gestural behaviour. This is called aprosodiaand may mimic and mask a depressive disorder. Oftenthese patients not complain of feeling depressed.

Emotional lability or hyperemotionalism is character-ized by sudden, easily provoked episodes of crying orlaughing, that may or may not be appropriate to the context.

Sometimes the diagnostic procedure is prevented fromthe consequences of stroke: for aphasic patients is moredifficult to express in words their thoughts and feelings. Isnecessary to develop an assessment of emotional distressin aphasic stroke patients. Visual Analogue Mood Scaleseems not to be a reliable way to assess depression afterstroke among patients with aphasia or other cognitive im-pairments (54).

A strong relation between psychological symptomsand personality traits such as neuroticism and avoidancecoping style, suggests that if emotional distress are pre-

sent, assessment of personality traits may be needed totarget interventions (66, 67). In addition, after the stroke isnecessary to detect the emotional impact on apathy, mood,anxiety, fatigue and self efficacy.

Quality of Life AssessmentA substantial proportion of stroke survivors had very

poor health-related Quality of Life. Specific scales pro-posed to measure quality of life after stroke have an italiantranslation and validation. Generic instruments have beenwidely used to collect Quality of Life data in stroke sur-vivors (67): including the Medical Outcomes Short-FormHealth Survey SF-36, and the Euroqol. Both have beencriticized for a lack of sensitivity when applied to strokepopulations. More specific scales have been developed inthe last years, such the Stroke Impact Scale (68), theStroke Specific Quality of Life Scale (69) and the Burdenof Stroke Scale (70). However neuropsychological disor-ders confound subjective data: all scales significantly un-derestimated patient reports of stroke related disabilitycaused by a failure to adjust, for the effect on self-reportof spatial neglect, deficits of magnitude estimation, patho-logic alteration of self-awareness, and alteration in distrib-uted cortical systems supporting emotional semantics andabstraction (71). These scales can be burdensome to com-plete for patients and need to be filled after discharge fromthe rehabilitation service.

Caregiver’s Indirect ObservationsPsychologist have to evaluate the patient’s psycholog-

ical functions before stroke onset, with the help of a pa-tient’s close relative. Should be used an interview aboutpsycosocial and cognitive history and a proxy tool. To ob-tain premorbid history of cognitive status in elder people,the Informant Questionnaire for Cognitive Decline in theElderly could be completed by a caregiver of the patient.Post stroke emotional and behavioural syndromes may bealso assessed with proxy scale as NeuroPsychiatric Inven-tory (72).

The impact on family caregivers of stroke survivor isan important area that has to be investigated (73).

Activity and ParticipationThe functioning and disability after stroke are clini-

cally meaningful and of great importance for the patientUnderstanding the cognitive functioning and disability

after stroke is needed to choose the appropriate instru-ments for action planning. In order to define the socialoutcome is necessary to investigate the consequences ofimpairment and activity on “participation,” the term usedto describe a person in their social context in line with theInternational Classification of Functioning, Disability andHealth (74). The use of inappropriate instruments may ob-scure treatment effects.

A routine poststroke neuropsychological assessmentwith standardized instruments requires that psychologisthave an excellent understanding of typical manifestationsof the neuropsychological disorders, and also a specifictraining.


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TimingStroke survivors should have a neuropsychological as-

sessment during early phases of rehabilitation and at latertime, depending on progress occurred.

TREATMENT

Cognitive rehabilitationCognitive or neuropsychological rehabilitation is a

specific approach designed to address difficulties withmemory, attention, spatial functions, language, emotion,relation and other aspects of mental functioning. There isevidence for the effectiveness of cognitive rehabilitation(18, 75, 76) in patients with neuropsychological deficits inthe post-acute stage after a focal vascular brain lesion.This conclusion is based on a limited number of ran-domised controlled trials, and is supported by a consider-able amount of evidence coming from non-randomisedstudies. Last year a Consensus Conference about neu-ropsychological rehabilitation was held in Italy. In the ex-perts’ conclusion is enough evidence to award a grade A,B, or C recommendation to neuropsychological rehabilita-tion in patients with neuropsychological deficits afterbrain lesion (77).

Patients who demonstrate cognitive impairment in thescreening process should be referred to a psychologistwith specific expertise for neuropsychological assess-ment, to determine the severity of impairment, the impactof deficits on function, relationship, safety, quality of life,and to implement appropriate remedial, compensatory andadaptive intervention strategies.

Neuropsychological Rehabilitation of AttentionImpaired attention is the most prominent neuropsycho-

logical change in stroke survivors (78-80). Impaired atten-tion can reduce cognitive productivity when other cogni-tive functions are intact and is key to learning. Attentiontraining may have a positive effect on specific, targetedoutcomes and should be implemented with appropriate pa-tients (9, 75, 76). A validated program for the rehabilita-tion of attention in stroke samples is Attention ProcessTraining (81). It is a theoretically based, hierarchical, mul-tilevel treatment, including sustained, selective, alter-nating, and divided attention. Early identification and re-habilitation of attention should be part of poststroke reha-bilitation program.

Neuropsychological Rehabilitation of Executive FunctionDespite the high incidence, executive disorder did not

have enought evidence available for neuropsychologicaltreatment in stroke population (76).

Neuropsychological Rehabilitation of MemoryCognitive rehabilitation programs are designed to up-

grade the memory function or to teach patients ways ofcoping in spite of their memory problems. Compensatorystrategies can be used to improve memory outcomes. (75,76). In particular the paging system significantly reduceseveryday failures of memory and planning in stroke sur-vivors (82). Errorless learning approach might provide a

useful additional strategy to design practical interventionsfor everyday memory problems (83). There is not enoughevidence from randomized controlled trial to decidewhether cognitive rehabilitation for memory problemsafter stroke is helpful or not (9).

Neuropsychological Rehabilitation of NeglectNeuropsychological rehabilitation specifically tar-

geted at neglect appeared to improve the ability to detectvisual targets. The training in visual scanning is the ap-proach most often related to the improved performance:it is not clear its impact on ability to perform acts ofdaily life or on the ability to carry out an independentlife (10). There is an increasing evidence about the ef-fect on neglect by Prism Adaptation Therapy (84, 85).Neglect is an heterogeneous condition and it is unlikelythat a single rehabilitation approach would be appro-priate for all types and severity and co-morbidity. Strokesurvivors with neglect should to receive neuropsycho-logical rehabilitation.

Neuropsychological Rehabilitation of ApraxiaStrategic or compensatory training appears to be ef-

fective in the treatment of apraxia and should be consid-ered (14).

Neuropsychological Rehabilitation of Vascular DementiaThere is not a sufficient evidence to support the reha-

bilitation of people with mild to moderate vascular de-mentia. While numerous reports suggest the usefulness ofthis approach, no randomized controlled trials have beenpublished (86).

Neuropsychological Rehabilitation of Anosognosia andApathy

Patients need to be highly motivated to participate incognitive rehabilitation treatment. Anosognosia and ap-athy may be a barrier to participation. The neuropsycho-logical rehabilitation process does not provide valid inter-ventions to reduce apathy and anosognosia after stroke.

Neuropsychological Rehabilitation and Functional Limitations

Neuropsychological rehabilitation should be tailoredaccording to cognitive impairments and functional limita-tions as well as remaining cognitive abilities, identifiedthrough assessment and developed in relation to the needsand goals of patient and caregiver. An individualized,client-centred approach should be considered to facilitateresumption of desired activities such as return to work,leisure, driving, volunteer participation, financial manage-ment, home management and other instrumental activitiesof living.

Cognitive behavioural therapy of emotional distressAdaptation to stroke requires complex, long-term

change in stroke survivors’ lives. The amount of evidencesto support the routine use of psychological approaches instroke rehabilitation is limited (12). Lack of standardizeddiagnostic and outcome measuring criteria, and differing


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analytic methods precluded clear determination of thepsychotherapy to produce remission of post stroke depres-sion (87). However, there is emerging evidence that somepsychological interventions, when delivered early afterstroke, have the potential to prevent and treat depression(88). Cognitive behavioural therapy is an effective treat-ment of depression in general population and in the el-derly, and there is some indication that it may be effectivefor people with stroke (89). Programs intended to increasethe perception of self-efficacy in problem solving, makingdecision and planning actions for specifical targets, couldprevent some of the difficulties which individuals facewhen discharged from rehabilitation. Evidence to supportself-management interventions is as yet inconclusive, ac-cording to a Cochrane review, but is the best evidenceavailable up to now. Self-management program include:problem-solving, decision-making, resource utilization,collaboration and taking action (90). The skills should alsobe something which the individual feels confident thatthey will achieve, and perceived self-efficacy appears tobe at least one of the key mechanisms responsible for im-provement in health behaviours following a self-manage-ment program. However some individuals may have diffi-culties with this model of self-appraisal, particularly ifcognitive impairments are relevant.

The small positive benefit of psychological strategiesprobably endorses the use of more structured approachesto the delivery of education and advice targeting emo-tional recovery and adjustment to the effects of stroke.

The emotional resources available for people to copewith stress can be the element of discrimination distin-guishing those who seem to manage their disability fromthose who do not.

There may also be a number of areas of overlap be-tween the strategies required to live with stroke and otherchronic diseases. Having a stroke, recovering from astroke, and getting on with the rest of life after a strokemight be regarded by many as a stressor. Learning to copewith a new disability takes place after discharge from re-habilitation service.

However, more evidence is required before recom-mendations can be made about the routine use of suchtreatments after stroke, as only a small proportion ofstroke survivors are eligible to participate. It is also neces-sary to give consideration to the specific cognitive impair-ments associated with stroke, individual’s insight intotheir problems and modify psychological interventionsappropriately.

Educational InterventionStroke survivors and their carers often feel they have

not been given enough information about stroke. Providinginformation in the form of booklets, leaflets or informationpacks may not improve their understanding of stroke ortheir general well-being. Educational lectures may be moreeffective but trials are not yet conclusive (91).

Quality of Life as NeuroPsychological OutcomeThe perceived Quality of Life should be considered the

best outcome of stroke survivors. Strengthening of family

support, treatment of depression and emotional distress,reduction of cognitive dependence may be the decisivefactors in improving post-stroke Quality of Life. The as-sessment of the Quality of Life could be an indicator of theeffectiveness of the post-stroke neuropsychological reha-bilitation, but sensitive measure is needed.

Conclusions

Neuropsychological syndromes are present in the vastmajority of stroke survivors. Clinical stroke evaluationsthat ignore the many and varied cognitive, emotional andbehavioural syndromes are not representative of the pa-tients mental status. Neuropsychological interventions, as-sessment, treatment and rehabilitation needs to be devel-oped in rehabilitation unit to improve the quality of life ofstroke survivors.

Validation of the protocols needs to be completed tosee how well they detect neuropsychological impairmentand how well they improve cognition, emotion and ad-justing in relation to cerebrovascular disease. And it isneed of new cognitive behavioural therapy for apathy andanosognosia.

Future research should examine the patient character-istics that optimize the outcomes of neuropsychologicalrehabilitation.

These indications represent a beginning and are influ-enced by the individual expertise. This publication is anopen invitation for debate, study, validation and con-sensus.

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Reprint request: Silvia Toniolo - U.O. di Neuropsicologia, San Giacomo Ospedale Privato Accreditato UU.FF. Omnicomprensive diMedicina Riabilitativa, Via S. Bono 3, 29028 Ponte dell’Olio, Piacenza, Italy - E-mail: [email protected]

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