Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke, 6th edition update 2019

This needs to change from guideline development to protocol development. Guidelines are lazy and not terribly useful in getting to 100% recovery. Survivors need certainty and guidelines don't provide that. Stress, anxiety and depression are a result of not having protocols.  This change won't occur until we get survivors in charge. Firings should start as soon as possible. 

Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke, 6th edition update 2019 

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Krista L Lanctôt, M Patrice Lindsay, Eric E Smith, ...

First Published June 21, 2019 Research Article

https://doi.org/10.1177/1747493019847334

Article information

Abstract

The 2019 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Mood, Cognition and Fatigue following Stroke is a comprehensive set of evidence-based guidelines addressing three important issues that can negatively impact the lives of people who have had a stroke. These include post-stroke depression and anxiety, vascular cognitive impairment, and post-stroke fatigue. Following stroke, approximately 20% to 50% of all persons may be affected by at least one of these conditions. There may also be overlap between conditions, particularly fatigue and depression. If not recognized and treated in a timely matter, these conditions can lead to worse long-term outcomes. The theme of this edition of the CSBPR is Partnerships and Collaborations, which stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care to optimize recovery and outcomes. Accordingly, these recommendations place strong emphasis on the importance of timely screening and assessments, and timely and adequate initiation of treatment across care settings. Ideally, when screening is suggestive of a mood or cognition issue, patients and families should be referred for in-depth assessment by healthcare providers with expertise in these areas. As the complexity of patients treated for stroke increases, continuity of care and strong communication among healthcare professionals, and between members of the healthcare team and the patient and their family is an even bigger imperative, as stressed throughout the recommendations, as they are critical elements to ensure smooth transitions from acute care to active rehabilitation and reintegration into their community.

Keywords Stroke, transient ischemic attack, depression, vascular cognitive impairment, fatigue, guidelines

Introduction

Globally, stroke is the second most common cause of all deaths (11.8%), behind ischemic heart disease at 14.8%.¹ In Canada, every year, approximately 62,000 people with stroke and transient ischemic attack (TIA) are treated in Canadian hospitals, representing one patient every 9 min.² Not counted in this statistic are the estimated nine silent strokes that occur for each symptomatic stroke, often resulting in subtle mood and cognitive changes.³ With advancements in acute stroke care interventions and rapid systems response, mortality from stroke is declining. While these achievements are to be celebrated, stroke remains a leading cause of adult disability, with over 400,000 people living with its effects.⁴ Access to inpatient rehabilitation varies across regions, with only 19% of people accessing inpatient rehabilitation following an acute stroke inpatient stay. There are also gaps in availability of specialized services outside large urban centers.
Common consequences of stroke, including post-stroke depression (PSD) and anxiety, vascular cognitive impairment (VCI), and post-stroke fatigue (PSF), create challenges that may impede recovery and lead to poor functional outcomes and decreased quality of life. Following stroke, between 20% and 50% of all persons may be affected by at least one of these conditions.^5–7 There can be overlap in the occurrence of these conditions, increasing the complexity of diagnosis and appropriate management. Fatigue and depressive symptoms have been shown to co-exist in up to 30% of stroke survivors, which in turn may be associated with cognitive and mobility impairments.⁸ The overall prevalence of depression in persons with mild cognitive impairment (MCI) was 32% in a meta-analysis including the results of 57 studies.⁹ Persons with depression may progress more quickly from MCI to dementia.¹⁰ These conditions all have the potential to delay or impede recovery, which may lead to worse long-term outcomes.^11–13 Unfortunately, these conditions may not be obvious to the person who experienced a stroke, their healthcare providers or their informal caregivers, especially if symptoms are mild or manifest slowly and progressively, or are present only later in the recovery process, when care becomes more fragmented in the community. Furthermore, recent reports on the quality of stroke services across Canada have shown that screening and monitoring of patients for PSD, fatigue, and vascular cognitive functioning issues are completed in just over half of people seen in stroke prevention clinics following stroke or TIA.¹⁴ As a result, these conditions may not be recognized and treated in a timely manner, leaving patients and their families overwhelmed and lost as they try to navigate the healthcare system, and underscoring the need for a standardized system of care for addressing these conditions across the continuum.¹⁵
The 2019 update of the Canadian Stroke Best Practice Recommendations (CSBPR): Mood, Cognition and Fatigue following Stroke is a comprehensive summary of current evidence-based recommendations, focusing on the management of people who have already had an initial stroke or TIA. The theme of this edition of the CSBPR is Partnerships and Collaborations, which stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care of stroke patients to optimize recovery and outcomes. The importance of a coordinated and organized multidisciplinary approach to guide screening, assessment, and management decisions are emphasized throughout these guidelines, which are appropriate for use by clinicians who care for people who have experienced a stroke and their families, across multiple settings.

What’s new in 2019?

In areas where insufficient evidence exists, a new section, entitled clinical considerations has been added to each section, representing recommendations based on weaker evidence and/or expert consensus-based practices. In the depression section, new literature has been incorporated which suggests that prophylactic antidepressant medication can be effective in some stroke patients. There is a new, novel therapeutic agent, actovegin, which enhances oxidative metabolism in the brain and may help in the recovery of cognitive function following ischemic stroke. While it is not used currently in clinical practice, it may become more widely used in the future. There is also an updated comparison table of assessment tools for screening for VCI and updated information on the management of PSF.

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.^16,17 The methodology has been used in previously published updates^18,19 and can be found on our Canadian Stroke Best Practices website at www.strokebestpractices.ca. An interdisciplinary group of experts in the areas of depression, anxiety, cognition, and fatigue were convened and participated in reviewing, drafting, and revising all recommendation statements. Selected members of the group, considered to be experts in their fields, have conducted clinical trials on the topics addressed in this module and have extensive publication records. The writing group included stroke neurologists, a geriatric psychiatrist, a clinical pharmacologist, neuropsychologists, occupational therapists, a speech-language pathologist, family physician, nurses, people who have experienced a stroke and evidence-based methodology experts. This interdisciplinary approach, which ensured that all perspectives were considered in the development of the recommendations, mitigated the risk of potential or real conflicts of interest from individual members.
A systematic literature search was conducted by experienced personnel to identify evidence for each topic area addressed in the Mood, Cognition and Fatigue following Stroke module. The literature for this module was updated up to February 2019. The writing group was provided with comprehensive evidence tables that included summaries of all high-quality studies identified through the literature searches (evidence tables are available at www.strokebestpractices.ca). Systematic reviews, meta-analyses, randomized controlled trials, and observational studies were included, where available. The writing group discussed and debated the quality and value of the evidence and, through consensus, developed a set of proposed recommendations. Through their discussions, additional research may have been identified and included in the evidence tables if consensus on the value of the research was achieved.
All recommendations were 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 was obtained among the writing group and validated through the internal and external review process. This level of evidence was used cautiously, and only when there was a lack of stronger evidence for topics considered important system drivers for stroke care (e.g. issues related to screening and assessment). In some sections, the expert writing group felt there was additional information that should be included. Since these statements did not meet the criteria to be stated as recommendations, they were included under the term, 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 Canadian Best Practice Recommendations for Stroke Care (update 2019)

Table 1. Summary of criteria for levels of evidence reported in the Canadian Best Practice Recommendations for Stroke Care (update 2019)

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After a draft set of recommendations had been developed, they underwent an internal review conducted by the Canadian Stroke Best Practices and Quality Advisory Committee, then were sent for external review to several Canadian and international experts who were not involved in any aspects of the guideline development. All feedback received was given careful consideration during the editing process. All recommendations are also accompanied by five additional supporting sections devoted to: the rationale (i.e. the justification for the inclusion of the selected topics), system implication (to ensure the structural elements and resources are available to achieve recommended levels of care), performance measures (to monitor care delivery and patient outcomes), a list of implementation resources, and a summary of the evidence on which the recommendations were based. Brief summaries of current research evidence are provided at the beginning of each section below. More detailed evidence summaries and links to all evidence tables, and additional knowledge translation information for the recommendations included in this publication can be found at: http://www.strokebestpractices.ca. 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.

Recommendations Section 1: Mood and stroke

Post stroke depression occurs frequently. One of the most current and comprehensive estimates, obtained from a systematic review that included the results of 61 prospective studies, suggests that approximately 30% of all stroke survivors experience depressive symptoms at some point following the event.⁵ The prevalence of depressive symptoms among stroke survivors is greater than that in the general population. The estimate obtained from one population-based study²⁰ indicated that over a two-year period, the development of new-onset depression was over three times greater (25.4% vs. 7.8%; adj HR = 4.09, 95% confidence interval (CI) 4.00–4.18) in persons recovering from stroke compared to a large, age and sex-match community-based sample. Risk factors for the development of PSD include increasing age, living alone, high levels of comorbidity, a history of depression, female gender, physical disability (modified Rankin Scale score >2 at discharge from hospital), increased initial stroke severity, cognitive impairment, and prior history of stroke.^13,20–22 Depression has also been associated with poorer functional outcomes and higher mortality.^13,23
Since the frequency of depression is highest during the first year following stroke,⁵ episodic screening should be conducted during this period. Screening can be performed during the acute inpatient stay, at the point of transition to, or during inpatient rehabilitation, upon discharge to the community and during routine health assessments. Although screening for depression has been shown to be feasible for most patients, it may not be in a sizable minority due to cognitive deficits or unresponsiveness during the early period following stroke. Karamchandani et al.²⁴ reported that while 70% of patients were eligible for depression screening prior to hospital discharge or transfer to another service, the remaining 30% of patients were not, due to aphasia, other medical condition, hospice/comfort measures, or prolonged intubation. Swartz et al.¹¹ describes the feasibility of using the two-item version of the Patient Health Questionnaire during routine clinical practice for 1500 outpatients attending a stroke prevention clinic. All patients were able to complete the screen, 89% of whom did so in less than 5 min. While many previously validated screening tools exist, those with the highest sensitivities identified from a recent meta-analysis include the 20-item Center of Epidemiological Studies-Depression Scale, the 21-item Hamilton Depression Rating Scale, and the 9-item Patient Health Questionnaire.²⁵
The use of antidepressants is the mainstay of treatment for depression. Once diagnosed, use of antidepressants has been associated with a reduction of depressive symptomatology. Xu et al.²⁶ included 11 randomized controlled trials in a meta-analysis of patients with a clinical diagnosis of PSD and reported that antidepressant treatment was associated with a significant reduction in depression scores (standardized mean difference = −0.96, 95% CI −1.41 to −0.51, p < 0.0001) and better response to treatment (risk ratio = 1.36, 95% CI 1.01–1.83, p = 0.04). Similarly, a Cochrane review²⁷ including the results from 12 RCTs reported the odds of remission of depression (i.e. a reduction of ≥50% in depression scale scores) were significantly higher with pharmacotherapy, although many adverse events were reported. Most of the agents evaluated in these reviews were selective serotonin reuptake inhibitors and, to a lesser extent, tricyclic antidepressants. A longer duration of treatment has been shown to be effective. In one systematic review, Chen et al.²⁸ observed an almost perfect inverse linear relationship between length of treatment and decrease in depression rating scale scores (Spearman’s rho = −0.93, p = 0.001). The benefit of antidepressants to improve functional recovery and reduce dependency in persons following stroke is uncertain, given the conflicting results of the FLAME trial,²⁹ which reported improved functional outcome following 90 days of treatment with 20 mg of fluoxetine (vs. placebo), and the recent FOCUS trial,³⁰ which reported no differences in dependency between groups (20 mg fluoxetine vs. placebo) at six or 12 months. The use of antidepressants has been associated with reductions in emotional lability,³¹ a common consequence of stroke as well as the development of PSD. In pooled analysis, based on 776 observations, the risk for development of PSD was significantly reduced with the use of prophylactic pharmacotherapy (odds ratio (OR) = 0.34, 95% 0.22–0.53, p < 0.001).^32,33
Non-pharmacological interventions for the treatment of PSD include different forms of psychotherapy, physical activity, non-invasive brain stimulation, and acupuncture. While psychotherapy (including problem-solving therapy, cognitive behavioral therapy, and motivational interviewing) is probably one of the most commonly used strategies, it has not been shown to be an effective treatment for depression in person recovering from stroke when used in isolation²⁷; however, these same techniques may be effective when used in combination with pharmacotherapy.³⁴ Behavioral therapy was shown to be effective for the treatment of PSD in persons with aphasia.³⁵ Although not widely used in clinical practice, acupuncture has been shown to be effective in the treatment of PSD. In a meta-analysis including the results of 15 RCTs,³⁶ treatment with acupuncture was associated with improved odds of recovery/remission compared with pharmacotherapy (OR = 1.48, 95% CI 1.10–1.97). Non-invasive brain stimulation, using either repetitive transcranial magnetic stimulation or transcranial direct current stimulation (tDCS), is another example of a non-traditional treatment that has been shown to improve symptoms of depression.^37,38 Physical activity was also associated with a small, but significant reduction in depression scores in a meta-analysis that pooled the results of 13 RCTs (SMD = −0.13, 95% CI −0.26 to −0.01, p = 0.03).³⁹

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