Nurses play a key role in improving the mental well-being of people after a stroke

Nurses play an important role in helping patients manage emotional and social health issues, or psychosocial health, after stroke. Better screening and assessment of psychosocial needs are essential to provide optimal patient care.

These findings are highlighted in a new statement from the American Stroke Association, a division of the American Heart Association, titled “Nursing’s Role in Psychosocial Health Management After Stroke.” published in the diary Heart attack.

Although significant advances have been made in stroke prevention and treatment, stroke remains the second leading cause of death and a leading cause of disability worldwide. The latest research indicates that 16% to 85% of stroke survivors experience psychosocial symptoms such as depression, anxiety, stress, fatigue, and/or reduced quality of life during their recovery.

“Stigma often surrounds discussions about psychosocial health, so it is critical for nurses and all health care professionals to create a safe and therapeutic environment for patients and provide hope and comprehensive education on the topic,” said scientific explanation group chair Patricia A. Zrelak, Ph.D., RN, FAHA, a regional quality nurse advisor for stroke programs for Kaiser Permanente Northern California and a member of the American Heart Association’s Council on Cardiovascular and Stroke Nursing.

The scientific statement provides a comprehensive overview of the most recent evidence published between 2018 and 2023 on the psychological health of stroke patients.

The statement focuses on the effects, underlying causes, screening, diagnosis and treatment of five major emotional and social health factors, including depression, stress, anxiety, fatigue and quality of life. The scientific statement aims to create a guideline for nursing care during a patient’s recovery after a stroke, from prevention of adverse psychosocial health conditions to identification and treatment of symptoms.

“After a stroke, emotional, cognitive, behavioral and/or personality changes may occur,” Zrelak said.

“These conditions can develop immediately after a stroke or occur later, sometimes more than a year later, and they can also fluctuate in intensity over time. In addition, psychosocial symptoms are interrelated and patients who experience them are at greater risk of developing other mental health conditions. Effective and regular screening is essential for early detection and treatment.”

Depression

Depression affects about 30% of stroke survivors and is especially common in the first three months after a stroke. Symptoms of depression may include: persistent sad, anxious, or “empty” mood; restlessness and irritability; loss of interest or pleasure in hobbies and activities; difficulty concentrating and thinking; sleeping more or less; changes in appetite; and weight gain or loss.

Post-stroke depression impairs cognitive and functional recovery and increases the risk of death and/or another stroke.

The AHA/ASA Guidelines for the Early Treatment of Patients with Acute Ischemic Stroke recommend routine depression screening for all post-stroke patients. Nurses can help educate stroke survivors and their families about symptoms, prevention, and treatment options, such as medication management and/or cognitive behavioral therapy.

Tension

A 2022 study found that post-stroke stress and post-traumatic stress disorder (PTSD) affect about one in six (about 16.5%) stroke survivors. These conditions can increase the risk of additional health problems, including anxiety and poor medication adherence. Screening stroke patients for stress and PTSD should occur when they are admitted to the hospital and continue during rehabilitation and outpatient visits after hospital discharge.

Nursing interventions that can help reduce patient distress include stroke education and self-management strategies, such as mindfulness and meditation. Nurses can also consider the coping styles of stroke survivors. People with a high-anxiety coping style are at significantly higher risk for PTSD after stroke compared to people with a low-anxiety coping style.

Tension

The frequency of anxiety ranges from 20%–25% in the first few months after stroke, increasing to 32% as the year progresses, with a prevalence of 34% over five years. Factors such as younger age at stroke, lower income, inability to work, social isolation, previous mental illness, and/or severity of stroke are factors that increase the risk of developing anxiety. Anxiety is also linked to a higher risk and severity of depression.

Standard anxiety screening and early detection can lead to early treatment, greater patient engagement, and improved recovery for stroke survivors. While established clinical guidelines exist for the treatment of general anxiety, more research is needed on interventions for anxiety after different types of stroke.

Fatigue

Fatigue after a stroke can occur at any time. However, it is most common in the first six months after a stroke. Symptoms of fatigue may include decreased physical and mental energy levels that interfere with daily activities and difficulty with self-control, emotions, and memory. Women and people with depression, sleep problems, anxiety, and/or multiple health conditions are at greater risk of developing fatigue after a stroke.

More research is needed to identify effective management strategies for post-stroke fatigue, as there are currently no proven treatments. However, interventions aimed at improving general physical fitness may help prevent, reduce, or treat post-stroke fatigue and other components of psychosocial health.

Quality of life

Returning to the same quality of life after a stroke is a challenge, even more so after a severe stroke. Physical strength, speech, depression, anxiety, and the ability to return to work and social activities are factors that contribute to a stroke survivor’s quality of life. However, conditions such as chronic pain can negatively impact recovery and the return to independent living.

Physical activities that include interpersonal engagement, such as yoga and tai chi, have been shown to have positive effects on patients’ quality of life. Nurses can help stroke survivors improve their quality of life after stroke by linking patients to social services in their area, such as stroke support groups and community organizations.

“Mental and emotional well-being are critical to recovery, and nurses play an important role in supporting stroke survivors,” Zrelak said. “It is important to engage stroke survivors and their caregivers so they are aware of these psychosocial conditions and ways they can help. Early detection of symptoms and treatment have the potential to improve recovery after stroke.”

The statement also highlights existing research showing that stroke outcomes vary significantly among people in different racial and ethnic groups. Social determinants of health, such as structural racism, socioeconomic status, inadequate housing, and/or limited access to health care, including mental health care, can all impact a stroke survivor’s recovery.

Zrelak adds, “The stroke care team plays a critical role in addressing these health care disparities by providing targeted interventions and tailored treatments to improve mental health care and overall care coordination for those most at risk.

“More research is needed to understand how we can best support the psychosocial well-being of people after a stroke, so that they can better resume their daily activities and have a better quality of life.”