hhh stroke pathway - hospital authority · hhh stroke pathway: a multi-disciplinary service model...

HHH Stroke Pathway: A Multi-disciplinary Service Model for

Enhancing Early Identification and Intervention for Mood and Cognitive

Impairment among Young Stroke Patients Teddy C.K. Cheung

Reg Psychol (Clin), APHKPS, MSSc Clin Psy (CUHK); C Psychol, AFBPsS, MSc Cog Neuropsy (Lond), PGDip Clin Paed Neuropsy (Lond)

Clinical Psychologist / Neuropsychologist UCH, HHH/KEC

A Patient Example • M/54, Right-hander; Ed: Master; Architect Partner • w/ Rt ICH Stroke with delusional features • Admitted TKOH AED: 8/3 • Transferred QEH NS: 8/3 -8/4 • Transferred TKOH: 8/4 – 23/4 • PT session X 12 : 10/4 -23/4

(NHS, 2011)

Implications • “Stroke services need to consider how to develop and

maintain the knowledge and skills in all clinical staff to provide appropriate psychological support to people with stroke, and how to provide the high-intensity support needed by a minority of people with cognitive and mental health issues.

• The 2016 NICE Quality Standard QS2 is clear that a clinical neuropsychologist/clinical psychologist with expertise in stroke rehabilitation should be a core member of the multi-disciplinary team.

• Commissioners should also plan for the long term management of psychological difficulties of delayed onset (e.g. anxiety, depression).” (2.12.3, p.27)

(Royal College of Physicians, 2016)

Psychological care – organization and delivery

• Services for people with stroke should have a comprehensive approach to delivering psychological care that includes specialist clinical neuropsychology/clinical psychology input within the multi-disciplinary team.

• Services for people with stroke should offer psychological support to all patients regardless of whether they exhibit specific mental health or cognitive difficulties, and use a matched care model to select the level of support appropriate to the person’s needs.

• Services for people with stroke should provide training to ensure that clinical staff have an awareness of psychological problems following stroke and the skills to manage them.

• Services for people with stroke should ensure that the psychological screening and assessment methods used are appropriate for use with people with aphasia and cognitive impairments.

• Services for people with stroke should provide screening for mood and cognitive disturbance within six weeks of stroke (in the acute phase of rehabilitation and at the transfer of care into post-acute services) and at six and 12 months using validated tools and observations over time.

• Services for people with stroke should include specialist clinical neuropsychology/clinical psychology provision for severe or persistent symptoms of emotional disturbance, mood or cognition.

• Services for people with stroke should consider a collaborative care model for the management of people with moderate to severe neuropsychological problems who have not responded to high-intensity psychological interventions or pharmacological treatments. This care model should involve collaboration between the GP, primary and secondary physical health services and case management, with supervision from a senior mental health professional and should include long-term follow-up.


SADQ-10 All age

Cut-off ≥ 5 (Fax all to CPD for record purpose)

MO Referral

Nurse

Acute stroke patient

Manual Referral to CP PCA

• Prelim results • CP initial recommendations

CP Neuropsy

Assessment

Dementia Assessment

Treatment Planning/ Recommendations - Patient training

- Team involvement

Mild/ Moderate

Review after discharge

(3-6 months)

Severe

Communicable?

HADS-14 < Age 65

Cut-off ≥ 15

GDS-15 ≥ Age 65

Cut-off ≥ 7

Mood

MoCA (<Age 65), Mini-MoCA (≥ Age 65), VFT (All age)

Cognitive

(If screening Indicative)

Mood

iMAN Screening—Decision Tree (Nov 16)

CPD: Department of Clinical psychology; MO: Medical officer; CP PCA: Patient Care Assistant (Clinical Psychology); CP: Clinical Psychologist; SADQ: Stroke Aphasic Depression Questionnaire; MoCA: Montreal Cognitive Assessment; Mini-MoCA: Montreal Cognitive Assessment 5-Minute Protocol; VFT: Verbal Fluency Test; HADS: Hospital Anxiety and Depression Scale; GDS: Geriatric Depression Scale

AMT vs HK-MoCA

(Wong et al, 2017)

Admission

iMAN

CP recommendations to CMO

Manual Referral by nurses upon admission

- Average: 1.55 days (SD= 4.50)

iMAN screening completed upon referral

-Average: 1.74 days (SD= 1.68)

Dated: Apr 2014 - May 2016

Cognitive outcome (MoCA)

Tx (T2-T1), vs control (T2-T1), p=n.s., Cohen’s d=.85 (Cheung et al, in press)

Indications for CP Neuropsychology Services

Key Specialties

1. General appraisal of cognitive and behavioural functioning

• Characterizing the cognitive capacities (S/W) of brain-injured patients so as to determine rehabilitation potential/treatment direction (placement, return to work, and recommendations for independent living)

REH / GERI / PSY / MED / PED / FM

2. Monitoring the neuropsychological status of patients who have undergone medical or surgical intervention

• E.g., drug therapy for Parkinson’s disease; temporal lobectomies for pharmacoresistant seizure disorders

NS / NEU

3. Distinguishing organic from psychiatric or medical disease • E.g., pseudodementia, pseudoseizures; obstructive sleep apnea

PSY / NEU / MED / FM


4. Differentiation of different types of dementias basing on cognitive-behavioral-emotional characteristics and detailed psychometric testing

• E.g., Alzheimer’s disease, frontal-temporal dementia, dementia with Lewy Bodies, etc.

REH / GERI / PSY / MED / FM

5. Medicolegal situations • To factor the influence of affective variables, the possibility of

malingering, and the patient’s premorbid status into the diagnostic picture

REH / GERI / PSY / MED / FM

6. Neurological conditions presenting with mild or subtle cognitive change, usually not detected by routine cognitive screening

• Mild closed head trauma • Post-concussion syndrome • Early stages of degenerative dementia syndromes

GERI / PSY / MED / FM / AED


7. Identification of lateralization of language and memory (by Wada testing and/or fMRI) for epilepsy surgery

NS / NEU

8. Carbon monoxide poisoning REH / NEU / PSY / MED / AED

9. Developmental disorders To identify developmental learning disorders that may

influence the cognitive and behavioural presentation of a patient, such as dyslexia, ADHD, and nonverbal learning disability

PED / PSY / FM

References

(NHS, 2011)

Assessment principles • 1 mth after stroke or just before discharge, or at

six week follow-up • 3 mth after stroke, usually post discharge to judge

persistence of early-onset problems and emergence of new problems

• 6 mth after stroke when much physical and social recovery has stabilised and likely longer-term problems can be assessed – Assessment at six month and annual reviews will

allow identification of those with long-term problems

Assessment of mood • Level 1

– Simple brief standardized measures

• Level 2 – Further assessment on pt and carers

• Level 3 – Referral for specialist assessment by clinical

psychology / neuropsychology / psychiatry

Assessment of cognition

• Brief screen – MoCA / ACE-R / RBANS – In combination of functional assessment by OT – within first few weeks

• Detailed assessment – after first few weeks – With clear pathway for CP / neuropsy referral

Rehabilitation

• Clinical neuropsychology provision should be targeted for those people – who are most likely to benefit, – who are returning to cognitively demanding roles, – where risks are unable to be sufficiently

minimised

National Clinical Guideline for Stroke, 5th Edition (2016) by Royal College of Physicians

(NICE accredited) Excerpts

Cognitive impairment - General • People with stroke should be considered to have at least some cognitive

impairment in the early phase. Routine screening should be undertaken to identify the person’s level of functioning, using standardised measures. – Screening tools provide a general overview of a person’s cognitive functioning,

but can fail to detect specific problems, and have limited ability to identify specific cognitive strengths and weaknesses.

– Examples of standardised screening tools used in UK stroke services include the Montreal Cognitive Assessment (MOCA) (Nasreddine et al, 2005) and the Oxford Cognitive Screen (OCS) (Demeyere et al, 2015)

• Any person with stroke who is not progressing as expected in rehabilitation should receive a detailed assessment to determine whether cognitive impairments are responsible, with the results explained to the person, their family and the multidisciplinary team.

• People with communication impairment after stroke should receive a cognitive assessment using valid assessments in conjunction with a speech and language therapist. Specialist advice should be sought if there is uncertainty about the interpretation of cognitive test results.

• People with cognitive problems after stroke should receive appropriate adjustments to their multidisciplinary treatments to enable them to participate, and this should be regularly reviewed.


Cognitive impairment - General • People with acute cognitive problems after stroke whose care is

being transferred from hospital should receive an assessment for any safety risks from persisting cognitive impairments. Risks should be communicated to their primary care team together with any mental capacity issues that might affect their decision-making.

• People with stroke returning to cognitively demanding activities such as driving or work should have their cognition fully assessed.

• People with continuing cognitive difficulties after stroke should be considered for comprehensive interventions aimed at developing compensatory behaviours and learning adaptive skills.

• People with severe or persistent cognitive problems after stroke should receive specialist assessment and treatment from a clinical neuropsychologist/clinical psychologist.


Mood and well-being • People with stroke with one mood disorder (e.g. depression) should be assessed for others (e.g.

anxiety). • People with or at risk of depression or anxiety after stroke should be offered brief psychological

interventions such as motivational interviewing or problem-solving therapy (adapted if necessary for use with people with aphasia or cognitive problems) before considering antidepressant medication.

• People with mild or moderate symptoms of psychological distress, depression or anxiety after stroke should be given information, support and advice and considered for one or more of the following interventions:

• ‒ increased social interaction; • ‒ increased exercise; • ‒ other psychosocial interventions such as psychosocial education groups. • People with aphasia and low mood after stroke should be considered for individual behavioural

therapy e.g. from an assistant psychologist. • People with depression or anxiety after stroke who are treated with antidepressant medication

should be monitored for adverse effects and treated for at least four months beyond initial recovery. If the person’s mood has not improved after 2-4 weeks, medication adherence should be checked before considering a dose increase or a change to another antidepressant.

• People with severe or persistent symptoms of emotional disturbance after stroke should receive specialist assessment and treatment from a clinical neuropsychologist/clinical psychologist.

• People with persistent moderate to severe emotional disturbance after stroke who have not responded to high intensity psychological intervention or pharmacological treatment should be considered for collaborative care. Their care should involve collaboration between the GP, primary and secondary physical health services and case management, with supervision from a senior mental health professional and should include long term follow-up.


Psychological care – organization and delivery

• Services for people with stroke should have a comprehensive approach to delivering psychological care that includes specialist clinical neuropsychology/clinical psychology input within the multi-disciplinary team.

• Services for people with stroke should offer psychological support to all patients regardless of whether they exhibit specific mental health or cognitive difficulties, and use a matched care model to select the level of support appropriate to the person’s needs.

• Services for people with stroke should provide training to ensure that clinical staff have an awareness of psychological problems following stroke and the skills to manage them.

• Services for people with stroke should ensure that the psychological screening and assessment methods used are appropriate for use with people with aphasia and cognitive impairments.

• Services for people with stroke should provide screening for mood and cognitive disturbance within six weeks of stroke (in the acute phase of rehabilitation and at the transfer of care into post-acute services) and at six and 12 months using validated tools and observations over time.

• Services for people with stroke should include specialist clinical neuropsychology/clinical psychology provision for severe or persistent symptoms of emotional disturbance, mood or cognition.

• Services for people with stroke should consider a collaborative care model for the management of people with moderate to severe neuropsychological problems who have not responded to high-intensity psychological interventions or pharmacological treatments. This care model should involve collaboration between the GP, primary and secondary physical health services and case management, with supervision from a senior mental health professional and should include long-term follow-up.


Implications • “Stroke services need to consider how to develop and

maintain the knowledge and skills in all clinical staff to provide appropriate psychological support to people with stroke, and how to provide the high-intensity support needed by a minority of people with cognitive and mental health issues.

• The 2016 NICE Quality Standard QS2 is clear that a clinical neuropsychologist/clinical psychologist with expertise in stroke rehabilitation should be a core member of the multi-disciplinary team.

• Commissioners should also plan for the long term management of psychological difficulties of delayed onset (e.g. anxiety, depression).” (2.12.3, p.27)


hhh stroke pathway - hospital authority · hhh stroke pathway: a multi-disciplinary service model...

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