Psychological screening for
people with and without
communication difficulties after
stroke
Fiona Stewart, Speech and Language Therapist,
City Hospitals Sunderland NHS Foundation Trust
Kirsty Bramley, Speech and Language Therapist, Northumbria
Healthcare NHS Foundation Trust
Debby Townson, Consultant Clinical Psychologist,
NTW, Newcastle Stroke Services
Aims of the workshop
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To recap on national guidelines for screening patients
for issues of mood after experiencing a stroke.
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To explore why we screen and assess mood after a
stroke: the functions and purpose of screening tool &
assessments.
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To explore mood screening measures and
assessment techniques for people with and without
communication problems after stroke.
Most people will have some
psychological issues after a stroke
Stroke is a sudden event that takes people out of their
prior health status and functioning without warning. It is
a frightening event and people have a number of
challenges to face, including being in hospital and being
away from their environment, not being with important
people in their life and being out of their usual routines.
This is in addition to the consequences of the stroke
itself.
Lots to cope with, a model of
“normal” adjustment:
Stage Models of Adjustment: One way of looking at coming to
terms with a stroke is to liken the emotional adjustment to stroke
as being similar to the process of grieving following bereavement.
Wilkinson (1995) suggested that patients may go through a
number of stages, which include:
Individual differences in adjustment to
stroke:
The Individual
Personality
Attitudes
Relationships
Interests
Activities
Expectations
The consequences of
stroke
Severity
Extent
History
Cause
Prognosis
Twining (1988) suggests the emotional adjustment to
stroke is considered as the interaction between the
person and the handicaps faced after stroke.
Don’t forget the range of
psychological problems after stroke
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Depression
Anxiety/ Worry
Emotionalism
Problems with adjustment
Fatigue
Difficulties in coping
Apathy
Anger
Problems with social re-integration
RCP National Clinical Guidelines for Stroke, 2008 (and 2012).
Depression and Anxiety: common
problems after stroke:
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What are the prevalence figures for:
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Depression?
30% of patients will suffer from depression at some point post stroke
(British Psychological Society 2010)) and a significant proportion of
these remain potentially undiagnosed or inadequately treated (Hackett
et al, 2005).
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Anxiety?
Rates for anxiety following stroke have been estimated to be between
22-28% in the acute stage and at follow-up, that means one in four
patients are anxious.
Themes behind each disorder
• Deb to add
Untreated psychological disorders
lead to higher levels of:
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Mortality
Suicide
Long term disability and institutionalisation
Hospital readmission
Higher utilisation of outpatient services
Patient distress.
National guidelines on screening
• National Stroke Strategy (2007)
Central importance of a psychological pathway of rehabilitation;
• RCP National Clinical Guidelines for Stroke (2009)
Patients with stroke should be routinely screened for depression anxiety
and cognition
• NICE Quality Standard for Stroke (2010)
Screen within 6 weeks of diagnosis … to identify mood disturbance and
cognitive impairment
• NICE Quality Standard for Depression in Adults (2011)
People with depression should receive appropriate psychosocial
interventions or collaborative care according to the degree of depression,
associated chronic health problems and its impact on function
• NICE Quality Standards for Long term conditions (2009)
(http://www.nice.org.uk/nicemedia/live/12327/45865/45865.pdf)
NHS Stroke Improvement guidance
http://www.improvement.nhs.uk/stroke/Psychologicalcareafterstroke/tabid/177/Default.aspx
Interventions in the stepped care
model
Level 1: Assess all admitted patients (rating scale); symptomatic
patients take a detailed interview (confirm symptoms; possible
causes; history; impact; treatment preferences);
Functions of the screening process.
What screening is:
When assessing mood, we aim to:
• identify those with a potential problem, e.g. using screening
measures, often carried out by staff such as nurses, OT’s;
• gain an understanding of the nature of the mood problem in
order to plan treatment. For this we need to determine the
severity of the problem, how intrusive (distressing) it is to the
individual or how it is affecting their functioning (or
motivation);
• monitor change in mood over time;
• develop intervention plans to assist change.
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The RCP further suggests that we should keep the patient’s
mood under review.
Review of mood over the adjustment
process
• Accelerated Stroke Improvement Programme guidelines
recognises the need to assess a patient at 4 potential time
points:
• One month after stroke or just before discharge, or at six week
follow-up;
• 3 months after stroke;
• 6 months after stroke when much physical and social recovery
has stabilised and likely longer-term problems can be
assessed;
• annual reviews to identify those with long-term problems
• If there is cause for concern at any other time reassessment
and treatment is recommended.
Screening is not a:
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Tick box approach;
A one off exercise;
Taking a measure of one day only: bear in mind
that the patient is asked, and staff asked to
comment upon symptoms in the last 2 weeks
therefore it is important that it is done by someone
who knows the person;
Something that can be ignored if people have
aphasia as there are plenty of tools available and
the needs of this group with challenges faced after
stroke.
Screening alone does not improve outcome!
Some help is needed to get better.
Screening tools for depression after
stroke: Burton 2011
Tools for people without
communication problems:
Burton 2011
Examples of Scales
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Depression (and Anxiety) scale for someone who doesn’t have a
language problem.
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The Hospital Anxiety and Depression Scale–Anxiety (HADS-D)
which acts as a screening measure for depression in those without
significant cognitive or communication disability. Seven of the items
relate to depression (HAD-D) and seven relate to anxiety (HAD-A).
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Each item on the questionnaire is scored from 0-3 and this means
that a person can score between 0 and 21 for either anxiety or
depression. Bjelland et al (2002) through a systematic review of a
large number of studies identified a cut-off point of 8/21 for anxiety or
depression.
Other detailed assessment scales can be helpful when a person is
identified to have depression or anxiety. These can gather more
information about the symptoms experienced. A popular measure is
the Beck Depression Inventory (BDI) or Beck Anxiety Inventory. See
Lincoln, Morris and Kneebone 2011 for a thorough review.
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Use the information in the
questions to inform management
plans
For example:
• “I cannot enjoy the hobbies I used to enjoy”
• For most people after a stroke this is true. We can
explore this though by asking what the person can
still do and asking relatives to try to bring things in,
or do things with people when they come in etc.
Yale questions
Two questions:
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1. Prior to your stroke, have you ever felt sad or depressed?
(Yes/No)
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2. Since your stroke, have you been feeling sad or
depressed?
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NB: a further clinical assessment should follow if these two
are affirmative in line with national guidance.
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Also be mindful of the range of psychological problems we
may face: I might not be depressed but I may be very
stressed, or anxious, or angry.
Tools for people with
communication problems:
Burton 2011
Depression measures for people with
language problems: self report
• Depression Intensity Scale Circles (DISCS)
If the patient points
to this circle (a
score of 2), or any
higher- this would
indicate low mood.
Depression measures for people with
language problems: Instructions
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The DISCS is a mood screening tool designed for use with
patients that have suffered a brain injury, for example after
stroke.
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The tool is displayed on a laminated card (you can find one of
these in the toolkit) and the patient is asked to point to each of
the circles individually to ensure that they are able to see
them all. If the patient accomplishes this, you can then go on
to explain what the different circles mean. The circles
basically show how depressed an individual is, from no
depression at the bottom of the scale, to depression which is
as bad as it can possibly be at the top of the scale.
Depression measures for people with
mild language problems: instructions
cont
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Point to each individual circle in ascending order (from no
depression to most severe depression) and explain that as
you go from the bottom to the top, the depression (or
sadness) is becoming more and more severe. Finally, ask the
patient which of the circles shows how depressed they feel
today?
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The DISCS can be administered by any healthcare
professional and the scoring of the tool is as straightforward
as the administration of it. The bottom circle is scored as 0 (no
depression) and other circles are scored from 1-5, with 5
being the most severe depression. If the patient points to
this circle (a score of 2), or any higher- this would
indicate low mood
Depression measures for people with language
problems: observation measure
The SADQ-H10 requires the rater to score the patient on 10 different behaviours,
shown below:
1.
Did he/she have weeping spells this week?
Every dayOn 4-6 days
On 1-4 days
Not at all
2.
Did he/she have restless disturbed sleep this week?
Every dayOn 4-6 days
On 1-4 days
Not at all
3.
Did he/she avoid eye contact when you spoke to him/her?
Every dayOn 4-6 day
On 1-4 days
Not at all
4.
Did he/she burst into tears this week?
Every dayOn 4-6 days
On 1-4 days
5.
Not at all
Did he/she complain of aches and pains this week?
Every dayOn 4-6 days
On 1-4 days
Not at all
Depression measures for people with
language problems: observation measure cont
6.
Did he/she get angry this week?
Every day
On 4-6 days
On 1-4 days Not at all
7.
Did he/she refuse to participate in social activities this week?
Every day
On 4-6 days
On 1-4 days
Not at all
8.
Was he/she restless and fidgety this week?
Every day
On 4-6 days
On 1-4 days
Not at all
Did he/she sit without doing anything this week?
Every day
On 4-6 days
On 1-4 days
Not at all
9.
10.
Did he/she keep him/herself occupied during the day?
Every day
On 4-6 days
On 1-4 days
Not at all
Depression measures for people with language
problems: observation measure scoring
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For questions 1-9; “Every day” receives a score of 3, “On 4-6 days” receives a
score of 2, “On 1-4 days” receives a score of 1 and “Not at all” receives a score
of 0. On the final question, number 10, this scoring system is reversed so that
“Not at all” receives a score of 3, and “Every day” receives a score of 0.
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The total score is dependent on the frequency of the behaviours (how many
days within the past week the behaviour has been exhibited). If an individual
scores 6 or more points out of 10, for two consecutive weeks, this would
indicate a problem with mood. As a score of 6+ needs to be obtained in
consecutive weeks to indicate a mood problem, it is important that the SADQ H10 is completed on a weekly basis.
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As with all mood screening tools, as well as looking at the score that a patient
has received, you should also use your judgement and knowledge of that
patient to guide your assessment and the strategies that you use with them.
Strategies such as relaxation CDs or increasing activities/interactions can be
beneficial.
Screening for anxiety for those
with communication problems
Table: Behavioral Outcomes of Anxiety (BOA). Kneebone et al 2012
Often
1. Does he/she appear particularly tense
or on edge?
2. Does he /she have a strained face?
3. Does he/she avoid activities or social
engagements without good reason?
4. Does he/she appear fearful of falling?
5. Does he/she have trouble falling or
staying asleep?
6. Is he/she jumpy or easily startled?
7. Is he/she restless or constantly on the
move (e.g. do they pace)?
8. Is he/she easily tired?
9. Does he/she appear anxious?
10. Does he/she appear to panic, or have
unusual episodes of breathlessness or
hyperventilation?
Sometimes
Rarely
Never
Which tool to use?
• Quality standard: Every service should have a protocol across the
stroke pathway (see examples).
• Has the tool been validated for use with patients with stroke?
Sensitive and specific?
• How long does it take to administer and score the tool?
• What funds are required to purchase the tool? Initial purchase?
Cost of record forms?
• What level of training is required to administer the tool?
• Which tools do other local services use? ESD, IAPT, GPs
• Is the tool acceptable and relevant to patients?
Good practice:
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Privacy to talk.
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Explain the reasons for assessment and gain consent.
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Leave enough time to properly explore the issues, to have an honest
conversation about how someone may truly be feeling.
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Remember your core listening and communication (warmth,
genuineness and empathy) when asking a patient about they are
feeling.
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Use your clinical judgement to supplement the results.
Good questions: the personal perspective:
what is causing the person distress?
• If the person can express their opinions it is always a good
idea to ask the person how they are feeling, and what is going
on for them. That often gives us a bit of an idea of possible
problems. You may aIso want to speak to family members
about what is going on and what helps a person.
Asking specific questions to identify how someone is feeling can
uncover what they are thinking.
• “You/they just looked really worried/down/angry. Can you tell
me what went through your mind?”
• “Are there any times when you/they particularly anxious or
down and when you experience these symptoms?”
• “Does anything help?”
Looking for patterns of symptoms, techniques
for people with aphasia
• The following section will look at:
Understanding aphasia- medical model
• Severity
• Mild/ moderate/ severe
• Receptive and/ or expressive
• Eg George has mild receptive dysphasia with severe word
retrieval difficulties
• Patterns of deficits and retained skills
• Eg Written word finding is preserved. Sometimes George is
able to write a recognisable key word
• Communication strategy
• Support verbal comprehension by reducing background
noise, using short sentences, and signaling a change in
topic.
• Support expression by ensuring pen/paper available, and
allowing plenty of time for George to write.
Understanding aphasia- person centred
approach
• Jo Bloggs has moderate receptive and severe expressive
difficulties. He has severe word finding problems, but can
indicate yes and know reliably. He uses drawing and gesture
effectively, eg gesture for garage extension; can draw
recognisable sausages versus chicken drumsticks. After
months in residential care he now lives alone independently.
He participated in a Rehab UK programme and now attends
Community Integration groups.
Understanding aphasia- person centred
approach
• Mrs Mop has just returned home from hospital. She has mild
receptive difficulties and word finding problems. Friends tell her
she is ‘amazing’. She has stopped attending church and lunch
club because she can’t follow conversation and participate.
She believes she will ‘never be the same again’.
Which person has the more severe aphasia?
Who is most likely to be depressed and how do we find
that out?
TITLE TO BE ADDED
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Supported conversation
PPPP Pen Paper Photos Pictures
Top tips for aphasia
It’s not rocket science!!
Good Practice in assessing mood in people
with aphasia
• Be prepared! (Girl guides)
• SADQ- know the observations over past week
• Communication assessment results and strategy from SLT
• Cognitive impression or assessment (OT initial assessment/
SLT assessment results)
• Pictures and scales- eg sleeplessness; embarrassment;
depression
• What makes it better pictures and scales- eg music; bath;
TV
• Top tips for aphasia
The Blue Peter conversation…
• Here’s one I made earlier…
Beyond Screening......
• Exploring someone's mood is important, consider replacing
your therapy session with a session discussing mood, anxiety
and their concerns and hopes for their future.
• This session will help inform you and other members of the
team
• Stories are intentional, they are told with intent, that they will
be listened to and acted upon
• The session will need to be supported by communication
ramps
Supported Conversation IN
• Remember the top 10 tips for talking to PWA
• Getting the message IN:
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Speak naturally
Use short sentences
Have an expressive tone of voice
Say things like “ I know you know”
As you are talking: write down key words
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use gesture
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use pictures
Supported Conversation OUT
• To help the PWA get their message OUT:
• Ask questions that need a yes or no answer
• At the start these questions can be general then become more
specific
• Concentrate on one thing at a time
• Offer single written words as a multiple choice if possible
• Say “can you show me”
• TIME
Supported conversation VERIFY
• Using the words written, pictures drawn and photos used:
• Reflect what the PWA’s message is
• Expand on what they might be trying to say
• Summarize
• This is how it might look
Workshop
• Groups of 3: 1 PWA and 2 listeners
• Folder contains some limited picture materials and a topic for
you to explore
• The PWA is not allowed to speak, write or use their right hand
• Use the strategies we’ve described and get some information
from the person with aphasia
• How was it from both perspectives?
• How accurate was the information you gained from the PWA?
• What helped the most?
• Would you do anything differently now?
Supported Conversation
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People with aphasia (PWA) are competent
We must get the right information IN
Help the PWA get their message OUT
We then need to VERIFY that we have understood correctly.
To help us do this we need a simple toolkit:
Pen
Paper
• Basic pictures
Using the measures well with all
clients: Summary
Screening informs treatment, by:
• Prompting further assessment/monitoring;
• Share the results with the patient/family as appropriate and
with the rehab team, getting ideas from them as to what may
help;
• Discuss the effects of mood (and cognitive problems) on
engagement with rehabilitation, possibly changing rehab
goals for a while or where/how we deliver rehab;
• Plan for safe discharge (e.g. suicide risk considered);
• Develop pathways- What support is available locally? Who is
doing what, when;
• Give information as to how people can get back in touch or
access services for mood related problems when needed.
This bears in mind psychological needs are not defined in
relation to time post stroke.
The Ambition for Psychological
Care After Stroke: Summary
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All stroke services should have a pathway and provide
psychological care by asking patients, using screening tools and
following national guidance;
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People with stroke should experience a culture where
psychological and physical issues are of equal importance (nb It
needs to be acceptable for staff to spend time with patients,
exploring and supporting the impact of the stroke). This should be
acknowledge as a valid use of clinical time;
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Skills development for the whole team needs to focus on
understanding adjustment after stroke, identifying psychological
difficulties and providing compassionate caring;
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People with stroke and psychological disorders are managed in a
service capable of identifying and managing their needs for as
long as they need.
Further reading/information
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Accelerated Stroke Improvement website: *add link
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This includes information on screening, protocols for services
in assessing mood.
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Lincoln Kneebone 2012 book *add
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Please add others
NECVN Stroke Competencies
This session has covered an awareness of the following stroke
specific competencies:
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1.1.1 Describe and demonstrate the components of effective
communication e.g. listening skills, verbal and non-verbal
skills, negotiation and influencing.
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1.1.10 Demonstrate rapport building, empathy and
personalising communication for the individual during
interactions with person/carer.
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5.1.1 Select and complete appropriate standardised and nonstandardised clinical assessments within the parameters of
own role.
NECVN Stroke Competencies
continued
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5.1.2 Complete screening assessments for emotional difficulties,
interpret the results and develop intervention plans with the MDT.
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5.1.3 Understand and interpret results of the assessments and
feedback the results to the person, family and team.
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5.1.15 Identify need, seek advice and refer individuals for further
specialist assessment.
Further information contained in
your pack from this workshop:
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Tips on communicating with people with aphasia
Tips on general communication with patients
Examples of mood protocol pathways
Ways to help a person after stroke
For further information please contact:
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Fiona Stewart *add
Kirsty Bramley *add
Debby Townson at debby.townson@ntw.nhs.uk
The PAAST toolkit contains:
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Psychological Care after Stroke
Dealing with distress worksheet
Unhelpful thinking habits sheet
Formulation sheets
Activity schedules
Problem solving sheets
Depression after Stroke information leaflet (Stroke Association)
Physical symptoms of anxiety (body outline)
BOA (Behavioural Outcomes of Anxiety)
Worry decision tree
Worry diary
Graded hierarchy for anxiety
Toilet schedule
Health anxiety pie chart
Health anxiety thought record
Health anxiety thought diary
Relaxation scripts
Relaxation for aphasia
DISCS (The Depression Intensity Scale Circles)
SADQ H10
SADQ H
SADQ Community
Distress scale (including aphasia friendly distress scale)