Life After Stroke: Defining Patterns of Behavior

Transcription

1 Life After Stroke: Defining Patterns of Behavior John J. Volpi, MD Co-Director, Eddy Scurlock Stroke Center Houston Methodist Hospital Neurological Institute

2 Disclosures I will be discussing off label indications of many drugs Speaker for Avanir and Johnson & Johnson Previous research for Pfizer Ongoing research with Boehringer, Astra Zeneca

3 A different set of objectives More questions than answers

4 A different set of objectives More questions than answers

5 Surviving Stroke About 4 out of 5 patients who have a stroke will return home

6 Surviving Stroke As patients return home, behavioral effects of stroke become increasingly important to patients and caregivers but resources and doctor s visits decrease

7 Questions about our current behavioral approach Are we properly assessing for behavioral changes with our scales? Are our common behavioral diagnoses precise and applicable to stroke patients? Are we missing features of frontal lobe dysfunction? What specific treatment considerations do stroke patients have when using medications? What future projects can we accomplish?

8 Measuring disability after stroke

9 Barthel Index, mrs, NIHSS Feeding, Grooming, Bathing, Dressing, Bowels, Bladder, Toileting, Transfers, Mobility, Stairs Fully normal, Independent but some activity changed, Requires help with ADL, Requires help with walking, Bed bound We are not capturing worsening mood, breakdown in relationships in these common scales. QOL questionnaires are useful (e.g., CREST trial differentiating stroke vs MI in a combined primary endpoint) Why? Difficulty to quantify, time consuming to administer, hard to measure when changes occur after 90 days

10 Mood Disorders Do we have the diagnoses we need?

11 Post Stroke Depression Not specifically in the DSM V Categorized as mood disorder due to a general medical condition Major meaning at least 4 criteria of MDD, minor meaning at least 2 Highly prevalent in studies 30-60% of patients

12 Depression treatment options and issues in stroke patients SSRI: platelet dysfunction SNRI: Hypertension TCA: Cognitive and bladder symptoms Buproprion: lowering seizure threshold All: delayed onset of effect

13 Debate over Depressive etiology Anatomy and pathophysiology of stroke directly or leads to depression arising from a change in brain function The etiology of poststroke depression: a review of the literature and a new hypothesis involving inflammatory cytokines G Spalletta, P Bossù, A Ciaramella, P Bria, C Caltagirone and R G Robinson

14 Debate over Depressive etiology Anatomy and pathophysiology of stroke directly or leads to depression arising from a change in brain function OR Disability from stroke changes behavioral outlook and the consequence of that reaction is depression

15 Debate over Depressive etiology Anatomy and pathophysiology of stroke directly or leads to depression arising from a change in brain function OR Disability from stroke changes behavioral outlook and the consequence of that reaction is depression

16 Are we lumping too many behaviors in depression? Frustration Denial Anger Guilt Psychomotor Agitation Poor Sleep

17 Are we lumping too many behaviors in depression? Frustration (Broca s aphasia) Denial (Anosagnosia) Anger (Disinhibition) Guilt (crying from pseudo bulbar affect) Psychomotor Agitation (akathesias) Poor Sleep (Acquired sleep apnea)

18 It wouldn t really matter if the treatments were similar and effective, but there are major differences and multiple treatment considerations. How s your mood? Do you enjoy doing pleasurable activities, such as going out with the family? These are the cardinal criteria for depression and if not present, the other features are likely not caused by depression (or cured by antidepressants).

19 Other Behavioral Disorders Adjustment disorder Post stroke psychosis Pseudobulbar affect

20 Other Behavioral Disorders Adjustment disorder Post stroke psychosis Pseudobulbar affect

21 Pseudobulbar Affect Emotional outbursts characterized by laughing and/or crying Many names, including: Emotional incontinence Post stroke emotional lability

22 Pseudobulbar Affect Emotional outbursts characterized by laughing and/or crying Many names, including: Emotional incontinence Post stroke emotional lability certain brain diseases, such as hemiplegia, brainwasting, and senile decay, have a special tendency to induce weeping. Charles Darwin, 1872

23 Pseudobulbar Affect Unfortunate nomenclature What is bulbar affect? Most studies performed in MS, ALS, TBI where phenotype is more striking; stroke patients rarely report or endorse laughing symptoms. Crying in stroke patients is more often attributed to disability, frustration than random outbursts. Not a new condition but drawing much more attention through marketing of a novel therapy (Dextromethorphanquinidine)

24 Pseudobulblar affect No formal diagnostic criteria Not listed in DSM V CNS-LS inventory of symptoms Universally associated with neurological condition Striking cases are very rare (1-2%) Subtle cases are common (30%)

25 Are we missing PBA in stroke patients?

26 Treatment for PBA with Dextromethorphan- Quinidine (DMQ) Unique therapeutic target Blocks pre and post-synaptic glutamate action at NMDA receptors Augments inhibitory pathways without sedation

27 Current diagnostic options Treatment options driven by our therapeutic options Depression Anhedonia Sleep disturbance Poor appetite Pervasive PBA Outbursts Laughing/Crying Brief Normal Mood

28 Current diagnostic options Treatment options driven by our therapeutic options Depression SSRI SNRI TCA PBA DMQ SSRI TCA

29 Current diagnostic options Missing a diagnosis? Depression Anhedonia Sleep disturbance Poor appetite Pervasive PBA Outbursts Laughing/Crying Brief Normal Mood

30 Current diagnostic options Missing a diagnosis? Depression Anhedonia Sleep disturbance Poor appetite Pervasive? PBA Outbursts Laughing/Crying Brief Normal Mood Irritability Quick temper Easily stuck Preoccupations

31 Gap in diagnostic options Irritability Emphasizes inter personal dysfunction Quick temper Lack of control over experiencing vs expressing Easily stuck Poor prioritization of goals and effort Preoccupations Difficulty contextualizing present

32 Gap in diagnostic options Irritability Emphasizes inter personal dysfunction Quick temper Lack of control over experiencing vs expressing Easily stuck Poor prioritization of goals and effort Preoccupations These symptoms do not meet criteria for MDD or PBA, but can lead to significant stress on patients, caregivers, and families Difficulty contextualizing present

33 Executive Function Acquired developmental skills Corresponds to frontal lobe development Discounting and contextualization of stimuli across time (present > past) Variable importance of tasks Probabilistic thinking Mental flexibility Interpreting behaviors of others

34 Should we define this constellation of symptoms? Post stroke executive dysfunction Frontal lobe infarcts But many other infarcts influence frontal lobe input cerebellar, thalamus, limbic system, cingulate Indirect dysfunction also possible Acquired sleep apnea worsens frontal lobe function

35 Means of assessing frontal lobe function Limited in bedside testing Airport question, Similes, Set shifting exercises, disinhibition questions (words that start with F ) Better assessed in formal neuropsychiatric testing or from caregiver history Disinhibition behaviors

36 Therapy options Neuroleptics commonly used but sedating May get more benefit from SSRI/TCA/DMQ Goal of restoring inhibitory pathways, possibly through non-rx options Sleep Social engagement Caregiver and family education

37 What next? Broaden our diagnostic options As neurologists, we must own these conditions there are not enough psychiatrists and DSM V is too broad for some CVA specific concerns Behavioral consequences are as important to treat as other late effects CVA CVA patients with PBA are 15% more likely to be placed in nursing homes, not dissimilar to risk from recurrent CVA

38 Future Research Scales Simple to complete questionnaires that capture behavioral issues not obvious in the office Research on current and future RX Form support groups Observe

39 Thank you