Article Archive
May/June 2018

Medication Monitor: Poststroke Care Warrants Specialized Attention
By Mark D. Coggins, PharmD, BCGP, FASCP
Today's Geriatric Medicine
Vol. 11 No. 3 P. 5

Poststroke conditions can severely limit the ability of stroke survivors to independently perform activities of daily living, resulting in a profound effect on their quality of life. In fact, stroke continues to be the No. 1 preventable cause of disability in the United States.1 Additionally, poststroke rehabilitation has significant consequences on families, with 74% of stroke survivors requiring poststroke care from family caregivers following discharge to the home.2

Evidence suggests there is a tremendous need and increased expectation for health care professionals (HCPs) to include family caregivers and provide them with more extensive education and training on a survivor's condition and treatment plans, including medication management and information on the risk for poststroke complications.3

Inadequate training of family caregivers often leaves these primary caregivers ill prepared for the physical, cognitive, and emotional devastation of stroke. Lack of appropriate discharge planning along with early discharge of stroke survivors can place unrealistic demands on caregivers.4 HCPs' failure to address these issues with families can significantly hamper poststroke rehabilitation; caregiver stress is a leading cause of costly long-term institutionalization of stroke survivors.5

For stroke survivors and their family caregivers, a common frustration surrounds a perceived lack of sufficient support related to poststroke conditions following discharge. Many point out that they feel as though HCPs expect them to ask questions. But without knowing specifically what to ask, how can stroke survivors or family caregivers ask appropriate questions? As HCPs, we must do more to support stroke survivors' journeys across settings through the acute to chronic phases of rehabilitation efforts.

Common concerns it's important to discuss with these patients and their family caregivers include poststroke depression (PSD), challenges arising from changes in emotional state and unexpected behaviors, communication challenges, and seizures risk. These areas often leave everyone feeling helpless, especially if there has been inadequate preparation. However, these concerns deserve increased attention.

Poststroke Depression and Suicide6
PSD was previously discussed in greater detail in the September/October 2015 issue of Today's Geriatric Medicine.6

PSD prevalence is estimated to be 30% to 50%.6 The risk of depression in stroke survivors is double that seen in the general population. Unfortunately, despite the known risk, nearly 70% of stroke survivors experiencing persistent depression are untreated with antidepressants at both three and 12 months poststroke.6

PSD can lead to various degrees of frustration, anxiety, sadness, fear, and hopelessness. Some individuals experience decreased appetite and weight loss, disturbed sleep patterns, loss of energy, sense of worthlessness, anhedonia, psychomotor retardation, and/or agitation. Furthermore, depression increases mortality, worsens preexisting medical conditions, including cardiovascular disease and diabetes, and ultimately may lead to suicidal ideation, which has been reported up to 24 months after a stroke. A number of studies consistently show a significant increase in suicide risk for individuals who have experienced a stroke regardless of other influencers.

The consequences of PSD left unrecognized and untreated, along with the risk of suicide, are especially troublesome.

Thomas's Story
Recently, I heard firsthand the devastation stroke had had on one stroke survivor, Thomas (the name has been changed), and his family, as related to me by his daughter.

Thomas, a white male from a small town bordering the southern states of Mississippi and Louisiana, was a man of tremendous faith, an Air Force veteran, and a retired electrician. Typical of many people born and raised in the 1930s and '40s, Thomas lived his life with a stoic toughness, believed in working hard for what he had, and faced life's challenges head-on.

At the age of 56, Thomas suffered the first of three myocardial infarctions (MIs), occurring over the course of 15 years. The first MI was severe, necessitating his being resuscitated. Later, Thomas told his family, "I saw heaven's beauty," and he became extremely distraught that he hadn't been able to stay. However, Thomas knew he would return one day but only on God's terms.

Thomas fought his way back to health following each MI so that he could return to work and continue his passion for the outdoors. For Thomas, hard work and showing respect for the life God had given him were what living was all about. Each year he would sow a two-acre garden. Thomas found tremendous enjoyment in sharing his crops with others, including the ladies from the city offices, who loved to see him coming with freshly pulled turnip greens.

Thomas was a "people person," so when he held his legendary fish fries, everyone, including complete strangers, was welcome. Plenty of food with no shortage of laughs was typical of these events. While cooking, Thomas would joke around and tell stories of his hunting and fishing escapades to anyone who would listen.

At the age of 73, Thomas suffered a stroke, which was more devastating than any of his previous MIs. In an instant, the life of this strong, proud, and fun-loving man changed forever. During his stroke rehabilitation, no one had prepared the family for what followed, including his extreme mood swings, depression, anger, cursing, and irritability. Even with therapy, the shortest walks left Thomas severely fatigued. His stroke rehabilitation focused primarily on physical recovery with little discussion about depression risk, emotional and behavioral changes, or strategies to help the family monitor and respond to these prevalent concerns. His daughter indicated there was no mention about the possible need for antidepressant therapy or potential for suicidal ideation.

One year later, Thomas survived another stroke. He had difficulty adjusting to the short-term rehabilitation center in which he was placed. The center had difficulty managing his behaviors and insisted on discharging him home. However, Thomas' wife refused to take him home if he was not given something for his obvious depression and anxiety. Only his wife's persistence resulted in the prescription of an antidepressant for Thomas.

The second stroke left Thomas with significant communication challenges, in which he would mix up words. For example, he would often misuse a word like "pecan" when he meant "love," or confuse words such as "tar" and "bar" when he wanted to say "car." His inability to effectively speak and tell his stories led to outbursts of anger targeted at his loved ones and others who failed to understand him. Over the next several months, Thomas became increasingly frustrated and overwhelmed as his life became a shell of what it once was.

Tragically, one Sunday morning, without saying a word to his wife, who was washing dishes while waiting for him to get ready for church, Thomas walked out the front door onto his front lawn, where he shot and killed himself.

Thomas' journey illustrates the worst-case risk associated with PSD. Prescribers must take an aggressive approach in identifying risks and appropriate treatment. A combination of family support, therapy, and medication can greatly benefit anyone suffering from despair. In addition to helping with depression, antidepressants also have been shown to help with anxiety as well as cognitive and functional recovery. Recent evidence indicates that selective serotonin reuptake inhibitors (SSRIs), such as escitalopram and sertraline, are also helpful in motor recovery (eg, improved movement and coordination).

Pseudobulbar Affect7
Pseudobulbar affect (PBA) is a neurological condition characterized by sudden and unpredictable episodes of crying or laughing, often in socially inappropriate situations.

The inappropriateness, intensity, and suddenness of the outbursts can make a person suffering from PBA feel as though he or she has lost control over his or her life. A disconnect between an individual's emotions and external expressions can be frustrating, both for the person and for family members. While a diagnosis needs to be made by a medical professional, it's important to educate stroke survivors and their families about PBA signs and symptoms so that potential treatments may be considered. Additionally, better understanding of PBA can help those with the disorder reclaim confidence while improving their relationships and quality of life.

PBA is commonly seen in stroke survivors as well as in Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis (ALS), or multiple sclerosis (MS), or among persons who have experienced traumatic brain injury. PBA is often misdiagnosed as depression, bipolar disorder, generalized anxiety disorder, schizophrenia, a personality disorder, or epilepsy.

The goal of treatment for PBA is to reduce the severity and frequency of emotional outbursts. Medication options include antidepressants such as SSRIs, which can help reduce the frequency and severity of PBA episodes. Keep in mind that PBA and depression are not the same. Antidepressant doses used for the treatment of PBA are typically prescribed at doses lower than those used to treat depression.

The combination dextromethorphan hydrobromide and quinidine sulfate known as Nuedexta is the only FDA-approved drug indicated specifically for PBA. A study on people with MS and ALS showed that those taking the medication had about one-half as many laughing and crying episodes as those taking a placebo.

Encourage individuals to be open about their PBA disorder so people are not surprised or confused when an episode occurs. Additional coping strategies focused on distraction techniques, slow breathing, and relaxation may also be helpful.

Stroke is the leading cause of seizures in the elderly. Predicting who will have a seizure is difficult, making it important to warn stroke survivors and their families about this risk. Experiencing seizures following a stroke or watching someone experience a seizure can be a frightening experience. Poststroke seizure risk should be taken seriously, and both stroke survivors and caregivers should be fully educated on how to handle a seizure if it should occur.

The Epilepsy Foundation estimates that seizures strike 22% of stroke survivors. The seizure may last only a few seconds or minutes and trigger involuntary body movements, strange sensations, or blackouts.

Seizures occurring after a stroke can be classified as acute onset (up to two weeks poststroke) or late onset (more than two weeks poststroke), with the latter having a higher recurrence rate in both ischemic and hemorrhagic stroke. Most acute onset seizures don't result in epilepsy (ongoing seizures), and treatment after one such seizure is often not necessary. Patients are more likely to suffer seizures following hemorrhagic strokes, making more aggressive treatment more likely. Most people will require antiepileptic treatment only in the short term, and their prescribers may discontinue treatment after a seizure-free period. Individuals with epilepsy will require lifelong anticonvulsants.

Most antiepileptic drugs (AEDs) impair cognition in elderly patients. This side effect has been reduced with the new generation of AEDs, such as lamotrigine, gabapentin, and levetiracetam. However, these are more costly than older agents such as phenytoin, valproate sodium, and carbamazepine. The choice of AED should be guided by the individual characteristics of each patient, including concurrent medications and medical comorbidities.

— Mark D. Coggins, PharmD, BCGP, FASCP, is vice president of pharmacy services and medication management for Diversicare, which operates skilled nursing centers in 10 states. He was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.

1. Impact of stroke (stroke statistics). American Heart Association and American Stroke Association website. Updated June 6, 2016.

2. Dewey HM, Thrift AG, Mihalopoulos C, et al. Informal care for stroke survivors: results from the North East Melbourne Stroke Incidence Study (NEMESIS). Stroke. 2002;33(4):1028-1033.

3. Tsai PC, Yip PK, Tai JJ, Lou MF. Needs of family caregivers of stroke patients: a longitudinal study of caregivers' perspectives. Patient Prefer Adherence. 2015;9:449-457.

4. Creasy KR, Lutz BJ, Young ME, Stacciarini JM. Clinical implications of family-centered care in stroke rehabilitation. Rehabil Nurs. 2015;40(6):349-359.

5. Horner RD. The high cost of stroke to society, the family, and the patient. Pharmacotherapy. 1998;18(3 Pt 2):87S-93S.

6. Coggins MD. Poststroke depression. Today's Geriatric Medicine. 2015;8(5):6-8.

7. Pseudobulbar affect. Mayo Clinic website. Updated April 1, 2016.

8. Seizure management, part 1: when to start anti-epileptic drugs. Inferscience website. Published November 1, 2016.