9/7/2013 RECOVERY AFTER SUBARACHNOID HEMORRHAGE Lisa T Hannegan, MS CNS, ACNP I HAVE NO FINANCIAL Department of Neurological Surgery University of California, San Francisco DISCLOSURES TO REPORT OVERVIEW OF RECOVERY AFTER SUBARACHNOID HEMORRHAGE 1
9/7/2013 “People see you looking good and tell you that you are doing great. Yet you have to work so hard to appear normal (when you really aren’t) that it is exhausting” • 1981 • Delayed operations • Standard Medical Therapy • Outcome • Favorable 46% • Unfavorable 18% • Dead 36% The Cooperative Aneurysm Study 2
9/7/2013 • Verbal- most often impaired (14-61%) • Visual (14-49% • Short-term • Long-term Memory • MRI study done at one year • Frontal lobes • 76 SAH survivors and 30 controls • Diffuse injury • Reduced total gray and white matter volume that • Variation in tests done correlated with executive function deficits and incidence • Significantly reduced hippocampal volumes bilaterally that correlated with visual memory impairment • Bendel et al. (2010) Executive Function Executive Function 3
9/7/2013 • Reflects the interaction of all the separate cognitive domains. • This includes the activities of daily living and return to work Language Functional Outcome • Complex daily functions • Ability to care for oneself • Much more frequently impaired at 44-93% • Impairments are not as common (4-12%) • Driving • Deficits are related to visual memory, visuospatial function and psychomotor function Activities of Daily Living Instrumental Activities of (ADLs) Daily Living 4
9/7/2013 Social • Depression in 5-50% • Anxiety affects 27- 54% • PTSD Physical Emotional Quality of Life Mood and Anxiety • Daily fatigue in 31% • Profound sleep • Daily fatigue in 31% disturbances in 37- 45% Sleep and Fatigue Sleep and Fatigue 5
9/7/2013 • Daily fatigue in 31% • Daily fatigue in 31% • Profound sleep disturbances in 37- • Profound sleep 45% disturbances in 37- 45% • Significantly lower quality of life scores • Significantly lower quality of life scores • No obvious improvement Sleep and Fatigue Sleep and Fatigue “ I mean there are times when I’m just bawling I am so tired at the end of the day. I realize I do a lot of covering up. I mean I’m blind from this side having to reorient. ” over--I have no vision here. And when I am really tired, I’m banging into things and I’m constantly Headache 6
9/7/2013 • Cognitive function in SAH survivors with “good” outcome evaluated after 6 months • Impaired cognitive flexibility, planning, problem solving and inhibition • Intact judgment and estimation Manning et al. (2005) Long Term Outcomes Clipping versus Coiling • Extensive cognitive and functional • Persistent headache, impairments depression and forgetfulness • More use of neuropsych testing • Low return to work rate • Comprehensive rehab strategies Perimesencephalic Conclusions Hemorrhage 7
9/7/2013 “Now technology is a huge problem for me. I had been back to work for 2 years and getting by doing my old job (except a little slower) when my computer software was updated to Office 2010. I couldn’t learn to use it, so I had to quit.“ SAH Survivor RETURN TO WORK • One of the most important aspects of real-life functioning • One of the most important aspects of real-life functioning • 40% of SAH survivors are unable to return to their previous work Return to Work Return to Work 8
9/7/2013 • Financial stability • Subarachnoid • Improved self-esteem hemorrhage occurs • Improved satisfaction during the peak and quality of life scores productive years • Social interactions • Effect on the family • Enhanced cognitive structure function and physical • Effect on the family recovery finances Benefits of Work after Return To Work SAH • Pace of activity • Multi-tasking • Cognitive dysfunction • Lack of quiet time to recover • Depression • Lack of understanding by co-workers • Fatigue • Using energy to hide emotional and cognitive difficulties Cognition: Challenges Barriers to Return to at Work Work 9
9/7/2013 • Preventing those around them at work from knowing their post stroke deficits • Refusal to use assistive devices • Not seeking assistance from professional resources for fear of losing more independence Patients who experience fatigue after stroke are more likely to be unemployed or have lost or changed jobs compared with those with no fatigue after stroke Hidden Physical (Lerdal et al., 2009) Fatigue Limitations “I was taken to a baseball game as a special treat from my family. When we got there, I became completely overwhelmed by all the stimulation and jostling and the speed of the crowd. I had to go right home.” POST-TRAUMATIC STRESS DISORDER 10
9/7/2013 • Prospective study • Prospective study • Evaluated at 3 and 13 • Evaluated at 3 and 13 months months • Neuropsych battery: • Neuropsych battery: • Cognition • Cognition • Physical disability • Physical disability • Sleep • Sleep • Fatigue • Fatigue • Coping • Coping • Quality of life • Quality of life • Global mental status • Global mental status • PTSD • PTSD “Neither physical nor cognitive impairments, on average, seem severe enough to explain the Noble et al. Noble et al. QoL reduction” • Only 4.1% of patients had physical dependence • Only 4.1% of patients had physical dependence • 8% demonstrated impairment in attention • 8% demonstrated impairment in attention • 12% impaired cognitive function • 12% impaired cognitive function • With regard to QoL, patients scored significantly worse than the norms across all domains ( P < 0.006 ) Study Outcomes Study Outcomes 11
9/7/2013 • At 3 months • Moderate to severe PTSD in 37.1% (norm 8%) • Trauma • Functional impairment in 75% • Re-experiencing • At 13 months • Avoidance • Persistent incidence of 37.1% PTSD • Hyperarousal • Functional impairment in 82% • 59% pathological fatigue and 45% pathological sleep • Fear and guilt disorders Criteria for PTSD Study Outcomes Diagnosis • Transformative powers of suffering • Psychotherapy • Positive change • Cognitive Behavioral Therapy arising from struggle • Exposure Therapy • Change of perspective • Pharmacology • Appreciation • sertraline (Zoloft) • Transition from “why • paroxetine (Paxil) me?” to “what for?” Treatment of PTSD Post-traumatic Growth 12
9/7/2013 “ I’m always fatigued. Not sleepy, but just bone-tired. like to get into it. ” Sometimes it’s really hard to get out of my chair, so I don’t IN THEIR OWN WORDS “At work, to be on the phone when someone is talking or “I feel like an alien. I can’t to….be on the computer and move at warp speed like phone. That just was not everyone else does. Simple going to work! And I couldn’t things like grocery shopping be on the computer for more or walking down a busy street me. ” than a certain amount of time. are overwhelming” That was also very hard for 13
9/7/2013 “Some of the problems and “I can’t watch medical or quirks I had before are hospital shows on TV any magnified by the hemorrhage” more.” “As the caregiver, I have post- traumatic stress. When my wife sleeps at night, she has nightmares “I am still not able to travel that wake me up and scare me anywhere that is away from when she calls out. But it is even my hospital and my doctors.” worse when she sleeps soundly and quietly. I wake up and can’t hear her and startle wide awake to check and see if she is still alive.” 14
9/7/2013 “I was an investment banker. Now I have lost two jobs and “I feel bad for my husband. each time I look for a job I need He’s my caregiver. My to decrease my expectations aneurysm caused huge further. I am interviewing for a changes to our finances, our job tomorrow that I would never marriage, and our have considered taking before. relationship.” Now I just hope I get it.” “We need more information, more resources, lists of what to do for disability, unemployment and the DMV. “No one prepared us for how We need referrals to advanced to recover from this.” therapy like cognitive therapy or vocational therapy. We need social workers.” 15
9/7/2013 “A life coach would be “The hardest thing to great, but I can’t afford it, understand is how long the and I know that most could healing process is.” not.” “You have to do more “Tell people to get out of everyday so you can the house and not be so relearn things.” isolated” 16
9/7/2013 “Focus on coping and on “Find something that brings you joy.” what you have” “Life is just different.” “You can’t spend all your time complaining.” 17
9/7/2013 “You can go from depression “It’s a matter of reassessing and feeling bad to accepting yourself and finding your and giving back and being calling.” happy” “ Sometimes hardship is just hardship. It’s like that joke about the little boy who looks through a pile of s… hoping to “Support groups are a huge find the pony – and clearly the help. Everyone needs sharing pony isn’t there. To look for and support.” the gift when you are in the midst of suffering doesn’t really work…. 18
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