Stroke Care Management: Motivation and Engagement
Lack of motivation can impact negatively on the individual’s participation in rehabilitation and recovery phases post-stroke. Decreased participation and engagement during rehabilitation greatly influences the level of function gained, length of stay in the hospital, mood and discharge destination.
Motivation is the drive or reason that a patient has to participate in their rehabilitation. However, motivation levels can be negatively affected by apathy and depression, which are commonly seen in the stroke patient population. In the literature and in clinical practice, the terms “depression” and “apathy” are often used interchangeably. In psychiatric medicine, apathy is viewed as a symptom of depression. Neurologically there are distinct differences between these two phenomenon.
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Prevalence of depression post-stroke is ten to 15 percent. Apathy is estimated to be present in 29.5 to 40.2 percent of post-stroke patients, almost three times higher than the rate of depression. Apathy is described as “reduced motivation to engage in activities or general lack of initiative”.
Damage to or reduced perfusion of the prefrontal cortex and basal ganglia is thought to be associated with depression and apathy. Prefrontal cortex damage is more likely to be found in patients experiencing depression and basal ganglia damage more likely seen in patients with apathy. Apathy is more often seen to impact on functional recovery than depression.
Strategies and Interventions
There are some strategies and interventions that have been shown to help patients suffering from depression and apathy following a stroke.
- Therapeutic Connection
Clinicians can influence motivation through their manner, the level of support they offer to the patient and the level of their involvement as perceived by the patient. Developing rapport with the patient and being genuine in any interaction underpins therapeutic connectivity.
Motivation is enhanced when there are clear goals which are personally relevant and developed with mutual understanding, negotiation and interaction. Goals and therapy need to be personalised, functional and meaningful. Patients are less motivated if tasks are not meaningful to them. Describing goals using the patient’s language is as important as the development of the goal itself.
- Music Therapy
Collectively study findings provide evidence that music engages and facilitates a wide range of cognitive functions. There is indication that listening to music during neural recovery enhances focused attention and verbal memory. Results were better when music most relevant to the individual was utilised for at least 60 minutes per day.
- Cognitive Stimulation
Enhancing perception, attention, comprehension, learning, remembering, problem-solving and reasoning are the goals of cognitive stimulation. Providing opportunities for social interactions with others including family, friends and pets (and incorporating them in their rehabilitation plan) will stimulate cognitive processes.
- Person-Centred Care Planning
Acknowledging the patient as a unique individual who is an expert on themselves underpins person-centredness. Providing choices through the provision of information and education may enable them to become more engaged and confident in decision-making processes.
Ascertaining the most likely cause for lack of motivation and disengagement in rehabilitation and recovery post-stroke should determine the path of the treatment plan and the adoption of most effective interventions. Implementation of appropriate interventions decreases the risk of continued motivational impact on recovery post-stroke, optimises functional independence and improves the patient’s quality of life post-discharge.
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- Hama S, Yamashita H, Yamauaki S, Kurisuk K, 2011. Post-stroke depression and apathy:Interactions between functional recovery, lesion location and emotional response. Psychogeriatrics, 11, 68-76. doi:10.1111/j.1479-8301.2011.00358.x
- Harris A, Elder J, Schiff N, Victor J, Goldfine A, 2014. Post stroke apathy and hypersomnia lead to worse outcomes from acute rehabilitation. Trans/Stroke Res, April;5(2), 292-300 doi:10.1007/s12975-013-0293-y
- Caeiro L, Ferro JM, Costa J, 2013. Apathy Secondary to Stroke: A Systematic Review and Meta-Analysis. Cerebrvasc Dis, 35,23-39 doi: 1159/000346076
- Robinson R, Jorge R, Clarence-Smith K, Starkstein M, 2009. Boule-Blind Treatment of Apathy in Patients with Post Stroke Depression Using Nefiracetam. J.Neuropsychiatry Clin Neuro Sci, 21 (2) 144-151
- Ishizaki J, Mimura M 2011 Dysthymia and Apathy: Diagnosis and Treatment, Depression Research and Treatment, vol 2011 doi:10.1155/2011/893905
- Sarkaemo T, Tervamiemi M, 2008 Music Listening enhances cognitive recovery and mood after middle cerebral artery stroke, Brain 131, 866-876 doi:10.1093/brain/awn013
- Priyamuada R, Ranjan R, Chaudhury S 2015, Cognitive rehabilitation of attention and memory in depression, Ind Psychiatry J, Jan-Jun 24 (1) 48-53
- MacDonald GA, Kayes NM, Bright F (2013) Barriers and facilitators to engagement in rehabilitation for people with stroke: a review of the literature New Zealand Journal of Physiotherapy 41(3): 112-121.
Author Annette Horton
Annette Horton is a Registered Nurse with over 30 years extensive nursing, rehabilitation and management experience. Since 2004 Annette has held a Nurse Unit Manager position of a regional rehabilitation unit in Queensland. Annette is a member of the Australasian Rehabilitation Nurses Association (ARNA) and has presented several papers at ARNA national conferences. Annette has her own nursing blog entitled Nurseconvo, and more recently has become a contributing writer for Ausmed. Interests include stroke, rehabilitation, continence, leadership and management, coaching and case management. See Educator Profile