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Nursing Interventions for Poststroke Fatigue

2015; Lippincott Williams & Wilkins; Volume: 46; Issue: 10 Linguagem: Inglês

10.1161/strokeaha.115.009534

1524-4628

Smi Choi‐Kwon, Pamela H. Mitchell, Jong S. Kim,

Long-Term Effects of COVID-19

HomeStrokeVol. 46, No. 10Nursing Interventions for Poststroke Fatigue Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBNursing Interventions for Poststroke Fatigue Smi Choi-Kwon, PhD, RN, Pamela H. Mitchell, PhD, RN and Jong S. Kim, MD, PhD Smi Choi-KwonSmi Choi-Kwon From the College of Nursing, the Research Institute of Nursing Science, Seoul National University, Seoul, Korea (S.C.-K.); School of Nursing, University of Washington, Seattle (P.H.M.); and Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, Korea (J.S.K.). , Pamela H. MitchellPamela H. Mitchell From the College of Nursing, the Research Institute of Nursing Science, Seoul National University, Seoul, Korea (S.C.-K.); School of Nursing, University of Washington, Seattle (P.H.M.); and Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, Korea (J.S.K.). and Jong S. KimJong S. Kim From the College of Nursing, the Research Institute of Nursing Science, Seoul National University, Seoul, Korea (S.C.-K.); School of Nursing, University of Washington, Seattle (P.H.M.); and Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, Korea (J.S.K.). Originally published11 Aug 2015https://doi.org/10.1161/STROKEAHA.115.009534Stroke. 2015;46:e224–e227Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2015: Previous Version 1 Fatigue affects as many as 25% to 75% of stroke survivors.1,2 This poststroke fatigue (PSF) is often disabling and negatively influences on neurological recovery3 and patients' quality of life.4,5 There are numerous definitions of PSF, which includes subjective feelings of exhaustion and lack of physical or mental energy that interfere with everyday activity.6 PSF is associated with both biological and psychocognitive factors. The aim of this article is to provide an overview on PSF assessment, causative factors, treatment interventions, and nursing implications.Assessment of PSFMultiple instruments have been used to assess fatigue, none of which are specific to stroke. Commonly used assessment instruments that have been evaluated for patients with stroke are listed in Table 1.7–9 For nurses involved in stroke care, the PSF case definition developed by Lynch et al10 is likely the most useful. Nurses may ask 2 questions to stroke survivors in either the hospital or the community. Hospital patients meet the definition of PSF if since their stroke, the patient has experienced fatigue, a lack of energy, or an increased need to rest every day or nearly every day. In addition, stroke survivors living in the community meet the definition if over the past month, there has been at least a 2-week period when the patient has experienced fatigue, a lack of energy, or an increased need to rest every day or nearly every day. This fatigue has led to difficulty taking part in everyday activities.10Table 1. Poststroke Fatigue Assessment InstrumentsInstrumentCharacteristics and SourceFatigue Assessment ScaleShort, unidimensional instrument; focused on severity; good psychometric properties7Fatigue Impact ScaleShort, unidimensional instrument; focused on impact; good psychometric properties8FSSCommonly used scale in stroke patients; FSS-7 has better psychometric properties than FSS-108,9Vitality scale of the 36-item Short FormSubscale with good face validity7Multidimensional Fatigue Symptom Inventory general subscaleComprehensive instrument; good psychometric properties; best face validity7,8Fatigue domain from the Profile of Moods StatesSubscale that can be used alone; good psychometric properties7,8FSS indicates Fatigue Severity Scale.Causative Factors Related to PSFEvidence indicates that PSF is a multifaceted phenomenon associated with many causative mechanisms. Although older adults11,12 and females11,12 were found to report PSF more frequently than young or male stroke survivors, this was not confirmed by other studies.13–15 PSF has been reported to be less common in married (versus single) people and in those living at home (versus living in an institution),11 whereas another study reported no such relationship.12 Patients with PSF are more often unemployed and change their jobs than in those without,14 but the cause and effect relationship remains unclear.Biological FactorsNeurological or Physical DeficitsOverall neurological deficits,11,14 motor dysfunction,13 and speech disturbances (aphasia or severe dysarthria)11,14 are related to PSF. The impact may be at least partly attributed to associated depression, especially in the chronic stage.15,16Medical Comorbidities and MedicationsNurses should pay attention to PSF and identify treatable causes by checking for signs, such as hypotension, arrhythmia, edema, and relevant laboratory test results (eg, complete blood count, albumin, glucose, renal function, liver function, and tests for infection). Moreover, comorbid medical diseases, such as hypotension, diabetes mellitus, heart failure, and anemia, as well as the drugs used for these conditions, may cause fatigue.2 Poststroke eating difficulties related to dysphagia, poor attention, and appetite loss17 can induce malnutrition18 and may result in PSF.19 For nutritional deficiency, nurses should be aware of the fact that oral or parenteral high-dose thiamine may improve fatigue.20 Sleep disturbances in general21 or daytime sleepiness,22 which are common in patients with stroke, are reported to be related to PSF. Several studies have found an association between poststroke pain and PSF23,24 although this link was not confirmed by others.21Prestroke FatiguePrestroke fatigue is closely related to PSF9,11,14 although complete characterization of prestroke fatigue has not been made. Excessive fatigue has been recognized as a risk factor for stroke per se,25 and one study14 has reported that patients with prestroke fatigue more often had medical comorbidities than those without. Thus, prestroke fatigue may be related to conditions that increase stroke risk, such as diabetes mellitus, congestive heart failure, or subclinical strokes.Psychocognitive FactorsDepression is also closely related to PSF.9 Although this relationship may be connected to the inclusion of a fatigue item in depression scales, the relationship is still positive even when studies that used depression scales containing a fatigue item are excluded.26 However, PSF patients rarely express worthlessness, hopelessness, and suicidal ideation, suggesting that fatigue and depression are separate constructs. Anxiety26 and cognitive impairment16 may be the causes of PSF. Nurses should assess carefully the prescription of the patients' that can potentially produce fatigue and symptoms such as depression, anxiety, sleep disturbances, and pain. Nursing management should be based on this assessment.Other FactorsDamage to the basal ganglia,27 brain stem, and thalamic reticular formation6 have been associated with PSF, possibly by way of altering dopaminergic or adrenergic neurotransmitters. However, most studies failed to find an association between PSF and brain lesion location.13,14 These controversial results may result either from an insufficient number of patients with a lesion involving a particular brain area27 or from multidimensional causes of PSF. It has also been suggested that chronic inflammation and immunologic changes may be related to PSF.28Pharmacological and Nonpharmacological InterventionsIn both the acute and the chronic care settings, numerous multifaceted nursing interventions assist patients to cope and manage PSF. The most prevalent and evidence-based pharmacological and nonpharmacological interventions are listed in Table 2.Table 2. Interventions for Poststroke FatigueAuthor/yrMethodology/DesignInterventionEffectsPharmacological Ogden/1998Randomized controlled trial (n=18)100 mL of 1.5 mg/mL tirilazad mesylate or placebo for 10 dEffective29 Choi-Kwon/2007Double-blind, placebo-controlled trial (n=83)Fluoxetine 20 mg or placebo daily for 3 moIneffective32 Brioschi/2009An open study with an ABA design and no placebo (n=40)Modafinil; initial dose of 50 mg/d, increased up to 200 mg at 2 moEffective30 Johansson/2012A double-blind, randomized, crossover design (n=12)(−)-OSU6162; from 15 to 45 mg BIDImproved mental stamina31 Karaiskos/2012An open-label, controlled clinical trial (n=60)Duloxetine group (60–120 mg/d), citalopram control group (20–40 mg/d), sertraline control group (50–200 mg/d)All ineffective33 Costantini/2014Case study (n=3)Thiamine 600 mg/d orally (n=2) or 100 mg/wk parenterally (n=1)All effective20Nonpharmacological Lorig/2001Longitudinal design as follow-up to a randomized controlled trial (n=1140)Chronic disease self-management programIneffective34 Clarke/2012Randomized controlled trial (n=16)Fatigue Management Group vs General Stroke Education control groupBoth groups effective35 Kim/2012Nonsynchronized, nonequivalent control group (n=45)Enjoyable intervention that appeared more like a game or a playEffective in the experimental group36 Zedlitz/2012Randomized, controlled trial (n=68)A 12-wk cognitive therapy program and graded activity trainingEffective37 Hofer/2014Preliminary study (n=8)A mindfulness-enhanced, integrative neuropsychotherapy programEffective38ABA design is measurement A followed by B, and A.Among the pharmacological interventions, tirilazad mesylate, a neuroprotective agent, was reported to be effective in treating fatigue in a randomized trial containing female subarachnoid hemorrhage patients.29 In addition, modafinil, a drug for hypersomnia, was effective in patients with brain stem-diencephalic strokes but not in those with cortical strokes.30 The monoaminergic stabilizer (–)-OSU6162 was reported to relieve PSF in patients with mental fatigue in a nonrandomized study,31 whereas selective serotonin reuptake inhibitors, such as fluoxetine,32 duloxetine, citalopram, and sertraline, were not effective.33For nonpharmacological interventions, general stroke education, including a fatigue management program, may be beneficial.34,35 An enjoyable movement intervention that was similar to a game was effective in alleviating fatigue in a small study with a nonsynchronized, nonequivalent control group pre and post test design.36 A combination of cognitive-behavioral therapy and graded activity training37 and cognitive-behavioral therapy with mindfulness techniques seem to be effective in alleviating PSF.38 Regular exercise and increasing daily step count in the early stage of stroke were reported to decrease fatigue at 6 and 12 months,39 and walking and water aerobics were perceived by patients as helpful in relieving PSF.40 Therefore, nurses should recommend physical exercise for patients with PSF that always take into consideration individualized needs pertaining to their condition, age, and resources.TAKE-HOME POINTSPoststroke fatigue is a common, debilitating, yet far neglected symptom with multifactorial causes. The neuroscience and rehabilitation nurses should consistently identify and address the multiple factors associated with the development and management of poststroke fatigue. The establishment of a fatigue education program in routine nursing care during hospitalization for patients with stroke and caregivers should be considered.DisclosuresDr Choi-Kwon was supported by the National Research Foundation of Korea (810-20140026). Dr Mitchell has had support from an National Institutes of Health grant, R01 NR 007755. Dr Kim reports no conflicts.FootnotesCorrespondence to Smi Choi-Kwon, RN, PhD, College of Nursing, the Research Institute of Nursing Science, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul, 110–799, South Korea. E-mail [email protected]References1. Wu S, Mead G, Macleod M, Chalder T. Model of understanding fatigue after stroke.Stroke. 2015; 46:893–898. doi: 10.1161/STROKEAHA.114.006647.LinkGoogle Scholar2. Choi-Kwon S, Kim JS. 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October 2015Vol 46, Issue 10 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.115.009534PMID: 26265127 Manuscript receivedJune 1, 2015Manuscript acceptedJune 25, 2015Originally publishedAugust 11, 2015Manuscript revisedJune 25, 2015 KeywordsstrokefatiguedepressionassessmentinterventionnursingPDF download Advertisement SubjectsBehavioral/Psychosocial Treatment