Hi. I'm delighted to be here to talk about problems with thinking and behavior following stroke. My aims today will be to give a bit of an overview on cognition and behavior and stroke, to think about some of the common cognitive and behavioral consequences of stroke and to illustrate the approach of the neuropsychological rehabilitation group in dealing with people who have had strokes that are referred to US. Stroke is a very serious problem, obviously, and cognitive consequences are very common post stroke. So we see them in 50 to 70% of stroke survivors in early days. Within the first couple of weeks, 92% of all stroke patients fail in at least one cognitive domain, and therefore, it's critical that we identify cognitive deficits early days and consider them to be an important target for rehab. We need to do cognitive screening for stroke patients in order to plan our best rehabilitation approaches to plan our discharge destination to provide psycho education, tow our patients and their relatives about some of the problems they may face. Going forward, we need to predict cognitive and functional outcome, and we really need to follow our stroke guidelines that recommend cognitive screening early days after stroke. Probably the most widely used measure for cognitive screening in people with stroke is the mini mental status examination. However, it's really not sensitive enough to detect cognitive difficulties in our stroke patients, and therefore the Mocha is the preferred instrument for cognitive screening after stroke at this point, and I want to introduce you to Jane. Um Jane was referred to me by her neurosurgeon in June of 2019, and it was a very vague and clear call for help. Help this family. I saw Jane for assessment in June and July of 2019 and then worked with her weekly in rehab up through early 2020. I still see her for follow ups. Cognitive domains most commonly affected by stroke include the the usual suspects language, particularly for people with the dominant hemisphere lesion, visual, spatial and visual perceptual problems for people with non dominant lesions, and then the other domains of cognition that are seeing in most kinds of brain injury, including information processing, speed problems, problems with attention and working memory, memory challenges, executive function difficulties, as well as a proxy A and ignore Jha now I want to make a point that these domains are often considered as separate and individual problems, and we can look at each one individually, making assessment in a plan for each one. But the reality is that they are not separate, and they interact in complex ways and affect each other. And so we have to take into account this entire complexity we add in behavioral problems such as irritability, aggression, agitation, uh, eating problems, apathy, alterations and the ability to regulate emotional experience and the picture girls even more complicated. In addition, we have to consider interacting factors, so the most common physical factors for people following stroke would be paying fatigue and deeply GIA sensory changes. We also have to consider theme the usual anxiety and depression, which people experience with any kind of traumatic illness or injury. And we also have to take a look at trans diagnostic fetters. These could include the kinds of things that don't fit into a diagnostic category and psychiatric terms, but are common experiences for people who undergo trauma, including loss of self confidence and drop him self esteem. Rumination about the problems are is very common preoccupation with health status can be crippling for some people. People often also talked about developing a new sense of their mortality after experiencing a life threatening injury. They talk about new values in their life. So what is important might change might change from being very ambitious at work to a focus on family. And finally, there are also changes in sense of self or identity that are extremely important to consider in working with our stroke patients. So back to Jane Jane came to me. She had a history of a severe right hemisphere. Sarah Beller stroke in 2011 when she was only 36 years old from a Navy M rupture. Jane had severe cerebral ataxia, right more than left. Severe dis are three. Uh, and her son was born by Caesarian section at seven months during her neurosurgery. She was pregnant when she had the the A V M rupture. He, as a consequence, has severe cerebral policy, So I saw both Jane and her husband, Mike, together. Mike reported a phenomenal history of wild mood swings, aggression, screaming, crying, throwing plates, having huge panic attacks. He said Jane was really unpredictable. She did a lot of dangerous things like driving her wheelchair into traffic. She had outburst that were dangerous and frightening for their Children. She slept with a knife under her pillow and for example, one time there were insects on the kitchen counter and she sprayed raid all over the counter, even though the Children were nearby and might have have ingested it, Mike said, We're at a breaking point. I'm ready to put her in a home somewhere and move on with my life. Now what Jane say to this? Jane said. The problems aren't so bad. I actually feel sharper in my thinking abilities. Now. Maybe I cry a little more easily than before. No, not really angry, but I am lonely and I don't have anybody to talk Thio. So I thought I didn't realize all these problems would be happening after a cerebellum stroke. I had better read up a little bit and learn a bit more about this. So I investigated and identified the Cerebellum Cognitive Affective syndrome, which was identified by shaman and colleagues in the late 19 nineties. They identified four symptom clusters that air common of this syndrome language impairments, impaired visual processing abilities, problems with executive functions and personality changes with blunting of affect or abnormal behavior. And they attributed the ideology to functional disruption off the reciprocal pathways that connect cerebellum with the limbic circuitry and the pre frontal, temporal and parietal association core disease. So my apologies that this is very difficult to see. Um, this is a scale that Shaman and his group developed in order to assess the see cast the cognitive Serbia Effective syndrome. And it has items related to language to visual perception and visual spatial ability to executive abilities and to behavioral kinds of things. So if you're interested in having a look at it, there's ah reference there, or you can contact me, and I'd be happy to send it around. It's It's I found it very useful. Um, so I'd like to talk a little bit about the specifics from common problems. Post stroke. The first is language disorder or aphasia, three main categories of Feige, or non fluent aphasia, in which the speech is characterized by, um, telegram attic sentences where the small words are omitted so the person might say, want food or go now. Very simple comprehension is usually relatively preserved, and this is typical of a more interior lesion. Expressive aphasia is characterized by severe difficulty and comprehension and production of fluent but non sensible speech containing para phases, words that don't actually have meaning and so on. And the person is often very unaware that they are not being understood by others. Global. If Asia represents a more extensive lesion and includes elements of both of these kinds of aphasia a little bit about spatial neglect also part of thesis e cat scale and common in people with strokes. So spatial neglect involves impaired awareness of stimuli on one side of the body, even though there's no sensory loss to that side. So people experience things like missing things that are on the affected side of their body. Um, they might ignore. People bump into doors without realizing there, there, um, they might not dress on one side or shave their face on one side or comb their hair. Um, might not eat food on one side of the plate, not read one side of the page and so on. And these drawings illustrate someone with neglect left neglect. Who is admitting all the details on the left side of the space visual perception involves our use of visual information to determine the size, shape and position of objects that we see. It allows the brain to work out how far away things are and where they are in relation to other things. So examples would include judging depths or distances. So you might have trouble recognizing that a cup is almost full and you might overfill it. Or you might have trouble going down a step knowing how far down it ISS, it's hard to tell differences between foreground and background. For example, seeing a white plate on a white table might be difficulty, and it could be hard to do common everyday things like anticipate putting food on a fork and then getting it into your mouth. So back to the scale that I mentioned earlier, you'll notice here that there's a cube. So I asked Jane to copy that Cube, and she was really very unable to do that. Obviously, she's failed this item, so the scale has language items. It has visual spatial visual perceptual items, and it also addresses executive functioning executive functions. And this is one of my favorite definitions. Are those cognitive abilities that enable us to determine goals, formulate new and useful ways of achieving them, and then follow and adapt this proposed course of action in the face of competing demands and changing circumstances, Often over long periods of time, I'm going to say a little bit more about how we address executive functions and our team. So executive functions are such a complex category and there are many different models for understanding them. And I have identified this one by Don Studies, which is based on his examination of four cognitive domains that are linked to discrete neuro anatomical pathways and represent the four key elements of executive functioning energy ization, which involves initiating and getting going with things. Executive cognition, which involves the planning, organizing, sequencing and so on. The third is really the affective domain. It's the emotional and behavioral self regulation domain that involves the ability to regulate and monitor and manage our emotional experience and expression. And the last has to do with medic cognition or being aware and cognizant of the changes that we've experienced. And it also involves our links to other people theory of mind, um, mental izing empathy, things like that. So bringing it into clinical level. We divide these into four domains, called doing, thinking, feeling and acting and aware awareness and socializing. And part of no psych rehab is helping people increase their awareness and sense of self. So I asked people to go through this, um, this chart and think about examples and identify their own strengths and challenges with executive functions. I did this with Jane, and she became more and more able to reflect and think about her own executive difficulties. And the items in red are the things that she identified and I agree with are her biggest challenges. So she really has trouble. She's a concrete thinker. She doesn't think outside the box. She has trouble monitoring what she does and making sense of it and reflecting in a thoughtful way on herself. Her biggest challenges in that feeling and acting box. So being able to regulate her emotions and being in control off her feelings and actions, she also began to recognize that her awareness of her own thoughts and feelings was limited and that she didn't really know herself with her injury very well. So here I'm just gonna put a big plug for patient education. I think that it's essential for people to learn to understand why they're having the cognitive and emotional behavioral changes that they are in order for them to be able to tolerate them, reduce the sense of threat they feel as a result, and move on to manage them better. So we do this through formulation, which is basically a way to integrate the consequences of the stroke into the person who presents to us. So their background, their identity and values their views, they're coping styles. And so on the middle row are the changes that people experience on their thinking, mood and physical well being and then thes all impact on ah persons functional abilities. So can they work, take care of themselves, engage in social and recreational activities, drive and so on. From this, we get a shared understanding off the overall complexity and picture off the post stroke life of this patient, and we develop our preliminary goals. Now here is Jane's formulation. Up at the top left, you'll see her family and social. So her husband, um, little Billy, who is now eight, and they also had a second child, Amelia, who's now for her other family members and friends air in here. I will note that Mike, her husband, said that her social social circle is much more restricted than what she presents. Here on the top, right, you'll see Jane sense of who she is as a person. She's family oriented. Her personal qualities air all about being determined, driven, ambitious, independent, confident, passionate, etcetera. She sees herself is a very sociable person, and her friends agree with this vivacious, friendly, funny, sociable, personable. And she reports her interest to be reading education, politics, um, spending time with her Children and working out, even though obviously she's really compromised in many of these areas. These are very important aspect of her sense of self. The middle role on the left physical, her attacks, it just quite severe desire. Sharia also results in speech. That's very difficult to understand. I may be understood maybe 70 to 80% after I've been working with her for a while. No other physical kinds of complaints. Mood wise, she's beginning toe, acknowledge more problems. Sad, angry, yes, loads of anxiety, lonely and struggling to rely on other people so much in the cognitive box. I think you'll be surprised to see she has very good intelligence. Overall, she doesn't personally report cognitive difficulties, although obviously are just brief screening showed language, visual spatial problems and executive function difficulties. And then there's a box called emotion Regulation difficulties that goes between the mood and the cognitive boxes because it's rooted in executive functions but manifested as mood problems. The bottom left boxes communication already mentioned. She's very distorted threat, but she's not really very keen to use a communication device. So that was our one area where we didn't get very far. Functionally, living with a family needs complete help with personal care and household tasks. She, amazingly enough, completed her MBA degree last year, using her iPhone and her left non dominant hand entirely to do the whole course. Online says something about her personal qualities. She's not working or driving and has not a lot of outside activities. Her goals, um, improve communication, manage anger, outbursts is now being acknowledged. Anxiety and low mood being acknowledged, being more independent, doing more, improving her health and so on. So are interventions. We always start with a goal focused approach that means that we have to attend to Jane's goals and her family's, and not to whatever ours might be. I have to admit that I was hoping that she'd work on her communication a bit, but that wasn't a goal for her. The interventions included calming strategies for the emotion, this regulation problems as well. A psycho education, meta cognitive strategies for executive function problems, those air cognitive. But we also did a lot of adjustment work, using identity and working on her sense of who she was as a person. I met with her weekly over three months. We did a lot of email check ins and monthly reviews. Through the first year, we developed a tool kit for Jane. Her goals were up at the top there, and each of the goals has an arrow pointing to a a tool kit. She uses this as a visual representation. She can keep it in front of her, and it reminds her off her her goals and her tools. So the anger, anxiety and low mood were all addressed through strategies involving mindfulness teaching. Through APS on her phone, she developed the idea of using imagining her visualizing the faces of her two Children and this really helped her when she would get angry, particularly angry at her husband, she would see her kids, and that would really help her grasps. Um, control, Um, I referred her to a neuro psychiatrist, and her meds were adjusted on. We believe that's been helpful as well, and she used some visual imagery but techniques as well. So these are techniques for emotion adjustment, and for her, the important thing here is this body of the box below that these have helped to keep her stress down, control her anger, stay more relaxed but critically, she says. I'm less anxious when I'm in control, and this reflects her sense of a strong, independent woman. And as we regained some of her sense of identity, thes experiences returned to her and on the right. We have other sorts of strategies that we use. She wanted to be more independent, and so she felt that using ah ah Walker, rather than just being pushed by the people, would increase her independence and using a travel wheelchair, which gave her a little bit more independence is well, so those things were tweaks into what she already had, But they spoke to her sense of identity. She was lonely, so she identified some chat rooms for stroke survivors. Uh, this was perfect because her language was impaired and she lived in a rural area, so she didn't really have access to many in person groups. But these groups were very useful as her behavior calm down and improved. Her family, especially her husband, were more willing to spend good time with her and to include her in family activities. And this had a very beneficial effect. And finally she decided to write a book, and she recently completed ah, book about her experience of having this stroke. We always have to look at our outcomes. So I used an anger and anxiety diary for her, and after a few months that improved. A great deal is we'll see, and we also looked at the goals that she specifically have has and referred back to those. So after three months, her anger and anxiety episodes reduced to zero. Her husband abandoned his plan to separate from her, instead asking her to plan a family holiday, and the other goals were also achieved except for the communication and have been maintained for several months. now I will add a caveat that her husband says that this is not a problem free situation. She continues to minimize obsessive behaviors and some other kinds of things that are giving him challenges. So it's It's not perfect, but it's greatly improved from the initial assessment that we have. So Jane reflects a variety of typical stroke problems, including aspects of language, visual perception, lots of visual sorry, executive function problems as well as probable other cognitive problems. But the main point here is we have to understand this in the complexity off her physical and speech problems, her sense of identity and her values and goals. And so these were the things we chose to focus on, even if they might not have been, to somebody else's view, the most serious problems. So I hope that I've conveyed that cognitive and behavioral changes post stroke are not just a list off discreet problems. They need to be seen as interrelated and complex and in the context of the person's sense of self and family and thank you very much. There are a number of approaches to therapy. One type remediation is focused on restoration of the skill retention therapy focuses on enhancing skills to prevent decline. Promotion uses self management strategies to promote health and wellness. The goal of prevention is to avoid injury and disability. Our focus and cognitive rehab is primarily compensatory. Using the compensatory model, we focus on teaching patients, techniques, strategies and the use of external AIDS to compensate for cognitive and visual deficits. Our patients tend to have deficits in the following areas. Executive function, attention, memory fatigue, visual spatial function and communication. There is not unusual for our patients to have problems in many of these areas. I'm going to share with you a few of the strategies we use to help our patients. Memory is a complex process involving three stages, encoding storage and retrieval. It can be compared to a filing system where information is taken in processed, filed away and easily retrieved. Our patients often have trouble in one of these areas. Our patients may have problems in a variety of memory areas such as procedural memory, episodic memory, semantic memory and working memory. They may complain, forgetting appointments, not remembering names, getting procedures, forgetting to return phone calls, inability to do math calculations in their head, getting lost when driving, not remembering directions from the boss, not remembering discussions and not remembering what they did yesterday. Internal strategies involved teaching the brain to retain information using different mental strategies. Some of the internal strategies include associations, visual imagery and use of the mental blackboard. An example of an association would be associating a new activity within existing routine, such as taking medications at meal times. Visual imagery is simply creating a mental picture of something to help support memory. The mental blackboard is a visualization strategy where patients imagine carrying a blackboard around inside their head. The patient visualizes writing or drawing things to remember on the blackboard and checks it throughout the day. External memory systems are very effective and could be paper Elektronik or a combination of both. Examples of a paper model would be a calendar planner or checklist. Smartphones and computers allow use of multiple memory aids, such as auditory alerts for appointments, medication APS to remind individuals to take or renew medication and reminders that can be activated by location, such as reminding an individual to call home when they exit their place of work. Smart speakers such as Alexa Google Home and echo Dot are also good external memory aids and could be used for such things as recalling the day or time as cooking reminders and medication reminders. Some examples of instructional methods for memory include airless learning, space retrieval and over learning and errorless learning. The opportunity for mistake's is minimized. Heirless learning is utilized for many reasons. For example, it improves learning for individuals with memory deficits. Some individuals with cognitive deficits are unable to learn by trial and error, and learning without errors is more enjoyable. Mistakes can get stuck in the memory so the individual learns the mist ake. Therefore, mistake's should be avoided. Based retrieval is a method where the information and individual is learning is repeated over increasing time in a row. For example, repeating information immediately after a one minute delay after a two minute delay after five minutes and after 30 minutes over learning refers to practicing a new skill beyond the point of mastery. The theory is that the repeated practice at a task makes it become virtually automatic. Executive function is the complex process that allows us to set goals, manage ourselves and get things done, Donald's dust categorized executive function skills into four domain energy ization, executive cognition, emotional and behavioral self regulation and meta cognition. Energy ization is the doing domain. This domain describes the ability to get started with a task, stay engaged, display alertness and attention, keep up momentum and have energy. Our patients report being tired all the time. Being unable to get started on important task. Filling board Having low energy family members report that their loved one is slow to react and often sees a patient as not caring or lazy. Executive cognition. As known as the thinking domain, this domain includes skills like planning, problem solving, the ability to self monitor thoughts and actions, and flexible and abstract thinking. Our patients are often very concrete thinkers. They may be unable to understand subtlety or abstract concepts. They often jump into action without planning. The act of planning and placing a simple phone call could be difficulty. These patients often get lost if interrupted in the middle of a task and have difficulty restarting the task. Family members are often frustrated with patients of an ability to make decisions and their indifference to advice. The emotional and behavioral self regulation domain is responsible for feelings and actions. It includes the ability to control emotions and thoughts, the ability to think before speaking or acting, controlling emotional responses and having emotions that are typical to a situation. Deficits in this area may cause a patient's emotions to come up quickly and be more difficult to manage. They may be stronger than what is appropriate for the situation. A patient may cry for no reason or laugh at inappropriate times. Patients may have trouble controlling thoughts and actions. Families may complain of their loved ones being emotional, mean or impulsive. Meta cognition is the awareness and socializing domain. This domain impacts a person's ability to understand how they impact others, allows a person to be sympathetic and to read the emotions of others. It allows an individual toe look at things from another person's point of view. Individuals with deficits in this area may not understand the effect of their brain injury on themselves or others. They may not understand the point of view of their family members and have a harder time getting along with others. They may report the loss of friends and families. Family members have described patients with deficits in this area as being a completely different person than they were before. There are a number of executive function tools and strategies. I'm going to give you a short introduction to some of the techniques we use. Gold Management Framework, or G. M F, is used in many settings, including business and management. It is based on the work of lovin Adele and works well with the brain injured population, helping them with decisions and problem solving. The version we use has six steps. The first is identifying the main goal. It is important to be a specific as possible. Step two is to identify possible solutions or actions enlisting them, identifying and weighing the pros and cons for each possible step occurs and step three. Once pros and cons are identified and considered a solution or action should be chosen. This occurs and step four. So five is the action of implementing the solution. Selected Step six consists of a review process and should include reflection on what was learned, what could have been done differently and what was done well to stop think technique is used for planning and decision making as well as reducing impulsivity. This technique of stop, think, then act allows the patient to consider their plan before acting. It also works well in the midst of a task when a patient is feeling confused or overwhelmed. Many patients with brain injuries have trouble with concentration at school or work. There are a number of simple strategies that can be used to help toe limit auditory distractions. Noise canceling headphones, white noise and quiet offices can help. Visual distractions could be limited with the use of a cubicle by clearing the office space of clutter and moving the individual away from distractions such as an entryway, high traffic area or break room. Short breaks can also help to improve attention and focus use of a time management app such as Pomodoro or work Break reminder to individuals toe alternate work with short rest breaks. Another attention deficit, we commonly see, is unilateral inattention. These patients may not be aware of a respond to stimuli presented on the affected side and often do not have good insight or awareness into this deficit. This makes it difficult for the patient to remember to use compensatory technique. Anchoring provides a visual target. The patient is trained to return their eyes to the target when scanning to the affected side. Examples include placing bright post it notes along the side of a computer screen, a bright line drawn along the edge of a piece of paper or a page in a book, or using a bright placemat when eating a guide is a strategy where the individual uses a finger or an object, such as a piece of paper, to direct the eyes toward the site of inattention. The lighthouse strategy teachings the patient to scan in a fashion similar to that of a lighthouse lamp of strategies or unsuccessful that may be necessary to modify a patient's environment. Examples of this would be moving phones, computers, etcetera away from the side with unilateral inattention and moving it more toward the side of visual awareness. Fatigue is a common problem. There are a number of strategies to assist with managing fatigue. Energy conservation techniques often refer to the three piece prioritizing, planning and pacing. Using this technique, individuals decide what needs to be done and what can wait. They plan activities in task tow, avoid extra trips and extra work. They rest often and before feeling tired, sleep hygiene techniques are also an effective way of decreasing fatigue. Thes techniques involve a number of strategies, including keeping a regular sleep schedule having a bedtime routine, making the environment appropriate for sleep by making the bedroom dark, cool and quiet, and shutting off Elektronik devices like the phone or computer 30 to 60 minutes before bed. Examples of managing the environment would include creating a place for everything and keeping everything in its place to make things easier to find. Reducing clutter, using good lighting and turning off the TV when concentrating recharging is simply participating in a task that recharges energy levels, such as listening to music, taking a power nap, going for a walk or using mindfulness techniques. Strategies such as the gold management framework can also be used to decrease mental effort. I would like to thank you for allowing me to share. Some of the strategies are team uses with you. I have only scratched the surface of each area and invite you to contact me with any questions you may have. Hello and thank you for attending this presentation. My name is Tryst Weber. I'm a psychiatric nurse practitioner. I work in adult psychiatry and with the Emergency Psychiatric Assessment Team. The topic of this presentation is the management of post stroke depression. So the objectives for this presentation are to define and understand post stroke depression. Identify current tools for screening and diagnosis. A swell is to summarize the current treatment options for post stroke depression. I have no actual or potential conflicts of interest in relation to this presentation. So to start with basics, what is depression? So based on the D. S M five depression is a period of at least two weeks, during which a person will experience the following symptoms. Depressed mood, markedly diminished interest, insomnia or hyper. Somini A. Which is sleeping too much fatigue, feeling of worthlessness. Excessive or inappropriate guilt. And these need to occur most of the day nearly every day. The symptoms need to cause significant distress or impairment and social, occupational or other important areas of functioning, and they should not be attributable to the effects of a substance or another medical condition. What are some risk factors for depression? Temperamental. That's things like neuroticism or negative affect. This can increase the likelihood of depressive episodes in response to stressful life events. There's environmental factors like adverse childhood experiences, genetic and physiological factors such as heredity, her heritability, um, and course modifiers is gonna be virtually any core Mobic Condition can increase the risk of developing depression. Chronic and disabling conditions are often complicated by depressive episodes. Some basic facts about depression. It affects about one in 15 adults in any given year. One in six people will experience depression at some point. Generally, that first episode will occur during the late teens to mid twenties. Women are more likely than men to experience depression. And there's evidence that one third of women will experience a major depressive episode in their lifetimes. Depression is one of the most growing causes of global disability and is a major contributor to the global burden of disease. So what is post stroke depression? So and per the D. S M post stroke depression is a mood disorder superimposed upon another medical condition. So you would write that out as stroke with depressive, manic or mixed symptoms. Depression is more common in the setting of stroke than other illnesses that cause a similar level of disability. It occurs in one third of stroke survivors, and it's considered the most frequent and burdensome neuropsychiatric. Post stroke complication. The criteria for post stroke depression are the same as for major depression. Um, but the diagnosis is often complicated by the somatic symptoms and cognitive deficits of a post stroke patient. Cem Path of Physiology Ah, it's not still entirely understood. Ah, in the first few weeks after a stroke, grief reaction by a patient due to the loss of function can muddle the distinction between a normal grieving process or grief response and post stroke depression. So there's four main hypotheses on the development of post stroke depression. There's the vascular depression hypothesis, which states that it develops as a result of silence cerebral infarction. And this is something that is occurring at high rates in late onset depression. There's the immune dysfunction hypothesis that refers to association between stroke and various pro inflammatory side of kinds. Um, in areas responsible for mood regulation. There's the neurotransmitter hypothesis, which states that their projections in Toronto projections sending from the mid brain and the brain stem that are interrupted by lesions, and that this also decreases the availability of the mano a means that regulate our moods. Such a serotonin, dopamine and norepinephrine. Then there is the neuro Genesis hypothesis in. This refers to the role of new neurons in the hippocampus and mood regulation, and it also is related to the pharmaceutical effective antidepressants, Um, and the brain derived neurotrophic factor. BDNF is, um, in area of interest in this theory, so another or overview of some of the path of physiological mechanisms glutamate, toxicity, um, increased inflammation in the HP axis. Lower levels of Mono Amin's, an abnormal neurotrophic response this year have just provided a list of some studies that have associate ID the location of the stroke, um, in relation to the severity of the depressive symptoms. So this study here, from 1998 shows that depression was significantly associated with larger lesions involving the right cerebral hemisphere. There's another notable study here from 2014 with she at all, uh, that frontal lobe lesions or significantly associated with persistent recurrent post stroke depression. And that was done with 10,067 patients in that study. So screening for post stroke depression, the majority of stroke patients are not screened, and there's no optimal tool to measure depression. This population, specifically meta analyses, have found that screening tools such as the Hamilton Depression rating scale, the C E S d and the P H Q nine, which many people are probably familiar with, have shown the have the best results. However, there are also shorter tools like the P H Q two and the lesser known, at least to me. Wooley questions um, which are faster and easier to administer and seem to have comparable sensitivity and specificity. However, at this point there is insufficient evidence to support replacing the longer questionnaires outright. So when to screen the best time to screen is not yet well established. Um, screening immediately after a stroke, UM may present with difficulties due to the other symptoms that the patient might have, such as adjustment reactions, disturbances and fatigue or sleep and confusion. So it may be better to screen during inpatient rehab or, at some point during out patient follow up when the patient presentation is mawr consistent and the symptoms arm or well established screening should also b'more than just completing these questionnaires. There should be some sort of plan in place to follow up on a positive screen. And so after the positive screen, um, it's important to distinguish post stroke depression from post stroke apathy, which can occur in 40% of stroke survivors. Um, post stroke apathy is characterized by reduced motivation, goal directed, behavior impaired emotional range and cognition. Severe cases can exhibit Jebaliya, which is the absence of will power or the ability to act decisively little to no spontaneous speech or movement. Post stroke apathy has a different path of physiology from post stroke depression, so it might not respond to the same treatments which, in post stroke depression. One of those includes antidepressants. Um, it's better treated with psychotherapy and stroke rehab. So after the positive screen continued, when you consider the overlap between post stroke depression and post stroke symptoms, loss of appetite, fatigue, concentration impairment, sleep disturbances So it may be more helpful to focus on the non somatic symptoms. Um, going back to the criteria for major depression, hopelessness, helplessness, worthlessness, negative self talk, um, guilt. Um, additional instruments that can help in this diagnosis are the stroke of phase IQ, depression questionnaire and the aphasic depression rating scale. Other differential diagnoses There's post stroke suitable or affect, which is brief periods of emotional liability and Buddhist regulation and this is primarily treated with pharmacological interventions. But these are not necessarily limited to antidepressants. Um, we want to rule out that this is theon set of delirium or dementia mimicking depression, um, or that this is simply a catastrophic reaction to a major life event. Um, and that will be manifested severe frustration, sadness, anger or aggression. Um, this can use will often occur in the context of expressive aphasia, or when a person is asked to perform a function which previously they were able to do. But now they cannot. And then there's also adjustment disorder, which is defined as a pathological and abnormally intense reaction to his stressor, causing significant distress and impairment but generally less less acute than major depression. This is best treated with psychotherapy. Um, in the benefit of antidepressant use here is less established. So for the treatment of post stroke depression, um, it is generally treatable but also widely undertreated. Um, many people do not seek treatment because of the stigma surrounding depression and mental health in general, and for those that do, they encounter many barriers like cost, lack of access to services, lack of perceived efficacy of their treatments, This is something that you will commonly experience when treating people with depression. In general, the best outcomes are obtained by a combination of pharmacological, psychosocial and stroke focus treatments. Some pharmacological interventions. Uh, meta analyses suggest that antidepressants or more effective than placebo in reducing the symptoms of post stroke depression. There's no clear evidence that any particular antidepressant is the most effective. But SS arise are generally well tolerated due to their side effect profile. However, there are some important considerations. Um, with SS arise and those are that they can increase the risk of bleeding. Um, and interestingly, they can also increase the risk of ischemic stroke by causing a constriction of cerebral vasculature. Um, there have been some studies that show that there is evidence of C v a related to the use of SS arise. But overall that this risk is low. Um, as histories, of course, also have varying levels of interaction with the C I. P for 50 enzymes as inhibitors, and so that can influence the effect of other medications. And so that has to be, um, taken into consideration as well. Psychosocial interventions. Um, these include psychotherapy, cognitive rehab as well as complementary and alternative therapies. So some examples for psychotherapy There's cognitive behavioral therapy, which is commonly used. Um, motivational Interviewing Life review therapy. Um, recent meta analysis found that CBT alone or in combination with into antidepressants a significant improvement in depressive symptoms for people with post stroke depression for cognitive rehab that is basically defined as medical and therapeutic services used to rehabilitate thinking skills and paired by a brain injury. And that's sort of a multidisciplinary approach. Complementary and alternative therapies that includes things such as acupuncture, music and art therapy, exercise therapy, stroke focused interventions, thes air interventions that don't specifically target depressive symptoms. Um, but they're looking at the ideological investigation of the stroke, promoting independence and quality of life and the prevention of new strokes. And through 33 have lifestyle modification and medication. Euro modulation. This includes E, C T. And repetitive transcranial magnetic stimulation so easy it has been used for refractory cases of PSD. Um, it's safe, but it does require comprehensive evaluation before starting treatment. Um, specifically to rule out cardiac disease. Um, there are limited studies done specifically with people in the post stroke population, uh, tms, um as an area of growing interest because it's able to specifically target um, areas of the brain. However, um, there still needs further studies done for the overall efficacy of certain protocols that could be used as well as the long term effects. This year is just an overview of those treatment modalities, which we just reviewed. Um, I think this table gives a really good overview and the summary of the strengths and limitations of each. So spend a few seconds on this. Is the prevention of post stroke depression possible? Um, there's limited limited evidence at this point. That's prophylactic treatment with antidepressants, UH, can reduce the risk of developing poster of depression. Um, however, longer courses of treatment may be more effective. Um, a cocker interview was done in 2000, and eight did not find that antidepressants were effective in preventing post stroke depression. Um, there's also limited studies done on preventative psychosocial interventions. So one of the major limitations of these studies air high dropout rates and a narrow enrollment criteria, so more research needs to be done in this area. So, in summary, post stroke depression is a common consequence of stroke, which can have Ah, significant. Maybe an underestimation impact on both short and long term outcomes for stroke survivors. Um, for clinicians, it's helpful to be familiar with the symptoms and the ideology of PSD, um, and related psychiatric disorders in order to effectively identify it, the treatment of which involves a multidisciplinary approach. This incorporate psychiatry, physical therapy, occupational therapy, psychology, complementary and alternative treatments. More research must be done toe Identify the most effective treatments for the prevention and treatment of PSD. Um, but existing evidence supports the use of a combination of psychotherapy and antidepressants. Here's my references, and that concludes my presentation. I'd like to thank everyone again for attending today and listening, so thank you for your time, and I hope that this was educational and beneficial for your future practice.