Stroke Care Management: Motivation and Engagement
Published: 22 November 2015
Published: 22 November 2015
Decreased participation and engagement during rehabilitation greatly influences the level of function gained, length of hospital stay, 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 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 phenomena.
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Prevalence of depression post-stroke is 10 to 15%. Apathy is estimated to be present in 29.5 to 40.2% 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 is more likely to be seen in patients with apathy. Apathy is seen to impact on functional recovery more often than depression.
There are some strategies and interventions that have been shown to help patients suffering from depression and apathy following a stroke.
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 that 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' language is as important as the development of the goal itself.
Collectively, study findings provide evidence that music engages and facilitates a wide range of cognitive functions. There is an 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.
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.
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 the 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.