How to Handle an Impulsive Stroke Patient

Following a stroke, the patient is often beset with number of losses, ranging from loss or dysfunction of gross and fine motor functioning, speech, cognition and comprehension, vision, judgment, initiative, memory, navigation and orientation. Alterations in emotional and personality functioning, along with impulse control issues, complicate adaptation and treatment. Impulsivity problems create risks and dangers for the patient and others and demand the formulation of a treatment plan.

Instructions

Identify Impulsivity Problems and Precursors

• 1

  Identify and diagnose impulsivity dysfunctions. Obtain a full neurological, cognitive and behavioral evaluation. This is useful to assess current functioning, but is also helpful to establish a baseline in case of further complications or strokes. Have a comprehensive exam by a physician, followed by a functional evaluation by a neurologist or neuropsychologist.

• 2

  Carefully observe the stroke patient and review possible impulse control issues that take place in the home or within the treatment residence setting. Write down issues that need to be addressed to guide discussions with caretakers and providers.

  Impulsivity issues can range from micro-behaviors to complicated sequential behaviors that involve complex decisions and social action. For example, the patient may stand up too quickly and lose balance; get up from a wheel chair without first locking the wheels, thus causing a fall; or grab for things and pull away before having full grip-causing drops. The stroke patient may manifest emotional impulsivity and social disinhibition, expressing anger quickly, yelling, crying, getting into arguments, or making inappropriate or rude sexual remarks. She may spend money foolishly or try to cook, leave the home, drive or place herself at risk despite repeated admonitions. These may seem like natural attempts to retain autonomy, but there is likely a neurological basis for impulse control issues.

• 3

  Identify any emotional precursors to impulsive behaviors. Fear, anxiety, anger, and sadness may be symptoms of an underlying mood disorder that contributes to impulsivity, emotional or behavioral problems.

• 4

  Identify need-based precursors to impulsive behaviors. For example, if the patient is getting up and walking around without assistance, identify the reasons for the action (e.g., to turn on the television, go to the bathroom, etc).

Formulate Comprehensive Treatment Plan

• 5

  Discuss the problem behaviors and precursors that have been identified with a medical doctor and other professionals. Discuss possible medications. Stimulants or other ADHD medications can help with impulsivity, short-term memory, and behavioral disinhibition. Antidepressants and anxiolytics can be effective for underlying mood disorders.

• 6

  Enroll the patient in a rehabilitation program that addresses identified need areas. Rehabilitation can aid in all areas of functioning and can mitigate the impact of impulsivity problems.

• 7

  Have a team meeting of all caretakers. For each problem identified, develop possible solutions.

Implement Interventions

• 8

  Create a safe environment that assumes impulse control problems. Develop built-in delays related to problem behaviors. For example, use a wheel chair safety belt, hide car keys, lock doors, limit access to keys, credit cards and checkbooks, and so forth as necessary.

• 9

  Administer medications as prescribed

• 10

  Provide structure, support, and supervision. Make sure all providers are aware of behavior issues. Redirect the patient’s energy and impulsivity by creating positive structured activities and social opportunities.

• 11

  Regarding emotional reactivity and impulsivity, set clear limits, but do not escalate incidents. Remain calm. Use distraction, redirection, and delay. For example, if the patient wants something but can’t have it right away, affirm the time when they will be able to get what they want. Keep a list of wants and needs so the patient can feel their needs are being tended to. Use empathy and validation. Do not patronize, but rather listen to the patient, understand their needs, and create an environment that is responsive to their needs.