Nursing Interventions for Post-stroke Fatigue

Fatigue affects as many as 25%–75% of stroke survivors.^1,2 This post-stroke fatigue (PSF) is often disabling, and negatively influences on neurological recovery³ and patients’ quality of life ^{4, 5}. There are numerous definitions of PSF that include subjective feelings of exhaustion and lack of physical or mental energy that interfere with everyday activity.⁶ PSF is associated with both biological and psycho-cognitive factors. The aim of this article is to provide an overview on PSF assessment, causative factors, treatment interventions, and nursing implications.

Assessment of Post-stroke Fatigue

Multiple instruments have been used to assess fatigue, none of which are specific to stroke. Commonly used assessment instruments that have been evaluated for stroke patients are listed in Table 1.^7–9 For nurses involved in stroke care, the PSF case definition developed by Lynch and colleagues is likely the most useful.¹⁰ Nurses may ask two 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.”¹⁰

Table 1.

Post-Stroke Fatigue Assessment Instruments

Instrument	Characteristics and Source
Fatigue Assessment Scale (FAS)	Short, unidimensional instrument; focused on severity; good psychometric properties7
Fatigue Impact Scale (FIS)	Short, unidimensional instrument; focused on impact; good psychometric properties8
Fatigue Severity Scale (FSS)	Commonly used scale in stroke patients; FSS-7 has better psychometric properties than FSS-108, 9
Vitality scale of the 36-item Short Form (SF-36)	Subscale with good face validity7
Multidimensional Fatigue Symptom Inventory (MFSI) general subscale	Comprehensive instrument; good psychometric properties; best face validity7, 8
Fatigue domain from the Profile of Moods States (POMS)	Subscale that can be used alone; good psychometric properties7, 8

Causative Factors Related to PSF

Evidence indicates that PSF is a multifaceted phenomenon associated with many causative mechanisms. Although older adults^{11, 12} and females^{11, 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 (vs. single) people and in those living at home (vs. living in an institution),¹¹ while another study reported no such relationship.¹² Patients with PSF are more often unemployed and change their jobs than in those without¹⁴, but the cause and effect relationship remains unclear.

Biological Factors

Neurologic or Physical Deficits

Overall neurologic deficits^{11, 14} motor dysfunction¹³ 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, 16}

Medical Comorbidities and Medications

Nurses should pay attention to PSF and identify treatable causes by checking for signs such as hypotension, arrhythmia, edema, and relevant laboratory test results (e.g., complete blood count, albumin, glucose, renal function, liver function, and tests for infection). Moreover, comorbid medical diseases such as hypotension, diabetes, heart failure, and anemia, as well as the drugs used for these conditions, may cause fatigue.² Post-stroke eating difficulties related to dysphagia, poor attention, and/or 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 stroke patients, are reported to be related to PSF. Several studies have found an association between post-stroke pain and PSF,^{23, 24} although this link was not confirmed by others.²¹

Pre-stroke Fatigue

Pre-stroke fatigue is closely related to PSF,^{9, 11, 14} although complete characterization of pre-stroke 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 pre-stroke fatigue more often had medical comorbidities than those without. Thus, pre-stroke fatigue may be related to conditions that increase stroke risk, such as diabetes, congestive heart failure, or subclinical strokes.

Psycho-cognitive Factors

Depression 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 Factors

Damage to the basal ganglia,²⁷ brainstem 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 multidimensional causes of PSF. It has also been suggested that chronic inflammation and immunologic changes may be related to PSF.²⁸

Pharmacological and Non-pharmacological Interventions

In both the acute and chronic care settings, numerous multifaceted nursing interventions assist patients to cope and manage post-stroke fatigue. The most prevalent and evidence-based pharmacological and non-pharmacological interventions are listed in Table 2.

Table 2.

Interventions for Post-stroke Fatigue

Author/Year	Methodology/Design	Intervention	Effects
Pharmacological
Ogden/1998	Randomized controlled trial (n=18)	100 mL of 1.5 mg/mL tirilazad mesylate or placebo for 10 days	Effective29
Choi-Kwon/2007	Double-blind, placebo-controlled trial (n=83)	Fluoxetine 20 mg or placebo daily for 3 months	Ineffective32
Brioschi/2009	An open study with an ABA design and no placebo (n=40)	Modafinil; initial dose of 50 mg/day, increased up to 200 mg at 2 months	Effective30
Johansson/2012	A double-blind, randomized, cross-over design (n=12)	(−)-OSU6162; from 15 to 45 mg b.i.d.	Improved mental stamina31
Karaiskos/2012	An open-label, controlled clinical trial (n=60)	Duloxetine group (60–120 mg/day), citalopram control group (20–40 mg/day), sertraline control group (50–200 mg/day)	All ineffective33
Costantini/2014	Case study (n=3)	Thiamine 600 mg/day orally (n=2) or 100 mg/week parenterally (n=1)	All effective20
Non-pharmacological
Lorig/2001	Longitudinal design as follow-up to a randomized controlled trial (n=1140)	Chronic disease self-management program	Ineffective34
Clarke/2012	Randomized controlled trial (n=16)	Fatigue Management Group vs General Stroke Education control group	Both groups effective35
Kim/2012	Nonsynchronized, nonequivalent control group (n=45)	Enjoyable intervention that appeared more like a game or a play	Effective in the experimental group36
Zedlitz/2012	Randomized, controlled trial (n=68)	A 12-week cognitive therapy program and graded activity training	Effective37
Hofer/2014	Preliminary study (n=8)	A mindfulness-enhanced, integrative neuropsychotherapy program	Effective38

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 brainstem-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 (SSRIs) such as fluoxetine,³² duloxetine, citalopram, and sertraline were not effective.³³

For non-pharmacological 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 non-synchronized, nonequivalent control group pre- and post-test design.³⁶ A combination of cognitive-behavioral therapy and graded activity training(COGRAT)³⁷ and cognitive-behavioral therapy with mindfulness techniques appear 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 Points

PSF 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 PSF. The establishment of a fatigue education program in routine nursing care during hospitalization for stroke patients and caregivers should be considered.