Long-term cognitive
complaints and
compensation strategies
after aneurysmal
subarachnoid
hemorrhage
BACHELOR PSYCHOBIOLOGY
RODERICK VAN NIEVELT
10444173
1 CONTENTS Abstract ...2 Introduction...2 Methods ...4 Patients ...4 Data acquisition ...4 Classification of data ...5 Qualitative data ...5 Quantitative data ...6 Data analysis ...6 Results ...7 Quantitative results ...7 Qualitative results ...8 Discussion ...9 Conclusion ... 11 References ... 11 Appendix ... 16
2 ABSTRACT
Aneurysmal subarachnoid hemorrhage (aSAH) from a ruptured intracranial aneurysm accounts for 5% of all strokes, which carries a 35% mortality rate in the first three months after ictus. Diagnosing proves to be difficult, as in 40% of the cases a severe headache is the only symptom present, which can abate in minutes or hours. Almost half (46%) of the people who survive an aSAH, experience long-term cognitive complaints, severely affecting their quality-of-life experience and the functional status of their everyday life. To cope with these long-term cognitive complaints, patients use compensation strategies. This research aims to stratify these compensation strategies using the data from the Checklist of Cognition and Emotion (CLCE-24) made by van Heugten in 2007 and aims to investigate if these cognitive complaints persist in the long-term. Interviews with patients (n=47) were conducted the long-term (1-3 years) after ictus, which was compared to the data of the same questionnaire filled out three months after ictus. A Wilcoxon signed rank test resulted in a significant difference in the number of cognitive complaints reported (p<0.001) between the two groups, indicating cognitive complaints persist in the long-term. Furthermore, a framework for compensation strategies has been created to stratify the compensation strategies corresponding to the cognitive complaints to assist future patients in dealing with cognitive complaints.
Aneurysmal subarachnoid hemorrhage, aSAH, compensation strategies, cognitive complaints INTRODUCTION
Aneurysmal subarachnoid hemorrhage (aSAH) account for 5% of all strokes, which carries a 35% mortality rate in the first three months (van Gijn et al., 2007) after ictus. If the aneurysm ruptures, blood pours into the subarachnoid space between the dua mater and pia mater. This causes the intracranial blood pressure to rise substantially and causes a thunderclap headache. The rising of this intracranial pressure causes transient global ischemia, combined with the presence of the intracranial blood, can lead to brain injury (Macdonald, 2014). Almost half (46%) of the patients who survive an aSAH have to contend with long-term cognitive complaints, severely impacting their everyday life (Suarez et al., 2006).
Earlier research has shown aSAH has distinct demographic characteristics, which has been stable over the past 40 years. The population-based incidence rate is approximately 6-8 per 100.000 per year, but varies per country (Fridriksson et al., 2001, Kowalski et al., 2004, Risselada et al., 2011, Zacharia et al., 2010). Cigarette smoking, hypertension, cocaine use and heavy alcohol use are the main risk factors for an aSAH (Qureshi et al., 2001, Broderick et al., 2003). Furthermore, patients with family history with aSAH also have increased risk of receiving aSAH (Teunissen et al., 1996, Suarez et al., Al-Khindi et al., 2010).
Lastly size and aneurysm location are significant factors for aneurysm ruptures, with rupture of the anterior communicating artery as the most frequent rupture site (29%) (Molyneux et al., 2002).
The most prominent symptom of an aSAH is an onset of a severe headache (Suarez et al., 2006). To determine if a patient has an aSAH, confirmation of the presence of subarachnoid blood is needed. This is done by performing a non-contrast CT scan (Figure 1). When reviewed by a neurologist and presenting suggesting symptomatology, a follow up of a lumbar puncture and analysis of the cerebrospinal fluid is done
(Cruickshank et al., 2008). Followed by CT or MRI angiography to
Figure 1: CT scan of patient with aSAH. The lighter grey area at the arrow indicates blood in the subarachnoid space (Suarez et al., 2006)
3 determine the location of the aneurysm, of which the CT version is most used as it is less invasive and faster to use (Korogi et al., 1999, Vieco et al., 1995).
The two main treatments consist of surgical clipping and coil embolization of the ruptured aneurysm. Each aneurysm has to be evaluated individually to decide which patient receives which treatment. This depends on age, aneurysm’s location,
morphology and overall medical condition (Britz & Gavin, 2005). When treating an aneurysm with microsurgical clipping, a craniotomy, the surgical removal of a part of the skull, is performed by a neurosurgeon to reach the aneurysm in the brain. A clip is then placed on the neck of the aneurysm to cut off the blood flow from the vein as demonstrated in Figure 2. When the clip is in place theremoved piece of skull will be put back into place and the clip prevents blood flowing out of the aneurysm. Coiling has been the alternative to clipping for nearly 30 years. The platinum coils are attached to an endovascular delivery wire and enter through the femoral artery in the groin into the
patients’ blood circulation. This is done by an intervention radiologist and once the coils are in the right position, they are detached from the wire, remaining in the aneurysm, which causes the blood to cloth. Often multiple coils are used, which can vary in diameter and length, to stop the blood flow out of the aneurysm as seen in figure 3 (Molyneux et al., 2005, 2009, Zacharia et al., 2010).
These treatments attempt to prevent further complications such as rebleeding (7% of patients), which has a 50% mortality rate and a heightened risk on permanent neurological damage (Bambakidis & Selman, 2004). Patients who undergo surgery within 24 hours have a significant lower chance of rebleeds and fare better than those who are treated later (Tack et al., 2019). Other complications consist of hydrocephalus (17% of patients), delayed cerebral ischemia leading from vasospasms (46% of patients). The latter is most common and can develop after four to twelve days due to significant narrowing of blood vessels after the aneurysmal rupture (Harrod et al., 2005, Suarez et al., 2006, Chen et al., 2017, Nassar et al., 2019) Researchers have hypothesized that complications like vasospasms and heightened intracranial pressure play a role in the cognitive outcome of patients (Hillis et al., 2000, Ørbo et al., 2008, Al-khindi et al., 2010)
Almost half of the patients (46%) who survive an aSAH have to contend with long-term cognitive complaints. Research has shown that cognitive complaints can persist for at least 75 months after ictus and in some cases the rest of their lives (Powell et al., 2002). These cognitive complaints can differ per patient and can consist of
Figure 2 Clipping of a ruptured aneurysm. The surgical clip prevents blood from flowing out of the ruptured aneurysm.
Figure 3: Coiling of the aneurysm. The endovascular wire is pushed to the locus of the aneurysm, after which the platinum coil is released in the aneurysm. (Suarez et al., 2006)
4 deficits in verbal or nonverbal memory, psychomotor speed and executive or visual-spatial functioning (Kreiter et al., 2002, Mayer et al., 2002, Proust et al., 2009, Al-khindi et al., 2010). Verbal memory is the most frequent domain affected after aSAH with a range of 14 to 64%, followed by visual memory ranging from 14% to 49% (Powell et al., 2002, Mayer et al., 2002, Proust et al., 2009). The wide range in the prevalence can be caused by various effects such as age, years of education or ruptured aneurysms in the anterior circulation, as well due to the use of different standardized tests. Another domain affected by patients who survive an aSAH is the executive function, which is predominantly mediated by the frontal lobes (Stuss & Levine, 2002). Generally executive function is explained as the competence of higher order cognitive abilities such as planning, problem solving, attention and decision making (Kreiter et al., 2002). These cognitive complaints can have devastating effects on the quality of life (QoL) of patients to such extent that they might never return to work or need assistance in their everyday life. This is often described as the functional outcome of patients affecting activities of their daily lives (Al-Khindi et al., 2010).
Compensation is often defined as a set of behaviors aimed at mitigating or adapting to loss (Bäckman & Dixon, 1992). The strategies are used to proactively delay or minimize loss of function (Farias et al., 2018) and are widely accepted as a rational intervention for patients with mild cognitive impairment (Huckans et al., 2013). In other fields of research compensation strategies have shown promising effects, compensating for gait
impairments in Parkinson disease (Nonnekes et al., 2019) and providing more personalized clinical recommendations aiming to maintain or even improve their day-day functioning (Lin et al., 2020). These compensation strategies are often individualized and not applicable to every patient contending similar cognitive complaints.
Therefore, this research aimed to determine whether these cognitive complaints persist in the long-term after aSAH, which compensation strategies are most often employed and are most effective to deal with these complaints.
METHODS PATIENTS
This present study is part of the COMPSTRAT study. All patients (n=351) who visited the aftercare outpatient clinic of the University Medical Center (UMC) Utrecht in the long term after aSAH were contacted by mail or letter to participate in this research. The purpose and course of the study were all explained before the patients took the questionnaire. Patients who were not cognitive able to fill out the CLCE-24 questionnaire or were younger than 18 years old were excluded from participating in the research.
DATA ACQUISITION
On average 10 weeks after ictus, patients filled out the CLCE-24 questionnaire during an appointment at the aftercare outpatient clinic of the UMC Utrecht. This study asked the same patients to fill out the same questionnaire in the long-term, years after ictus. The questionnaire used in this research was slightly modified in comparison to the original of van Heugten et al in 2007. In this modified version each question contained two parts. Firstly, the patient was asked to fill out if they had issues with a certain topic (e.g., doing things at once or having trouble remembering things), asking them to fill out their cognitive complaints. The patients were able to fill out the questionnaire digitally, without word- or time limit. Secondly, the patients were asked to fill out if they had specific strategies they applied to cope with these complaints or issues described in the first part of the
5 question. A version is included in the Appendix section on page 15 for further information. All interviews were scheduled after a visit at the aftercare outpatient clinic, and the questionnaires took 20-40 min to fill in, depending on the information filled out in the open questions. The data from the CLCE-24 has 4 answer-options: Yes, and the complaints are annoying, Yes, but the complaints don’t bother me, No and Doubt. If the patient answered one of the first two options, they were ranked as cognitive complaints. If a patient answered that they were in doubt, it was only ranked as a cognitive complaint if the follow up question explained the reason for answering they were in doubt. The CLCE-24 is naturally divided into two parts containing questions about cognitive complaints and complaints of emotional value.
CLASSIFICATION OF DATA
As mentioned earlier this research consists of a combination of quantitative research and qualitative research.
QUALITATIVE DATA
After several face-to-face discussions and teleconferences, subsequently a consensus was reached on the construction of the classification scheme as shown in table 1. Using the 24 questions of the CLCE-24 questionnaire it was decided to create a more compact and clear view of the cognitive complaints present and their corresponding compensation strategies. This was done due to two main reasons. Firstly, some questions of the CLCE-24 tend to overlap e.g. “Do you have trouble remembering information” and “Do you feel forgetful”, while in essence the underlying mechanism is the same. In some cases, both questions triggered two different responses from patients, and at times different compensation strategies. Secondly, when combining quantitative and qualitative research as Bryman stated in 2006, the two ways of examining the data each fulfill different roles. Unfortunately, the size of the qualitative data does not always allow for a quantitative method of presenting the results in a scheme. The data was thoroughly analyzed, which led to the following subcategories of cognitive complaints: Forgetfulness is a common cognitive complaint shown in patients who suffer from MCI. The Mayo Foundation for Medical Education and Research states forgetfulness as losing train of thoughts, forgetting important meetings, appointments or having trouble finding your way in familiar environments. When a patient reported a cognitive complaint corresponding to these characteristics it was classified as such. Attentional
deficits are the most frequently reported deficits by patients with aSAH as Ravnik and colleagues found in their
research in 2006. Interestingly enough these patients score significantly higher on tests of attention than on other cognitive domains. This discrepancy could be the result of misinterpretation of their cognitive deficits as impairments of attention, but as explained earlier still leaves the patient with attentional complaints. This is why it is listed as a subcategory in the scheme. Another common cognitive complaint is the incapability or struggle with planning. The loss of structure in patients' daily lives can be frustrating and confusing, often described as higher-level cognitive abilities (Al-Khindi et al., 2010). Language comprehension is a broad category which involves written and oral information (Al-Khindi et al., 2010). Research has shown that old age and aneurysm location are predictors to a lower comprehension of language function (Hillis et al., 2000). These cognitive complaints can have a severe impact on daily functioning. Proactiveness / Social are subdivisions of the quality-of-life experience as McKevitt et al., described in their research in 2003. Together with emotional functioning, social functioning are the most prevalent cognitive complaints in the quality-of-life domain. The emotional functioning in this scheme is subdivided into Sadness, Irritability and Fear as these are the most prominent cognitive complaints which came forward from the patient data. Table 1 shows the framework used for classifying cognitive complaints and their respective compensation strategies. Every compensation strategy was
6 classified and the data is reported as % of patients who used compensation strategies per classification of complaints.
Table 1: Framework of cognitive complaints and their corresponding compensation strategies based on CLCE-24 questionnaire.
Cognitive Complaints
Compensation Strategies
Forgetfulness Making lists, taking notes on phone, agenda, record conversations, stay positive/joke about it, take pictures
Attentional deficits Talk about it to environment, take breaks, ask environment for help, avoid external stimuli, use headphones to avoid distraction (noise canceling)
Proactiveness/social Ask environment for help, plan social appointments, select contacts who do not take up too much energy, meet in “neutral places” where you can leave whenever you want
Structure/Planning Making lists, keeping diary, ask for help, think twice, take the time to think everything through
Language comprehension
Take the time for reading, take baths, read things twice, take a rest in between and start over, use noise canceling headphones to take away external stimuli
Emotional handling Count to ten, take deep breaths, explain situation, let the emotions happen as they will pass easily (crying)
Irritability Retreat to find rest, count to ten, indicate boundaries, try to find and take away the source of irritation, ask environment to signal when irritated, explain irritations Down / Fear Do things which are still possible, ask for help of friends and family, talk about
feelings and expressing them, take extra walks, play games, take your mind of thoughts
QUANTITATIVE DATA
To determine whether the cognitive complaints persist in the long-term in comparison to 3 months after ictus, the data from both CLCE-24 questionnaires was compared to each other. The data of 3 months after ictus was present in the database of UMC Utrecht and the long-term data was collected in this research. The data was presented as means (+/-SD) of the reported cognitive complaints and emotional complaints (+/-SD) following the two parts of the CLCE-24.
DATA ANALYSIS
After the mean comparison, the data was checked on normality in IBM SPSS Statistics 24. After which a Wilcoxon signed rank test was performed on the data of the CLCE-24 questionnaires comparing the number of cognitive complaints in the long-term versus three months after ictus. The data was reported as Z and alpha was set as 0.05. This was done for the total score of the CLCE-24 and for both emotional- and cognitive complaints.
7 RESULTS
QUANTITATIVE RESULTS
Of all patients contacted (n=351), 47 patients filled out the modified CLCE-24 three months after ictus and in the long-term. None of the participants were excluded from this research. The rest of the patients have not yet replied, or did not yet fill in the CLCE-24 in the long-term. The mean age of the participants was 62 years old, of which 64% were female. The data was compared to an anonymized dataset of patients who had aSAH of the UMC Utrecht, as can be seen in table 2.
Table 2: Demographics of the included patients compared to an anonymized dataset of the UMC Utrecht. Location indicates the location of the aneurysm, and is shown in % anterior circulation. The Glasgow Outcome Scale (GOS) score is an ordinal scale, ranging from 1 (death) to 5 (good recovery).
Included (n=47) Database (n=1391)
Age (Mean in years (SD)) 61,83 (10,13) 58 (13,5)
Gender (% Female) 64% 71%
Location (% anterior circulation)
70,2% 64%
GOS 3 months (median, range)
5(3-5) 4(1-5)
A normality check was performed in the form of a descriptive analysis and showed that the data was not normally distributed. This led to a comparison of the means of cognitive complaints per group (long-term vs 3 months after ictus) and a Wilcoxon signed rank test resulted in a significant difference (p>0.001) in the cognitive complaint group as seen in table 3.
Table 3: Weighted means (+/-SD) of cognitive complaints per group (3months vs long-term) and the outcome of the Wilcoxon signed rank test.
Complaints 3 months after ictus (n=47)
mean (SD)
Long-term (1-3 years) after ictus (n=47) mean (SD)
Wilcoxon signed rank test (Z, p)
Cognitive 0.242* (0.187) 0.327* (0.197) -3.295, 0.001
Emotional 0.252 (0.110) 0.326 (0.159) -1.782, 0,075
The results from all questions together (cognitive and emotional) of the CLCE-24 also resulted in a significant difference between the groups Long-term and 3-months after ictus (p =0.032, Z=-2.974). This is presented in Figure 3 as a boxplot.
8
Figure 4: Boxplot of the Wilcoxon signed rank test. The x-axis shows the two groups compared to each other: Long-term cognitive complaints (LT_CC) and cognitive complaints 3 months after ictus (CC_3mnths). The Y-axis consists of the weighted means of the cognitive complaints per category.
QUALITATIVE RESULTS
To classify the compensation strategies used the earlier discussed model was used (table 1). As shown in table 4 these results present that patients use compensation strategies the most for social activities and proactiveness (42%). Every compensation strategy was counted and classified to match a category of cognitive complaints. The highlighted compensation strategies indicate the most used strategies in the data (n>4).
9
Table 4: Classification of compensation strategies according to the cognitive complaint framework. The highlighted compensation strategies indicate most frequently used strategies (n>4).
DISCUSSION
The goals of this research consisted of two main parts. To discover if cognitive complaints persist in the long-term and what kind of compensation strategies patients used, and which proved to be most effective.
The demographics of the included patients in this study in comparison to the database of the UMC Utrecht were very similar, which took away possible doubt if the data of this research would be representative for the rest of the study. The absence of data of the remaining patients (who have not yet filled in the second CLCE-24 test) did not seem to influence the general demographics of the data.
The significant difference found between the data of the two moments (long-term vs 3 months after ictus) of when the patients filled in the CLCE-24, is in line with earlier research as mentioned earlier (Persson et al., 2017).
Cognitive Complaints % Compensation
strategies used
Compensation Strategies
Forgetfulness 38% Making lists, agenda, taking notes on phone, record conversations, stay positive/joke about it, take pictures Attentional deficits 13% Talk about it to environment, take breaks, ask
environment for help, avoid external stimuli, use headphones to avoid distraction (noise canceling) Proactiveness/social 42% Ask environment for help, plan social appointments,
select contacts who do not take up too much energy, meet in “neutral places” where you can leave whenever you want
Structure/Planning 17% Making lists, keeping diary, ask for help, think twice, take the time to think everything through
Language comprehension
17% Take the time for reading, take baths, read things twice, take a rest in between and start over, use noise canceling headphones to take away external stimuli
Emotional handling 30% Count to ten, take deep breaths, explain situation, let the emotions happen as they will pass easily (crying)
Irritability 12% Retreat to find rest, count to ten, indicate boundaries, try to find and take away the source of irritation, ask environment to signal when irritated, explain irritations Down / Fear 9% Do things which are still possible, ask for help of friends and family, talk about feelings and expressing them, take extra walks, play games, take your mind of thoughts
10 The difference is also in line with our hypothesis and shows that cognitive complaints not only persist in the long-term, but might worsen in some cases. The data of figure 3 does present an interesting view, as the data from patients who filled out the CLCE-24 in the long-term shows that more patients reported a higher number of cognitive complaints in comparison to the 3 months after ictus. This could imply an intensification of cognitive complaints, but might also have another explanation. As this data is acquired much later, in some cases up to 4 years later, age could play a large role in the amount of reported cognitive complaints. As is widely known, age can have an immense impact on cognitive decline (Salthouse, 2009, James et al., 2011) and the occurrence of cognitive complaints. This does not take away the significant effect found, but should be taken into account before drawing conclusions. However, it is safe to say that the data showed that cognitive complaints persist in the long-term.
The difference between cognitive complaints and emotional complaints reported, although small, is in line with earlier research (van Heugten et al., 2007, Passier et al., 2010) showing a higher occurrence of cognitive complaints compared to emotional complaints. Although, there was no significant difference between the 3 months after ictus and long-term group in terms of emotional complaints, this does not mean the severity of the individual cases can be ignored. During data analysis the impact and severity of some individual cases were staggering. Ranging from endless rows with their partner, which did not happen as often before the aSAH, to not being able to handle their emotions well enough, severely impacting their quality of life. A few patients report seeing a psychologist, just to deal with these emotional complaints resulting from the aSAH. This is data which is often overlooked or missed in quantitative research, but adding a qualitative approach shows the gravity of some individual cases.
The gravity of these individual cases showed even more prominently in the data presenting the use of compensation strategies. The heterogeneity of the cognitive complaints and their corresponding compensation strategies used clearly shows from the framework used in table 4. The compensation strategies often refer to a very specific complaint e.g., one patient reports to take a bath when reading proves to be too difficult or takes up too much energy. The warmth, as reported, helped this patient calm the mind and thusly was able to continue reading. This is just one of the many cases observed in this research, which could help patients who might receive an aSAH in the future. Categorizing the compensation strategies and presenting them in time to patients could help take away the feel of unease and abandonment as described in Persson et al., 2017. In their research patients describe the cognitive complaints as an evident part of their everyday life, but failing to understand why they had these symptoms, let alone how to deal with them. This leads to the patient feeling abandoned, and left with a feeling of despair, which in turn could result to down thoughts and possibly emotional complaints. This emphasizes the importance of the use of this framework for future patients.
While analyzing the compensation strategies used by patients, it was one of the goals of this research to determine what strategy would have the most effect. Unfortunately, it was unable to deduct such a conclusion from the present data. In the framework the most frequent compensation strategies used are represented in red, which could indicate that they work best. However, it is impossible to make a reasonable deduction of the impact of the use of the compensation strategy on the score patients filled out in the CLCE-24 questionnaire. Let alone the heterogeneity of compensation strategies reported, indicating individuals cope with different cognitive complaints and use corresponding strategies. This implies that the question is not “which compensation strategy works best?”, but what strategy fits the patient’s cognitive complaint the best.
This study uses long-term as a classification, while in fact it is a group of patients who filled out the CLCE-24 questionnaire one to three years after ictus. The original idea was to group these patients in years after ictus, to explore if this would have an impact on the number of cognitive complaints reported. Unfortunately, the groups were not well distributed enough (there were only 4 patients with 3 years after ictus) to compare these groups
11 with each other. After discussions and teleconferences, the consensus was reached to pool these patients into one group: long-term. This has been done to get an indication of the comparison between the two groups. However, among the remaining patients who were contacted, but have not yet filled out the CLCE-24 questionnaire follow up, there are many who received an aSAH up to 7 years ago. When this data will be present, future research could subdivide the long-term-group into years after ictus. This could shed more light on the effect of time on cognitive complaints present, taken into account a correction for age will be done.
Further research could make use of the framework to add more compensation strategies. The variety of compensation strategies present in such a framework could give future or current patients grip on how to handle various but specific cognitive complaints. Subsequently, this could lead to a better grip on their life and returning to daily activities, which might now be impossible.
CONCLUSION
Years after an aSAH, patients have to contend with cognitive and emotional complaints, often misunderstood or not knowing why they are suffering from them. This research has shown that these cognitive complaints do persist in the long-term, and arguably worsen over time. The strategies used by patients to compensate for these cognitive complaints have been stratified in a framework, designed to help patients find strategies for their individual cognitive complaints. The use of such compensation strategies can have a direct impact on their daily lives.
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16 APPENDIX
Probleem Klacht aanwezig? Voorbeeld
Hebt u moeite om 2 dingen tegelijk te doen?
Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Planningslijst Hebt u moeite om de aandacht ergens bij te houden? Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt)
……… ……… ………
- 1 taak tegelijk
Hebt u moeite om alles bij te houden, bent u langzamer geworden? Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Vraag mensen te herhalen Hebt u moeite om nieuwe informatie te onthouden Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Opschrijven Hebt u moeite om informatie van langer geleden te onthouden, bent u vergeetachtig Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt)
……… ……… ………
17 Hebt u moeite om zelf
initiatieven te nemen? Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt)
……… ……… ………
- Dagplanning
Hebt u moeite met het plannen en/of organiseren van dingen? Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Agenda of planningslijst Hebt u moeite om concrete dagelijkse activiteiten uit te voeren (niet door verlamming) Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt)
……… ……… ………
- Forceren
Hebt u verminderd tot geen besef meer van tijd Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt)
……… ……… ………
- Digitale agenda
Hebt u verminderd tot geen besef van plaats, ruimte of persoon Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Opschrijven - Plaatjes
18 Hebt u geen aandacht
meer voor een deel van het lichaam of de omgeving Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt)
……… ……… ………
- Werken volgens een vast schema
Hebt u moeite om gesproken en/of geschreven taal te begrijpen Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Herhalen of overlezen
Hebt u moeite om zelf te praten of te schrijven Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Vermijding van woorden/zinnen
Bent u meer op uzelf gericht, hebt u minder sociale contacten Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Plannen sociale activiteiten Hebt u irreële verwachtingen Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Verwachtingen temperen
19 Bent u sneller emotioneel, moet u sneller huilen Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Emoties verbergen Bent u sneller geïrriteerd, prikkelbaar Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Anderen voorlichten Bent u onverschillig, koel, minder uiten van emoties Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Vroegere interesses opzoeken
Hebt u last van ontremming, moeite met controle van gedrag Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Bewust voorzichtig zijn Bent u somber, neerslachtig, depressief Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Praten met anderen
Hebt u angstgevoelens Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
20 Hoe gaat u hiermee
om?
(ook van toepassing als u geen moeite hiermee hebt)
……… ……… ………
- Hulpmiddelen
Bent u sneller en vaker moe Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel
Hoe gaat u hiermee om?
(ook van toepassing als u geen moeite hiermee hebt) ……… ……… ……… - Activiteiten verdelen Hebt u aanvullende problemen Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel Zijn er andere
problemen die niet aan de orde zij gekomen en hoe gaat u hiermee om?
……… ……… ……… Hebt u aanvullende problemen Ja, het is erg hinderlijk Ja, maar niet hinderlijk Nee Twijfel Zijn er andere
problemen die niet aan de orde zij gekomen en hoe gaat u hiermee om?
……… ……… ………
