Anosognosia after Stroke
Elizabeth M. Byrd, PhD
What follows is a familiar moment. You are in a patient’s room and remind them to call for help if they need to get out of bed. The patient assures you they will. Later, you get a call that the same patient attempted to get out of bed unassisted and has experienced a fall. In this instance, the reaction from nurses and care partners is usually the same. We assume they are not listening and are being nonadherent. While true for some, this is not always true for patients after they have had a cerebrovascular accident
AHP is a condition that can occur after stroke where individuals are unaware of their own impairment. Normally, movement relies on continuous comparison of what the brain plans to do and what the body can accomplish. After a stroke, this integration can be impaired, and the brain does not receive feedback indicating that movement has not occurred. As a result, patients may genuinely believe they can move normally despite clear and obvious motor deficits to the nursing staff and care partners.
This can be easy to misinterpret at the bedside. AHP often looks like inconsistency or nonadherence, rather than a deficit in awareness. Patients may agree with instructions and care plans, answer questions appropriately, and appear cognitively intact. Yet, once alone, that same patient will attempt to stand, decline rehabilitation exercises, and refuse to ask for assistance. Care partners can become frustrated as they encounter repeated safety concerns and resistance to help. Without understanding AHP, these interactions can become disturbing for those who may feel they are constantly reminding someone who seems capable of understanding.
In intervening, rural nurses and clinical personnel need to be aware that such a phenomenon exists and that patients do not have a cognitive issue but rather, an interruption in motor initiation and feedback because of the stroke. Second, education of care partners is essential in facilitating understanding. If they know their loved one is not being difficult/non-adherent, often the approach to care and spirit in which it’s delivered changes. Care partners knowing that unawareness is part of the stroke injury, and that with time and support, AHP often resolves, is essential in lessening caregiver burden.
In rural areas, responses to anosognosia should include the use of trained community health workers, the use of mobile/tele specialist teams, caregiver education, and community-based rehabilitation. Community health workers, particularly those who work with stroke survivors, should be trained to assess and identify unawareness after stroke. The use of multidisciplinary teams and telemedicine assessments may be needed and should be considered when there are significant geographic and systematic barriers to care. Caregivers are central to the identification and management of anosognosia, so should be coached on identification, safety precautions, and supervision needs of someone with AHP. Anytime complex instructions can be avoided and providing short and simple requests should be used. Although the management of anosognosia does not fundamentally differ in rural settings, identification may take longer because of reduced access to specialized stroke and rehabilitation resources.
Reference
Acharya, A. B., & Sánchez-Manso, J. C. (2023, April 24). Anosognosia. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513361/
Gainotti, G. (2019). History of anosognosia. Frontiers of Neurology and Neuroscience, 44, 75-82.
