What to do if aggression occurs after a stroke in older people

Medical certificate

Stroke is neurological in nature. The cause of this terrible disease is an acute violation of cerebral circulation. It is disrupted due to blockage of blood vessels by blood clots or due to embolism of the cerebral arteries. Stroke is most common among residents of developed countries. A sedentary lifestyle is thought to increase the risk of stroke. The brain is poorly supplied with oxygen, which leads to acute brain hypoxia and subsequent death of nerve cells.

Nervous tissue is the most delicate and sensitive. She absolutely cannot tolerate circulatory disturbances: this leads to the rapid onset of ischemia and disruption of the normal functioning of neurons. Just half an hour after the blood flow is disrupted, irreversible changes occur, which forms the picture of the disease. Thus, in case of a stroke, it is important to help the person as soon as possible, before the changes become irreversible.

In medicine, it is customary to divide stroke into two categories:

• ischemic, when there is complete occlusion of the lumen of the vessels;
• hemorrhagic, when the vessel ruptures and hemorrhage occurs into the surrounding tissue. In this case, a cerebral hematoma is observed.

The mechanisms of disease development are approximately the same, but the consequences may be different. Statistics say that in 80% of cases it is the ischemic form of stroke. Both forms of stroke are associated with atherosclerotic changes in the vascular system. Important: hemorrhagic stroke is more dangerous, since when a hematoma develops, a shift in the brain can sometimes occur.

Mania is a syndrome that, along with depression, is the main manifestation of bipolar affective disorder. Mania is characterized by a triad of symptoms: elevated mood (hyperthymia), ideational and mental arousal in the form of acceleration of thinking and speech, and motor agitation. It is also characterized by increased instinctive activity, increased distractibility, and overestimation of one’s own personality [1].

Affective disorders are widespread in various organic brain lesions [1, 2]. For example, the incidence of depression after stroke is about 30% [2]. The incidence of mania after stroke is not precisely known, but according to some authors it is about 1% [3]. Cases of the development of mania have also been described in other neurological diseases: multiple sclerosis, post-traumatic encephalopathy, epilepsy, Parkinson’s disease, etc. [4]. C. Krauthammer and G. Klerman [5] proposed in 1978 the concept of secondary mania associated with organic brain damage and its diagnostic criteria.

Diagnostic criteria for secondary mania according to C. Krauthammer and G. Klerman: a) duration of symptoms for at least 1 week; b) elevated and irritable mood; c) 2 of the following symptoms are present: d) hyperactivity, increased talkativeness, rapid train of thought, ideas of grandeur, decreased need for sleep, distractibility, reckless behavior; absence of a history of manic, depressive or other affective disorders, as well as symptoms of confusion (for example, delirium) accompanying mania.

D. Steffens and K. Krishnan [6] proposed a definition of post-stroke or vascular mania. It is a mania that develops in the presence of clinical (history of stroke or transient ischemic attack (TIA) and/or symptoms of focal brain injury), neuroimaging (altered white matter signal, cortical or subcortical infarcts) or neuropsychological (cognitive deficits in form of decreased regulatory functions, memory and speed of mental operations) symptoms. Additional criteria include onset at the age of 50 years and older, the absence of affective disorders in the family history and the presence of severe disability [6]. Later, C. Wijeratne and G. Malhi [7] revised this definition. Vascular mania is a form of mania that begins in patients 50 years of age or older, after an acute cerebrovascular accident (TIA or stroke) or with at least two vascular risk factors (arterial hypertension, hyperlipidemia, coronary heart disease, diabetes mellitus), and also with additional criteria, including changes according to neuroimaging and neuropsychological studies that go beyond the age norm [7].

Mania is an extremely rare manifestation of cerebral stroke. According to a meta-analysis by C. Santos et al. [8], which included 49 studies, over the past 50 years only 74 cases have been described in the world literature. R. Robinson et al. [9] purposefully examined 700 patients after a stroke and identified only 3 cases of mania; the same number of patients was noted by J. Dunne et al. [10], examining 661 patients, and L. Caeiro et al. [11] - 188 patients. In other words, in these studies, the incidence of mania after stroke ranged from 0.4 to 1.6%. In some cases, mania occurred as part of post-stroke bipolar affective disorder [12]. In terms of time, mania developed in different periods of stroke: from the most acute to 2 years after it [8].

Mania often develops as a result of right hemisphere strokes. Many authors explain this connection by damage to the frontal-subcortical loops, in particular the right orbitofrontal and limbic cortical-striato-thalamocortical loops, which are responsible for the control of the affective sphere and behavior in society, as well as motivation and spontaneity [8]. This finding is consistent with data on the high incidence of post-stroke depression, the opposite of mania, in left-hemisphere lesions [8]. However, in the literature there are reports of cases of the development of mania after strokes of various localizations [8]. It is likely that sometimes a significant role in the development of mania belongs to the phenomenon of diaschisis—a dysfunction of parts of the brain that are not directly damaged, but are connected to the affected area by a system of pathways [13].

Some authors have reported an association between the development of mania and subcortical atrophy according to neuroimaging data [14–17], genetic factors [15–17], and a history of mental illness [16, 17]. However, a meta-analysis by S. Santos et al. [8] did not confirm these data.

Functional neuroimaging methods have provided additional data on the mechanisms of development of mania after stroke. In the literature, there are two descriptions of cases of mania after right hemisphere strokes with examination data using single-photon emission computed tomography [18, 19]. Both cases demonstrated hypoperfusion in the right hemisphere and hyperperfusion in the left hemisphere, indicating an important role of interhemispheric imbalance in its development. In particular, A. Koreki et al. [19] showed that in a patient with hemorrhage in the right putamen, mania was observed against the background of hypoperfusion in the right temporal and frontal regions and hyperperfusion in the inferolateral, prefrontal regions, temporal lobe, as well as in the medial and lateral regions of the parietal lobe of the left hemisphere . A study conducted after the resolution of manic symptoms revealed a decrease in hypoperfusion in the right frontotemporal region and resolution of hyperperfusion in the structures of the left hemisphere. The authors suggested that the development of post-stroke mania in the described patient was based on the phenomenon of contralateral disinhibition [19]. In this case, it was manifested by an increase in the activity of the structures of the left hemisphere due to damage to the right, as a result of a violation of interhemispheric inhibition. In turn, increased activity of the left frontal cortex relative to the right frontal lobe was associated with the development of positive affect and an increase in motivational and motor activity and, as a consequence, symptoms of mania. Damage to the left insular cortex can lead to the development of elevated mood, thereby contributing to the development of mania. In another study, in 3 patients with mania after strokes in the right subcortical region, positron emission tomography revealed a decrease in the metabolic rate in the basal temporal lobes, probably due to the phenomenon of diaschisis. These data highlight the role of limbic system disorders in the development of mania [20].

Mania can develop after strokes in the vertebrobasilar system; there are reports of the development of mania after cerebellar strokes [21–25]. Damage to the cerebellum, along with typical motor disorders, can lead to the development of cognitive-affective syndrome, manifested by disorders of regulatory functions, visuospatial skills, speech, mood, and behavior [25]. Mania may be a rare manifestation of cerebellar cognitive-affective syndrome. The development of mania after cerebellar strokes is probably based on the disconnection of connections between the posterior lobe of the cerebellum and the associative cortex and between the posterior part of the vermis and the structures of the limbic system [26]. These data are supported by studies that revealed cerebellar atrophy in patients with mania as part of bipolar affective disorder [27].

There are reports in the literature [28, 29] of the development of manic symptoms after subarachnoid hemorrhage (SAH). In particular, L. Caiero et al. [29] conducted a neuropsychological examination of 108 patients in the acute period of SAH and found signs of mania in 2 of them. The authors found no association between the development of manic symptoms and the neuroanatomical characteristics of SAH.

Mania can develop as part of behavioral disturbances in a rare hereditary cerebrovascular disease - cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). Symptoms of mania may even be the first symptom of this disease [30].

From a clinical point of view, the symptoms of primary mania in bipolar disorder and secondary mania after a stroke are not fundamentally different [8, 17]. According to a meta-analysis [8], the most common symptoms of post-stroke mania were elevated mood (91%), pathological talkativeness (71%), decreased need for sleep (69%), and agitation (63%). A case has been described of a change in the drawing style of an artist with symptoms of mania after a stroke in the middle cerebral artery system [31]. The meta-analysis made it possible to identify the most characteristic features of patients with post-stroke mania. The typical patient was a man with no past or family history of psychiatric disorders, at least one vascular risk factor, no evidence of subcortical atrophy, and a history of right hemisphere stroke (patients with mania that developed up to 2 years after stroke were included in this analysis). A separate analysis of patients with mania that developed immediately after a stroke gave a similar result [8].

Mania after a stroke must be differentiated from disinhibition syndrome due to damage to the orbitofrontal cortex and its connections, which, in addition to elevated mood, is characterized by dysphoria, as well as severe impairment of regulatory cognitive functions. Behavioral disorders within post-stroke epilepsy may have features of mania. To exclude epilepsy as a cause of manic symptoms, a detailed medical history is important, as well as an electroencephalographic study. Mania-like symptoms may occur as part of a positive psychological response to recovery of neurological deficits. However, in such cases their severity is much less, and their duration is shorter.

Symptoms of hyperactive delirium may resemble mania, but unlike the latter, they develop more acutely, are fluctuating in nature, and are accompanied by global cognitive and behavioral impairment. Symptoms of mania and delirium may occur together. In such cases we are talking about delirious mania or Bell's mania [32]. Some authors consider delirious mania as a form of catatonic syndrome [33]. In the literature [34, 35] there are descriptions of delirious mania after an ischemic stroke in the region of the right thalamus, brainstem and cerebellum.

Patients with mania after a stroke cannot undergo full rehabilitation due to low adherence to rehabilitation treatment. Therefore, timely treatment of mania after a stroke is very important. In terms of treatment, firstly, it is necessary to exclude iatrogenic causes of mania: discontinue psychostimulant drugs (for example, stimulant antidepressants prescribed for depression), normalize the sleep-wake cycle. Secondly, choose psychopharmacotherapy. In post-stroke mania, the use of antiepileptic drugs is more preferable, while lithium preparations are undesirable due to potential side effects and a narrow therapeutic index [36]. Data on the treatment of mania after stroke were reported in 47 of 74 (64%) cases included in the systematic review by Santos et al. [8]. In 62% of cases, normothimic drugs were used (lithium drugs, carbamazepine, valproate), in 32% typical neuroleptics (haloperidol), in 19% atypical neuroleptics (olanzapine, risperidone), in 13% benzodiazepine tranquilizers (lorazepam, diazepam) [8] .

Thus, mania is a rare neuropsychiatric manifestation of stroke. Its timely diagnosis and correction are important for successful rehabilitation and require a multidisciplinary approach with the involvement of a psychiatrist/psychotherapist. Further study of cases of post-stroke mania may help to clarify the neuroanatomical substrate for the development of this syndrome in bipolar disorder and other mental illnesses.

Causes of stroke

Stroke is a so-called multifactorial disease. It is believed that stroke has many different causes, each of which makes a specific contribution:

• unhealthy lifestyle, which may include overeating and physical inactivity;
• great psycho-emotional stress;
• bad habits, especially smoking;
• hypertonic disease;
• some other factors, including heredity.

These factors can act together or separately.

What are the causes of aggressive behavior in people who have had a stroke? They are:

• damage to areas of the cerebral cortex responsible for emotions, behavior and intelligence;
• extensive brain damage. This is the most common cause of aggression.

One of the common consequences of a stroke is paresis of the facial muscles. The man's face contorts. Important: aggression in people who have suffered a stroke may develop not as a result of damage to areas of the brain, but already during the rehabilitation period, when a person cannot come to terms with the loss of certain functions of his body.

How to prevent an attack of aggression?

The first step to prevent attacks of aggression in older people should be to analyze the situation:

• when aggression appears;
• what precedes it;
• the reasons for this behavior of the old man.

Only after you understand why your elderly relative is starting to get nervous can you correct the situation for the better. We will have to change ourselves and change our attitude towards the elderly:

1. To come to terms with the fact that an elderly person will never be the same again, that he will forget more and more often, spoil something, do it wrong, not as quickly as he would like. The main thing here is not to get irritated yourself, not to scold the old man for being slow or forgetful, not to show aggression so as not to provoke it in response.
2. Constantly take into account the state of his health; in old age, few people have excellent health: they suffer from pain, vision declines, hearing decreases, all this does not give old people confidence, they react more and more negatively to any irritants.
3. Try not to create situations where an elderly person might make a mistake, and if this happens, do not criticize him in vain: what’s done is already done.
4. In situations where the old man can no longer take care of himself, carry out hygiene procedures very delicately, without causing him unnecessary discomfort, he already feels awkward.

Manifestations of aggression in post-stroke psychosis

Aggression after a stroke has a number of features. Usually, when inappropriate behavior develops, the patient is dangerous to himself and others. The aggressive state does not develop immediately, but gradually, over two or three months. It is characterized by the following:

• self-criticism disappears;
• the patient withdraws into his thoughts and withdraws from everyone;
• intense psycho-emotional background;
• slurred speech;
• interest in surrounding things and people disappears;
• inappropriate behavior, especially at night;
• weight loss.

In a person who has suffered a stroke, aggression is often accompanied by a depressive state. Aggression is characterized by attacks. Most often it appears at night. Emotional instability leads to increased vulnerability of the patient, and this, in turn, causes him an inferiority complex. A vicious circle arises. Relatives observe with horror that a loved one has become different, distant and aggressive.

Some advice to others

If you witness an episode of inappropriate behavior, try to follow these recommendations:

• Be calm.
• Remove from the apartment (house) all sounds that irritate the patient (music, TV), excessive lighting and dangerous objects.
• Talk to the patient calmly, kindly, and say soothing phrases. Don’t swear, don’t raise your voice at him;
• Do not leave the patient alone.
• In case of a severe attack, immediately call a specialized assistance team, and be sure to consult with a specialist, even if the aggressive behavior was short-lived.

A person has become aggressive - what to do?

Scientists have not yet developed a reliable method for fully restoring people after a stroke. Attention from family and friends is of great importance. A person who has suffered a stroke is in great need of support from relatives. The best solution is to avoid the development of post-stroke psychosis and depression. In some cases, psychotherapy may be required. It is important that the victim himself understands the need to combat manifestations of aggressiveness. Then there is a chance for healing. With mild forms of psycho-emotional disorder, love and care from loved ones will be quite enough. Prescription of antidepressants brings good results. In general, treatment after a stroke includes:

• angioprotectors - drugs that strengthen the walls of blood vessels;
• nootropics - drugs that improve cerebral circulation;
• thrombolytics - drugs that thin the blood.

The faster the recovery processes in the brain take place, the sooner a person will get rid of depression and psychosis.

Treatment of aggression after stroke at the Verimed clinic

To stop such manifestations and stabilize the patient’s mental state, specialists try to use a whole range of measures.

Treatment for aggression during stroke includes:

• Prescription of tranquilizers. A specific drug is selected for each patient. His choice is based on the specific manifestations of the pathology and the doctor’s experience. For a faster development of the effect, the medicine is administered as an injection intramuscularly or intravenously;
• Use of antipsychotics. It is justified in more difficult situations. Such drugs have a more powerful effect due to the addition of an antipsychotic effect to the tranquilizing (sedative) effect.
• Prescribing antidepressants if the patient’s complaints reveal elements of a depressed state. The selection of these medications is associated with certain difficulties. It is not always possible to achieve the desired result immediately. The choice of an antidepressant is complicated by the fact that the effect of their use is noticeable only after a month of use.
• Acupuncture, which has a very mild therapeutic property. They resort to it during the interictal period.
• Massage and physical therapy (both passive and active), the health-improving and preventive results of which are very great.
• Methods of psychotherapy. Working with patients as psychologists and psychotherapists allows them to eliminate the main causal components of aggression after a stroke, help them correctly understand their situation, find and set goals for their future life.

Patients are recommended to undergo sanatorium-resort treatment. A favorable climate, a change of environment, and rehabilitation measures can significantly mitigate or even completely eliminate the signs of aggressive reactions.

Treatment of aggression in women differs in duration and the need to use special enhanced versions of psychotherapeutic methods. The conditions of the Verimed clinic, the qualifications and personal characteristics of the doctors allow us to help all patients who apply. Have you encountered this problem? Don't wait for tomorrow - just call us now!

How to respond to aggressive behavior?

Never take your relative's aggressive behavior as a personal insult. Remember - this is simply an emotional, yes, unpleasant for you, but not directed at you, reaction of an elderly person to some serious irritant.

In order to cope with the aggressive behavior of an old man, you must:

• be prepared for possible aggressive behavior and have several rehearsed options for responding to it;
• Do not give in to emotions under any circumstances, it is better to simply leave the “battlefield” for a while and calm down yourself;
• do not get into a quarrel, do not respond in the same spirit: “calm, only calm,” otherwise the old man’s aggressive behavior will only intensify;
• try to somehow switch the attention of an elderly relative to something positive, start a conversation on abstract topics.

After the attack passes, it is best to act as if nothing happened. Under no circumstances try to punish the old man in any way, let him feel how he offended you and how wrong he was. Most likely, after some time he will not remember his attack of anger and will not understand why your attitude towards him suddenly changed so dramatically.

If such attacks of aggression begin to recur with alarming regularity, especially if they become more frequent, it is necessary to show your relative to a psychiatrist as soon as possible. With timely consultation with a doctor, such attacks can be stopped with the help of medication.