Screening for Post-Stroke Depression and Cognitive Impairment at Baseline Predicts Long-Term Patient-Centered Outcomes After Stroke

Background: Independence and reintegration into community roles are important patient-centered outcomes after stroke. Depression and cognitive impairment are common post-stroke conditions that may impair long-term function even years after a stroke. However, screening for these post-stroke comorbidities remains infrequent in stroke prevention clinics and the utility of this screening for predicting long-term higher-level function has not been evaluated. Aims: To evaluate the ability of a validated brief Depression, Obstructive sleep apnea, and Cognitive impairment screen (DOC screen) to predict long-term (2-3 years after stroke) community participation and independence in instrumental activities of daily living post stroke. Methods: One hundred twenty-four patients (mean age, 66.3 [standard deviation = 15.7], 52.4% male) completed baseline depression and cognitive impairment screening at first stroke clinic visit, and telephone interviews 2 to 3 years post stroke to assess community independence (Frenchay Activities Index [FAI]) and participation (Reintegration to Normal Living Index [RNLI]). A subset of these patients also consented to complete detailed neuropsychological testing at baseline. Univariate and multivariate linear (FAI) and logistic (RNLI) regression analyses were used to determine the individual relationship between baseline data (predictors) and follow-up scores. Results: Older age (β = −0.17, P = .001), greater stroke severity (β = 1.84, P = .015), more depressive (β = −2.41, P = .023), and cognitive (β = −2.15, P = .046) symptoms independently predicted poor instrumental activity ( R2 = .27; P < .001). Measures of executive dysfunction were the strongest correlates of poor instrumental activity. Higher depression risk was the only significant predictor of participation on the RNLI in regression modeling (odds ratio = 0.46, P = .028). Conclusions: Baseline DOC screening in stroke prevention clinics shows that symptoms of depression and cognitive impairment are independent predictors of impaired higher-level functioning and community reintegration 2 to 3 years after stroke. Novel rehabilitation and psychological interventions targeting people with these conditions are needed to improve long-term patient-centered outcomes.

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Abstract WP427: Cognitive Function of Ten-year Stroke Survivors Compared to Non-stroke Individuals: the Lund Stroke Register

Stroke ◽

10.1161/str.47.suppl_1.wp427 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Hossein Delavaran ◽

Ann-Cathrin Jönsson ◽

Håkan Lövkvist ◽

Susanne Iwarsson ◽

Sölve Elmståhl ◽

...

Keyword(s):

Cognitive Impairment ◽

Cognitive Assessment ◽

Executive Dysfunction ◽

Screening Methods ◽

Stroke Survivors ◽

Cognitive Screening ◽

Severe Cognitive Impairment ◽

Post Stroke ◽

Increased Risk

Introduction: Post-stroke cognitive impairment (PSCI) has a considerable impact on patients and society. However, the characteristics and prevalence of long-term PSCI may be influenced by assessment methods and selection bias. We therefore used two cognitive screening methods to assess PSCI in ten-year stroke survivors, made comparisons with non-stroke individuals, and compared these screening methods. Methods: The Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were administered and compared in a population-based consecutive sample of ten-year stroke survivors. In addition, age- and sex-matched non-stroke controls were assessed with the MMSE. Regression analyses adjusting for education compared the stroke survivors’ MMSE performance with the controls. Moderate/severe cognitive impairment, approximating to dementia, was defined using MMSE<24 and MoCA<20 as cut-offs. To detect those with mild cognitive impairment, alternative cut-offs of MMSE<27 and MoCA<25 were also used. Results: In total, 127 of 145 stroke survivors participated. The total MMSE-scores were similar for stroke survivors (median 27) and 354 controls (median 27; p =0.922); as well as proportions with MMSE<24 (23% vs. 17%; p =0.175) or MMSE<27 (47% vs. 49%; p =0.671). After adjustment for education, stroke survivors showed an increased risk for moderate/severe cognitive impairment defined by MMSE<24 (OR=1.82; p =0.036). Executive dysfunction was seen in 42% of the stroke survivors vs. 16% of the controls as evaluated by MMSE ( p <0.001). According to MoCA, moderate/severe cognitive impairment (MoCA<20) was observed in 28% of the stroke survivors; any degree of cognitive impairment (MoCA<25) was seen in 61%; and 45-61% displayed executive function deficits. Conclusions: PSCI including executive dysfunction is common among ten-year stroke survivors, who have an increased risk of moderate/severe cognitive impairment compared to non-stroke controls. The prevalence of long-term PSCI may have been previously underestimated, and MoCA may be more suitable for post-stroke cognitive assessment.

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Abstract TMP45: Predicting Long-term Body Function, Activity & Participation After Stroke: The Prevailing Role of Cognition in Determining Functional Outcome

Stroke ◽

10.1161/str.48.suppl_1.tmp45 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Arunima Kapoor ◽

Krista Lanctot ◽

Mark Bayley ◽

Alex Kiss ◽

Richard Swartz

Keyword(s):

Cognitive Impairment ◽

Functional Outcome ◽

Stroke Severity ◽

Post Stroke ◽

Body Function ◽

Multiple Levels ◽

Multiple Domains ◽

Levels Of Functioning ◽

The Impact

Background: Stroke can impact multiple levels of function and result in complex disability. Few studies have examined limitations across the range of functions from body function to social participation, or explored the impact of post-stroke comorbidities, such as depression, obstructive sleep apnea (OSA) and cognition, on function, especially in the long-term. We aimed to determine post-stroke predictors of multiple levels of functioning approximately 2 years after a stroke, and to specifically evaluate the impact of depressive symptoms, OSA and cognitive impairment on outcome. Hypothesis: We hypothesized that in addition to traditional predictors of outcome–age and stroke severity–depression, OSA and cognitive impairment will predict functional outcome in multiple domains. Methods: Baseline assessment of depression, apnea and cognitive impairment with 2-year follow-up assessment of functional outcome to evaluate each of the three levels of functioning as stated in the WHO International Classification of Functioning: Body Function (Montreal Cognitive Assessment), Activity (modified Rankin) and Participation (Reintegration to Normal Living Index). Results: A total of 162 patients were enrolled at approximately 2 years and 5 months post-stroke. Forty one percent had activity limitations, 58% were cognitively impaired and 68% had restrictions in participation. Long-term activity limitation was predicted by greater age (OR = 0.95), stroke severity (OR = 1.69) and cognitive impairment (OR = 1.28) at baseline. Body function impairment was predicted by greater age (OR = 0.96), and cognitive impairment (OR = 1.49). Participation restriction was predicted by cognitive impairment (OR = 1.26). Conclusion: Baseline cognition predicts long-term function in multiple domains and is a better predictor of long-term participation than age or baseline stroke severity. In view of the widespread impact of post-stroke cognitive impairment on every level of functioning, routine post-stroke cognitive screening and target interventions are warranted. Greater attention to functional domains beyond activity could further optimize recovery and enhance outcome after stroke.

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Abstract WP141: Identifying Modifiable Predictors of Long-term Functional Outcome After Stroke

Stroke ◽

10.1161/str.47.suppl_1.wp141 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Arunima Kapoor ◽

Richard Swartz ◽

Krista Lanctot ◽

Mark Bayley ◽

Alex Kiss

Keyword(s):

Cognitive Impairment ◽

Sleep Apnea ◽

Functional Outcomes ◽

Stroke Severity ◽

Stroke Patients ◽

Long Term Outcomes ◽

Post Stroke ◽

Baseline Visit ◽

Modifiable Factors

Introduction: Disability is often an assumed and accepted consequence of stroke. Post-stroke disability is frequently attributed to demographic risk factors such as age and stroke severity. These factors cannot explain all the variability in stroke outcomes. Other factors, such as post-stroke depression, sleep apnea and cognitive impairment can impact function, and yet their relationships to long-term outcomes are rarely assessed. The primary purpose of our research is to understand the role of these potentially modifiable factors in predicting long-term post-stroke functional outcomes. Hypothesis: Stroke patients who screen positive for depression, sleep apnea or cognitive impairment at baseline will have significantly worse long-term functional outcome. Methods: A follow up outcome assessment of stroke patients is being conducted by telephone 2-3 years after an initial baseline visit where their risk of depression, sleep apnea and cognitive impairment was assessed. Baseline predictors such as age and stroke severity are also abstracted from their baseline visit. Assessment measures were selected to evaluate numerous levels of human functioning and include the following: modified Rankin Scale, MoCA, Barthel Index, Frenchay Activites Index and Reintegration to Normal Living Index. The primary outcome is mRS Score, with a score ≥ 2 indicating poor outcome. Results: Seventy six patients have been enrolled in our study and projected enrolled of another 100 patients should be complete by December 2015. Based on preliminary data, our prognostic logistic regression model including only stroke severity and age is statistically significant, χ2(2)= 29.06, p < 0.001. This model explains 42.7% (Nagelkerke R2) of the variance in long-term outcomes and correctly classifies outcome in 78.9% of patients. Future analyses with the full sample size and addition of potentially modifiable factors will verify whether these factors increase the predictive value of our prognostic model. Conclusion: By identifying modifiable factors related to poor functional outcomes, this study may allow the development of novel interventions to alter the trajectory of this vulnerable population to help optimize long-term function after stroke.

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Persistent cognitive impairment associated with cerebrospinal fluid anti-SARS-CoV-2 antibodies six months after mild COVID-19

Neurological Research and Practice ◽

10.1186/s42466-021-00135-y ◽

2021 ◽

Vol 3 (1) ◽

Author(s):

Max Borsche ◽

Dirk Reichel ◽

Anja Fellbrich ◽

Anne S. Lixenfeld ◽

Johann Rahmöller ◽

...

Keyword(s):

Central Nervous System ◽

Cerebrospinal Fluid ◽

Nervous System ◽

Cognitive Impairment ◽

Female Patient ◽

Acute Phase ◽

Neuropsychological Testing ◽

Important Challenge ◽

Central Nervous System Invasion

AbstractNeurological long-term sequelae are increasingly considered an important challenge in the recent COVID-19 pandemic. However, most evidence for neurological symptoms after SARS-CoV-2 infection and central nervous system invasion of the virus stems from individuals severely affected in the acute phase of the disease. Here, we report long-lasting cognitive impairment along with persistent cerebrospinal fluid anti-SARS-CoV-2 antibodies in a female patient with unremarkable standard examination 6 months after mild COVID-19, supporting the implementation of neuropsychological testing and specific cerebrospinal fluid investigation also in patients with a relatively mild acute disease phase.

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Association of Depression and Anxiety With Cognitive Impairment 6 Months After Stroke

Neurology ◽

10.1212/wnl.0000000000011748 ◽

2021 ◽

pp. 10.1212/WNL.0000000000011748

Author(s):

Owen A Williams ◽

Nele Demeyere

Keyword(s):

Cognitive Impairment ◽

Acute Stroke ◽

Spatial Attention ◽

Anxiety Symptoms ◽

Cognitive Domain ◽

Stroke Severity ◽

Depression And Anxiety ◽

Post Stroke ◽

Domain Specific ◽

Post Stroke Depression

Objective:Investigate the associations between general cognitive impairment and domain specific cognitive impairment with post-stroke depression and anxiety at six-months post-stroke.Methods:Participants were confirmed acute stroke patients from the OCS-CARE study who were recruited on stroke wards in a multi-site study and followed up at a 6 months post-stroke assessment. Depression and anxiety symptoms were assessed by the Hospital Anxiety and Depression Scale sub-scales, with scores greater than seven indicating possible mood disorders. General cognitive impairment at follow-up was assessed using the Montreal Cognitive Assessment, stroke-specific cognitive domain impairments was assessed using the Oxford Cognitive Screen. Linear regression was used to examine the associations between cognition and depression/anxiety symptoms at 6-months, controlling for acute-stroke severity and ADL-impairment, age, sex, education, and co-occurring post-stroke depression/anxiety.Results:437 participants mean age=69.28 years (S.D.=12.17), 226 male (51.72%), were included in analyses. Six-month post-stroke depression (n=115, 26%) was associated with six-month impairment on the MoCA (beta [b] =0.96, standard error [SE] =0.31, p=0.006), and all individual domains assessed by the OCS: spatial attention (b=0.67, SE=0.33, p =0.041), executive function (b=1.37, SE=0.47, p=0.004), language processing (b=0.87, SE=0.38, p=0.028), memory (b=0.76, SE=0.37, p=0.040), number processing (b=1.13, SE=0.40, p=0.005), praxis (b=1.16, SE =0.49, p=0.028). Post-stroke anxiety (n=133, 30%) was associated with impairment on the MoCA (b=1.47, SE=0.42, p=0.001), and spatial attention (b=1.25, SE=0.45, p=0.006), these associations did not remain significant after controlling for co-occurring post-stroke depression.Conclusion:Domain-general and domain-specific post-stroke cognitive impairment was found to be highly related to depressive symptomatology but not anxiety symptomatology.

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Association among depression, cognitive impairment and executive dysfunction after stroke

Dementia & Neuropsychologia ◽

10.1590/s1980-57642012dn06030007 ◽

2012 ◽

Vol 6 (3) ◽

pp. 152-157 ◽

Cited By ~ 13

Author(s):

Luisa Terroni ◽

Matildes F.M. Sobreiro ◽

Adriana B. Conforto ◽

Carla C. Adda ◽

Valeri D. Guajardo ◽

...

Keyword(s):

Cognitive Impairment ◽

Neuropsychological Tests ◽

Executive Dysfunction ◽

Stroke Survivors ◽

Stroke Patients ◽

Adequate Treatment ◽

Post Stroke ◽

Quantitative Studies ◽

Post Stroke Depression ◽

The Relationship

ABSTRACT The relationship between depression and cognitive impairment, frequent after stroke, is complex and has not been sufficiently elucidated. Objective: To review the relationship between post-stroke depression and cognitive impairment. Methods: We performed a PubMed database search spanning the last ten years, using the terms post-stroke depression, cognitive dysfunction, cognitive impairment and neuropsychological tests. Our target studies were original quantitative studies that investigated the relationship between post-stroke depression (PSD) and cognitive impairment in stroke patients. Articles published in English, Spanish, Italian and Portuguese were considered. Selection criteria were the use of neuropsychological tests to assess cognitive function, and of either instruments to diagnose major depression, or scales to assess depressive symptoms, within the first three months after stroke. Results: Six original quantitative studies fulfilled the criteria. The prevalence of PSD within the first three months after stroke ranged from 22% to 31%. Incidence ranged from 25% to 27% and was evaluated in only two studies. PSD was associated with increased cognitive impairment. Cognitive impairment was reported in 35.2% to 87% of the patients. Post-stroke cognitive deficits were reported mostly in executive function, memory, language, and speed of processing. Conclusion: Executive dysfunction and depression occur in stroke survivors, are frequently coexistent, and also associated with worse stroke prognosis. Healthcare professionals need to address and provide adequate treatment for depression and executive dysfunctions in stroke patients early in the first three months after stroke. Future studies should evaluate the efficacy of programs evaluating the early detection and treatment of PSD and executive dysfunction in stroke survivors.

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The Impact of Pre- and Post-Stroke Statin Use on Stroke Severity and Long-Term Outcomes: A Population-Based Cohort Study

Cerebrovascular Diseases ◽

10.1159/000501543 ◽

2019 ◽

Vol 47 (5-6) ◽

pp. 260-267 ◽

Cited By ~ 1

Author(s):

Clare Flach ◽

Maria Elstad ◽

Walter Muruet ◽

Charles D.A. Wolfe ◽

Anthony G. Rudd ◽

...

Keyword(s):

Population Based ◽

Stroke Recurrence ◽

Stroke Severity ◽

Stroke Incidence ◽

Post Stroke ◽

Improvement Programs ◽

The Impact ◽

The Relationship ◽

Statin Use

Background: The benefit of statins on stroke incidence is well known. However, data on the relationship between pre- and post-stroke statin use, recurrence, and survival outcomes are limited. We aim to investigate the short- and long-term relationships between statin prescription, stroke recurrence, and survival in patients with first-ever ischemic stroke. Methods: Data were collected from the population-based South London Stroke Register for the years 1995–2015. Patients were assessed at the time of first ever stroke, 3 months, and annually thereafter. Data on vascular risk factors, treatments prescribed, sociodemographic characteristics, stroke subtype, survival, and stroke recurrence were collected. Cox proportional hazard analyses were used to assess the relationship of statin prescriptions pre- and post-stroke on stroke severity, long-term recurrence and survival. Results: Patients prescribed statins both pre- and post-stroke showed a 24% reduction in mortality (adjusted Hazard Ratio [aHR] 0.76, 0.60–0.97), those who were prescribed statins pre-stroke and then stopped post-stroke showed greater risk of mortality (aHR 1.85, 1.10–3.12) and stroke recurrence (aHR 3.25, 1.35–7.84) compared to those that were not prescribed statins at any time. No associations were observed between pre-stroke statin and severity of the initial stroke overall, though a protective effect against moderate/severe stroke (Glasgow Coma Scale ≤12) was observed in those aged 75+ years (aOR 0.70, 0.52–0.95). Conclusions: Statins play a significant role in improving the survival rates after a stroke. Adherence to the National Guidelines that promote statin treatment, primary and secondary prevention of stroke should be monitored and a focus for quality improvement programs.

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Tracking elemental changes in an ischemic stroke model with X-ray fluorescence imaging

Scientific Reports ◽

10.1038/s41598-020-74698-2 ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

M. J. Pushie ◽

N. J. Sylvain ◽

H. Hou ◽

S. Caine ◽

M. J. Hackett ◽

...

Keyword(s):

Cellular Response ◽

Time Course ◽

Parameter Method ◽

Stroke Severity ◽

Stroke Model ◽

Post Stroke ◽

Cellular Events ◽

Developed Nations ◽

The Brain

Abstract Stroke is a leading cause of long-term disability in adults and a leading cause of death in developed nations. The cascade of cellular events and signalling that occur after cerebral ischemia are complex, however, analyzing global element markers of metabolic state affords the means to monitor stroke severity, status of injury, and recovery. These markers provide a multi-parameter method for assessing changes through the post-stroke time course. We employ synchrotron-based elemental mapping to follow elemental changes in the brain at 1 h, 1-, 2-, and 3-days, and at 1-, 2-, 3-, and 4-weeks post-stroke in a photothrombotic stroke model in mice. Our analysis reveals a highly consistent metabolic penumbra that can be readily identified based on the level of dysregulated potassium and other key elements. Maps of elemental distributions are also useful to demarcate events in the cellular response to the inflammatory cascade, including ion dysregulation, recruitment of cells to the lesion, and glial scar formation.

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Post-stroke depression, obstructive sleep apnea, and cognitive impairment: Rationale for, and barriers to, routine screening

International Journal of Stroke ◽

10.1177/1747493016641968 ◽

2016 ◽

Vol 11 (5) ◽

pp. 509-518 ◽

Cited By ~ 33

Author(s):

Richard H Swartz ◽

Mark Bayley ◽

Krista L Lanctôt ◽

Brian J Murray ◽

Megan L Cayley ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Cognitive Impairment ◽

Sleep Apnea ◽

Routine Screening ◽

Screening Tools ◽

Stroke Recurrence ◽

Post Stroke ◽

Obstructive Sleep ◽

Post Stroke Depression ◽

The Impact

Stroke can cause neurological impairment ranging from mild to severe, but the impact of stroke extends beyond the initial brain injury to include a complex interplay of devastating comorbidities including: post-stroke depression, obstructive sleep apnea, and cognitive impairment (“DOC”). We reviewed the frequency, impact, and treatment options for each DOC condition. We then used the Ottawa Model of Research Use to examine gaps in care, understand the barriers to knowledge translation, identification, and addressing these important post-stroke comorbidities. Each of the DOC conditions is common and result in poorer recovery, greater functional impairment, increased stroke recurrence and mortality, even after accounting for traditional vascular risk factors. Despite the strong relationships between DOC comorbidities and these negative outcomes as well as recommendations for screening based on best practice recommendations from several countries, they are frequently not assessed. Barriers related to the nature of the screening tools (e.g., time consuming in high-volume clinics), practice environment (e.g., lack of human resources or space), as well as potential adopters (e.g., equipoise surrounding the benefits of treatment for these conditions) pose challenges to routine screening implementation. Simple, feasible approaches to routine screening coupled with appropriate, evidence-based treatment protocols are required to better identify and manage depression, obstructive sleep apnea, and cognitive impairment symptoms in stroke prevention clinic patients to reduce the impact of these important post-stroke comorbidities. These tools may in turn facilitate large-scale randomized controlled treatment trials of interventions for DOC conditions that may help to improve cardiovascular outcomes after stroke or TIA.

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Progression of mild cognitive impairment to dementia: a challenge to current thinking

The British Journal of Psychiatry ◽

10.1192/bjp.bp.105.014779 ◽

2006 ◽

Vol 189 (5) ◽

pp. 399-404 ◽

Cited By ~ 65

Author(s):

Anja Busse ◽

Matthias C. Angermeyer ◽

Steffi G. Riedel-Heller

Keyword(s):

Cognitive Impairment ◽

Mild Cognitive Impairment ◽

Community Sample ◽

Neuropsychological Testing ◽

Time Dependent ◽

Current Thinking ◽

Conversion Rates ◽

Over Time ◽

Long Term Studies

BackgroundStudies of conversion from mild cognitive impairment to dementia suggest a linear progression over time. Conversion rates during lifetime may extend to 80–90%.AimsThis study examines the time-dependent evolution from mild cognitive impairment to dementia. Current assumptions regarding yearly and lifetime conversion rates are challenged.MethodA community sample of 1045 dementia-free individuals aged 75 years and over was examined by neuropsychological testing based on 6 years of observation.ResultsApproximately 60–65% of people with mild cognitive impairment develop clinical dementia during their life. Progression from mild cognitive impairment to dementia appears to be time dependent, occurring primarily within the initial 18 months.ConclusionsFurther long-term studies are needed to examine the time-dependent evolution from mild cognitive impairment to dementia and to establish age-specific conversion rates during lifetime.

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