Dimensions of Poststroke Depression and Neuropsychological Deficits in Older Adults

Depressive symptoms profile and dementia risk after spontaneous intracerebral haemorrhage

INTRODUCTION

Depressive symptoms are commonly reported after spontaneous intracerebral haemorrhage (ICH) and frequently associated with cognitive decline. Using hierarchical clustering analysis (HCA), we aimed to identify different post-ICH depressive symptoms profiles and to evaluate their association with dementia risk.

METHODS

We included consecutive patients from the prospective Prognosis of Intracerebral Haemorrhage (PITCH) study who survived 6 months after the ICH. We performed HCA using depressive symptoms severity (assessed using the Montgomery-Åsberg Depression Rating Scale (MADRS)), along with the presence of apathy and anxiety (screened using Neuropsychiatric Inventory questionnaire). Baseline clinical/neuroimaging characteristics and risk of incident dementia were compared between different profiles using univariate and multivariable models.

RESULTS

Of 265 six-month ICH survivors, 221 (83%) underwent neuropsychiatric screening (mean age 65.5 years; 57% male). Using HCA, 3 profiles were identified: (1) without significant depressive symptoms (n = 152; median MADRS score = 2 [IQR 0-4]); (2) depressive symptoms with predominant apathy (n = 41; median MADRS score = 15 [IQR 5-20], 68% with apathy); (3) depressive symptoms profile with predominant anxiety (n = 28; median MADRS score = 17 [IQR 9-25]; 100% with anxiety). Compared to patients without depressive symptoms, patients with depressive symptoms and predominant apathy (but not those with predominant anxiety) were more likely to have cerebral atrophy (OR = 2.4, 95% CI = 1.4-4.2) and had significantly higher long-term new-onset dementia risk (adjusted hazard ratio = 2.2, 95% CI = 1.3-3.8).

CONCLUSION

Screening for apathy and anxiety on top of depressive symptoms might help identifying patients at risk for dementia. Future studies on treatment should account for different post-ICH depressive symptoms profiles that may impact on cognitive function.

Factor structure and reliability of the symptom measurement of post-stroke depression in the rehabilitation stage

BACKGROUND

The incidence of Post Stroke Depression (PSD) in the Rehabilitation Stage is high, which can bring serious physical and psychological disorders to patients. However, there is still a lack of targeted tools for screening PSD in the rehabilitation stage. Therefore, the aim of this study was to evaluate the factor structure and reliability of a measurement instrument to screen for PSD in the rehabilitation stage.

METHODS

A cross-sectional study was conducted on 780 hospitalized stroke patients who were within the rehabilitation stage from May to August 2020. Exploratory factor analysis (EFA) as well as first- and second-order confirmatory factor analysis (CFA) were performed to evaluate the factor structure of the newly developed Symptom Measurement of Post-Stroke Depression in the Rehabilitation Stage (SMPSD-RS). The reliability and validity of the SMPSD-RS were also verified using several statistical methods.

RESULTS

EFA extracted a 24-item, five-factor (cognition, sleep, behavior, emotion, and obsession) model that can clinically explain the symptoms of PSD during the rehabilitation stage. A first-order CFA confirmed the EFA model with good model fit indices, and the second-order CFA further confirmed the five-factor structure model and showed acceptable model fit indices. Acceptable reliability and validity were also achieved by the corresponding indicators.

CONCLUSION

The SMPSD-RS was proven to have a stable factor structure and was confirmed to be reliable and valid for assessing PSD symptoms in stroke patients during the rehabilitation stage.

Pathophysiology, Assessment, and Management of Post-Stroke Cognitive Impairment, Depression, and Fatigue

Post-stroke cognitive impairment, depression, and fatigue are common, persistent, and disabling. This review summarizes current knowledge on the pathophysiology, assessment, and management of these debilitating neuropsychiatric sequelae of stroke. We briefly review evolving knowledge on the neural mechanisms and risk factors for each condition. We describe patient-reported outcome measures and clinician rating techniques that can be used to assist in screening and comprehensive assessment. We then discuss behavioral and pharmacologic management strategies. Heterogeneity of stroke remains a challenge in management and new research is still needed to optimize and personalize treatments for stroke survivors.

Neuroimaging of neuropsychological disturbances following ischaemic stroke (CONNECT): a prospective cohort study protocol

INTRODUCTION

Neuropsychiatric distubance is a common clinical manifestation in acute ischemic stroke. However, it is frequently overlooked by clinicians. This study aimed to explore the possible aetiology and pathogenesis of neuropsychiatric disturbances following ischaemic stroke (NDIS) from an anatomical and functional perspective with the help of neuroimaging methods.

METHOD AND ANALYSIS

CONNECT is a prospective cohort study of neuroimaging and its functional outcome in NDIS. We aim to enrol a minimum of 300 individuals with first-ever stroke. The neuropsychological disturbances involved in this study include depression, anxiety disorder, headache, apathy, insomnia, fatigue and cognitive impairment. Using scales that have been shown to be effective in assessing the above symptoms, the NDIS evaluation battery requires at least 2 hours at baseline. Moreover, all patients will be required to complete 2 years of follow-up, during which the NDIS will be re-evaluated at 3 months, 12 months and 24 months by telephone and 6 months by outpatient interview after the index stroke. The primary outcome of our study is the incidence of NDIS at the 6-month mark. Secondary outcomes are related to the severity of NDIS as well as functional rehabilitation of patients. Functional imaging evaluation will be performed at baseline and 6-month follow-up using specific sequences including resting-state functional MRI, diffusion tensor imaging, T1-weighted imaging, T2-weighted imaging, diffusion-weighted imaging, arterial spin labelling, quantitative susceptibility mapping and fluid-attenuated inversion recovery imaging. In addition, we collect haematological information from patients to explore potential biological and genetic markers of NDIS through histological analysis.

ETHICS AND DISSEMINATION

The CONNECT Study was approved by the Ethics Review Committee of the First Hospital of the University of Science and Technology of China (2021-ky012) and written informed consent will be obtained from all participants. Results will be disseminated via a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2100043886.

A Review on Motor Imagery with Transcranial Alternating Current Stimulation: Bridging Motor and Cognitive Welfare for Patient Rehabilitation

Research has shown the effectiveness of motor imagery in patient motor rehabilitation. Transcranial electrical stimulation has also demonstrated to improve patient motor and non-motor performance. However, mixed findings from motor imagery studies that involved transcranial electrical stimulation suggest that current experimental protocols can be further improved towards a unified design for consistent and effective results. This paper aims to review, with some clinical and neuroscientific findings from literature as support, studies of motor imagery coupled with different types of transcranial electrical stimulation and their experiments onhealthy and patient subjects. This review also includes the cognitive domains of working memory, attention, and fatigue, which are important for designing consistent and effective therapy protocols. Finally, we propose a theoretical all-inclusive framework that synergizes the three cognitive domains with motor imagery and transcranial electrical stimulation for patient rehabilitation, which holds promise of benefiting patients suffering from neuromuscular and cognitive disorders.

Rest-Activity Rhythm Characteristics Associated With Depression Symptoms in Stroke Survivors

OBJECTIVE

To examine which 24-hour rest-activity rhythm (RAR) characteristics are associated with depression symptoms in stroke survivors.

DESIGN

Cross-sectional observational study examining associations of RAR characteristics with the presence of depression symptoms adjusting for age, sex, race, and medical comorbidity.

SETTING

Community setting.

PARTICIPANTS

Stroke survivors: (1) recruited locally (N women=35, N men=28) and (2) a nationally representative probability sample (the National Health and Nutrition Examination Survey [NHANES]; N women=156, N men=124).

INTERVENTIONS

None.

MEASUREMENTS

Objective RAR characteristics derived from accelerometer recordings including activity onset/offset times and non-parametric measures of RAR strength (relative amplitude), stability (interdaily stability), and fragmentation (intradaily variability). The presence of depression symptoms was categorized using Patient Health Questionnaire scores.

RESULTS

In both samples, the only RAR characteristic associated with depression symptoms was intradaily variability (fragmentation): local sample, odds ratio=1.96 [95% confidence interval=1.05-3.63]; NHANES sample, odds ratio=1.34, [95% confidence interval=1.01-1.78]). In the NHANES sample, which included both mild and moderate/severe depression, the association between 24-hour sleep-wake fragmentation and depression symptoms was driven by moderate-to-severe cases.

CONCLUSIONS

Stroke survivors with higher levels of RAR fragmentation were more likely to have depression symptoms in both samples. These findings have implications, given prior studies in general samples linking RAR fragmentation with future depression and dementia risk. Research is needed to establish the potential consequences, mechanisms, and modifiability of RAR fragmentation in stroke survivors.

The Impact of Post-Stroke Depressive Symptoms on Cognitive Performance in Women and in Men: A 4 Month Prospective Study

Background: Depressive symptoms have been associated with cognitive impairment after stroke, and women may be specifically affected. Objective: The aim of this study was to investigate gender-specific characteristics in the relationship between changes in depression severity and changes in cognitive performance after stroke. Methods: We prospectively evaluated 73 patients without a previous history of depression in the first and fourth months after a first ischemic stroke. The severity of depressive symptoms was assessed using the 31-item version of the Hamilton Rating Scale for Depression, and executive function, attention, working memory, and verbal fluency were assessed using a neuropsychological battery. Results: We included 46 (63.0%) men and 27 (36.9%) women, with mean ages of 55.2 (SD ± 15.1) and 46.8 (SD ± 14.7) years, respectively. We found significant improvement in the digit span forward and Stroop dots from month 1 to month 4 post stroke for both men and women. Women, but not men, presented a correlation between changes in phonemic verbal fluency and changes in the 31-item version of the Hamilton Rating Scale for Depression scores. Improvement in depression was correlated with improvement in verbal fluency, and worsening in depression was correlated with worsening in verbal fluency. Conclusions: Our results suggest that women might be more vulnerable to the relationship between depressive symptoms and cognitive performance, and improvement of depression may be necessary for women's improvement in phonemic verbal fluency from the first to the fourth month after a stroke. We did not adjust the results for multiple comparisons. Thus, our findings might be considered preliminary, and confirmatory studies, also focusing on specific characteristics of women that could explain these differences, are warranted.

Does fluoxetine reduce apathetic and depressive symptoms after stroke? An analysis of the Efficacy oF Fluoxetine-a randomized Controlled Trial in Stroke trial data set

OBJECTIVE

Apathy is a common and disabling symptom after stroke with no proven treatments. Selective serotonin reuptake inhibitors are widely used to treat depressive symptoms post-stroke but whether they reduce apathetic symptoms is unknown. We determined the effect of fluoxetine on post-stroke apathy in a post hoc analysis of the EFFECTS (Efficacy oF Fluoxetine-a randomized Controlled Trial in Stroke) trial.

METHODS

EFFECTS enrolled patients ⩾18 years between 2 and 15 days after stroke onset. Participants were randomly assigned to receive oral fluoxetine 20 mg once daily or matching placebo for 6 months. The Montgomery-Åsberg Depression Rating Scale (MADRS) was administered at baseline and 6 months. Individual items on this scale were divided into those reflecting symptoms of apathy and depression. Symptoms were compared between fluoxetine and placebo groups.

RESULTS

Of 1500 participants enrolled, complete MADRS data were available for 1369. The modified intention-to-treat population included 681 patients in the fluoxetine group and 688 in the placebo group. Confirmatory factor analysis revealed that apathetic, depressive, and anhedonic symptoms were dissociable. Apathy scores increased in both fluoxetine and placebo groups (both p ⩽ 0.00001). In contrast, fluoxetine was associated with a reduction in depressive scores (p = 0.002).

CONCLUSION

Post-stroke apathetic and depressive symptoms respond differently to fluoxetine treatment. Our analysis suggests fluoxetine is ineffective in preventing post-stroke apathy.

Motivation as a Measurable Outcome in Stroke Rehabilitation: A Systematic Review of the Literature

Motivated behaviours are thought to lead to enhanced performances. In the neurorehabilitation field, motivation has been demonstrated to be a link between cognition and motor performance, therefore playing an important role upon rehabilitation outcome determining factors. While motivation-enhancing interventions have been frequently investigated, a common and reliable motivation assessment strategy has not been established yet. This review aims to systematically explore and provide a comparison among the existing motivation assessment tools concerning stroke rehabilitation. For this purpose, a literature search (PubMed and Google Scholar) was performed, using the following Medical Subject Headings terms: "assessment" OR "scale" AND "motivation" AND "stroke" AND "rehabilitation". In all, 31 randomized clinical trials and 15 clinical trials were examined. The existing assessment tools can be grouped into two categories: the first mirroring the trade-off between patients and rehabilitation, the latter reflecting the link between patients and interventions. Furthermore, we presented assessment tools which reflect participation level or apathy, as an indirect index of motivation. In conclusion, we are left to put forth a possible common motivation assessment strategy, which might provide valuable incentive to investigate in future research.

The effect of action modules on resilience and psychological health of stroke patients: A pilot non-randomised control trial

AIMS AND OBJECTIVES

To determine whether interventions that use the Specific Thematic Nursing Care Action Modules (STNC-AM) platform improve patients' psychological health over a two-month period.

BACKGROUND

Stroke survivors often are left with a disability after a stroke, which can have an impact on their physical and mental health. Therefore, it is necessary for stroke patients to have tailored programmes in the face of post-stroke mental health concerns and the need for care information.

DESIGN

A non-randomised controlled pilot study was conducted.

METHODS

Participants included 44 post-stroke patients at a medical university hospital, between 1 August 2019-28 February 2021, of whom 24 were assigned to the control group and 20 were assigned to the intervention (STNC-AM). Data were analysed on an intention-to-treat basis. We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Checklist (case-control studies) for this study.

RESULTS

There were no statistical differences between the two groups at baseline. At the end of two months, however, the scores for resilience, depression and positive factors illness representation were statistically different between the two groups (p < .05). The results of the generalised estimating equation model analysis indicated that resilience and anxiety remained more significant in decreasing depression in the intervention group than in the control group.

CONCLUSION

This preliminary trial suggests that, although action modules may be associated with a decrease in depression post-stroke, part of this effect was likely associated with an increase in resilience and a decrease in anxiety of the patients.

RELEVANCE TO CLINICAL PRACTICE

The STNC-AM platform provides a coaching platform that helps patients and caregivers to be effective and accessible.

Longitudinal Trajectories of Post-Stroke Depression Symptom Subgroups

BACKGROUND

Post-stroke depressive symptoms are prevalent and impairing, and elucidating their course and risk factors is critical for reducing their public health burden. Previous studies have examined the course of post-stroke depression, but distinct depressive symptom dimensions (eg, somatic symptoms, negative affect [eg, sadness], anhedonia [eg, loss of interest]) may vary differently over time.

OBJECTIVE

The present study examined within-person and between-person associations between depressive symptom dimensions across 3 timepoints in the year following discharge from in-patient rehabilitation hospitals, as well as the impact of multiple clinical variables (eg, aphasia).

METHODS

Stroke survivors completed the Center for Epidemiologic Depression Scale (CES-D) at discharge from post-stroke rehabilitation ("T1") and at 3-month ("T2") and 12-month ("T3") follow-ups. Scores on previously identified CES-D subscales (somatic symptoms, anhedonia, and negative affect) were calculated at each timepoint. Random intercept cross-lagged panel model analysis examined associations between symptom dimensions while disaggregating within-person and between-person effects.

RESULTS

There were reciprocal, within-person associations between somatic symptoms and anhedonia from T1 to T2 and from T2 to T3. Neither dimension was predictive of, or predicted by negative affect.

CONCLUSIONS

The reciprocal associations between somatic symptoms and anhedonia may reflect a "vicious cycle," and suggest these 2 symptom dimensions may be useful indicators of risk and/or intervention targets. Regularly assessing depression symptoms starting during inpatient rehabilitation may help identify stroke survivors at risk for depression symptoms and facilitate early intervention.

The Structural and Functional Neuroanatomy of Post-Stroke Depression and Executive Dysfunction: A Review of Neuroimaging Findings and Implications for Treatment

Post-stroke depression and executive dysfunction co-occur and are highly debilitating. Few treatments alleviate both depression and executive dysfunction after stroke. Understanding the brain network changes underlying post-stroke depression with executive dysfunction can inform the development of targeted and efficacious treatment. In this review, we synthesize neuroimaging findings in post-stroke depression and post-stroke executive dysfunction and highlight the network commonalities that may underlie this comorbidity. Structural and functional alterations in the cognitive control network, salience network, and default mode network are associated with depression and executive dysfunction after stroke. Specifically, post-stroke depression and executive dysfunction are both linked to changes in intrinsic functional connectivity within resting state networks, functional over-connectivity between the default mode and salience/cognitive control networks, and reduced cross-hemispheric frontoparietal functional connectivity. Cognitive training and noninvasive brain stimulation targeted at these brain network abnormalities and specific clinical phenotypes may help advance treatment for post-stroke depression with executive dysfunction.

Exploring the Use of Brain-Computer Interfaces in Stroke Neurorehabilitation

With the continuous development of artificial intelligence technology, "brain-computer interfaces" are gradually entering the field of medical rehabilitation. As a result, brain-computer interfaces (BCIs) have been included in many countries' strategic plans for innovating this field, and subsequently, major funding and talent have been invested in this technology. In neurological rehabilitation for stroke patients, the use of BCIs opens up a new chapter in "top-down" rehabilitation. In our study, we first reviewed the latest BCI technologies, then presented recent research advances and landmark findings in BCI-based neurorehabilitation for stroke patients. Neurorehabilitation was focused on the areas of motor, sensory, speech, cognitive, and environmental interactions. Finally, we summarized the shortcomings of BCI use in the field of stroke neurorehabilitation and the prospects for BCI technology development for rehabilitation.

Prognosis of stroke upper limb recovery with physiological variables using regression tree ensembles

Objective.This study assesses upper limb recovery prognosis after stroke with solely physiological information, which can provide an objective estimation of recovery.Approach.Clinical recovery was forecasted using EEG-derived Event-Related Desynchronization/Synchronization and coherence, in addition to Transcranial Magnetic Stimulation elicited motor-evoked potentials and upper limb grip and pinch strength. A Regression Tree Ensemble predicted clinical recovery of a stroke database (n= 10) measured after a two-month intervention with the Fugl-Meyer Assessment for the Upper Extremity (FMA-UE) and the Action Research Arm Test (ARAT).Main results.There were no significant differences between predicted and actual outcomes with FMA-UE (p= 0.29) and ARAT (p= 0.5). Median prediction error for FMA-UE and ARAT were of 0.3 (IQR = 6.2) and 3.4 (IQR = 9.4) points, respectively. Predictions with the most pronounced errors were due to an underestimation of high upper limb recovery. The best features for FMA-UE prediction included mostly beta activity over the sensorimotor cortex. Best ARAT prediction features were cortical beta activity, corticospinal tract integrity of the unaffected hemisphere, and upper limb strength.Significance.Results highlighted the importance of measuring cortical activity related to motor control processes, the unaffected hemisphere's integrity, and upper limb strength for prognosis. It was also implied that stroke upper limb recovery prediction is feasible using solely physiological variables with a Regression Tree Ensemble, which can also be used to analyze physiological relationships with recovery.