Personality traits and course of symptoms of depression and apathy after stroke: Results of the CASPER study

Stroke Severity, Caregiver Feedback, and Cognition in the REGARDS-CARES Study

BACKGROUND

Cognitive impairment after stroke is common and is present in up to 60% of survivors. Stroke severity, indicated by both volume and location, is the most consequential predictor of cognitive impairment, with severe strokes predicting higher chances of cognitive impairment. The current investigation examines the associations of 2 stroke severity ratings and a caregiver-report of poststroke functioning with longitudinal cognitive outcomes.

METHODS AND RESULTS

One hundred fifty-seven caregivers and stroke survivor dyads participated in the CARES (Caring for Adults Recovering From the Effects of Stroke) project, an ancillary study of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) national cohort study. The Glasgow Outcome Scale and modified Rankin Scale scores collected at hospitalization discharge were included as 2 primary predictors of cognitive impairment. The number of caregiver-reported problems and impairments at 9 months following stroke were included as a third predictor. Cognition was measured using a biennial telephone battery and included the domains of learning, memory, and executive functioning. Multiple cognitive assessments were analyzed up to 5 years poststroke, controlling for prestroke cognition and demographic variables of the stroke survivor. Separate mixed models showed significant main effects of the Glasgow Outcome Scale (b=0.3380 [95% CI, 0.14-0.5]; P=0.0009), modified Rankin Scale (b=-0.2119 [95% CI, -0.32 to -0.10]; P=0.0002), and caregiver-reported problems (b=-0.0671 [95% CI, -0.09 to -0.04]; P<0.0001) on longitudinal cognitive scores. In a combined model including all 3 predictors, only caregiver-reported problems significantly predicted cognition (b=-0.0480 [95% CI, -0.08 to -0.03]; P<0.0001).

CONCLUSIONS

These findings emphasize the importance of caregiver feedback in predicting cognitive consequences of stroke.

Post-Stroke Depression in Older Adults: An Overview

Detailed data on post-stroke depression (PSD) in older adults are limited in spite of the high vulnerability of this population to stroke. In fact, PSD prevalence in older adults ranges from 16.0 to 43.9%; however, timing and instruments of evaluation often differ significantly across all available studies. The etiology, genetic and inflammatory factors, as well as structural brain alterations, are claimed as part of a multifaceted mechanism of action in PSD onset. Thus, the aim of this narrative review was to further elaborate on the prevalence, etiology, diagnosis, consequences and treatment of PSD in older adults. The consequences of PSD in older adults may be devastating, including a poor functional outcome after rehabilitation and lower medication adherence. In addition, lower quality of life and reduced social participation, higher risk of new stroke, rehospitalization, and mortality have been reported. In this scenario, treating PSD represents a crucial step to prevent these complications. Both pharmacological and non-pharmacological therapies are currently available. The pharmacological treatment utilizes antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TAs) and new multimodal antidepressants (NMAs). Non-pharmacological therapies include psychological interventions and non-invasive brain stimulation techniques, while excluding drug administration. In the general population experiencing PSD, SSRIs (sertraline in particular) are the most prescribed, whereas the combination of antidepressants and psychotherapy is underused. Furthermore, about one-third of patients do not receive treatment for PSD. In regard to older adults with PSD, the possibility of more adverse effects or contraindications to antidepressant prescription due to comorbidities may limit the therapeutic window. Although drugs such as citalopram, escitalopram, sertraline, venlafaxine, and vortioxetine are usually well tolerated by older patients with PSD, the few randomized controlled trials (RCTs) specifically considering older adults with PSD have been conducted with fluoxetine, fluvoxamine, reboxetine, citalopram and nortriptyline, often with very small patient samples. Furthermore, data regarding the results of non-pharmacological therapies are scarce. High-quality RCTs recruiting large samples of older adults are needed in order to better manage PSD in this population. In addition, adequate screening and diagnosis instruments, with reliable timing of evaluation, should be applied.

Depressive Symptoms in Young and Middle-Aged Stroke Patients: A Transition Analysis

BACKGROUND

There is heterogeneity in depressive symptoms. However, latent classes of depressive symptoms and the transition and influences of these in young and middle-aged stroke patients are unclear.

OBJECTIVES

The aim of this study was to identify the latent classes of depressive symptoms and their transition patterns over time and the influencing factors in young and middle-aged stroke patients from stabilization to 6 months after discharge.

METHODS

This is a longitudinal study following the Strengthening the Reporting of Observational Studies in Epidemiology checklist. A total of 272 young and middle-aged stroke participants were recruited from a hospital neurology ward in Henan Province, China. Participants completed a questionnaire on sociodemographic and health information. Latent transition analysis was used to evaluate the transition pattern of latent classes from stabilization to 6 months after discharge and its influencing factors.

RESULTS

One hundred seventy-nine participants were included in the analysis. Three latent classes of depressive symptoms were identified as "mild symptoms," "grief-sleep-fatigue symptoms," and "severe symptoms." Most participants remained in the original latent class from stabilization to 6 months after discharge (probability of 83.8%, 83.8%, and 88.8%). From 3 to 6 months after discharge, the participants with fewer complications were more likely to transition into the mild symptom class.

DISCUSSION

The findings indicate that from stabilization to 6 months after discharge, depressive symptoms in young and middle-aged stroke patients in China transitioned gradually from the severe symptom class to the mild symptom. Patients with fewer numbers of poststroke complications were more likely to transition to the mild symptoms class. Future research should focus on depressive symptoms in early-stage stroke patients and provide sufficient psychological support to patients with a high number of complications.

The prevalence of apathy in stroke patients: A systematic review and meta-analysis

BACKGROUND

Apathy is a frequent neuropsychiatric disorder in stroke patients. However, its prevalence rates have conflicting results across studies. This meta-analysis aimed to estimate the overall prevalence of apathy in stroke patients from 1990 to 2022.

METHODS

PubMed, Web of Science, Embase and PsycINFO were systematically searched to identify relevant articles published from January 1, 1990 to October 29, 2022. Literature quality was assessed with the National Institutes of Health Study Quality Assessment Tool. The pooled prevalence, subgroup analyses and meta-regression were calculated by STATA 16.0.

RESULTS

A total of 39 observational studies involving 5168 stroke patients were eligible for this meta-analysis. The pooled prevalence of apathy in stroke patients was 33.0% (95% CI, 27.6-38.4). Subgroup analyses showed that the pooled prevalence of apathy among stroke patients was higher in Japan (36.6%), China (33.7%) and Turkey (63.5%) compared to that in other countries (30.2%). The pooled prevalence of apathy was higher in ischemic stroke samples (36.1%) than in hemorrhagic stroke samples (14.4%). The pooled prevalence of apathy measured with the Apathy Evaluation Scale (38.3%) was the highest in stroke patients. Meta-regression presented that higher literature quality was significantly associated with lower prevalence, while stroke severity, mean age and female percentage were not significantly associated with the prevalence of apathy in stroke patients.

CONCLUSION

Our findings revealed that the overall prevalence of apathy in stroke patients was 33.0% based on the current evidence. Furthermore, the prevalence was significantly correlated with countries, stroke subtypes, apathy criteria, and literature quality.

Neuroticism is associated with increase in depression symptoms over time in older adults with type 2 diabetes

OBJECTIVES

The likelihood of depression symptoms in those with type 2 diabetes (T2D) is high. Psychological risk factors enhancing comorbidity of depression symptoms in T2D are yet to be determined. The present study examines the cross-sectional and longitudinal relationship between personality traits and distinct depression dimensions in older adults with T2D.

METHODS

Participants were older adults (age ≥65yeas) with T2D from the Israel Diabetes and Cognitive Decline (IDCD) study (N = 356), with complete data on depression [Geriatric Depression Scale (GDS) - 15 item version] and its dimensions- namely, dysphoric mood, apathy, hopelessness, memory complains and anxiety, and on personality [Big Five Inventory (BFI)]. Logistic and mixed linear regression models examined cross-sectional and longitudinal associations while adjusting for socio-demographics, cognition, cardiovascular and diabetes-related factors.

RESULTS

Cross-sectionally, high neuroticism was associated with high scores in total GDS and in all depression-dimensions, except memory complaints. Higher extroversion was associated with lower total GDS and with lower scores on all depression dimensions, except anxiety. High levels of neuroticism were associated with increase in total number of depression symptoms over time.

CONCLUSIONS

In older adults with T2D, neuroticism and extroversion are associated with most depression dimensions suggesting that these traits relate to a global depression symptomatology rather than to any specific dimension or phenomenology. High neuroticism was associated with increase in depression symptoms over time, highlighting its role in the development of depression symptoms in older adults with T2D.

Altered Resting-State Brain Activity and Functional Connectivity in Post-Stroke Apathy: An fMRI Study

Apathy is a common neuropsychiatric disease after stroke and is linked to a lower quality of life while undergoing rehabilitation. However, it is still unknown what are the underlying neural mechanisms of apathy. This research aimed to explore differences in the cerebral activity and functional connectivity (FC) of subjects with post-stroke apathy and those without it. A total of 59 individuals with acute ischemic stroke and 29 healthy subjects with similar age, sex, and education were recruited. The Apathy Evaluation Scale (AES) was used to evaluate apathy at 3 months after stroke. Patients were split into two groups-PSA (n = 21) and nPSA (n = 38)-based on their diagnosis. The fractional amplitude of low-frequency fluctuation (fALFF) was used to measure cerebral activity, as well as region-of-interest to region-of-interest analysis to examine functional connectivity among apathy-related regions. Pearson correlation analysis between fALFF values and apathy severity was performed in this research. The values of fALFF in the left middle temporal regions, right anterior and middle cingulate regions, middle frontal region, and cuneus region differed significantly among groups. Pearson correlation analysis showed that the fALFF values in the left middle temporal region (p < 0.001, r = 0.66) and right cuneus (p < 0.001, r = 0.48) were positively correlated with AES scores in stroke patients, while fALFF values in the right anterior cingulate (p < 0.001, r = -0.61), right middle frontal gyrus (p < 0.001, r = -0.49), and middle cingulate gyrus (p = 0.04, r = -0.27) were negatively correlated with AES scores in stroke patients. These regions formed an apathy-related subnetwork, and functional connectivity analysis unveiled that altered connectivity was linked to PSA (p < 0.05). This research found that abnormalities in brain activity and FC in the left middle temporal region, right middle frontal region, right cuneate region, and right anterior and middle cingulate regions in stroke patients were associated with PSA, revealing a possible neural mechanism and providing new clues for the diagnosis and treatment of PSA.

Personality changes after acquired brain injury and their effects on rehabilitation outcomes

Acquired brain injury (ABI) is often associated with personality changes. Pre- as well as post-injury personality traits are related to rehabilitation outcomes. However, it largely remains unclear whether post-injury personality shows any associations with rehabilitation outcomes over and above pre-injury personality. Using a case-control design, this study investigated (1) personality changes after ABI from patients' and significant others' perspective, and (2) relations of pre- and post-ABI personality traits to rehabilitation outcomes in the short- and long-term. 40 patients with ABI (85% stroke, 15% traumatic brain injury), 46 healthy controls and their significant others participated. Personality was assessed with NEO-FFI, rehabilitation outcomes (activities, participation, depression) were measured at two and ten months after ABI. Patient-ratings indicated decreases in extraversion and a trend towards reduced conscientiousness. Significant others reported increases in patients' neuroticism. Pre- as well as post-injury personality traits were associated with depression and activities at both short- and long-term timepoints after ABI. The association was strongest for long-term depressive symptoms where personality trait variables accounted for 49% of variance (Radjusted2). Our results confirm that ABI patients and significant others perceive personality changes, albeit in different dimensions. Pre- and post-ABI personality traits showed associations with rehabilitation outcomes, especially with emotional adjustment after the injury.

Counseling in Aphasia: Information and Strategies for Speech-Language Pathologists

Purpose The purpose of this tutorial is to provide an overview of mental health concerns of persons with aphasia (PWAs), strategies that speech-language pathologists (SLPs) can use to address the mental health concerns of PWAs within their scope of practice, guidance related to how SLPs can help facilitate access to appropriate mental health services, and suggestions for the future of pre- and postcertification education regarding counseling in aphasia for SLPs. Method This tutorial begins with a case study that is used as a reference point throughout the tutorial. It then introduces the gap in mental health services for PWAs that prompted this work, walks SLPs through common mental health concerns PWAs experience, and provides guidance for SLPs related to counseling techniques they can utilize within their sessions and referral to counseling professionals. We end by reiterating the need for more mental health awareness and training for SLPs and suggestions for incorporating more training related to addressing client mental health concerns and developing effective collaborations with rehabilitation and mental health counselors, as needed. Conclusions The mental health needs of PWAs are not being met. This is partly due to a lack of training in counseling for SLPs and a lack of training in communication techniques for rehabilitation and mental health counselors. With this tutorial, we hope to bring more awareness to the current need for mental health services for PWAs and to provide SLPs with some tools for addressing these needs among their clientele.

Emotions after stroke: A narrative update

AIM

In this narrative review we aimed to describe how stroke affects emotions and update the readers on the emotional disturbances that occur after stroke.

METHODS

We searched Medline from 1.1.2013 to 1.7.2019, personal files and references of selected publications. All retrieved systematic reviews and randomized controlled trials were included. Other references were selected by relevance.

SUMMARY OF REVIEW

The emotional response includes a reactive behavior with arousal, somatic, motivational and motor components, and a distinctive cognitive and subjective affective experience. Emotional category responses and experiences after stroke can show dissociations between the behavioral response and the cognitive and affective experiences. Emotional disturbances that often occur after stroke include fear, anger, emotional indifference, lack of understanding of other emotions, and lack of control of emotional expression. Emotional disturbances limit social reintegration of the persons with stroke and are a source of caregiver burnout. The evidence to support the management of the majority of emotional disorders in stroke survivors is currently weak and of low or very low methodologic quality. An exception are the disorders of emotional expression control where antidepressants can have a strong beneficial effect, by reducing the number and duration of the uncontrollable episodes of crying or laughing.

CONCLUSION

Our current knowledge of the emotional disorders that occurs in acute stroke patients and in stroke survivors is heterogeneous and limited. Joint efforts of different research approaches, methodologies and disciplines will improve our current understanding on emotional disorder after stroke and indicate rational pathways to manage them.

Neurobehavioral disability in stroke patients during subacute inpatient rehabilitation: prevalence and biopsychosocial associations

BACKGROUND AND OBJECTIVES

There are scarce data on post-stroke neurobehavioral disability (NBD). The aim of this study was to identify the prevalence of NBD in a subacute inpatient stroke population and examine potential associations with demographic, stroke-related, functional and psychosocial variables.

METHODS

82 survivors of stroke were consecutively recruited during their inpatient rehabilitation admission. Nursing staff rated NBD in patients using the St Andrews -Swansea Neurobehavioral Outcome Scale (SASNOS). Measures of patient functional independence (FIM), cognition (MoCA), and mood symptoms (HADS) were collected in addition to nursing reports of whether observed NBD negatively impacted on the patient or those around them.

RESULTS

NBD relating to interpersonal relationships (44.4% of participants) and cognition (52.4%) were highly prevalent within the sample while NBD relating to inhibition (1.2%), aggression (3.6%), and communication (2.5%) were relatively rare. Presence of NBD was significantly associated with reduced functional independence (rs=0.39, p < 0.01) and associated with trends in cognitive impairment (rs=0.29, p = 0.03), increased anxiety (rs=-0.43, p = 0.02) and depressive symptoms (rs=-0.43, p = 0.02). Presence of NBD was significantly correlated with negative impact to the patient and those around them across all SASNOS domains (rs range 0.42 - 0.45, all p ≤ 0.01).

CONCLUSIONS

NBD is common within a subacute stroke inpatient population, particularly interpersonal and cognitive difficulties and preliminary analyses indicate associations with reduced functional ability, cognition and mood. There is a need to provide education and support to clinicians to facilitate routine assessment and management of NBD following stroke.