Emotions, behaviours and mood changes in stroke

Knowledge, Beliefs, and Experiences With Mental Health Services and Help-Seeking in People With Aphasia and Care Partners

PURPOSE

Supporting psychological well-being in persons with aphasia (PWA) can improve social and health outcomes; however, PWA and their care partners (CPs) are often not receiving mental health support. Previous research explores this from the perspective of health care professionals.

AIMS

The aim of this study was to examine knowledge, beliefs, and experiences related to mental health services directly from PWA and CPs.

METHOD

The study included 11 PWA and 11 CPs. Participants completed a guided survey (virtual) with opportunities for elaboration related to the knowledge, beliefs, and experiences of mental health.

RESULTS

There was variability in personal preferences for referrals, types of coping strategies, and confidants for general thoughts and feelings and those specific to aphasia. PWA identified health care professionals as people to share thoughts and feelings, whereas CPs chose family and friends more often. Both CPs and PWA reported communication difficulty and finding a counselor as "sometimes" preventing access to services but cited fear and trust as "always" preventing access.

CONCLUSIONS

Knowledge, beliefs, and experience with help-seeking and mental health services are personal and variable. Assessing barriers unique to living with aphasia, such as communication challenges and locating a suitable counselor, must also be considered within more complex and personal barriers of fear and trust that are consistently reported in the general public. Health professionals across the continuum of aphasia care need to understand the communication challenges of living with aphasia in tandem with understanding individual differences to personalize approaches to mental health services and help-seeking.

Spectrum of neuropsychiatric symptoms in chronic post-stroke aphasia

BACKGROUND

Neuropsychiatric symptoms (NPS) have been insufficiently examined in persons with aphasia (PWA) because most previous studies exclude participants with language and communication disorders.

AIM

To report a two-part study consisting of a literature review and an observational study on NPS in post-stroke aphasia.

METHODS

Study 1 reviewed articles obtained from PubMed, PsycINFO, Google Scholar and Cochrane databases after cross-referencing key words of post-stroke aphasia to NPS and disorders. Study 2 examined language deficits and activities of daily living in 20 PWA (median age: 58, range: 28-65 years; 13 men) with the Western Aphasia Battery-Revised and the Barthel Index, respectively. Informants of these 20 PWA were proxy-evaluated with the Neuropsychiatric Inventory and domain-specific scales, including the Stroke Aphasia Depression Questionnaire-10 item version and the Starkstein Apathy Scale. In addition, an adapted version of the Hospital Anxiety and Depression Scale was directly administered to the PWA themselves. This observational study is based on the baseline assessment of an intervention clinical trial (EudraCT: 2017-002858-36; ClinicalTrials.gov identifier: NCT04134416).

RESULTS

The literature review revealed a broad spectrum of NPS in PWA, including depression, anxiety, apathy, agitation/aggression, eating and sleep disorders, psychosis, and hypomania/mania. These findings alert to the need for improving assessment and treatment approaches of NPS taking into consideration their frequent occurrence in PWA. Study 2 showed that the 20 participants had mild- to-moderate aphasia severity and were functionally independent. A wide range of comorbid NPS was found in the post-stroke aphasic population (median number of NPS: 5, range: 1-8). The majority of PWA (75%) had depressive symptoms, followed by agitation/aggression (70%), irritability (70%), anxiety (65%) and appetite/eating symptoms (65%). Half of them also presented symptoms of apathy, whereas euphoria and psychotic symptoms were rare (5%). Domain-specific scales revealed that 45% of participants had apathy and 30% were diagnosed with depression and anxiety.

CONCLUSION

Concurrent NPS are frequent in the chronic period of post-stroke aphasia. Therefore, further research on reliable and valid assessment tools and treatment for this aphasic population is strongly warranted.

Association between Poststroke Depression and Psychological Crisis: A Retrospective Cross-Sectional Study

Objective

To investigate the association between poststroke depression (PSD) and psychological crisis in patients who have experienced a stroke within 6 months.

Methods

This was a retrospective cross-sectional study that enrolled patients within 6 months after stroke onset. The investigators reviewed medical charts to obtain patients' baseline characteristics, and a psychologist evaluated each patient for depression using the Taiwanese Depression Questionnaire (TDQ) and for psychological crisis using the Triage Assessment System (TAS). A generalized linear model (GLM) was used to analyze the association between the results of the TDQ and TAS.

Results

Ninety-seven patients with stroke were included. Age (p = 0.003), time since onset of stroke (p = 0.041), diabetes mellitus (p = 0.004), hypertension (p = 0.016), heart disease (p = 0.005), and TDQ score were significantly different between the hemorrhagic stroke group and the ischemic stroke group. The TDQ score was significantly lower in the hemorrhagic stroke group (p = 0.012). The TDQ score was associated with the TAS total score and each domain score, and the presence of heart disease was associated with poorer TAS score in the behavioral domain (p = 0.016).

Conclusion

PSD is likely an important component of psychological crisis in stroke patients. For clinicians, a comprehensive psychologic evaluation is necessary to optimize treatment.

Investigating the needs of family caregivers of older stroke patients: a longitudinal study in Iran

BACKGROUND

The high burden of care associated with older stroke patients is a factor that threatens the health of family caregivers. Identifying the needs of family caregivers in this group of patients can help provide effective solutions. The present study aimed to determine the needs of family caregivers of older stroke patients.

METHODS

The sample size of this longitudinal study included 200 family caregivers of older stroke patients from two hospitals in Iran. Data collection included demographics, responses to family caregivers' needs questionnaires, and the Barthel Index which was taken in four stages including admission time, pre-discharge, two weeks and 12 weeks post-discharge.

RESULTS

The results showed that all participants at all stages of the study identified "respect for the patient when providing education, treatment, or rehabilitation" as one of their needs. There was a statistically significant relationship between the older adult survivor's age and the number of family caregivers' needs two weeks post-discharge (p = 0.012) and 12 weeks post-discharge (p = 0.008). There was a significant relationship between the patient's hospitalization period and the number of caregivers' needs three months after the patient's discharge (p = 0.028), and a significant statistical relationship between the pre-discharge physiotherapy of the patients and the number of their caregivers' needs during the two weeks post-discharge (p = 0.018). There was also a statistically significant relationship between the patient's level of dependence and the number of caregivers' needs (p = 0.0001). On the contrary, there was no significant relationship between the sex, place of living, and underlying disease history of the patient and the number of caregivers' needs (p > 0.05).

CONCLUSION

The results of the present research indicate that the total number of caregivers' needs decreases with increasing duration of the disease. However, respite and care provision planning by other family members, seeking assistance from professional caregivers, and the search for community support resources can help reduce the burden of care of caregivers and give them the opportunity to meet their needs in different dimensions of patient care provided.

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.

The Big Five personality factors and psychological well-being following stroke: a systematic review

PURPOSE

To identify and appraise studies investigating the relationship between the Big Five personality factors and psychological well-being following stroke and evidence for personality change.

METHODS

Systematic searches of six databases (PsychINFO, CINAHL, Ovid Medline, Cochrane, PubMed, and Web of Science) were conducted from inception to June 2017. Studies involving adult stroke samples that employed a validated measure of at least one of the Big Five personality factors were included. Two reviewers independently assessed the eligibility and methodological quality of studies.

RESULTS

Eleven studies were identified that assessed associations between personality and psychological well-being after stroke (nine studies) or post-stroke personality change (two studies). A consistent finding was that higher neuroticism was significantly related to poorer psychological well-being. The evidence for the other Big Five factors was mixed. In terms of personality change, two cross-sectional studies reported high rates of elevated neuroticism (38-48%) and low extraversion (33-40%) relative to normative data. Different questionnaires and approaches to measuring personality (i.e., self vs. informant ratings, premorbid personality vs. current personality) complicated comparisons between studies.

CONCLUSIONS

People high on neuroticism are at increased risk of poor psychological well-being after stroke. Prospective longitudinal studies are needed to address the limited research on post-stroke personality change. Implications for rehabilitation High neuroticism is associated with poorer psychological well-being after stroke. Assessing personality characteristics early after stroke may help to identify those at risk of poor psychological outcomes.

Perceptual Accent Rating and Attribution in Psychogenic FAS: Some Further Evidence Challenging Whitaker's Operational Definition

A 40-year-old, non-aphasic, right-handed, and polyglot (L1: French, L2: Dutch, and L3: English) woman with a 12-year history of addiction to opiates and psychoactive substances, and clear psychiatric problems, presented with a foreign accent of sudden onset in L1. Speech evolved toward a mostly fluent output, despite a stutter-like behavior and a marked grammatical output disorder. The psychogenic etiology of the accent foreignness was construed based on the patient's complex medical history and psychodiagnostic, neuropsychological, and neurolinguistic assessments. The presence of a foreign accent was affirmed by a perceptual accent rating and attribution experiment. It is argued that this patient provides additional evidence demonstrating the outdatedness of Whitaker's (1982) definition of foreign accent syndrome, as only one of the four operational criteria was unequivocally applicable to our patient: her accent foreignness was not only recognized by her relatives and the medical staff but also by a group of native French-speaking laymen. However, our patient defied the three remaining criteria, as central nervous system damage could not conclusively be demonstrated, psychodiagnostic assessment raised the hypothesis of a conversion disorder, and the patient was a polyglot whose newly gained accent was associated with a range of foreign languages, which exceeded the ones she spoke.

Validation and Cross-Cultural Adaptation of a Chinese Version of the Emotional and Social Dysfunction Questionnaire in Stroke Patients

The objectives of this study were to develop a cross-cultural Chinese version of the Emotional and Social Dysfunction Questionnaire (ESDQ-C) and test its validity and reliability among Chinese-speaking stroke patients. Various methods were used to develop the ESDQ-C. A cross-sectional study was used to examine the validity and reliability of the developed questionnaire, which consists of 28 items belonging to six factors, anger, helplessness, emotional dyscontrol, indifference, inertia and fatigue, and euphoria. Satisfactory convergence and known-group validities were confirmed by significant correlations of the ESDQ-C with the Profile of Mood States–Short Form ( p < .05) and with the Hospital Anxiety and Depression Scale ( p < .05). The internal consistency was represented by Cronbach’s alpha, which was .96 and .79 to .92 for the entire scale and subscales, respectively. Appropriate application of the ESDQ-C will be helpful to identify critical adjustment-related types of distress and patients who experience difficulty coping with such distress.

Does touch massage facilitate recovery after stroke? A study protocol of a randomized controlled trial

BACKGROUND

Despite high quality stroke care, decreased sensorimotor function, anxiety and pain often remain one year after stroke which can lead to impaired health and dependence, as well as higher healthcare costs. Touch massage (TM) has been proven to decrease anxiety and pain, and improve quality of health in other conditions of reduced health, where reduced anxiety seems to be the most pronounced benefit. Thus there are reasons to believe that TM may also reduce anxiety and pain, and improve quality of life after stroke. Further, several studies indicate that somatosensory stimulation can increase sensorimotor function, and it seems feasible to believe that TM could increase independence after stroke. In this study we will evaluate effects of TM after stroke compared to sham treatment.

METHODS

This is a prospective randomized open-labelled control trial with blinded evaluation (PROBE-design). Fifty patients with stroke admitted to stroke units will be randomized (1:1) to either a TM intervention or a non-active transcutaneous electrical nerve stimulation (non-TENS) control group. Ten sessions of 30 min treatments (TM or control) will be administered during two weeks. Assessment of status according to the International Classification of Functioning, Disability and Health (ICF), including body function, activity, and participation. Assessment of body function will include anxiety, pain, and stress response (heart rate variability and salivary cortisol), where anxiety is the primary outcome. Activity will be assessed by means of sensorimotor function and disability, and participation by means of health-related quality of life. Assessments will be made at baseline, after one week of treatment, after two weeks of treatment, and finally a follow-up after two months. The trial has been approved by the Regional Ethical Review Board.

DISCUSSION

TM seems to decrease anxiety and pain, increase health-related quality of life, and improve sensorimotor functions after stroke, but the field is largely unexplored. Considering the documented pleasant effects of massage in general, absence of reported adverse effects, and potential effects in relation to stroke, it is essential to evaluate effects of TM during the sub-acute phase after stroke. The results of this project will hopefully provide important knowledge for evidence-based care.

TRIAL REGISTRATION

ClinicalTrials.gov: NTC01883947.

Current Australian speech-language pathology practice in addressing psychological well-being in people with aphasia after stroke

PURPOSE

Psychological well-being is essential to overall health; however, there is a paucity of research on how to address psychological well-being in stroke survivors with aphasia. This study describes the current beliefs, attitudes and practices of Australian speech-language pathologists in addressing psychological well-being in people with aphasia after stroke.

METHOD

A 26-item web-based survey consisting of open and closed questions was distributed to Australian speech-language pathologists through four electronic databases.

RESULT

Australian speech-language pathologists (n = 111) utilized counselling and clinical approaches to address psychological well-being in people with post-stroke aphasia. The majority of speech-language pathologists did not feel comfortable with addressing psychological well-being in people with aphasia and sought support from other health professionals in this practice. Self-perception of being under-skilled was the main barrier identified to adequate practice in this domain, followed by inadequate time, inadequate staffing and people with aphasia declining referral to counselling. The main facilitators reported by speech-language pathologists to address psychological well-being included personal interest, personal and professional experience and availability of counselling health professionals for people with aphasia. There were small-to-medium statistically significant correlations between speech-language pathologists reporting additional training in counselling and perceived knowledge of, confidence in and satisfaction with managing psychological well-being in people with aphasia.

CONCLUSION

This study identifies factors requiring attention in order to enable speech-language pathologists to facilitate improved psychological well-being in people with aphasia.

The relationship between post-stroke depression and physical recovery

BACKGROUND

Post-stroke depression (PSD) is a serious and common complication of stroke. In this prospective study on the relationship between clinical PSD and physical recovery, we focused on (1) distinguishing between depression and apathy, (2) issues in assessment of PSD, and (3) timing of assessment.

METHODS

Japanese stroke patients (n=117) were studied. We used self-rating scales [Zung Self-Rating Depression Scale (SDS) for depression; Apathy Scale (AS) for apathy] and observer-rating scales [Montgomery-Åsberg Depression Rating Scale (MADRS) for depression; Neuropsychiatric Inventory-Nursing Home (NPI-NH) for apathy] to assess psychological state. We assessed physical disability using the Functional Independence Measurement (FIM). Two-way analysis of covariance was used to determine effects of depression and apathy on functional outcome. We evaluated PSD twice, within 10 days after hospitalization and four weeks later.

RESULTS

Objective scales gave higher prevalence than subjective scales for both depression and apathy. A significant effect of apathy on FIM recovery was seen with objective scale assessment during hospitalization; there was a marginal effect of depression at the same time.

LIMITATIONS

We did not consider the stroke size and location. In addition, we excluded patients with severe comprehension deficits or with a history of stroke.

CONCLUSIONS

Our findings indicate that depression and apathy could occur independently after stroke and could individually influence functional recovery. We obtained more accurate estimates of functional recovery using objective measures. Furthermore, our findings suggest that depression and apathy should be assessed not only at admission but also during hospitalization to estimate and enhance the functional recovery of stroke patients.

Impact of anxiety on verbal and visuospatial working memory in patients with acute stroke without severe cognitive impairment

BACKGROUND

Working memory is the most impaired cognitive domain in the acute phase of stroke. In a context where anxiety is highly prevalent, close attention must be paid to anxiety which could mimic mild to moderate working memory impairments. This is the first study to assess the contribution of state anxiety (the currently experienced level of anxiety) to the working memory (verbal, visuospatial) in patients with first-ever acute stroke without severe cognitive impairment.

METHODS

28 patients with first-ever acute stroke and 41 matched control subjects were exposed to a neutral condition and an anxiogenic condition in which verbal (VWM) and visuospatial working memory (VSWM) performance and state anxiety were assessed. State anxiety was assessed before the beginning of the experiment (baseline), after the neutral condition and after the anxiogenic condition.

RESULTS

The mean state anxiety score was higher in patients than in controls in the neutral (z = 1.9, p<0.05) and anxiogenic (z = 2, p<0.05) conditions despite a similar level at baseline. Multiple regression analyses with a dummy variable 'group' (patients vs controls) showed that increased state anxiety in patients contributed significantly more to both reduced VWM (β = -0.93, p<0.05) and VSWM (β = -1, p<0.05) performance between the neutral and anxiogenic conditions compared to controls.

CONCLUSIONS

In a stressful context, the contribution of state anxiety to reduced working memory performance is more pronounced in patients with acute stroke than in controls. These results are of particular relevance for clinicians assessing patients in the acute phase of stroke in which anxiety is highly prevalent.

Frequency, clinical correlates, and ratings of behavioral changes in primary brain tumor patients: a preliminary investigation

Purpose

Few studies have addressed the specific behavioral changes associated with primary brain tumor (PBT). This paper will report on the frequency and demographic/clinical correlates of such behaviors, and the reliability of rating such behaviors among people with PBT, family informants, and clinicians. The association of behavioral changes and patient functional status will also be discussed.

Methods

A total of 57 patients with 37 family informants were recruited from two large Australian metropolitan hospitals. Each completed three neuro-behavioral self-report measures; the Emotional and Social Dysfunction Questionnaire, the Frontal Systems Behavior Scale, and the Overt Behavior Scale. Patients also completed a depression symptom measure. Functional status was defined by clinician-rated Karnofsky performance status.

Results

Patients were on average 52 years old, a median of 4 months (range 1–82) post-diagnosis, with high grade (39%), low grade (22%), or benign tumors (39%). Patients reported frequency rates of 7–40% across various behavioral domains including anger, inappropriate behavior, apathy, inertia, and executive impairment. The presence of epileptic seizures was associated with significantly higher levels of behavioral changes. Notably, behavior did not correlate with tumor grade or treatment modality. There was moderate agreement between patients and relatives on the presence or absence of behavioral changes, and substantial agreement between relative and clinician ratings. Depressed patients did not generally report more changes than non-depressed patients. Increases in the relative and clinician-rated behavior scores were significantly correlated with decreasing functional status in the patient.

Conclusion

Behavioral changes were a common sequela of both benign and malignant PBT. Larger scale studies are required to confirm these results. The results suggest the importance of including behavior in brain cancer psychosocial assessments and the need to develop interventions to treat these patients and reduce the burden of care on families.

Mental Status and Behavioral Changes in the Early Postacute Phase of Care

Neurocognitive sequelae of stroke create a significant impact on the patient and frequently disrupt recovery from the physical manifestations. This article strives to review types of neurocognitive changes after stroke and discuss the underlying pathophysiology. Management options are presented for the diverse changes that may be encountered.

The Assessment of Poststroke Depression

Poststroke depression (PSD) is a common clinical consequence of stroke. PSD is associated with poor functional and social outcomes, reduced quality of life, the presence of cognitive impairment, and increased mortality. Despite the potential benefit associated with the identification and treatment of PSD, it often remains unrecognized and undertreated. The present study provides a critical review and synthesis of measurement properties for 10 instruments used in the assessment of depression following stroke. Assessment considerations specific to PSD are addressed, and tools are reviewed within the context of stroke. To facilitate the timely detection, diagnosis, and initiation of treatment for PSD, a two-step assessment process is recommended, thereby taking strategic advantage of the strengths and limitations associated with self-report and observer-rating assessment tools.

"When I Want to Cry I Can't": Inability to Cry Following SSRI Treatment

INTRODUCTION

We describe seven cases of patients with an inability to cry after treatment with selective serotonin re-uptake inhibitor (SSRI) medication, even during sad or distressing situations that would have normally initiated a crying episode, in the light of the role of the serotonergic system in emotional expression.

METHOD

Case series drawn from patients attended in a secondary care psychiatry service.

RESULTS

While excessive crying without emotional distress has been previously reported in the literature, and is associated with reduced serotonin function, these reports suggest cases of the reverse dissociation, where emotional distress and an urge to cry was present, but crying was impaired.

DISCUSSION

Although the case series presented here is new, these cases are consistent with the neuroscience of crying and their relationship with serotonergic function, and provide preliminary evidence for a double dissociation between subjective emotional experience and the behavioural expression of crying. This helps to further illuminate the neuroscience of emotional expression and suggests the possibility that the phenomenon is an under-recognised adverse effect of SSRI treatment.

Diagnosis and treatment of an obsessive-compulsive disorder following traumatic brain injury: a single case and review of the literature

A 27-year-old patient with traumatic brain injury and neuropsychiatric symptoms fitting the obsessive-compulsive disorder was investigated. Brain CT-scan revealed left temporal and bilateral fronto-basal parenchymal contusions. Main Outcome Measure was the Yale-Brown Obsessive Compulsive Scale at pre- and post-treatment and at 6 months follow-up. The combination of pharmacotherapy and psychotherapy resulted in lower intensity and frequency of symptoms. Our case illustrates the importance of a detailed diagnostic procedure in order to provide appropriate therapeutic interventions. Further studies are needed to guide the clinician in determining which patients are likely to benefit from a psychotherapeutic intervention in combination with pharmacotherapy.

Quality of life of elderly ischaemic stroke patients one year after thrombolytic therapy. A comparison between patients with and without thrombolytic therapy

Background

An observational study to examine whether thrombolytic therapy in stroke patients realizes better quality of life outcomes compared to patients without thrombolytic therapy one year after stroke. We also examined whether daily functioning, mental functioning and activities improved after thrombolytic treatment.

Methods

A total of 88 stroke patients were interviewed at home one year post-stroke. Health-related quality of life (HRQOL) was assessed using the RAND-36, disability with the Barthel Index, depression and anxiety with the Hospital Anxiety and Depression Scale, and a questionnaire about patient way of life was completed. People aged under 60, moving to a nursing home or with a haemorrhage were excluded.

Results

The thrombolysis group (TG) had more severe stroke (higher NIHSS) scores and were younger than the group without thrombolytic therapy (WTG). The primary outcome was HRQOL, which was high and nearly identical in both groups, however the TG had significantly better HRQOL for the ‘mental health’ and ‘vitality’ scales. Patients who stopped or reduced their hobbies because of stroke had a significantly worse HRQOL.

One year after stroke, more patients in the TG were totally or severely ADL dependent (12% TG and 0% WTG, p = 0.022). The level of dependence decreased in the TG (p = 0.042) and worsened in the WTG (p < 0.001) after one year. Being more dependent is related to diminishing daily occupations in both groups. In the TG the level of dependence had less impact on visiting family and friends and going on holiday. The prevalence of anxiety disorder and depression was low compared to other studies and there is no significant difference between the two groups.

Conclusion

No major differences in the primary outcome (HRQOL) could be found between the two groups. In addition, no essential difference could be found in mental functioning and participation. We expected that patients undergoing thrombolytic therapy would have worse quality of life because of the greater initial severity of their stroke. Therefore, thrombolytic therapy seems to be of great importance in achieving better quality of life in ischemic stroke patients who respond to this therapy.

Executive Dysfunction Immediately after Mild Stroke

The purpose of this study was to determine the presence of executive function deficits immediately after mild stroke that are known to impact participation in home, work, and community life. Individuals with mild stroke who were discharged from the acute setting to the home with few or no rehabilitation services were assessed within 1 week after discharge using a cognitive battery. Using rigorous criteria to identify a specific deficit in executive function, results showed that 66% of the population (N = 35) scored in the deficit range on at least one of the four measures of executive function; 27% of the population (N = 14) scored in the deficit range on two or more measures. Although deficits post-stroke are sometimes known to spontaneously recover, cognitive dysfunction of this nature often becomes chronic. This group is typically discharged with little or no rehabilitation; by detecting these deficits in the acute stage of stroke care, occupational therapists can make appropriate rehabilitation and follow-up recommendations.

Post-stroke depression: can we predict its development from the acute stroke phase?

OBJECTIVES

To identify possible predictive factors for post-stroke depression (PSD) in the acute phase of stroke.

METHODS

The study design was prospective, observational cohort study of patients with acute cerebral infarction (CI). Neurological and neuropsychological evaluations were conducted within the first 10 days from the onset of stroke and repeated at the 3-month follow-up. DSM-IV criteria were used to define PSD.

RESULTS

From a total of 85 patients with CI, 59 patients completed the 3-month follow-up and 17 of them (28.8 %) fulfilled PSD criteria at the 3-month follow-up. Melancholy index of the Hamilton Depression Rankin Scale (HDRS) was associated with a risk three times greater than that of PSD at the 3-month follow-up in the univariate analysis (OR 3.07; 95% CI 1.53-6.16; P = 0.002) with no significant influence of stroke severity or the location of brain infarction (right or left side). The receiver operating characteristic curves pointed to a melancholy index > or =1.5 as the optimal cut-off level associated with the development of PSD at the 3-month follow-up.

CONCLUSIONS

Melancholy index of the HDRS > or =1.5 could be a useful clinical tool to detect patients with acute stroke at high risk of developing PSD.

Interdependence of stroke survivors' recovery and their relatives' attitudes and health: A contribution to investigating the causal effects

PURPOSE

One goal of the study was to test specific hypotheses concerning the interdependence of the stroke survivors' recovery and their caregiving partners' attitudes and health. The other aim was to find an applicable method for investigating causal effects on the rehabilitation of chronically sick persons in longitudinal studies with medium-sized samples.

METHOD

The recovery of 81 stroke survivors regarding the physical and mental functioning in everyday life and their caregiving partners' health and attitudes were assessed twice, once after the patients left the hospital and again one year later. We applied the structure equation modeling and the cross-lagged partial correlation analysis (CLPC) for testing causal effects.

RESULTS

Particularly stroke victims' cognitive and emotional recovery seems to be influenced by psychosocial factors such as the caregiving partners' acceptance of a post-stroke life-situation. In contrast to this, the research suggests that the patients' recovery regarding physical functioning is not substantially affected by the partners, rather the patients' difficulties with motor functioning influence their partners' health.

CONCLUSIONS

Caregivers merit attention as part of rehabilitation interventions. We recommend the CLPC for investigating causal effects in the complex interdependence of chronically sick persons' convalescence and their family members' health and state of mind in medium-sized samples.

Psychosocial functioning after stroke: Psychometric properties of the patient competency rating scale

OBJECTIVE

Research on long-term effects of stroke therapy and rehabilitation requires further standardized instruments for the assessment of patients' recovery regarding psychosocial functioning. To the authors' knowledge, it is the first study which investigates the psychometric properties of the Patient Competency Rating Scale (PCRS) in stroke.

DESIGN AND METHODS

The study used a longitudinal design. One hundred and fifty-one stroke patients and their caregiving partners filled out the PCRS at two measuring times. Some other stroke outcome measures were used to assess the criterion validity of the separate PCRS-sub-scales. Examination of the factor structure employed factor analysis techniques. The reliability was evaluated with Cronbach's alpha.

RESULTS

Modifications of the initial hypothesized four-factor structure were necessary. The modified sub-scales showed good reliability and criterion validity for stroke survivors' assessment as well as for caregivers' assessment of the patients' functioning.

CONCLUSIONS

The modified PCRS can be recommended for use in longitudinal studies to evaluate long-term effects of therapy and rehabilitative measures on stroke survivors' recovery.

Validation of the Memory and Behavior Problems Checklist-1990R for use in acquired brain injury

OBJECTIVE

The Memory and Behavior Problems Checklist-1990R (MBPC-1990R) is a carer-rated measure of (a) problem behaviours and (b) corresponding carer reaction. Although originally developed and validated for dementia, its items are relevant to acquired brain injury (ABI). This study evaluated its validity in this population.

DESIGN

Cross-sectional study.

METHODS

In a national postal survey carried out to inform service planning, 222 family carers of adults with TBI (49%), strokes (26%), infections (18%), other (7%) completed the MBPC-1990R, Head Injury Behaviour Scale (HIBS), Barthel Index (BI), Northwick Park Dependency Score (NPDS), Carer Burden Interview (CBI), WHOQOL-BREF and GHQ-28.

RESULTS

MBPC-1990R problems correlated well with HIBS problems (r = 0.70), as did MBPC-1990R carer reaction with HIBS distress (r = 0.78) and CBI (r = 0.73) scores, indicating good convergent validity. Discriminant validity was inferred from absent/weak correlations between MBPC-1990R problems and both BI (r = -0.02) and NPDS (r = 0.24); likewise between MBPC-1990R carer reaction and WHOQOL-BREF physical, psychological, social, environmental sub-scales (r = -0.32 to -0.41) and GHQ-28 scores (r = 0.35). Factor analysis revealed excessive, cognitive, aggressive and passive/low mood sub-scales, which showed good internal consistency and varied across ABI groups.

CONCLUSIONS

The MBPC-1990R is supported as a measure of problem behaviours and carer reaction in ABI. Further validation in ABI groups is recommended.

Stroke and neurodegenerative disorders: 2. Poststroke medical complications

OBJECTIVE

This self-directed learning module highlights common poststroke medical complaints encountered on an inpatient rehabilitation unit. It is part of the study guide on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Using a case vignette format, this article specifically focuses on the differential diagnosis, evaluation and management of chest pain, mental status changes, weight loss and poor motivation in stroke patients. The goal of this article is to expand the learner's knowledge of how to diagnose and manage common medical complications of stroke patients in rehabilitation.

Mirror neuron system based therapy for emotional disorders

Mirror neuron system (MNS) represents one of the most important discoveries in the area of neuropsychology of past decades. More than 500 papers have been published in this area (PubMed), and the major functions of MNS include action understanding, imitation, empathy, all of which are critical for an individual to be social. Recent studies suggested that MNS can modulate emotion states possibly through the empathy mechanism. Here we propose that MNS-based therapies provide a non-invasive approach in treatments to emotional disorders that were observed in autism patients, post-stroke patients with depression as well as other mood dysregulation conditions.

Neural activity of the anterior insula in emotional processing depends on the individuals' emotional susceptibility

Differences in personality factors between individuals may manifest themselves with different patterns of neural activity while individuals process stimuli with emotional content. We attempted to verify this hypothesis by investigating emotional susceptibility (ES), a specific emotional trait of the human personality defined as the tendency to "experience feelings of discomfort, helplessness, inadequacy and vulnerability" after exposure to stimuli with emotional valence. By administering a questionnaire evaluating the individuals' ES, we selected two groups of participants with high and low ES respectively. Then, we used functional magnetic resonance imaging to investigate differences between the groups in the neural activity involved while they were processing emotional stimuli in an explicit (focusing on the content of the stimuli) or an incidental (focusing on spatial features of the stimuli, irrespectively of their content) way. The results showed a selective difference in brain activity between groups only in the explicit processing of the emotional stimuli: bilateral activity of the anterior insula was present in subjects with high ES but not in subjects with low ES. This difference in neural activity within the anterior insula proved to be purely functional since no brain morphological differences were found between groups, as assessed by a voxel-based morphometry analysis. Although the role of the anterior insula in the processing of contexts perceived as emotionally salient is well established, the present study provides the first evidence of a modulation of the insular activity depending on the individuals' ES trait of personality.

The smiley as a simple screening tool for depression after stroke: A preliminary study

In Hong Kong, there is a paucity of evidence to support which tool is superior in measuring depression after stroke (DAS). A simple, non-language-based, culturally neutral, non-verbal and easy to apply tool that is not highly dependent on training will be desirable.

OBJECTIVES

The present study aimed to examine the clinical utility of three smiley pictures in detecting DAS for older Chinese patients at 1 month after first-ever ischemic stroke.

METHODS

This was a cross-sectional study. A total of 253 stroke patients were interviewed by a research nurse at 1-month follow-up.

RESULTS

Taking Diagnostic and Statistic Manual (DSM IV) as the gold standard, the measurement properties of emoticon (sad) in terms of sensitivity, specificity, positive and negative predictive values, as well as Kappa's value were found comparable to Geriatric Depression Scale (GDS). The emoticon (happy) demonstrated a highly significant inverse relationship with all depression assessment tools (p<0.001). It was also found that the emoticon (flat) could capture 98% of all depressed subjects identified by DSM IV, although its predictive values were less satisfactory.

CONCLUSIONS

The smiley pictures seemed to fulfil the requirements for early and prompt screening among older patients. Cultural implication regarding emotions dissipation among Chinese patients should be further studied.

Poststroke depression: importance of its detection and treatment

BACKGROUND

Poststroke depression (PSD) is a complication that occurs in up to 30% of the patients who have had a stroke. Its development is associated with a poor functional prognosis and a negative impact on the patient's quality of life.

METHODS

In the present review, we summarize the diagnostic criteria, prevalence, predisposing factors, the lesion site, the impact of PSD on the clinical evolution of the patient, the current therapeutic approaches and even the relationship between depression and cerebrovascular disease.

RESULTS

There are differences in relation to prevalence, essentially due to the use of different diagnostic criteria. Also, there have been few studies focusing on the search for factors that are predictive of PSD (age, female sex, single vascular lesion independent of site) and the reluctance to initiate preventive treatments to minimize the effects on the clinical evolution of the patients. There have been several advances with respect to the treatment of PSD. It seems that treatments show improvement trends, but today there is not enough evidence to recommend a preventive therapy for depression in any stroke patient.

CONCLUSIONS

We consider that the prevalence of PSD is relevant and that the risk factors as well as the early diagnosis are important for the best management and prognosis of stroke patients. Further studies are needed in this field in order to reduce PSD.

The perception of emotional facial expressions in stroke patients with and without depression

BACKGROUND

Emotion perception may be impaired after stroke. No study on emotion perception after stroke has taken the influence of post-stroke depressive symptoms into account, although depressive symptoms themselves may hamper emotion perception.

OBJECTIVE

To compare the perception of emotional facial expressions in stroke patients with and without depressive symptoms.

METHODS

Twenty-two stroke patients participated whose depressive symptoms were classified using the Montgomery-Åsberg Depression Rating Scale (cutoff = 10) and who were compared with healthy controls. Emotion recognition was measured using morphed images of facial expressions.

RESULTS

Patients with depressive symptoms performed worse than controls on all emotions; patients without depressive symptoms performed at control level. Patients with depressive symptoms were less sensitive to the emotions anger, happiness and sadness compared with patients without depressive symptoms.

CONCLUSIONS

Post-stroke depressive symptoms impair emotion perception. This extends findings in bipolar disorder indicating that emotion perception deficits are strongly related to the level of depression.

An Exploration of Central Nervous System Medication Use and Outcomes in Stroke Rehabilitation

Conroy B, Zorowitz R, Horn SD, Ryser DK, Teraoka J, Smout RJ. An exploration of central nervous system medication use and outcomes in stroke rehabilitation.

OBJECTIVE

To study associations between neurobehavioral impairments, use of neurotropic medications, and outcomes for inpatient stroke rehabilitation, controlling for a variety of confounding variables.

DESIGN

Observational cohort study of post-stroke rehabilitation.

SETTING

Six inpatient rehabilitation hospitals in the United States.

PARTICIPANTS

Patients with moderate or severe strokes (N=919).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Discharge disposition, FIM score change, and rehabilitation length of stay (LOS).

RESULTS

Neurobehavioral impairments and use of many medications, including first-generation selective serotonin reuptake inhibitors, older traditional antipsychotic medications, and anti-Parkinsonian neuro-stimulants, have a statistical association with poorer outcomes, whereas use of the atypical antipsychotic medications has a positive association with improvement in motor FIM scores. Counter-intuitively, use of opioid analgesics is associated with a larger motor FIM score change but not an increase in LOS or reduced percentage of discharge to community. There was significant variation in use of neurotropic medications among the 6 study sites during inpatient stroke rehabilitation.

CONCLUSIONS

There are many opportunities to enhance a stroke survivor's ability to benefit from acute inpatient stroke rehabilitation through improved understanding of associations of neurotropic medications with outcomes for different patient groups.

Neuroanatomical correlates of behavioural disorders in dementia

Neurodegenerative diseases are associated with profound changes in social and emotional function. The emergence of increasingly sophisticated methods for measuring brain volume has facilitated correlation of local changes in tissue content with cognitive and behavioural changes in neurodegenerative disease. The current study examined neuroanatomical correlates of behavioural abnormalities, as measured by the Neuropsychiatric Inventory, in 148 patients with dementia using voxel-based morphometry. Of 12 behaviours examined, 4 correlated with tissue loss: apathy, disinhibition, eating disorders and aberrant motor behaviour. Increasing severity across these four behaviours was associated with tissue loss in the ventral portion of the right anterior cingulate cortex (vACC) and adjacent ventromedial superior frontal gyrus (vmSFG), the right ventromedial prefrontal cortex (VMPC) more posteriorly, the right lateral middle frontal gyrus, the right caudate head, the right orbitofrontal cortex and the right anterior insula. In addition, apathy was independently associated with tissue loss in the right vmSFG, disinhibition with tissue loss in the right subgenual cingulate gyrus in the VMPC, and aberrant motor behaviour with tissue loss in the right dorsal ACC and left premotor cortex. These data strongly support the involvement of the right hemisphere in mediating social and emotional behaviour and highlight the importance of distinct regions on the medial wall of the right frontal lobe in regulating different behaviours. Furthermore, the findings underscore the utility of studying patients with dementia for understanding the neuroanatomical basis of social and emotional functions.

Changes in artistic style after minor posterior stroke

BACKGROUND

Two professional painters experienced significant changes in their art as the main consequence of minor stroke located in the left occipital lobe or thalamus.

METHODS

The features of this artistic conversion were analysed on the basis of extensive neurological, neuropsychological, and psychiatric evaluations.

RESULTS

Both painters, initially unaware of the artistic changes, exhibited mild signs of executive dysfunction, but no general cognitive decline. The first painter, who showed mild visual-perceptive difficulties (dyschromatopsia and scotoma in his right upper visual field after left occipital stroke), together with increased anxiety and difficulty in emotional control, switched to a more stylised and symbolic art. The second painter, who also presented features of emotionalism related to his left latero-thalamic stroke, switched from an impressionist style to a more joyous and geometric, but more simplistic, abstract art.

CONCLUSIONS

These findings show that mild cognitive and affective modifications due to focal posterior brain lesions can have significant repercussions on artistic expression.

Is poststroke depression a vascular depression?

As we learn more about the relationships between depression and cerebrovascular disease (CVD), a complex picture is emerging in which the chain of causality seems to spiral on itself: progressive or focal brain damage, cognitive impairment, depressive symptoms, dementia, and cardiovascular diseases, all seem to be liable to lead to one or another. Stroke may lead to depression, and the inverse may also be true. Depression may lead to cognitive impairment and cardiovascular diseases, which in turn may lead to subtle brain impairment, thereby causing more depression and cognitive impairments, and so on. In this presentation, we provide a rapid glance at the complexities of such issues.

Cognitive impairment and functional outcome after stroke associated with small vessel disease

OBJECTIVES

Although stroke associated with small vessel disease (SSVD) can induce both motor and cognitive impairment, the latter has received less attention. We aimed to evaluate the frequency of the varying severity levels of cognitive impairment, the determinants of severe cognitive impairment, and the association of cognitive impairment with functional outcome after SSVD.

METHODS

Consecutive patients admitted to hospital because of SSVD were assessed at 3 months after stroke. We performed a semi-structured clinical interview to screen for cognitive symptoms. Severity of cognitive symptoms was graded according to the Clinical Dementia Rating Scale (CDR). Performance on psychometric tests (Mini-Mental State Examination, Alzheimer's Disease Assessment Scale (cognition subscale), Mattis Dementia Rating Scale (initiation/perseverence subscale; MDRS I/P)) of patients of different CDR gradings was compared with that of 42 healthy controls. Basic demographic data, vascular risk factors, stroke severity (National Institute of Health Stroke Scale; NIHSS), pre-stroke cognitive decline (Informant Questionnaire on Cognitive Decline in the Elderly; IQCODE), functional outcome (Barthel index; BI), Instrumental Activities Of Daily Living; IADL), and neuroimaging features (site of recent small infarcts, number of silent small infarcts, white matter changes) were also compared among the groups. Regression analyses were performed to find predictors of severe cognitive impairment and poor functional outcome.

RESULTS

Among the 75 included patients, 39 (52%) complained of cognitive symptoms. The number of patients in each CDR grading was as follows: 39 (52%) had a CDR of 0, 26 (34.7%) had a CDR of 0.5, 10 (13.3%) had a CDR of > or =1. Pre-stroke IQCODE and previous stroke predicted CDR> or =1. The NIHSS was associated with more impaired BI. The NIHSS and MDRS I/P contributed most to impaired IADL.

CONCLUSIONS

Half of the patients with SSVD complained of varying severity of cognitive problems 3 months after stroke. Pre-stroke cognitive decline and previous stroke predict severe cognitive impairment post stroke. Stroke severity and executive dysfunction contribute most to a poor functional outcome.

Acute stroke effects on emotions: an interpretation through the mirror system

PURPOSE OF REVIEW

The most recent reports on emotional consequences of stroke are hereby reviewed and analyzed. In particular the interpretation of some neurological presentations found in stroke patients, such as athymormia, dysprosody, emotional incontinence and emotional blunting is discussed. As current theories on mental functions do not provide satisfactory explanations for the above syndromes, a novel interpretative framework is proposed, based on neuropsychological experimental data on the 'mirror system'.

RECENT FINDINGS

Recent findings support both the fundamental role of the mirror system in imitative processes as well as the relevance of imitation for the emotional part of human personality and behavior.

SUMMARY

The mirror system appears to be of paramount relevance for empathy and social behavior. The model of analysis-by-synthesis is here discussed, together with neurological presentations resulting from stroke induced impairments of the mirror system. Speculations for further researches are also proposed.

Consequences of mild stroke in persons <75 years -- a 1-year follow-up

BACKGROUND AND PURPOSE

Mild strokes can be neglected regarding subtle sequels as fatigue, and cognitive and emotional changes. We have addressed this topic by exploring late consequences of an initially mild stroke (Barthel score >or=50). Accordingly, we assayed impairment, disability and handicap data 1 year after the first-ever stroke in persons <75 years, focusing on symptoms as fatigue, concentration difficulties, memory disturbances, emotional lability, stress resistance, anxiety and uneasiness, symptoms comprised in the astheno-emotional disorder (AED), and its relation to life satisfaction.

RESULTS

The mean value of the Barthel Index was 99.5 (SD 0.5) and 25% scored 0-1 on the Oxford Handicap Scale. AED was diagnosed in 71% of the patients, and fatigue was experienced by 72%. AED correlated significantly with life satisfaction, handicap and depression. Life satisfaction was significantly below that of norm values according to satisfaction with life as a whole, sex life and ability to manage selfcare.

CONCLUSIONS

Our findings emphasize that 'hidden dysfunctions' not so easily discovered within the hospital context are common consequences of mild stroke. The concept of mild stroke as principally founded in motor function or ability in P-ADL therefore seems to be insufficient with respect to the patient long-term perspective.