The Effect of Sleep Disturbances on the Functional Recovery of Rehabilitation Inpatients Following Mild and Moderate Stroke

Role of vitamin D in the association between pre-stroke sleep quality and poststroke depression and anxiety

PURPOSE

Poor sleep quality, mood disorders, and vitamin D deficiency are common in stroke. We investigated the association between serum vitamin D levels and pre-stroke sleep quality and the occurrence of poststroke depression (PSD) and poststroke anxiety (PSA) in acute ischemic stroke (AIS).

METHODS

This prospective cross-sectional study included hospitalized patients with AIS and age- and sex-matched controls. Vitamin D levels were measured within 24 h of admission. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) at admission. The severity of depression and anxiety symptoms was evaluated according to Beck Depression Inventory and Beck Anxiety Inventory scores, respectively, within 72 h after admission.

RESULTS

Comparing 214 AIS patients with 103 controls, patients had significantly higher scores of Beck Depression Inventory, Beck Anxiety Inventory, and PSQI and lower vitamin D levels (p < 0.001). Among AIS patients, Beck Depression Inventory (p = 0.004) and Beck Anxiety Inventory (p = 0.018) scores were significantly higher in bad sleepers (PSQI score ≥ 6) than in good sleepers (PSQI score ≤ 5). Correlation analysis revealed negative correlations between serum vitamin D levels and Beck Depression Inventory (r =  - 0.234; p < 0.001), Beck Anxiety Inventory (r =  - 0.135; p = 0.016), and PSQI (r =  - 0.218; p < 0.001) scores.

CONCLUSION

Decreased serum vitamin D levels at admission are associated with a high risk for PSD and PSA in patients with poor pre-stroke sleep quality during the early stages of AIS.

Insomnia Symptoms and Environmental Disruptors: A Preliminary Evaluation of Veterans in a Subacute Rehabilitation

OBJECTIVES

Evaluate insomnia symptoms and environmental disruptors at admission and discharge in a subacute rehabilitation care setting.

METHODS

Veterans (age ≥50) admitted to a Veterans Health Administration (VA) Hospital subacute rehabilitation between March and August 2022 completed baseline (N = 46) and follow up (N = 33) assessments with the Insomnia Severity Index (ISI), Sleep Need Questionnaire (SNQ), Epworth Sleepiness Scale (ESS), and an assessment of environmental sleep disruptors. Veterans were offered sleep resources after admission evaluations and outpatient referrals after discharge evaluations. Pearson correlation determined associations between length of stay (LOS), ISI, SNQ, and ESS scores at admission and discharge; chi-square and Wilcoxon Signed Rank Tests compared insomnia at admission and discharge.

RESULTS

One-half of participants reported clinically meaningful insomnia symptoms and sleep needs at baseline with no significant change at discharge. Almost all (89.1%) Veterans reported sleep was disturbed by environmental factors, primarily staff awakenings. LOS was correlated with ESS scores at discharge (r = .52, p = .002).

CONCLUSIONS

Environmental sleep disruption was common during a subacute rehabilitation admission and were not adequately addressed through sleep resources and treatment due to low uptake.

CLINICAL IMPLICATIONS

Providers should assess sleep at admission and lessen environmental sleep disruptors by reducing noise, light, and non-essential awakenings at night.

Development of insomnia in patients with stroke: A systematic review and meta-analysis

BACKGROUND AND AIM

Stroke is a serious threat to human life and health, and post-stroke insomnia is one of the common complications severely impairing patients' quality of life and delaying recovery. Early understanding of the relationship between stroke and post-stroke insomnia can provide clinical evidence for preventing and treating post-stroke insomnia. This study was to investigate the prevalence of insomnia in patients with stroke.

METHODS

The Web of Science, PubMed, Embase, and Cochrane Library databases were used to obtain the eligible studies until June 2023. The quality assessment was performed to extract valid data for meta-analysis. The prevalence rates were used a random-efect. I2 statistics were used to assess the heterogeneity of the studies.

RESULTS

Twenty-six studies met the inclusion criteria for meta-analysis, with 1,193,659 participants, of which 497,124 were patients with stroke.The meta-analysis indicated that 150,181 patients with stroke developed insomnia during follow-up [46.98%, 95% confidence interval (CI): 36.91-57.18] and 1806 patients with ischemic stroke (IS) or transient ischemic attack (TIA) developed insomnia (47.21%, 95% CI: 34.26-60.36). Notably, 41.51% of patients with the prevalence of nonclassified stroke developed insomnia (95% CI: 28.86-54.75). The incidence of insomnia was significantly higher in patients with acute strokes than in patients with nonacute strokes (59.16% vs 44.07%, P < 0.0001).Similarly, the incidence of insomnia was significantly higher in the patients with stroke at a mean age of ≥65 than patients with stroke at a mean age of <65 years (47.18% vs 40.50%, P < 0.05). Fifteen studies reported the follow-up time. The incidence of insomnia was significantly higher in the follow-up for ≥3 years than follow-up for <3 years (58.06% vs 43.83%, P < 0.05). Twenty-one studies used the Insomnia Assessment Diagnostic Tool, and the rate of insomnia in patients with stroke was 49.31% (95% CI: 38.59-60.06). Five studies used self-reporting, that the rate of insomnia in patients with stroke was 37.58% (95% CI: 13.44-65.63).

CONCLUSIONS

Stroke may be a predisposing factor for insomnia. Insomnia is more likely to occur in acute-phase stroke, and the prevalence of insomnia increases with patient age and follow-up time. Further, the rate of insomnia is higher in patients with stroke who use the Insomnia Assessment Diagnostic Tool.

Unscheduled changes in pre-clinical stroke model housing contributes to variance in physiological and behavioural data outcomes: A post hoc analysis

Ischaemic stroke presents a significant problem worldwide with no neuroprotective drugs available. Many of the failures in the search for neuroprotectants are attributed to failure to translate from pre-clinical models to humans, which has been combatted with rigorous pre-clinical stroke research guidelines. Here, we present post hoc analysis of a pre-clinical stroke trial, conducted using intraluminal filament transient middle cerebral artery occlusion in the stroke-prone spontaneously hypertensive rat, whereby unscheduled changes were implemented in the animal housing facility. These changes severely impacted body weight post-stroke resulting in a change from the typical body weight of 90.6% of pre-surgery weight post-stroke, to on average 80.5% of pre-surgery weight post-stroke. The changes also appeared to impact post-stroke blood pressure, with an increase from 215.4 to 240.3 mmHg between housing groups, and functional outcome post-stroke, with a 38% increased latency to contact in the sticky label test. These data highlight the importance of tightly controlled housing conditions when using physiological or behavioural measurements as a primary outcome.

Acquired brain injury (ABI) survivors' experience of occupation and activity during their inpatient stay: a scoping review

PURPOSE

This review aimed to characterise and map: (1) what type of evidence and what dominant study characteristics are available regarding acquired brain injury (ABI) survivors' experience of occupation and activity in hospital? (2) How are occupation and activity conceptualised in the literature? (3) How are ABI survivors experiencing occupation and activity while in hospital? (4) What factors create barriers or opportunities for engagement in occupations or activity in hospital? (5) Are there any knowledge gaps identified?

MATERIALS AND METHODS

A scoping review was conducted examining literature published between 2017 and 2022. Relevant studies were systematically retrieved from electronic databases.

RESULTS

Thirty-four publications were included. There were more quantitative studies (n = 18). Much of the research has been conducted outside of the UK. The populations studied were principally stroke (n = 22). The concept of activity rather than occupation predominates. Patients spend their time alone and inactive. Structural and contextual barriers for engaging in activity are identified. Qualitative study designs exclude ABI survivors with communication or cognitive impairment.

CONCLUSIONS

There is a paucity of research with ABI survivors in hospitals in the UK. Alternative methodological approaches such as ethnography would ensure those with communication or cognitive impairment are not excluded from research. Implications for rehabilitationRehabilitation professionals, especially occupational therapists, need to lead acquired brain injury (ABI) research in acute hospital settings in the UK.Conceptualisation of meaningful activity and occupation needs a clearer focus in ABI research.Qualitative studies frequently exclude participants with cognitive or communication impairments so methodologies that are more inclusive and representative of brain injury survivors are needed.

The multifaceted aspects of sleep and sleep-wake disorders following stroke

Sleep-wake disorders (SWD) are acknowledged risk factors for both ischemic stroke and poor cardiovascular and functional outcome after stroke. SWD are frequent following stroke, with sleep apnea (SA) being the most frequent SWD affecting more than half of stroke survivors. While sleep disturbances and SWD are frequently reported in the acute phase, they may persist in the chronic phase after an ischemic stroke. Despite the frequency and risk associated with SWD following stroke, screening for SWD remains rare in the clinical setting, due to challenges in the assessment of post-stroke SWD, uncertainty regarding the optimal timing for their diagnosis, and a lack of clear treatment guidelines (i.e., when to treat and the optimal treatment strategy). However, little evidence support the feasibility of SWD treatment even in the acute phase of stroke and its favorable effect on long-term cardiovascular and functional outcomes. Thus, sleep health recommendations and SWD treatment should be systematically embedded in secondary stroke prevention strategy. We therefore propose that the management of SWD associated with stroke should rely on a multidisciplinary approach, with an integrated diagnostic, treatment, and follow-up strategy. The challenges in the field are to improve post-stroke SWD diagnosis, prognosis and treatment, through a better appraisal of their pathophysiology and temporal evolution.

Sleep quality after stroke: A systematic review and meta-analysis

BACKGROUND

Sleep-related problems are debilitating and long-lasting conditions in individuals with stroke. We aimed to estimate the prevalence of poor sleep quality after stroke by conducting a systematic review and meta-analysis.

METHODS

Five databases (PubMed, Embase, Web of Science, Scopus, and CINHAL) were searched for literature published before November 2022. Studies recruiting participants with stroke, using a validated scale to measure sleep quality and in English were included. We used the Agency for Healthcare Research and Quality Scale and Newcastle-Ottawa Scale to assess the quality of eligible studies. Pooled prevalence and subgroup analyses were performed to understand the variation in sleep quality among studies. We followed the PRISMA checklist to report the study.

RESULTS

Thirteen studies were included for analysis (n = 3886). The pooled prevalence of poor sleep quality was 53% (95% CI 41-65%). Studies using PSQI with a cutoff point of 7 had a prevalence of 49% (95% CI 26-71%), whereas those with a cutoff point of 5 had a higher prevalence of 66% (95% CI 63-69%) (P = .13). Geographical location could explain the prevalence variation between studies. The majority of included studies had a medium level quality of evidence (10/13).

CONCLUSION

Poor sleep quality appears to be common in patients with stroke. Considering its negative impact on health, effective measures should be taken to improve their quality of sleep. Longitudinal studies should be conducted to examine the contributing factors and investigate the mechanisms that lead to poor sleep quality.

[Insomnia in neurological patients with disabilities]

Sleep is the most important factor reflecting the level of psychophysical well-being of a person and influencing him/her to the same extent. The greater susceptibility to sleep disturbances in patients with disabilities is associated with numerous factors. In the existing literature, there are few studies of insomnia in people with neurological disabilities. This article presents a current view on sleep disorders in disabled people and methods for their treatment.

Sleep Quality and Cognitive Function after Stroke: The Mediating Roles of Depression and Anxiety Symptoms

This study examined the association between post-stroke cognitive function and sleep status at 30 days post-stroke and evaluated the role of anxiety and depression as potential mediators of that association. The participants in this study were 530 acute ischemic stroke (IS) patients. Sleep disturbance at 30 days post-stroke was assessed by the Pittsburgh Sleep Quality Index. Basic patient information, cognitive function, depression, and anxiety status were assessed before discharge from the hospital. Stratified linear regression analysis models were fit to examine the associations between post-stroke sleep quality and the influencing factors. A structural equation model was developed to evaluate the role of anxiety and depression as potential mediators of sleep quality and cognitive function. At 30 days post-stroke, 58.7% of IS patients had sleep disturbance. Women and older IS patients were more likely to suffer poorer sleep quality (p < 0.05). A stratified linear regression analysis showed that the inclusion of cognitive function variables and indicators of depression and anxiety were statistically significant in predicting improvement in the sleep disturbance of AIS patients. Cognitive function, depression, anxiety, and sleep status were selected to construct a structural equation model. The total effect of cognitive function on sleep status was -0.274, with a direct effect of -0.097 and an indirect effect (through depression) of -0.177. The total effect of anxiety on sleep status was 0.235, with a direct effect of 0.186 and an indirect effect (through depression) of 0.049. IS patients often experience poor sleep quality. Depression in IS patients mediates two pathways: the pathway through which cognitive function affects sleep quality and the pathway through which anxiety affects sleep quality.

Reliability and validity of the Turkish version of general sleep disturbance scale (GSDS-T) in stroke

BACKGROUND

Stroke is a life-threatening condition with many complications. Sleep disturbances is one of them. Sleep disturbances effect quality of life, recovery and rehabilitation process. It is crucial to reveal sleep disturbances objectively in stroke patients. The aim of the study is to determine reliability and validity of the Turkish version of General Sleep Disturbance Scale (GSDS-T) in stroke patients.

METHODS

After translation and culture validation of the scale was done, Pittsburgh Sleep Quality Index (PSQI) and the Turkish version of the GSDS was applied at admission and at 24 h to the 58 patients with stroke.

RESULTS

Cronbach alpha coefficient of total score was found as 0.850 and test re-test reliability-related Cronbach alpha coefficient was 0.785.

CONCLUSION

GSDS-T is a reliable and valid tool to assess sleep disturbance in stroke patients.

Reduced serum vitamin D levels are associated with poor sleep quality in early stroke patients

Background

Poor sleep quality and vitamin D deficiency are common in stroke patients. Our aim was to evaluate the possible association between vitamin D and sleep quality in acute ischemic stroke (AIS) patients.

Methods

A total of 301 AIS patients were screened and completed 1-month follow-up. Serum 25-hydroxyvitamin D [25(OH)D] was used to assess the vitamin D status by a competitive protein-binding assay at baseline. All patients were divided into equal quartile according to the distribution of 25(OH)D. One month after stroke, sleep quality was evaluated by using Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) questionnaire; depression status was confirmed by 17-item Hamilton Depression Scale (HAMD).

Results

There were 89 (29.6%) AIS patients with poor sleep quality 1-month post-event. Within 24 h after admission, serum 25(OH)D levels were significantly lower in patients with poor sleep quality after stroke (P &lt; 0.001). In the results of multivariate-adjusted logistic regression analysis, the odds ratio (OR) of poor sleep quality was 6.199 (95% CI, 2.066–18.600) for the lowest quartile of 25(OH)D compared with the highest quartile. In patients without depression, reduced 25(OH)D were still significantly associated with poor sleep quality (OR = 8.174, 95% CI = 2.432–27.473). Furthermore, 25(OH)D and HAMD score were combined to enhance the diagnostic accuracy of poor sleep quality, with the area under the receiver operating characteristic curve of 0.775.

Conclusion

Reduced serum levels of vitamin D at admission were independently and significantly associated with poor sleep quality at 1 month after stroke. Our findings suggested the combination of vitamin D and depression status could provide important predictive information for post-stroke sleep quality.

Traditional East Asian Herbal Medicine for Post-Stroke Insomnia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Post-stroke insomnia (PSI) is a highly prevalent complication after stroke. Current evidence of psychotropic drug use for PSI management is scarce and indicates harmful adverse events (AEs). Traditional East Asian herbal medicine is a widely used traditional remedy for insomnia. However, so far, no study has systematically reviewed the efficacy and safety of traditional east asian herbal medicine (HM) for PSI. Therefore, we perform meta-analysis to evaluate the effectiveness and safety of HM for PSI. After a comprehensive electronic search of 15 databases, we review the randomized controlled trials (RCTs) of HM use as monotherapy for PSI. Our outcomes were the Pittsburgh sleep quality index and total effective rate. In total, 24 RCTs were conducted with 1942 participants. HM showed statistically significant benefits in sleep quality. It also appeared to be safer than psychotropic drugs in terms of AEs, except when the treatment period was two weeks. The methods used for RCTs were poor, and the quality of evidence assessed was graded “low” or “moderate.” The findings of this review indicate that the use of HM as a monotherapy may have potential benefits in PSI treatment when administered as an alternative to conventional medications. However, considering the methodological quality of the included RCTs, we were uncertain of the clinical evidence. Further, well-designed RCTs are required to confirm these findings.

Association Between Sleep Duration and Functional Disability in Inpatient Stroke Rehabilitation: A Pilot Observational Study

Objective

To describe the change in sleep duration during inpatient rehabilitation and to determine if sleep quality and sleep duration is associated with functional disability for individuals after stroke. It was hypothesized that participants who experienced optimal sleep during inpatient rehabilitation would have greater functional ability at discharge.

Design

Longitudinal observation study.

Setting

Inpatient rehabilitation unit at a large, urban hospital.

Participants

Thirty-seven individuals with acute stroke (N=37; mean age, 62.5±11.8y, male=20, female=17) were recruited from September 2018 to September 2019. Participants were invited to participate in the study by clinical personnel associated with their usual care as they were admitted to inpatient rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

Participants were asked to wear an actigraph for the duration of their rehabilitation program to assess sleep. The first 3 nights of actigraphy data were averaged to obtain total sleep time (TST) and sleep efficiency (SE) at admission, and the last 3 nights were averaged for TST and SE at discharge. Functional disability (primary outcome was FIM) at admission and discharge was gathered from the participants’ medical records. One-way analysis of variance and chi-square analyses assessed for group differences, and regression modeling was used to determine if sleep was associated with functional ability at discharge.

Results

Sixteen participants (43%) were categorized as “good sleepers” and 21 (57%) were “poor sleepers” based on their TST at admission. Of the poor sleepers, 14 participants (66%) remained short duration sleepers (<7h at admission and discharge). Sleep outcomes did not significantly predict FIM score at discharge.

Conclusions

Most participants had less than optimal sleep duration during inpatient rehabilitation. Efforts may be warranted to optimize sleep during inpatient rehabilitation.

Sleep disturbance predicts future health status after stroke

STUDY OBJECTIVES

We evaluated factors associated with the presence of sleep disturbance in patients with stroke and whether sleep disturbance predicted change in other patient-reported domains of health over time.

METHODS

Observational cohort study of 2,190 patients with stroke seen in a cerebrovascular clinic February 17, 2015 to July 5, 2017 who completed patient-reported outcome measures (PROMs) at ≥ 1 visit, including the Patient Health Questionnaire-9 depression screen, Quality of Life in Neurological Disorders (NeuroQoL) cognitive function and Patient-Reported Outcomes Information Measurement System (PROMIS) sleep disturbance, fatigue, anxiety, social role satisfaction, physical function, and pain interference. Separate multivariable models were constructed with PROMIS sleep disturbance as the dependent variable. Covariates included clinical and demographic variables, the Patient Health Questionnaire-9 depression screen scored on the PROMIS metric, and 1 of the 6 other PROMs. Among the 476 patients with ≥ 2 visits, linear regression models were constructed to determine the association of baseline sleep disturbance with follow-up PROMs after adjustment for the corresponding baseline PROMIS/NeuroQol scores, depression score, and clinical variables.

RESULTS

Younger age and all PROM scores were associated with sleep disturbance; depression had the greatest association among PROMs (beta estimate 0.53, 95% confidence interval, 0.49, 0.57), physical function had the least (-0.06, 95% confidence interval, -0.11, -0.01). Baseline PROMIS sleep disturbance score was associated with worse adjusted follow-up scores for depression, fatigue, social role satisfaction, and physical function.

CONCLUSIONS

Younger age and all 8 PROMs were associated with sleep disturbance in patients with stroke. The degree of sleep disturbance predicted future patient-reported outcomes for multiple domains of health. Further study is warranted to determine if interventions shown to improve sleep symptoms will also improve other outcomes.

Insomnia in neurological diseases

Insomnia is defined as difficulties of initiating and maintaining sleep, early awakening and poor subjective sleep quality despite adequate opportunity and circumstances for sleep with impairment of daytime performance. These components of insomnia - namely persistent sleep difficulties despite of adequate sleep opportunity resulting in daytime dysfunction - appear secondary or co-morbid to neurological diseases. Comorbid insomnia originates from neurodegenerative, inflammatory, traumatic or ischemic changes in sleep regulating brainstem and hypothalamic nuclei with consecutive changes of neurotransmitters. Symptoms of neurological disorders (i.e motor deficits), co-morbidities (i.e. pain, depression, anxiety) and some disease-specific pharmaceuticals may cause insomnia and/or other sleep problems.This guideline focuses on insomnias in headaches, neurodegenerative movement disorders, multiple sclerosis, traumatic brain injury, epilepsies, stroke, neuromuscular disease and dementia.The most important new recommendations are: Cognitive behavioral therapy (CBTi) is recommended to treat acute and chronic insomnia in headache patients. Insomnia is one of the most frequent sleep complaints in neurodegenerative movement disorders. Patients may benefit from CBTi, antidepressants (trazodone, doxepin), melatonin and gaba-agonists. Insomnia is a frequent precursor of MS symptoms by up to 10 years. CBTi is recommended in patients with MS, traumatic brain injury and. Melatonin may improve insomnia symptoms in children with epilepsies. Patients with insomnia after stroke can be treated with benzodiazepine receptor agonists and sedating antidepressants. For patients with dementia suffering from insomnia trazodone, light therapy and physical exercise are recommended.

Dynamic Prevalence of Sleep Disorders Following Stroke or Transient Ischemic Attack: Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

The exact prevalence of sleep disorders following stroke or transient ischemic attack (TIA) remains unclear. We aimed to determine the prevalence of sleep-disordered breathing, insomnia, periodic leg movement during sleep, and restless leg syndrome following stroke or TIA in acute, subacute, and chronic phases and examine the moderating effects of patient characteristics (eg, age) and methodological features (eg, study quality) on the prevalence.

METHODS

We performed a systematic review and meta-analysis. Embase and PubMed were searched from inception to December 18, 2019. We included 64 047 adults in 169 studies (prospective, retrospective, case-control, and cross-sectional study designs) reporting the prevalence of sleep disorders following stroke or TIA.

RESULTS

In the acute phase, the overall prevalence of mild, moderate, and severe sleep-disordered breathing was 66.8%, 50.3%, and 31.6% (95% CIs, 63.8-69.7, 41.9-58.7, and 24.9-39.1). In the subacute phase, the prevalence of mild, moderate, and severe sleep-disordered breathing was 65.5%, 44.3%, and 36.1% (95% CIs, 58.9-71.5, 36.1-52.8, and 22.2-52.8). In the chronic phase, the summary prevalence of mild, moderate, and severe sleep-disordered breathing was 66.2%, 33.1%, and 25.1% (95% CIs, 58.6-73.1, 24.8-42.6, and 10.9-47.6). The prevalence rates of insomnia in the acute, subacute, and chronic phases were 40.7%, 42.6%, and 35.9% (95% CIs, 31.8-50.3, 31.7-54.1, and 28.6-44.0). The pooled prevalence of periodic leg movement during sleep in the acute, subacute, and chronic phases was 32.0%, 27.3%, and 48.2% (95% CIs, 7.4-73.5, 11.6-51.7, and 33.1-63.5). The summary prevalence of restless leg syndrome in the acute and chronic phases was 10.4% and 13.7% (95 CIs, 6.4-16.4 and 2.3-51.8). Age, sex, comorbidities, smoking history, and study region had significant moderating effects on the prevalence of sleep disorders.

CONCLUSIONS

Sleep disorders following stroke or TIA are highly prevalent over time. Our findings indicate the importance of early screening and treating sleep disorders following stroke or TIA.

The Impact of Sleep Disorders on Functional Recovery and Participation Following Stroke: A Systematic Review and Meta-Analysis

Background

Adequate sleep is vital for health and quality of life. People with stroke and a concomitant sleep disorder may have poorer outcomes than those without a sleep disorder.

Objective

To systematically evaluate the published literature to determine the impact of sleep disorders on physical, functional recovery at the activity and participation level after stroke.

Methods

A systematic review was conducted using PubMed, CINAHL, Scopus, and PsycINFO. Studies were selected that reported outcomes on physical, functional recovery at the activity and participation levels in participants with stroke and a diagnosed sleep disorder. A meta-analysis was performed on included studies that reported Barthel Index (BI) and modified Rankin Scale (mRS) scores. Results: A total of 33 studies were included in the systematic review with 9 of them in the meta-analysis. The mean mRS score was 0.51 points higher in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: 0.23-0.78]. The mean BI score was 10.2 points lower in participants with stroke and sleep disorders versus participants with stroke without sleep disorder [95% CI: −17.9 to −2.6].

Conclusions

People with stroke and a sleep disorder have greater functional limitations and disability than those without a sleep disorder. Rehabilitation professionals should screen their patients with stroke for potential sleep disorders and further research is needed to develop sleep and rehabilitation interventions that can be delivered in combination. PROSPERO registration number: CRD42019125562.

Sleep problems worsen health-related quality of life and participation during the first 12 months of stroke rehabilitation

OBJECTIVE

Evaluate the impact of self-reported sleep problems on post-stroke recovery.

DESIGN

Cross-sectional secondary analysis of longitudinal data from the Locomotor Experience Applied Post-Stroke (LEAPS) rehabilitation and recovery study (phase-III single-blind randomized controlled clinical trial). Group medians were compared for three sleep problem groups across three time points.

SETTING

Outpatient and in-home physical therapy.

SUBJECTS

Adults during the first year following stroke (n = 408, 380, 360 at 2, 6, 12 months, respectively).

INTERVENTIONS

The original study compared effects of locomotor training with body weight support in the year post-stroke. This analysis evaluated function in three sleep/functional-impact groups: no sleep problems, sleep problems with no-to-minimal-impact and sleep problems with moderate-to-quite-a-bit of impact.

MAIN MEASURES

Participants' responses regarding if they had "a sleep problem, such as insomnia" and, if so, what the impact was on their function. Stroke Impact Scale subscales for strength, hand function, mobility, ADLs, memory, communication, emotion, participation, and percent recovery.

RESULTS

About 25% of people with stroke reported sleep difficulty, 10% perceived sleep problems negatively impact function. Groups self-reporting worse sleep performed worse in all functional subscales (except self-perceived percent recovery) during the first year post-stroke.

CONCLUSION

Self-reported poor sleep adversely effects post-stroke functional recovery.

Inconsistent Classification of Mild Stroke and Implications on Health Services Delivery

OBJECTIVE

To conduct a scoping review on classifications of mild stroke based on stroke severity assessments and/or clinical signs and symptoms reported in the literature.

DATA SOURCES

Electronic searches of PubMed, PsycINFO (Ovid), and Cumulative Index to Nursing and Allied Health (CINAHL-EBSCO) databases included keyword combinations of mild stroke, minor stroke, mini stroke, mild cerebrovascular, minor cerebrovascular, transient ischemic attack, or TIA.

STUDY SELECTION

Inclusion criteria were limited to articles published between January 2003 and February 2018. Inclusion criteria included studies (1) with a definition of either mild or minor stroke, (2) written in English, and (3) with participants aged 18 years and older. Animal studies, reviews, dissertations, blogs, editorials, commentaries, case reports, newsletters, drug trials, and presentation abstracts were excluded.

DATA EXTRACTION

Five reviewers independently screened titles and abstracts for inclusion and exclusion criteria. Two reviewers independently screened each full-text article for eligibility. The 5 reviewers checked the quality of the included full-text articles for accuracy. Data were extracted by 2 reviewers and verified by a third reviewer.

DATA SYNTHESIS

Sixty-two studies were included in the final review. Ten unique definitions of mild stroke using stroke severity assessments were discovered, and 10 different cutoff points were used. The National Institutes of Health Stroke Scale was the most widely used measure to classify stroke severity. Synthesis also revealed variations in classification of mild stroke across publication years, time since stroke, settings, and medical factors including imaging, medical indicators, and clinical signs and symptoms.

CONCLUSIONS

Inconsistencies in the classification of mild stroke are evident with varying use of stroke severity assessments, measurement cutoff scores, imaging tools, and clinical or functional outcomes. Continued work is necessary to develop a consensus definition of mild stroke, which directly affects treatment receipt, referral for services, and health service delivery.

Sleep Disruption After Brain Injury Is Associated With Worse Motor Outcomes and Slower Functional Recovery

Background. Sleep is important for consolidation of motor learning, but brain injury may affect sleep continuity and therefore rehabilitation outcomes. Objective. This study aims to assess the relationship between sleep quality and motor recovery in brain injury patients receiving inpatient rehabilitation. Methods. Fifty-nine patients with brain injury were recruited from 2 specialist inpatient rehabilitation units. Sleep quality was assessed (up to 3 times) objectively using actigraphy (7 nights) and subjectively using the Sleep Condition Indicator. Motor outcome assessments included Action Research Arm test (upper limb function), Fugl-Meyer Assessment (motor impairment), and the Rivermead Mobility Index. The Functional Independence Measure (FIM) was assessed at admission and discharge by the clinical team. Fifty-five age- and gender-matched healthy controls completed one assessment. Results. Inpatients demonstrated lower self-reported sleep quality (P < .001) and more fragmented sleep (P < .001) than controls. For inpatients, sleep fragmentation explained significant additional variance in motor outcomes, over and above that explained by admission FIM score (P < .017), such that more disrupted sleep was associated with poorer motor outcomes. Using stepwise linear regression, sleep fragmentation was the only variable found to explain variance in rate of change in FIM (R²_adj = 0.12, P = .027), whereby more disrupted sleep was associated with slower recovery. Conclusions. Inpatients with brain injury demonstrate impaired sleep quality, and this is associated with poorer motor outcomes and slower functional recovery. Further investigation is needed to determine how sleep quality can be improved and whether this affects outcome.

EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke

Sleep disorders are highly prevalent in the general population and may be linked in a bidirectional fashion to stroke, which is one of the leading causes of morbidity and mortality.Four major scientific societies established a task force of experts in neurology, stroke, respiratory medicine, sleep medicine and methodology, to critically evaluate the evidence regarding potential links and the impact of therapy. 13 research questions were evaluated in a systematic literature search using a stepwise hierarchical approach: first, systematic reviews and meta-analyses; second, primary studies post-dating the systematic reviews/meta-analyses. A total of 445 studies were evaluated and 88 included. Statements were generated regarding current evidence and clinical practice.Severe obstructive sleep apnoea (OSA) doubles the risk for incident stroke, especially in young to middle-aged patients. Continuous positive airway pressure (CPAP) may reduce stroke risk, especially in treatment-compliant patients. The prevalence of OSA is high in stroke patients and can be assessed by polygraphy. Severe OSA is a risk factor for recurrence of stroke and may be associated with stroke mortality, while CPAP may improve stroke outcome. It is not clear if insomnia increases stroke risk, while pharmacotherapy of insomnia may increase it. Periodic limb movements in sleep (PLMS), but not restless limb syndrome (RLS), may be associated with an increased risk of stroke. Preliminary data suggest a high frequency of post-stroke insomnia and RLS and their association with a less favourable stroke outcome, while treatment data are scarce.Overall, the evidence base is best for OSA relationship with stroke and supports active diagnosis and therapy. Research gaps remain especially regarding insomnia and RLS/PLMS relationships with stroke.

From Stroke to Dementia: a Comprehensive Review Exposing Tight Interactions Between Stroke and Amyloid-β Formation

Stroke and Alzheimer’s disease (AD) are cerebral pathologies with high socioeconomic impact that can occur together and mutually interact. Vascular factors predisposing to cerebrovascular disease have also been specifically associated with development of AD, and acute stroke is known to increase the risk to develop dementia.

Despite the apparent association, it remains unknown how acute cerebrovascular disease and development of AD are precisely linked and act on each other. It has been suggested that this interaction is strongly related to vascular deposition of amyloid-β (Aβ), i.e., cerebral amyloid angiopathy (CAA). Furthermore, the blood–brain barrier (BBB), perivascular space, and the glymphatic system, the latter proposedly responsible for the drainage of solutes from the brain parenchyma, may represent key pathophysiological pathways linking stroke, Aβ deposition, and dementia.

In this review, we propose a hypothetic connection between CAA, stroke, perivascular space integrity, and dementia. Based on relevant pre-clinical research and a few clinical case reports, we speculate that impaired perivascular space integrity, inflammation, hypoxia, and BBB breakdown after stroke can lead to accelerated deposition of Aβ within brain parenchyma and cerebral vessel walls or exacerbation of CAA. The deposition of Aβ in the parenchyma would then be the initiating event leading to synaptic dysfunction, inducing cognitive decline and dementia. Maintaining the clearance of Aβ after stroke could offer a new therapeutic approach to prevent post-stroke cognitive impairment and development into dementia.

Sleep and Stroke: New Updates on Epidemiology, Pathophysiology, Assessment, and Treatment

PURPOSE OF REVIEW

This review aims to discuss the most recent data on sleep disorders and stroke, highlighting relevant findings for the practicing neurologist or health providers who encounter patients with sleep disorders and stroke.

RECENT FINDINGS

Sleep apnea and abnormal sleep duration have the strongest association with stroke risk. Possible mechanisms include non-dipping of blood pressure during sleep, hypoxemia or reoxygenation leading to sympathetic activation, hypertension, atrial fibrillation and impaired cerebral hemodynamics. Treatment studies suggest that continuous positive airway pressure (CPAP) for sleep apnea could improve primary prevention of stroke, but data is equivocal for secondary prevention. However, CPAP could improve functional outcomes after stroke.

SUMMARY

Sleep disorders present an opportunity to improve stroke risk and functional outcomes. However, new strategies are needed to determine the patients at high-risk who would most likely benefit from targeted care. Novel methods for phenotyping sleep disorders could provide personalized stroke care to improve clinical outcomes and public health strategies.

[Long-term outcome prediction in patients with stroke]

AIM

To create a model to predict long-term stroke outcome using polysomnographic parameters.

MATERIAL AND METHODS

Authors prospectively enrolled 56 acute stroke patients. All subjects underwent clinical evaluation and polysomnographic study. A modified Rankin Scale was used to measure the degree of disability after stroke. Long-term stroke outcome was assessed 1 year post-stroke.

RESULTS AND CONCLUSION

REM-latency and apnea-hypopnea index are factors influencing long-term outcome of stroke. Including these parameters into the logistic regression model allows to predict stroke outcome at high levels of sensitivity and specificity.

Development and Evaluation of a Cognitive Behavioural Intervention for Chronic Post-Stroke Insomnia

BACKGROUND

Cognitive behavioural therapy for insomnia (CBTI) has been successfully applied to those with chronic illness. However, despite the high prevalence of post-stroke insomnia, the applicability of CBTI for this population has not been substantially researched or routinely used in clinical practice.

AIMS

The present study developed a 'CBTI+' protocol for those with post-stroke insomnia and tested its efficacy. The protocol also incorporated additional management strategies that considered the consequences of stroke.

METHOD

A single-case experimental design was used with five community-dwelling individuals with post-stroke insomnia. Daily sleep diaries were collected over 11 weeks, including a 2-week baseline, 7-week intervention and 2-week follow-up. The Insomnia Severity Index, Dysfunctional Attitudes and Beliefs About Sleep Scale, Epworth Sleepiness Scale, Fatigue Severity Scale and Stroke Impact Scale were administered pre- and post-treatment, as well as at 2-week follow-up.

RESULTS

At post-treatment, three participants no longer met diagnostic criteria for insomnia and all participants showed improvements on two or more sleep parameters, including sleep duration and sleep onset latency. Three participants showed a reduction in daytime sleepiness, increased quality of life and reduction in unhelpful beliefs about sleep.

CONCLUSIONS

This study provides initial evidence that CBTI+ is a feasible and acceptable intervention for post-stroke insomnia. Furthermore, it indicates that sleep difficulties in community-dwelling stroke populations are at least partly maintained by unhelpful beliefs and behaviours. The development and delivery of the CBTI+ protocol has important clinical implications for managing post-stroke insomnia and highlights directions for future research.