The Behavioural Outcomes of Anxiety scale (BOA): a preliminary validation in stroke survivors

Chinese version of the Death Anxiety Beliefs and Behaviours Scale: Psychometric properties based on CTT and IRT

OBJECTIVES

The Death Anxiety Beliefs and Behaviour Scale (DABBS) is a unique tool designed to assess the detrimental beliefs and avoidant behaviors linked to death anxiety. This study aimed to adapt the DABBS into Chinese and verify its psychometric characteristics within a community-dwelling older adult population.

METHODS

This study used a cross-sectional design and translated the DABBS into Chinese. The psychometric properties of 437 community-dwelling older persons were assessed using the Classical Test Theory (CTT) and Item Response Theory (IRT).

RESULTS

The DABBS consisted of affect, beliefs, and behaviours, with 18 entries in 3 dimensions. The I-CVI of the DABBS ranged from 0.857 to 1.000, and the S-CVI was 0.968; Cronbach's alpha of 0.905. Rasch analysis results showed that the 3 dimensions of the scale possessed good unidimensionality, and the entries were well-fitted to the dimensions in which they were located; each entry Infit MNSQ and Outfit MNSQ were in the range of 0.50 to 1.50; the analysis of the functional differences of items in different characteristic subgroups (gender) showed that the absolute value of DIF Contrast was <0.50. The results of the Wright map showed that the ability of the participants was normally distributed, and the difficulty of the scale's entries was adapted to the average ability level of older adults.

CONCLUSIONS

The present data indicate that the revised DABBS is a valid and reliable tool for assessing affect, beliefs, and behaviors associated with death anxiety in community-dwelling older individuals.

Evaluating the feasibility and acceptability of the Mood Assessment Post-Stroke (MAPS) mood screening training

Mood problems are common after stroke, and screening is recommended. Training may support staff knowledge and implementation of screening, but the feasibility of training programmes in the Australian healthcare system has not been formally established. This study aimed to assess the feasibility of a mood screening training for a multidisciplinary team (MDT) of stroke clinicians working in a post-acute inpatient rehabilitation service.Twelve staff from a rehabilitation service at a major hospital in Sydney, Australia participated in a 3-h interactive training session. The feasibility of running the course, assessment of knowledge gained via a consolidation exercise and quiz and acceptability of the training were assessed via focus groups.The in-person modality of the training hindered recruitment and assessment of participants' knowledge, though the actual measures themselves appeared appropriate. Nine participants provided feedback in two focus groups. Thematic analysis identified positive reactions to the training. However, low self-efficacy persisted and organisational/socio-cultural barriers to implementation emerged. Following training, the medical officers of the MDT had successfully implemented routine screening.Overall, the training appeared acceptable and to foster knowledge in staff. However, limitations to recruitment and administering evaluations were identified. The development of flexible online training may improve future evaluations of screening training programmes/pathways.

Development of the "Kalmer" relaxation intervention: co-design with stroke survivors with aphasia

PURPOSE

Anxiety is common after stroke and more prevalent in survivors with aphasia. Relaxation is an effective first-line therapy. The current study aimed to obtain the perspectives of stroke survivors with aphasia to inform the development of an accessible, technology-based, relaxation intervention.

MATERIALS AND METHODS

Qualitative co-design methods were used with twelve people with aphasia after stroke. The "Kalmer" Relaxation treatment package materials were iteratively based on participants' experiences and preferences; barriers and facilitators to treatment compliance were explored. Participants were also asked to consider how the intervention might be evaluated in a research trial.

RESULTS

A thematic analysis highlighted the importance and need for the development of an appropriate and inclusive relaxation product, to be implemented by health professionals early post-stroke. Several behavioural strategies to improve treatment adherence were recommended. Participants had varying perspectives on clinically meaningful treatment outcomes.

CONCLUSIONS

Overall, a co-designed accessible relaxation product was viewed as a necessary component of usual stroke care. Acceptability and feasibility and preliminary efficacy of the "Kalmer" intervention should be trialled in future studies. IMPLICATIONS FOR REHABILITATIONCo-designing psychological interventions for people with aphasia after stroke is needed to meet the needs of this at-risk population.Technology-based relaxation interventions to manage anxiety after stroke are viewed positively by people with aphasia and deemed acceptable and feasible.Clinical trials of these co-designed relaxation interventions are required before recommending integration into routine practice.

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.

Long-term anxiety in spontaneous intracerebral haemorrhage survivors

Background. Although anxiety is common in several neurological conditions, it has been poorly investigated after spontaneous intracerebral haemorrhage (ICH).

Aims. In consecutive ICH survivors, we assessed the long-term prevalence of anxiety and its clinical and radiological determinants.

Methods. Using the Hospital Anxiety and Depression scale (HADS), we evaluated ICH survivors enrolled in the prospective, single-centre Prognosis of Intracerebral Hemorrhage (PITCH) study. The prevalence of anxiety (defined as a HADS-anxiety subscale score > 7) was evaluated at three time points (1-2, 3-5, and 6-8 years after ICH), along with neurological symptoms severity, functional disability, and cognitive impairment scores. Clinical and radiological characteristics associated with anxiety were evaluated in univariate and multivariable models.

Results. Of 560 patients with spontaneous ICH, 255 were alive 1 year later, 179 of whom completed the HADS questionnaire and were included in the study. Thirty-one patients (17%; 95% confidence interval [CI] 12-23) had anxiety 1-2 years, 38 (27%; 95% CI 19-34) 3-5 years, and 18 (21%; 95% CI 12-30) 6-8 years after ICH. In patients with anxiety, the prevalence of associated depressive symptoms was 48.4% 1-2 years, 60.5% 3-5 years, and 55.5% 6-8 years after ICH. Among clinical and radiological baseline characteristics, only lobar ICH location was significantly associated with anxiety 1-2 years after ICH (odds ratio 2.8; 95% CI 1.2-6.5). Anxiety was not associated with concomitant neurological symptoms severity, functional disability, or cognitive impairment.

Conclusions. Anxiety is frequent in ICH survivors, often in association with depressive symptoms, even many years after the index event.

Depression, Anxiety, and Suicide After Stroke: A Narrative Review of the Best Available Evidence

Depression and anxiety each affect around 1 in 3 people during the first year after a stroke. Suicide causes the death of about 3 to 4/1000 stroke survivors during the first 5 years. This narrative review describes the best available evidence for the epidemiology of depression, anxiety, and suicide; their prevention; and the treatment of anxiety and depression. We conclude with directions for future research.

Exploring Associations Between a Biological Marker of Chronic Stress and Reported Depression and Anxiety in People With Aphasia

Purpose Living with the communication impairment of aphasia can be stressful. Chronic stress, depression, and anxiety are intimately linked, may be more pervasive in people with poststroke aphasia than the general population, and may influence cognitive function and treatment outcomes. In this project, we explored the psychological constructs of depression and anxiety and their associations with a biomarker measure of chronic stress in people with aphasia. Method Fifty-seven participants with aphasia completed measures of depression and anxiety and provided a hair sample from which to extract the stress hormone cortisol. Pearson product-moment correlational analyses were used to identify associations between depression, anxiety, and long-term level of cortisol via hair sample. Results While cortisol level was not associated with depression and anxiety across this sample of people with aphasia, a post hoc analysis showed a significant, positive correlation between a subset of participants with moderate and higher levels of depression and elevated cortisol level. Conclusions Chronic stress, depression, and anxiety have been little explored in people with aphasia to date, yet they are associated with future health consequences and impaired cognitive function, motivating further research as well as consideration of these factors in aphasia rehabilitation.

Psychometric properties of the Behavioural Outcomes of Anxiety questionnaire in stroke patients with aphasia

OBJECTIVE

To evaluate the psychometric properties of an observational, carer-completed anxiety screen for aphasic stroke patients.

DESIGN

Phase 1: A cross-sectional questionnaire design to establish psychometric properties. Phase 2: A randomized longitudinal design with treatment and control to evaluate sensitivity to change and repeatability/reliability.

SUBJECTS

Phase 1: 111 patient-carer dyads were recruited through stroke charities: patient mean age 69.7(10. 7), 6.2(5. 2) years since stroke, 76 male; carer mean age 64.7(12. 2), 27 male. Phase 2. A subsample of 50 dyads (29 completed).

MEASURES

All patients completed the Tension Rating Circles and the Frenchay Aphasia Screening Test. Carers completed the Behavioural Outcomes of Anxiety questionnaire, observational versions of the Hospital Anxiety and Depression Scale (HADS-A) and the Generalised Anxiety Disorder-7, and a feedback questionnaire.

INTERVENTION

Phase 2: 25 dyads were offered relaxation training and 25 acted as controls.

RESULTS

The Behavioural Outcomes of Anxiety questionnaire correlated .77 with the HADS-A and Cronbach's Alpha was .82 demonstrating validity and internal consistency. Using HADS-A cut-off > 7 as criterion the area under the curve was 0.90 and at cut-off of > 16 sensitivity (0.85) and specificity (0.85) were both good. Scores declined significantly more in a group given anxiety training ( n = 12) than in a control group ( n = 17), demonstrating sensitivity to change and construct validity. Two-week repeatability/reliability was .92. Feedback suggested the scale was acceptable.

CONCLUSIONS

The Behavioural Outcomes of Anxiety questionnaire shows promise as an anxiety screen for stroke patients with aphasia and is sensitive to change. Further analysis of dimensionality and discriminant validity is needed.

Predictors of anxiety after stroke: a systematic review of observational studies

BACKGROUND

Anxiety disorders or symptoms are relatively common after stroke. A better understanding of the predictors of anxiety in stroke patients may improve the management of these disorders. The current review was conducted to determine the predictors of anxiety after stroke.

METHODS

Relevant articles concerning population, hospital, or rehabilitation-based studies were identified by searching 10 electronic databases up to May 2014. Methodological quality appraisal, including the validity of prognostic models and data extraction were conducted by 3 reviewers.

RESULTS

A total of 18 studies were identified. Data from 3 population-based studies including 8130 patients, 8 hospital-based studies including 1199 patients, and 7 rehabilitation-based studies including 1103 patients were evaluated. Prestroke depression, stroke severity, early anxiety, and dementia or cognitive impairment after stroke were the main predictors of poststroke anxiety. Older age, physical disability or impairment, and use of antidepressant drugs were not associated with the presence of anxiety. Limitations of studies included wide variation in screening tools and cutoff scores, variability in the time frame of screening for anxiety, use of extensive exclusion criteria, and questionable statistical internal and external validity of the models.

CONCLUSIONS

Lack of methodological and statistical rigor affects the validity of proposed models to predict anxiety after stroke. Future research should focus on testing proposed models on both internal and external samples to ultimately inform future clinical practice.

Depression and anxiety symptoms post-stroke/TIA: prevalence and associations in cross-sectional data from a regional stroke registry

BACKGROUND

Mood disorders are commonly seen in those with cerebrovascular disease. Literature to-date has tended to focus on depression and on patients with stroke, with relatively little known about post-stroke anxiety or mood disorder in those with transient ischaemic attack (TIA). We aimed to describe prevalence of depression and anxiety symptoms in stroke and TIA cohorts and to explore association with clinical and socio-demographic factors.

METHODS

We used a city wide primary care stroke registry (Glasgow Local Enhanced Service for Stroke - LES). All community dwelling stroke-survivors were included. We described cross-sectional prevalence of depression and anxiety symptoms using the Hospital Anxiety and Depression Scale (HADS). Data on clinical and demographic details was collected and univariable and multivariable analyses performed to describe associations with HADS scores. We examined those with a diagnosis of 'stroke' and 'TIA' as separate cohorts.

RESULTS

From 13,283 potentially eligible stroke patients in the registry, we had full HADS data on 4,079. Of the 3,584 potentially eligible TIA patients, we had full HADS data on 1,247 patients. Across the stroke cohort, 1181 (29%) had HADS anxiety scores suggestive of probable or possible anxiety; 993 (24%) for depression. For TIA patients, 361 (29%) had anxiety and 254 (21%) had depression. Independent predictors of both depression and anxiety symptoms were female sex, younger age and higher socioeconomic deprivation score (all p < 0.001).

CONCLUSION

Using HADS, we found a high prevalence of anxiety and depression symptoms in a community-based cohort of patients with cerebrovascular disease.