Cognitive ability, education and socioeconomic status in childhood and risk of post-stroke depression in later life: A systematic review and meta-analysis

COVID-19 and stroke in women: impact on clinical, psychosocial and research aspects

Despite the growing interest in gender medicine, the influence of sex and gender on human diseases, including stroke, continues to be underestimated and understudied. The COVID-19 pandemic has overall impacted not only the occurrence and management of stroke but has also exacerbated sex and gender disparities among both patients and healthcare providers. This paper aims to provide an updated overview on the influence of sex and gender in stroke pathophysiology and care during COVID-19 pandemic, through biological, clinical, psychosocial and research perspectives. Gender equity and awareness of the importance of sexual differences are sorely needed, especially in times of health crisis but have not yet been achieved to date. To this purpose, the sudden yet worldwide diffusion of COVID-19 represents a unique learning experience that highlights critical unmet needs also in gender medicine. The failures of this recent past should be kept as food for thought to inspire proper strategies reducing inequalities and to address women's health and wellbeing issues, particularly in case of future pandemics.

Educational attainment, severity and short-term prognosis of intracerebral haemorrhage

Background

Educational attainment is a critical social determinant of health that impacts the risk and severity of incident ischaemic stroke, but less is known of its impact on intracerebral haemorrhage (ICH). The objective of this study is to determine whether educational attainment is associated with ICH severity and short-term prognosis.

Methods

Subjects were enrolled in a prospectively ascertained cohort with primary ICH from 1994 to 2020 at Massachusetts General Hospital. Educational attainment, medical history of ICH risk factors, ICH volume and ICH score were obtained on admission. The primary outcomes were ICH volume and the ICH score.

Results

Of 2539 eligible patients eligible, the median age of the sample was 74 (IQR 64-82) and 2159 (85%) had high school-only education. 1655 (65%) presented with an ICH volume less than or equal to 30 mL and 1744 (69%) presented with an ICH score less than 3. In multivariable logistic regression analyses controlling for age, income, employment history and prestroke diagnoses of hypertension and coronary artery disease, patients with high school-only education were more likely to have an ICH volume greater than 30 mL compared with college diplomates (OR 1.58, 95% CI 1.24 to 2.08) and more likely to have an ICH score of 3 or greater compared with college diplomates (OR 2.37, 95% CI 1.77 to 3.19).

Discussion

Prestroke educational attainment is independently associated with ICH severity and short-term prognosis, with lower educational attainment associated with larger ICH volumes and higher ICH scores. Future studies should examine how educational attainment impacts exposure to traditional clinical risk factors.

Post-stroke dizziness, depression and anxiety

OBJECTIVE

Vestibular and psychiatric disorders are very closely related. Previous research shows that the discomfort and dysfunction caused by dizziness in patients can affect psychological processes, leading to anxiety and depression, and the irritation of anxiety and depression can aggravate the discomfort of dizziness. But the causal relationship between dizziness in the recovery period of stroke and Post-stroke depression (PSD) / Post-stroke anxiety (PSA) is not clear. Identifying the causal relationship between them can enable us to conduct more targeted treatments.

METHODS

We review the epidemiology and relationship of dizziness, anxiety, and depression, along with the related neuroanatomical basis. We also review the pathophysiology of dizziness after stroke, vestibular function of patients experiencing dizziness, and the causes and mechanisms of PSD and PSA. We attempt to explore the possible relationship between post-stroke dizziness and PSD and PSA.

CONCLUSION

The treatment approach for post-stroke dizziness depends on its underlying cause. If the dizziness is a result of PSD and PSA, addressing these psychological factors may alleviate the dizziness. This can be achieved through targeted treatments for PSD and PSA, such as psychotherapy, antidepressants, or anxiolytics, which could indirectly improve dizziness symptoms. Conversely, if PSA and PSD are secondary to vestibular dysfunction caused by stroke, a thorough vestibular function assessment is crucial. Identifying the extent of vestibular impairment allows for tailored interventions. These could include vestibular rehabilitation therapy and medication aimed at vestibular restoration. By improving vestibular function, secondary symptoms like anxiety and depression may also be mitigated.

Association between socioeconomic status and post-stroke depression in middle-aged and older adults: results from the China health and retirement longitudinal study

INTRODUCTION

Post-stroke depression (PSD) is a common neuropsychiatric complication that affects approximately one-third of stroke patients. The treatment and prognosis of this disease are poor. Socioeconomic status (SES) is closely related to health outcomes; however, only a few previous studies have focused on the association between SES and PSD. Given the substantial population of stroke patients in China, it is crucial to examine the potential risk factors associated with PSD. Conducting studies on this population and investigating the influence of economic conditions can provide valuable guiding theoretical insights into PSD prevention and management.

METHODS

We used data from the 2018 China Health and Retirement Longitudinal Study and selected appropriate samples for analysis. Depression was estimated using the Center of Epidemiologic Studies Depression Scale-10, a validated tool for assessing depression in the general population. Multiple logistic regression analysis was employed to assess the association between SES and PSD and to evaluate any urban-rural differences.

RESULTS

Of the 749 respondents, 370 (49.4%) had depression. Stroke patients with a middle school education demonstrated a greater risk of developing depression than those with a primary school education or below after adjusting for all control variables (odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.03-2.51, P = 0.036). However, stroke patients with a high school education or above had a lower risk of developing depression than those with a primary school education or below (OR = 0.50, 95% CI: 0.28-0.88, P = 0.016). In rural areas, stroke patients with a high school or above education level had lower rates of depression than those with a primary school education or below (OR = 0.44, 95% CI: 0.21-0.91, P = 0.027). This difference was not significant in urban areas.

CONCLUSIONS

SES significantly influences the occurrence of PSD, which is reflected by education attainment and annual household expenditures. Education attainment was an independent influence on PSD, with a more pronounced effect in rural versus urban areas. We hope to reduce the prevalence of PSD and enhance the comprehensive management of this disease by modifying the influencing factors. Sex, self-reported health status, activities of daily living, night-time sleep duration, and life satisfaction also influenced the occurrence of PSD.

Factors associated with the effectiveness of immersive virtual therapy in alleviating depressive symptoms during sub-acute post-stroke rehabilitation: a gender comparison

BACKGROUND

The large-scale digitalization of healthcare has induced shifts in patient preferences, prompting the introduction of therapies utilizing novel technologies. In this context, the targeted application of these interventions is deemed as crucial as assessing their overall effectiveness. The aim of this study was to characterize the patient profile who benefited most from immersive virtual reality (VR) therapy.

METHODS

Based on the results from the previous randomized controlled trial study, we employed an exploratory study design to determine the factors associated with the most significant mental health improvement. A secondary analysis was conducted on a sample of 83 participants, with further analysis of participants with elevated depression symptoms, as indicated by a score of > 10 on the 30-item Geriatric Depression Scale (GDS-30). Both groups participated in a similar post-stroke rehabilitation program; however, the experimental group also received additional VR therapy through an immersive VR garden intervention. The GDS-30 was used to assess mood and depressive symptoms, and sociodemographic, cognitive status as well as stroke-related variables were considered as potential factors.

RESULTS

In both the experimental (mean change 5.3) and control groups (mean change 2.8), interventions significantly reduced depressive symptoms, with a more pronounced difference in the experimental group (p < 0.05). When examining gender differences, women exhibited greater improvement in the GDS, with mean between-group differences of 5.0 for the total sample and 6.0 for those with elevated depressive symptoms. Sociodemographic factors, cognitive status, and time from stroke were not found to be factors that alter the effectiveness of VR therapy.

CONCLUSIONS

While VR therapy as an adjunctive treatment for post-stroke rehabilitation seems especially effective for women with elevated depressive symptoms, the results should be interpreted with caution due to the study's small experimental group size. Traditional methods showed reduced effectiveness in women compared to men; thus, developing technologically advanced and gender-specific approaches can lead to more tailored therapy.

TRIAL REGISTRATION

NCT03830372 (February 5, 2019).

Comparing the Symptomatology of Post-stroke Depression with Depression in the General Population: A Systematic Review

Previous research into the phenomenological differences of post-stroke depression (PSD) has typically focused on comparisons of symptom profiles between stroke and non-stroke population controls. This systematic review aimed to synthesize these findings with results from other methodological approaches that contribute to an understanding of phenomenological differences. Articles were identified via a systematic search of seven databases and additional manual searching. A narrative synthesis approach was adopted because of the high methodological heterogeneity. Twelve articles comparing the symptomatology of depression between stroke and non-stroke controls were included. Three distinct methodological approaches, relevant to the aim, were identified: comparisons of profiles among groups with similar overall depression severity, comparisons of the strengths of correlations between a symptom and depression, and comparisons of latent symptom severity. The symptomatology of depression was generally similar between the groups, including somatic symptoms, despite the hypothesized interference of comorbid physical stroke effects. Despite high heterogeneity, there was a tentative indication that post-stroke depression manifests with comparatively less severe/prevalent anhedonia. Possible mechanisms for the observed similarities and differences are explored, including suggestions for future research.

Metabolic Alterations and Related Biological Functions of Post-Stroke Depression in Ischemic Stroke Patients

Background

Post-stroke depression (PSD) is one of the most common neuropsychiatric complications after stroke. However, the underlying mechanisms of PSD remain ambiguous, and no objective diagnosis tool is available to diagnose PSD. Previous metabolomic studies on PSD included patients with ischemic and hemorrhagic stroke indiscriminately, which is not conducive to elucidating and predicting the occurrence of PSD. The aim of this study is to elucidate the pathogenesis of PSD and provide potential diagnostic markers for PSD in ischemic stroke patients.

Methods

In total, 51 ischemic stroke patients at 2 weeks were included in this study. Those with depressive symptoms were assigned to the PSD group, while the others were assigned to the non-PSD group. Plasma metabolomics based on liquid chromatography-mass spectrometry (LC-MS) was performed to explore the differential plasma metabolites between the PSD and non-PSD groups.

Results

Principal component analysis (PCA), partial least squares discriminant analysis (PLS-DA) and orthogonal partial least-squares discriminant analysis (OPLS-DA) showed significant metabolic alterations between PSD patients and non-PSD patients. In total, 41 differential metabolites were screened out, mainly including phosphatidylcholines (PCs), L-carnitine and acyl carnitines, succinic acid, pyruvic acid and L-lactic acid. Metabolite-related pathway analysis revealed that alanine, aspartate and glutamate metabolism, glycerophospholipid metabolism and the citrate cycle (TCA cycle) may contribute to the pathogenesis of PSD. A panel of three signature metabolites [PC(22:5(7Z,10Z,13Z,16Z,19Z)/15:0), LysoPA(18:1(9Z)/0:0) and 1,5-anhydrosorbitol] was determined as potential biomarkers for PSD in ischemic stroke patients.

Conclusion

These findings are conducive to providing new insights into the pathogenesis of PSD and developing objective diagnostic tools for PSD in ischemic stroke patients.

Incidence of post-stroke depression symptoms and potential risk factors in adults with aphasia in a comprehensive stroke center

INTRODUCTION

Depression may be a frequent sequela after stroke, however, its incidence has rarely been reported. The likelihood of post-stroke depression (PSD) may relate to individual factors including the presence of aphasia, which also complicates PSD diagnosis. The current study's purpose was to investigate the incidence of PSD symptoms in adults with aphasia, compare it to the incidence of PSD symptoms in adults without aphasia, and to identify potential risk factors for developing PSD in adults with aphasia.

METHOD

Incidence proportions and relative risk were calculated using data compiled from 970 patient records at an urban tertiary care academic institution and comprehensive stroke center throughout the year of 2019. Focusing exclusively on adults with aphasia, the selected variables of age, gender, race, and aphasia severity were used to conduct logistic regression analyses to explore potential risk factors contributing to the development of PSD.

RESULTS

Adults with aphasia were 7.408 times more likely to exhibit PSD symptoms than adults without aphasia. Logistic regression controlling for the presence of aphasia showed a significant relationship between aphasia severity and post-stroke depression symptoms. Adults with aphasia were 2.06 times more likely to experience post-stroke depression symptoms with every 1-point increase in aphasia severity.

CONCLUSIONS

These findings align with earlier evidence identifying aphasia as a risk factor for experiencing PSD symptoms and also suggest aphasia severity is proportionate to the risk. This highlights the need for early identification of PSD symptoms in persons with aphasia in order to provide timely interventions.

Education Level Modulates the Presence of Poststroke Depression and Anxiety, But It Depends on Age

ABSTRACT

Depression and anxiety are common complications after stroke and little is known about the modulatory roles of education and age. Our study aimed to evaluate the modulatory effects of education level on anxiety and depression after stroke and their effect on each age group. Adults with first stroke took part in this cross-sectional observational clinical study. We used the following instruments: Hospital Anxiety and Depression Scale (HADS), Montreal Cognitive Scale, Pittsburgh Sleep Quality Index, Barthel index, and Functional Independence Measure. There were 89 patients. The mean (SD) age was 58.01 (13) years, mean (SD) years of education was 9.91 (5.22), 55.1% presented depression symptoms and 47.2% anxiety symptoms, 56.2% were young adults and 43.8% were older adults. We identified a negative association between education and anxiety score (r = -0. 269, p = 0.011) and depression score (r = -0.252, p = 0.017). In the linear regression analysis, we found that education is negatively associated with HADS, but this influence was more consistent in young adults. In conclusion, a higher education level reduces the risk of depression and anxiety, but their effect is less consistent in older adults.

Risk, Determinants, and Pharmacologic Treatment of Depression Following Acute Ischemic Stroke

Background and Purpose: We assessed risk and determinants of new-onset depression in acute ischemic stroke (AIS) patients of all ages and no known history of depression. Additionally, we assessed patterns of post-stroke depression (PSD) treatment with pharmacotherapy. Methods: Retrospective cohort study of de-identified Marketscan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits Datasets for adults age ≥18 years admitted with AIS from July 1, 2016-July 1, 2017. We created Kaplan-Meier curves of cumulative risk of PSD up to 1.5 years following index AIS admission. We performed Cox regression to report hazard ratios for determinants of PSD up to 1.5 years following AIS. We summarized proportions treated with pharmacotherapy and identified the most commonly prescribed medications. Results: Of 8089 AIS patients, 1059 were diagnosed with PSD. At 1 year, cumulative risk of PSD was 13.4% (standard error .4) and 15.3% (standard error .5) at 1.5 years. History of anxiety was most strongly associated with PSD and discharge home least. Among those with PSD, 68.8% were prescribed an antidepressant and 8.4% an antipsychotic. The most commonly prescribed antidepressant was sertraline (28.5%). Conclusions: Among AIS patients of all ages, there is a persistently elevated cumulative risk of new diagnosis of PSD in the 1.5 years following AIS. Of the >2/3 treated with an antidepressant, sertraline was most commonly prescribed. Screening and treatment strategies for PSD require further study.

Physical activity and depression in Indonesian adults with stroke: A nationwide survey

PURPOSE

To examine the associations between physical activity and depressive symptoms in adults with stroke.

DESIGN

We conducted a cross-sectional study involving the data of 3234 adults with stroke obtained from the 2018 Basic Health Research (Riset Kesehatan Dasar, RISKESDAS).

METHODS

Physical activity level in metabolic equivalents-minutes per week were determined using the Global Physical Activity Questionnaire according to the World Health Organization (WHO) guidelines on physical activity and sedentary behavior recommendations. Depression was assessed using the Mini-International Neuropsychiatric Interview. Multivariate binomial logistic regression analysis was performed to examine the predictive role of physical activity for depression after adjusting for confounders.

RESULTS

Adults with stroke who met the WHO recommendation of physical activity were independently and significantly associated with lower odds of depression after adjustment for confounders (adjusted OR = 0.757, p = 0.017).

CONCLUSIONS

Performing physical activity according to the WHO recommendation is associated with a lower likelihood of depression among Indonesian adults with stroke.

CLINICAL RELEVANCE

Clinicians should be informed by the findings of this study and prescribe exercise interventions or plan physical activities to optimize recovery and prevent poststroke depression.

Associations among depression, demographic variables, and language impairments in chronic post-stroke aphasia

INTRODUCTION

Depression may influence treatment participation and outcomes of people with post-stroke aphasia, yet its prevalence and associated characteristics in aphasia are poorly understood. Using retrospective data from an overarching experimental study, we examined depressive symptoms and their relationship to demographic and language characteristics in people with chronic aphasia. As a secondary objective, we compared prevalence of depressive symptoms among the overarching study's included and excluded participants.

METHODS

We examined retrospective data from 121 individuals with chronic aphasia including depression scale scores, demographic information (sex, age, time post onset of stroke, education, race/ethnicity, and Veteran status), and scores on assessments of general and modality-specific language impairments.

RESULTS

Approximately 50% of participants reported symptoms indicative of depressive disorders: 23% indicative of major depression and 27% indicative of mild depression. Sex (males) and comparatively younger age emerged as statistically significant variables associated with depressive symptoms; naming ability was minimally associated with depressive symptoms. Time post onset of stroke, education level, race/ethnicity, Veteran status, and aphasia severity were not significantly associated with depressive symptoms. Depression-scale scores were significantly higher for individuals excluded from the overarching study compared to those who were included.

CONCLUSIONS

The rate of depressive disorders in this sample was higher than rates of depression reported in the general stroke literature. Participant sex, age, and naming ability emerged as factors associated with depressive symptoms, though these links appear complex, especially given variable reports from prior research. Importantly, depressive symptoms do not appear to diminish over time for individuals with chronic aphasia. Given these results and the relatively limited documentation of depression in aphasia literature, depression remains a pressing concern for aphasia research and routine clinical care.

Mood disorders in children following neonatal hypoxic-ischemic encephalopathy

Background

Few studies on the consequences following newborn hypoxic-ischemic encephalopathy (NHIE) assess the risk of mood disorders (MD), although these are prevalent after ischemic brain injury in adults.

Objective

To study the presence of MD in children survivors of NHIE.

Methods

14 children survivors of NHIE treated with hypothermia and without cerebral palsy and 15 healthy children without perinatal complications were studied aged three to six years for developmental status (Ages and Stages Questionnaire 3 [ASQ-3]) and for socio-emotional status (Preschool Symptom Self-Report [PRESS] and Child Behavior Checklist [CBCL] 1.5–5 tests). Maternal depression was assessed using Montgomery-Asberg Depression Rating Scale (MADRS). Socio-economic factors such as parental educational level or monthly income were also studied.

Results

NHIE children did not present delay but scored worse than healthy children for all ASQ3 items. NHIE children showed higher scores than healthy children for PRESS as well as for anxious/depressive symptoms and aggressive behavior items of CBCL. In addition, in three NHIE children the CBCL anxious/depressive symptoms item score exceeded the cutoff value for frank pathology (P = 0.04 vs healthy children). There were no differences in the other CBCL items as well as in maternal MADRS or parental educational level or monthly income. Neither ASQ3 scores nor MADRS score or socio-economic factors correlated with PRESS or CBCL scores.

Conclusions

In this exploratory study children survivors of NHIE showed increased risk of developing mood disturbances, in accordance with that reported for adults after brain ischemic insults. Considering the potential consequences, such a possibility warrants further research.

Does urinary metabolite signature act as a biomarker of post-stroke depression?

BACKGROUND

It is difficult to conduct the precise diagnosis of post-stroke depression (PSD) in clinical practice due to the complex psychopathology of depressive disorder. Several studies showed that gas chromatography-mass spectrometry (GC-MS)-identified urinary metabolite biomarkers could significantly discriminate PSD from stroke survivors.

METHODS

A systematic review was performed for the keywords of "urinary metabolite" and "PSD" using Medline, Cochrane Library, Embase, Web of Science, PsycINFO, Wanfang, CNKI, CBM, and VIP database from inception to 31 March 2022.

RESULTS

Four related studies were included in the review. Differential urinary metabolites including lactic acid, palmitic acid, azelaic acid, and tyrosine were identified in all the included studies. As a significant deviation in the metabolite biomarker panel, glyceric acid, azelaic acid, phenylalanine, palmitic acid, pseudouridine, and tyrosine were found in at least 2 included studies, which indicated good potential for the differentiation of PSD.

CONCLUSION

The systematic review provided evidence that differential urinary metabolites analyzed by the GC-MS-based approach might be used as a biomarker for the diagnosis and prognosis of PSD.

Post-Stroke Depression: Prevalence, Associated Factors, and Relationship to Disability in a Tertiary Care Center in Sri Lanka

Background and Objectives  The prevalence of stroke in urban Sri Lanka is estimated at 10.4 per 1000 and is expected to rise. Post-stroke depression (PSD) is an independent predictor of poor long-term outcomes. It leads to suboptimal rehabilitation, decreased quality of life, and increased mortality and is under-recognized. The main objectives of this study were to estimate the prevalence of depression in stroke, assess factors associated with PSD, and assess the relationship of PSD to disability. Materials and Methods  A descriptive cross-sectional study was conducted at the Neurology and Medical Ward, National Hospital of Sri Lanka. Non-probability, consecutive sampling was used to collect data from patients with ischemic stroke admitted from January 2019 to January 2020. Patients with significant pre-existing depression, cognitive impairment, and language deficits were excluded. A structured, pre-tested interviewer-administered questionnaire was used to assess the prevalence and associated factors of PSD. Beck's Depression Inventory (BDI) was administered 3 months following the stroke to screen for depression. Modified Rankin Score (MRS) was used to assess disability on admission, discharge, and at 3 months. Results  Eighty-one stroke patients were screened. The mean age was 66.6 years (±standard deviation [SD]: 12.5). Male:female ratio was 1.2:1. Depression at 3 months of follow-up was observed in 35.8% (95% confidence interval [CI]: 25.4-47.2%) of participants. Following bivariate analysis, large vessel stroke ( p  < 0.001), cortical stroke ( p  < 0.001), frontal lobe lesions ( p  < 0.001), history of past stroke ( p  = 0.014), and sexual dysfunction ( p  = 0.026) were associated with increased risk of PSD. The odds of a person with severe disability developing PSD was 7.9 times more than a person with a less severe disability at discharge from hospital and at 3 months of follow-up (odds ratio [OR] =7.9; 95% CI: 2.7-23.3, p  = 0.000). Conclusions  PSD occurs in one-third of strokes, keeping with previous studies. The risk of having PSD is higher among patients with severe disabilities. The difference in risk factors identified compared with previous studies can be attributable to differences in methodology. Identifying risk factors for post-stroke depression is essential to mitigate the poor outcome.

Biological, Psychological, and Social Determinants of Depression: A Review of Recent Literature

Depression is one of the leading causes of disability, and, if left unmanaged, it can increase the risk for suicide. The evidence base on the determinants of depression is fragmented, which makes the interpretation of the results across studies difficult. The objective of this study is to conduct a thorough synthesis of the literature assessing the biological, psychological, and social determinants of depression in order to piece together the puzzle of the key factors that are related to this condition. Titles and abstracts published between 2017 and 2020 were identified in PubMed, as well as Medline, Scopus, and PsycInfo. Key words relating to biological, social, and psychological determinants as well as depression were applied to the databases, and the screening and data charting of the documents took place. We included 470 documents in this literature review. The findings showed that there are a plethora of risk and protective factors (relating to biological, psychological, and social determinants) that are related to depression; these determinants are interlinked and influence depression outcomes through a web of causation. In this paper, we describe and present the vast, fragmented, and complex literature related to this topic. This review may be used to guide practice, public health efforts, policy, and research related to mental health and, specifically, depression.

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.

European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment

BACKGROUND AND PURPOSE

The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis.

METHODS

Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations.

RESULTS

There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes.

CONCLUSIONS

These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.

European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment

The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research.

Risk Factors for Depressive Symptoms in Korean Adult Stroke Survivors: The Korea National Health and Nutrition Examination Survey IV-VII (2007-2018)

Depressive symptoms are common in stroke survivors, and they are associated with poor outcomes. Therefore, this study aimed to investigate the depressive symptoms in stroke survivors and the risk factors for depressive symptoms in stroke survivors. We included 33,991 participants who were 19 years or older and had completed a questionnaire about the history of stroke from the Korea National Health and Nutrition Examination Survey (KNHANES) IV–VII (from 2007 to 2018). The mean Patient Health Questionnaire-9 score and the prevalence of major depression, depressive symptoms, antidepressant treatment, suicidal ideation, and suicide attempts were significantly higher in stroke survivors than in non-stroke participants (4.4 vs. 2.6, 16.2% vs. 5.3%, 24.7% vs. 9.3%, 3.8% vs. 1.4%, 21.7% vs. 4.8%, and 2.5% vs. 0.6%, respectively, all p < 0.001). Complex sample multivariate logistic regression analysis revealed that the female sex, unemployment, a low education level, a low family income, and activity limitations were independent risk factors for depressive symptoms in stroke survivors. Activity limitations showed the highest odds ratio among the independent factors, and its causes were further analyzed. The most common causes of activity limitations were stroke sequelae and musculoskeletal problems. To reduce depressive symptoms in stroke survivors, attention needs to be paid to minimizing stroke sequelae and musculoskeletal problems along with regular screening for depressive symptoms.

Sex Differences in Post-Stroke Depression in the Elderly

OBJECTIVE

Post-stroke depression (PSD) occurs in approximately one-third of ischemic stroke patients. However, there is conflicting evidence on sex differences in PSD. We sought to assess sex differences in risk and time course of PSD in US ischemic stroke (IS) patients. We hypothesized that women are at greater risk of PSD than men, and that a greater proportion of women experience PSD in the acute post-stroke phase.

MATERIALS AND METHODS

We conducted a retrospective cohort study of 100% de-identified data for US Medicare beneficiaries admitted for ischemic stroke from July 1, 2016 to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression, stratified by sex, up to 1.5 years following index admission. We performed Cox regression to report the hazard ratio (HR) for diagnosis of depression up to 1.5 years post-stroke in females vs. males, adjusting for patient demographics, comorbidities, length of stay, and acute stroke interventions.

RESULTS

In elderly stroke patients, females (n=90,474) were 20% more likely to develop PSD than males (n=84,427) in adjusted models. Cumulative risk of depression was consistently elevated for females throughout 1.5 years of follow-up (0.2055 [95% CI 0.2013-0.2097] vs. 0.1690 [95% CI 0.1639-0.1741] (log-rank p < 0.0001). HR for PSD in females vs. males remained significant in fully adjusted analysis at 1.20 (95% CI 1.17-1.23, p < 0.0001).

CONCLUSIONS

Over 1.5 years of follow-up, female stroke patients had significantly greater hazard of developing PSD, highlighting the need for long-term depression screening in this population and further investigation of underlying reasons for sex differences.

The advances of post-stroke depression: 2021 update

Post-stroke depression (PSD) is one of common and serious sequelae of stroke. Approximately, one in three stroke survivors suffered from depression after stroke. It heavily affected functional rehabilitation, which leaded to poor quality of life. What is worse, it is strongly associated with high mortality. In this review, we aimed to derive a comprehensive and integrated understanding of PSD according to recently published papers and previous classic articles. Based on the considerable number of studies, we found that within 2 years incidence of PSD has a range from 11 to 41%. Many factors contribute to the occurrence of PSD, including the history of depression, stroke severity, lesion location, and so on. Currently, the diagnosis of PSD is mainly based on the DSM guidelines and combined with various depression scales. Unfortunately, we lack a unified mechanism to explain PSD which mechanisms now involve dysregulation of hypothalamic-pituitary-adrenal (HPA) axis, increased inflammatory factors, decreased levels of monoamines, glutamate-mediated excitotoxicity, and abnormal neurotrophic response. At present, both pharmacotherapy and psychological therapies are employed in treating PSD. Although great advance has been made by researchers, there are still a lot of issues need to be addressed. Especially, the mechanism of PSD is not completely clear.

Risk and Predictors of Depression Following Acute Ischemic Stroke in the Elderly

OBJECTIVE

We sought to comprehensively evaluate predictors of poststroke depression (PSD) in the United States and to compare PSD to post-myocardial infarction (MI) depression to determine whether ischemic stroke uniquely elevates risk of depression.

METHODS

This is a retrospective cohort study of 100% deidentified inpatient, outpatient, and subacute nursing Medicare data from 2016 to 2017 for US patients ≥65 years of age from July 1, 2016, to December 31, 2017. We calculated Kaplan-Meier unadjusted cumulative risk of depression up to 1.5 years after the index admission. We performed Cox regression to report the hazard ratio for diagnosis of depression up to 1.5 years after stroke vs MI and independent predictors of PSD, and we controlled for patient demographics, comorbid conditions, length of stay, and acute stroke interventions.

RESULTS

In fully adjusted models, patients with stroke (n = 174,901) were ≈50% more likely than patients with MI (n = 193,418) to develop depression during the 1.5-year follow-up period (Kaplan-Meier cumulative risk 0.1596 ± 0.001 in patients with stroke vs 0.0973 ± 0.000778 in patients with MI, log-rank p < 0.0001). History of anxiety was the strongest predictor of PSD, while discharge home was most protective. Female patients, White patients, and patients <75 years of age were more likely to be diagnosed with depression after stroke.

CONCLUSIONS

Despite the similarities between MI and stroke, patients with stroke were significantly more likely to develop depression. There were several predictors of PSD, most significantly history of anxiety. Our findings lend credibility to a stroke-specific process causing depression and highlight the need for consistent depression screening in all patients with stroke.

Neuropsychiatric Complications after Stroke

Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.

Depressed Mood after Stroke: Predictive Factors at Six Months Follow-Up

We aimed to know the prevalence of post-stroke depression (PSD) in our context, identify the variables that could predict post-stroke depression, by using the Hamilton Depression Rating Scale, occurring within six months after stroke, and identify patients at high risk for PSD. Methods: descriptive, cross-sectional and observational study. We included 173 patients with stroke (transient ischemic attack (TIA) included) and collected sociodemographic and clinical variables. We used the Hamilton Depression Scale (HDS) for depression assessment and Barthel Index and modified Rankin Scale (mRS) for functional assessment. The neurological severity was evaluated by the National Institutes of Health Stroke Scale (NIHSS). Results: 35.5% were women, aged 71.16 (±12.3). Depression was present in 42.2% patients (n = 73) at six months after stroke. The following variables were significantly associated with PSD: diagnosis of previous depression (p = 0.005), the modified Rankin Scale at discharge (p = 0.032) and length of hospital stay (p = 0.012). Conclusion: PSD is highly prevalent after stroke and is associated with the severity, left location of the stroke, and the degree of disability at discharge. Its impact justifies the evaluation and early treatment that still continues to be a challenge today.

Clinical management of cerebral small vessel disease: a call for a holistic approach

ABSTRACT

Cerebral small vessel disease (SVD) is a common global brain disease that causes cognitive impairment, ischemic or hemorrhagic stroke, problems with mobility, and neuropsychiatric symptoms. The brain damage, seen as focal white and deep grey matter lesions on brain magnetic resonance imaging (MRI) or computed tomography (CT), typically accumulates "covertly" and may reach an advanced state before being detected incidentally on brain scanning or causing symptoms. Patients have typically presented to different clinical services or been recruited into research focused on one clinical manifestation, perhaps explaining a lack of awareness, until recently, of the full range and complexity of SVD.In this review, we discuss the varied clinical presentations, established and emerging risk factors, relationship to SVD features on MRI or CT, and the current state of knowledge on the effectiveness of a wide range of pharmacological and lifestyle interventions. The core message is that effective assessment and clinical management of patients with SVD, as well as future advances in diagnosis, care, and treatment, will require a more "joined-up"' approach. This approach should integrate clinical expertise in stroke neurology, cognitive, and physical dysfunctions. It requires more clinical trials in order to improve pharmacological interventions, lifestyle and dietary modifications. A deeper understanding of the pathophysiology of SVD is required to steer the identification of novel interventions. An essential prerequisite to accelerating clinical trials is to improve the consistency, and standardization of clinical, cognitive and neuroimaging endpoints.

Are Depression and Dementia a Common Problem for Stroke Older Adults? A Review of Chosen Epidemiological Studies

Stroke is the second leading cause of death in the world. It is often associated with various long-term physical and neuropsychological consequences. The aim of this article is to present the results of research on the occurrence of dementia and post-stroke depression. Using the keywords: post-stroke dementia, post-stroke depression, post-stroke cognitive impairment, stroke, Polish and foreign bibliographic databases were searched: PubMed, Science Direct, Wiley, Google Scholar. Documents that met the eligibility criteria were selected for inclusion in this review. After the conducted analyses, 7 Polish articles and 13 English-language articles were qualified for the review. In the group of people after stroke, there is an increased risk of depression and dementia. According to the data, up to every third person can deal with one of these neuropsychiatric disorders. The presented research analyses indicate that the results obtained by the respondents, at any time after the stroke, indicate the presence of mild cognitive impairment or slight degree dementia among the majority of respondents. It was also shown that people with a stroke in the dominant hemisphere are more likely to experience post-stroke depression. Depression and post-stroke dementia are a common and significant complication of stroke that negatively affects the functional outcome. The huge focus on neuropsychiatric disorders occurring after stroke in modern research is very important because of their negative impact on recovery, quality of life and survival after stroke.

Post-stroke depression: A 2020 updated review

BACKGROUND

Post-stroke depression (PSD) is common and associated with higher mortality, poorer recovery, more pronounced cognitive deficits, and lower quality of life than is stroke without depression. This manuscript will conduct an updated, comprehensive and clinically-useful review of the risk factors, pathophysiology, assessment, prevention, and treatment of PSD.

METHODS

This narrative review summarizes articles obtained on PubMed, Medline, EMBase, Google Scholar and the Cochrane Database. This review prioritized articles with a more robust level of evidence, such as original articles with longitudinal data and/or larger samples, randomized controlled trials, systematic reviews, and metaanalyses.

RESULTS

One hundred twenty-four articles were reviewed, of which 44 (35%) were published before 2016 and 80 (65%) that were published since 2016.

DISCUSSION

Rates of PSD range from 18 to 33%, yet it is vastly underdiagnosed and undertreated. Risk factors for PSD include female sex, history of psychiatric illness, large or multiple strokes, injuries in frontal/anterior areas or in the basal ganglia, stroke occurrence within the past year, poor social support, and pronounced disability. The pathophysiology of PSD is multifactorial and likely involves decreased levels of monoamines, abnormal neurotrophic response, increased inflammation with dysregulation of hypothalamic-pituitary-adrenal axis, and glutamate-mediated excitotoxicity. The evidence for preventive interventions for PSD is somewhat inconsistent and modest. The best treatment for PSD consists of the combination of pharmacological, psychosocial and stroke-focused interventions.

CONCLUSION

PSD is a common, treatable condition that is associated with several negative outcomes. Early detection and proper management are critical to obtain better outcomes in individuals with PSD.

Socioeconomic Factors Predicting Depression Differ in the Acute Stage and at 1 year After Ischemic Stroke or TIA

INTRODUCTION

Considerable depressive symptoms follow stroke in about one third of patients. Initial depressive symptoms may wane after the acute phase of stroke, but persisting depressive symptoms adversely affect rehabilitation and quality of life. We set forth to evaluate predictors of depressive symptoms with a focus on socioeconomic factors.

METHODS

We evaluated clinical features and socioeconomic characteristics in 233 consecutive patients with acute ischemic stroke or TIA. Depressive symptoms could be evaluated in 168 subjects in the acute phase with a repeated testing after a mean of 14.7 months via telephone interview in 116 patients. Survival status, scores on the Center for Epidemiologic Studies-Depression Scale (CES-D), Beck Depression Inventory (BDI) and disability (modified Rankin scale, mRS) were recorded.

RESULTS

In the acute phase, employment status (p = 0.037) and level of education (p = 0.048) whereas one year later dependency (mRS≥3, p = 0.002) and income (p = 0.012) were the significant predictors of the severity of depressive symptoms. A change from independent (mRS≤2) to dependent living predicted worsening depressive symptoms (p = 0.008), whereas improving to functional independence from an initially dependent condition was associated with diminishing depressive symptoms (p = 0.077 for CES-D and p = 0.044 for BDI) in the first year after an acute ischemic cerebrovascular event.

CONCLUSIONS

Predictors of the severity of depressive symptoms differed in the acute phase and at follow-up. In addition to disability, education and employment status in the acute phase and income in the late phase predict the severity of depressive symptoms after ischemic stroke or TIA.

Cognitive Reserve as an Emerging Concept in Stroke Recovery

Stroke is a leading cause of death and disability. It is a complex and largely heterogeneous condition. Prognosis for variations in impairment and recovery following stroke continues to be challenging and inaccurate, highlighting the need to examine the influence of other currently unknown variables to better predict and understand interindividual differences in stroke impairment and recovery. The concept of "cognitive reserve," a feature of brain function said to moderate the relationship between brain pathology and clinical outcomes, might provide a partial explanation. This review discusses the potential significance of cognitive reserve in the context of stroke, with reference to reduced burden of disability poststroke, health promotion, intervention and secondary prevention of cognitive impairment, ease and challenges of translation into clinical practice, prognosis and prediction of recovery, and clinical decisions and trial stratification. Discussions from the review aim to encourage stroke clinicians and researchers to better consider the role of premorbid, lifestyle-related variables, such as cognitive reserve, in facilitating successful neurological outcomes and recovery following stroke.

Discriminative factors for post-stroke depression

BACKGROUND

Depression is the most common mood disorder following stroke. It can negatively affects different domains of patient's life. The present study aimed to explore demographic and clinical predictors of post stroke depression and determine discriminative cognitive, motor, and functional factors in stroke patients with and without depression.

METHODS

In a cross sectional study, 100 patients with stroke were investigated. Measurements consisted of Beck Depression Inventory-II, Trail Making Test A & B, Digit Span Subtest of Wechsler Memory Scale, Motricity Index (arm and leg motor), Trunk Control Test, Barthel Index, and Lawton Instrumental Activities of Daily Living. Demographics and clinical data including educational level, marital status, limb affected, cigarette smoking habits, diabetes mellitus, cardiac diseases, and blood pressure were also collected.

RESULTS

Multivariate logistic regression revealed that college level of education (OR = 8.78, 95% CI: 2.65-29.11, P < 0.001) and cardiac diseases (OR = 3.11, 95% CI: 1.19-8.13, P < 0.001) were significant demographic and clinical predictors of post stroke depression. Using stepwise discriminant function analysis, basic activities of daily living and trunk control with 88.0% classification accuracy, 81.1% sensitivity, and 95.7% specificity were as the best discriminators of post stroke depression.

CONCLUSIONS

Rehabilitation experts working with patients with stroke should pay special attention to trunk control and basic activities of daily living for preventing consequences of PSD particularly in those with higher educational level and cardiac diseases.

Mild to Severe Depressive Symptoms in Elderly Stroke Survivors and Its Associated Factors: Evidence From a Cross-Sectional Study in Zhejiang Province, China

Objective: The objective of the study is to explore the prevalence of mild to severe depressive symptoms in elderly stroke survivors and its associated factors. Methods: We did data analyses of 335 elders with stroke history. Data were collected in a survey conducted between 2014 and 2015, among permanent residents aged 60 and older in Zhejiang Province, China. Prevalence of mild to severe depressive symptoms among stroke survivors were calculated, and univariate analyses and multilevel logistic regression were used to explore its associated factors. Results: Prevalence of mild to severe depressive symptoms was 22.09% (95% CI: 17.65-26.53%) in elders with stroke history, more than twice compared to their counterparts not suffering stroke (9.77%, P < 0.001). In multilevel logistic regression, we found that elderly stroke survivors who were illiterate (OR = 2.33, p = 0.008), or had limitation in activities of daily living (OR = 3.04, p = 0.001) were more likely to be present with mild to severe depressive symptoms, respectively, while those with more fresh vegetable consumption were at lower odds (OR = 0.82, p = 0.047). Conclusions: Prevalence of mild to severe depressive symptoms was high in elderly stroke survivors. Targeted screening might be needed for those being illiterate, disabled in activities of daily living, and having little consumption of fresh vegetable. The association between fresh vegetable consumption and depressive symptom in stroke patients calls for further research.

Diversiform Etiologies for Post-stroke Depression

After the onset of stroke, many patients suffer from emotional behavior changes. Approximately, one-third of stroke survivors are affected by post-stroke depression (PSD), making it a serious social and public health problem. Post-stroke depression (PSD) has an important impact on the course, recovery, and prognosis of stroke. The pathogenesis of PSD is very complex, involving many factors such as biological mechanism and social psychological mechanisms. This article provides a brief review of the hot issues related to etiologies of PSD.