The influence of depression, social activity, and family stress on functional outcome after stroke

Return to work for stroke survivors with aphasia: A quantitative scoping review

The international incidence of stroke in people of working age is rising. As such, meaningful work return is a major rehabilitation goal for many individuals, including those with aphasia. This scoping review aimed to outline the post-stroke aphasia evidence related to work outcomes, factors influencing employment along with contemporary vocational-language and communication rehabilitation practice. The review employed terms related to aphasia, stroke, rehabilitation, and return to work in publications preceding 25.6.2023. Data were descriptively analysed, and vocational outcomes were summarized at defined timepoints. Of the 908 articles reviewed, 31 papers were included. Individuals with post-stroke aphasia consistently have lower rates of return to work than those post-stroke without aphasia. Employment at one year was 34.29% for those with aphasia compared to 58.46% for people without aphasia. No literature reported vocational-language assessment practices and there were minimal work-focused aphasia interventions identified. There was insufficient evidence to clearly identify person-related, rehabilitation, workplace or other factors influencing work return. This scoping review has identified that there are gaps in knowledge about the factors that influence work return and targeted vocational rehabilitation for this group. Future research to optimize return to work for individuals with aphasia is recommended.

Irritability in stroke: a protocol for a prospective study

Background

Poststroke irritability (PSI) is common among stroke survivors and can lead to a poor quality of life, difficulties in social interactions, criticism from caregivers, and caregiver stress. The planned study will evaluate the clinical, neuropsychological, and magnetic resonance imaging (MRI) correlates of PSI in a cohort of stroke survivors. In addition, the study will examine the 15-month progression of PSI.

Methods

This will be a prospective cohort study that will recruit 285 participants. Participants and their caregivers will undergo detailed assessments at a research clinic at 3, 9, and 15 months after stroke onset (T1/T2/T3). The irritability/lability subscale of the Chinese version of the Neuropsychiatric Inventory (CNPI) will be completed by caregivers. Potential covariates will also be measured. Patients will undergo MRI, including diffusion-weighted imaging, within 1 week of stroke onset. A stepwise logistic regression will be performed to evaluate the importance of lesions in the regions of interest (ROIs) along with other significant variables identified in univariate analyses. These analyses will be repeated for patients with and without PSI at T2 and T3. Repeated measures analysis of covariance (ANCOVA) will be used to assess changes in CNPI scores for the entire sample. In ANCOVA analyses, the frequency of infarcts in the ROIs will be treated as the predictor.

Discussion

This will be the first MRI study on PSI in stroke survivors. The findings will provide insights into the association of the orbitofrontal cortex, anterior cingulate cortex, anterior temporal lobe, insula, amygdala, thalamus, and basal ganglia lesions with the risk of PSI.

Feeling lonely and dissatisfied - understanding social network functioning in stroke survivors

BACKGROUND

Post-stroke social networks are associated with functional recovery. However, there is little information on the social networks of stroke survivors and whether institutionalised and community-dwelling stroke survivors view their social relationships differently.

PURPOSE

To i) examine social networks of stroke survivors and any influencing sociodemographic factors, as well as to ii) compare differences between institutionalised and community-dwelling stroke survivors.

METHODS

Stroke survivors were recruited from eight healthcare institutions in Singapore. Stroke Social Network Scale (SSNS) was administered to assess the social network functioning. Multidimensional State Boredom Scale (MSBS) was used to evaluate state boredom levels.

RESULTS

160 stroke survivors completed the study. Stroke survivors reported a mean (SD) of 53.7(17.2) on the SSNS total score. Institutionalised stroke survivors reported significantly lower SSNS scores than community-dwelling stroke survivors, (U = 1856.5, z=-4.234, p < .001). Nearly a third (30.6%, n = 49) of the stroke survivors reported feeling lonely. Only 28.1% (n = 45) stroke survivors reported being 'Very Satisfied' with their overall social network. Compared to community-dwelling stroke survivors, institutionalised stroke survivors felt more lonely (40.7%) and only 25% were very satisfied with their social network with all p < .05. A moderate correlation was found between SSNS 'Satisfaction' subdomain score and MSBS total score, r=-.401, p < .001.

CONCLUSIONS

Stroke survivors had poor functioning social relationships. This study found that the perceived social support of institutionalised stroke survivors was poorer than community dwelling stroke survivors. A large proportion of stroke survivors reported feeling lonely and were not satisfied with their social networks. Identifying those at risk may be a means to prevent loneliness, increase social network satisfaction to improve well-being and quality of life.

The Association between New-Onset Depressive Symptoms and Participating in Medical Check-Ups among Elderly Individuals

The association between adherence to medical check-ups and new-onset depressive symptoms, after adjusting for comprehensive risk factors such as social characteristics, remains unclear. This study aimed to assess the association between mental health and participating in medical check-ups. The survey data of participants aged 60 to 89 were recruited from the seventh Korean Longitudinal Study on Aging. The primary outcome was new-onset depressive symptoms within 2 years measured using the Center for Epidemiologic Studies Depression Scale. Participating in medical check-ups was defined as undergoing biennial medical check-ups. Multivariable logistic regression was performed to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) with consideration of a 2-year time lag. Among 4255 participants, the prevalence of new-onset depressive symptoms was 7.36% (n = 313). The prevalence of non-participation in medical check-ups was 11.96% (n = 509). The adjusted OR of new-onset depressive symptoms by non-participation in medical check-ups was 1.65 [95% CI 1.22-2.24; p = 0.001] after adjusting for various demographic, behavioral, occupational, and social participation characteristics. Our findings demonstrated a significant inverse relationship between participation in medical check-ups and new-onset depressive symptoms. It is necessary to monitor and manage depressive symptoms in vulnerable elderly individuals who do not participate in medical check-ups.

Caregiver strain and fatigue are independent determinants of anxiety among patients early after stroke

Anxiety and depression are common mental health disorders in stroke patients, and often co-occur. However, in contrast to depression, there is limited research about anxiety after stroke, although impact of anxiety can be substantial. Therefore, this cross-sectional observational study investigated determinants of anxiety after stroke and compared them with determinants of depression after stroke. Stroke surviving patients (n = 284) were seen six weeks after discharge from the hospital or rehabilitation setting. Of these, 238 patients answered all questions of the Hospital Anxiety and Depression Scale measuring anxiety (HADS-a) and 239 patients answered all questions measuring depression (HADS-d). Step-wise regression was used to identify independent determinants of anxiety and depression after stroke. Higher levels of anxiety were associated with a higher caregiver strain (p < 0.01) and more fatigue (p < 0.05). In contrast, higher levels of depression were associated with lower life satisfaction (p < 0.001) and less daily activities (p < 0.05), but also more fatigue (p < 0.001). Hence, our results show that both fatigue and caregiver strain are associated with higher levels of anxiety, but of these only fatigue is also associated with higher levels of depression. Practitioners should therefore ask for both anxiety and depression symptoms in stroke patients.

Impact of Stroke on Quality of Life of Stroke Survivors and Their Caregivers: A Qualitative Study from India

Objectives  Stroke is a significant global public health challenge attributable to an array of disabilities it causes alongside an impairment in cognition. The monetary impact of stroke care includes acute treatment expenses as well as outrageous expenses of postdischarge chronic hospital care and rehabilitation services. The current study aimed to study the perceptions along with experiences of stroke survivors and caregivers. Materials and Methods  In-depth interviews (IDIs) of stroke survivors and their primary caregivers were conducted at their home 2 months after their discharge from the hospital in Bhopal, India. These IDIs were later analyzed. Results  The following eight themes emerged: pervasive and irreversible, multifunction loss and dependency, holistic impact on the health of person and family, money and matter, nonaccommodative cost and baffled belief, professional paralysis, social crisis, and slow and obscured progress. The added obligation of taking care of a disabled stroke survivor along with adjusting their own lifestyle with financial apprehensions, worry about future, prolonged hours of care, and stress are major factors that increase the burden of the caregivers. Conclusion  Caregivers should be sensitized with proper counseling and training through health care institutions to ensure appropriate care and management of stroke survivors at home, as it will also help in addressing their psychosocial needs, and minimizing the knowledge gap, doubts and uncertainties about the disease and its aftereffects.

Auditory Comprehension Deficits in Post-stroke Aphasia: Neurologic and Demographic Correlates of Outcome and Recovery

Introduction: One of the most challenging symptoms of aphasia is an impairment in auditory comprehension. The inability to understand others has a direct impact on a person's quality of life and ability to benefit from treatment. Despite its importance, limited research has examined the recovery pattern of auditory comprehension and instead has focused on aphasia recovery more generally. Thus, little is known about the time frame for auditory comprehension recovery following stroke, and whether specific neurologic and demographic variables contribute to recovery and outcome.

Methods: This study included 168 left hemisphere chronic stroke patients stroke patients with auditory comprehension impairments ranging from mild to severe. Univariate and multivariate lesion-symptom mapping (LSM) was used to identify brain regions associated with auditory comprehension outcomes on three different tasks: Single-word comprehension, yes/no sentence comprehension, and comprehension of sequential commands. Demographic variables (age, gender, and education) were also examined for their role in these outcomes. In a subset of patients who completed language testing at two or more time points, we also analyzed the trajectory of recovery in auditory comprehension using survival curve-based time compression.

Results: LSM analyses revealed that poor single-word auditory comprehension was associated with lesions involving the left mid- to posterior middle temporal gyrus, and portions of the angular and inferior-middle occipital gyri. Poor yes/no sentence comprehension was associated almost exclusively with the left mid-posterior middle temporal gyrus. Poor comprehension of sequential commands was associated with lesions in the left posterior middle temporal gyrus. There was a small region of convergence between the three comprehension tasks, in the very posterior portion of the left middle temporal gyrus. The recovery analysis revealed that auditory comprehension scores continued to improve beyond the first year post-stroke. Higher education was associated with better outcome on all auditory comprehension tasks. Age and gender were not associated with outcome or recovery slopes.

Conclusions: The current findings suggest a critical role for the posterior left middle temporal gyrus in the recovery of auditory comprehension following stroke, and that spontaneous recovery of auditory comprehension can continue well beyond the first year post-stroke.

Self-rated health and psychological health among hypertensive patients in Palestine

The study has investigated the self-rated psychological health of hypertensive patients in Palestine. To that end, a stratified random sample of 502 hypertensive patients (aged ⩾ 18 years) was asked to complete a validated Arabic version of the General Health Questionnaire (GHQ-28). After collection, the data were analyzed using descriptive statistics, Mann-Whitney U test and logistic regression. In this study, it was found the mean scores for GHQ were statistically higher for females than males (p < 0.05). The females were found to be 1.701 (95% CI = 1.025-2.823) times more at risk of psychological disorders compared to males. In conclusion, improvement of social determinants of hypertensive patients can make a difference in their psychological/mental health.

Experimental models of focal and multifocal cerebral ischemia: a review

Rodent and rabbit stroke models have been instrumental in our current understanding of stroke pathophysiology; however, translational failure is a significant problem in preclinical ischemic stroke research today. There are a number of different focal cerebral ischemia models that vary in their utility, pathophysiology of causing disease, and their response to treatments. Unfortunately, despite active preclinical research using these models, treatment options for ischemic stroke have not significantly advanced since the food and drug administration approval of tissue plasminogen activator in 1996. This review aims to summarize current stroke therapies, the preclinical experimental models used to help develop stroke therapies, as well as their advantages and limitations. In addition, this review discusses the potential for naturally occurring canine ischemic stroke models to compliment current preclinical models and to help bridge the translational gap between small mammal models and human clinical trials.

An Investigation into the Relationship among Psychiatric, Demographic and Socio-Economic Variables with Bayesian Network Modeling

The aim of this paper is to investigate the factors influencing the Beck Depression Inventory score, the Beck Hopelessness Scale score and the Rosenberg Self-Esteem score and the relationships among the psychiatric, demographic and socio-economic variables with Bayesian network modeling. The data of 823 university students consist of 21 continuous and discrete relevant psychiatric, demographic and socio-economic variables. After the discretization of the continuous variables by two approaches, two Bayesian networks models are constructed using the bnlearn package in R, and the results are presented via figures and probabilities. One of the most significant results is that in the first Bayesian network model, the gender of the students influences the level of depression, with female students being more depressive. In the second model, social activity directly influences the level of depression. In each model, depression influences both the level of hopelessness and self-esteem in students; additionally, as the level of depression increases, the level of hopelessness increases, but the level of self-esteem drops.

Sustained administration of corticosterone at stress-like levels after stroke suppressed glial reactivity at sites of thalamic secondary neurodegeneration

Secondary neurodegeneration (SND) is an insidious and progressive condition involving the death of neurons in regions of the brain that were connected to but undamaged by the initial stroke. Our group have published compelling evidence that exposure to psychological stress can significantly exacerbate the severity SND, a finding that has considerable clinical implications given that stroke-survivors often report experiencing high and unremitting levels of psychological stress. It may be possible to use one or more targeted pharmacological approaches to limit the negative effects of stress on the recovery process but in order to move forward with this approach the most critical stress signals have to be identified. Accordingly, in the current study we have directed our attention to examining the potential effects of corticosterone, delivered orally at stress-like levels. Our interest is to determine how similar the effects of corticosterone are to stress on repair and remodelling that is known to occur after stroke. The study involved 4 groups, sham and stroke, either administered corticosterone or normal drinking water. The functional impact was assessed using the cylinder task for paw asymmetry, grid walk for sensorimotor function, inverted grid for muscle strength and coordination and open field for anxiety-like behaviour. Biochemically and histologically, we considered disturbances in main cellular elements of the neurovascular unit, including microglia, astrocytes, neurons and blood vessels using both immunohistochemistry and western blotting. In short, we identified that corticosterone delivery after stroke results in significant suppression of key microglial and astroglial markers. No changes were observed on the vasculature and in neuronal specific markers. No changes were identified for sensorimotor function or anxiety-like behaviour. We did, however, observe a significant change in motor function as assessed using the inverted grid walk test. Collectively, these results suggest that pharmacologically targeting corticosterone levels in the future may be warranted but that such an approach is unlikely to limit all the negative effects associated with exposure to chronic stress.

Major depressive disorder in patients with type 2 diabetes mellitus: Prevalence and clinical characteristics

BACKGROUND

This study investigated the prevalence of major depressive disorder (MDD) among Taiwanese patients with type 2 diabetes mellitus (T2DM).

METHODS

We enrolled patients with at least one service claim for ambulatory or inpatient care with a principal diagnosis of MDD and at least two service claims for ambulatory care or one service claim for inpatient care with a principal diagnosis of T2DM, as listed in Taiwan's National Health Insurance database.

RESULTS

We enrolled 715,756 people from the general population (GP), 61,589 patients with T2DM but without MDD, and 778 patients with both T2DM and MDD. The prevalence of MDD increased from 0.70% to 1.25% in the patients with T2DM, whereas it increased from 0.25% to 0.67% in the GP from 2000 to 2010. The higher prevalence of MDD was associated with the female sex, residing in the southern regions of Taiwan, and having comorbidities of cerebrovascular disease and anxiety disorder as well as higher comorbidity severity (Charlson comorbidity index, 1-2 and > 2).

LIMITATIONS

One limitation is the use of secondary data on diagnoses of MDD and T2DM. Another limitation is that we could not access some crucial related variables.

CONCLUSIONS

The prevalence of MDD was higher in the patients with T2DM than in the GP. In this study, the prevalence of MDD in the patients with T2DM was lower than that reported in Western countries.

Comparative efficacy and acceptability of antidepressant treatment in poststroke depression: a multiple-treatments meta-analysis

OBJECTIVE

The aim of this study is to create a rank order of the comparative efficacy and acceptability (risk of all-cause discontinuation) of antidepressant treatment in poststroke depression (PSD) by integrating direct and indirect evidence.

DESIGN

Multiple-treatments meta-analysis of randomised controlled trials.

PARTICIPANTS

Patients with depression following stroke.

INTERVENTIONS

10 antidepressants and placebo in the acute treatment of PSD.

OUTCOME MEASURES

The primary outcomes were the overall efficacy, defined as the mean change of the total depression score. The secondary outcome was the acceptability, defined as risk of all-cause discontinuation. These estimates as standardised mean differences or ORs with 95% CIs.

RESULTS

We identified 12 suitable trials, with data from 707 participants. All drugs were significantly more effective than placebo apart from sertraline, nefiracetam and fluoxetine. Most of the comparisons for acceptability revealed no significant differences except that paroxetine had significantly lower all-cause discontinuation than doxepin, citalopram and fluoxetine. Standardised mean differences compared with placebo for efficacy varied from -6.54 for the best drug (reboxetine) to 0.51 for the worst drug (nefiracetam). ORs compared with placebo for acceptability ranged from 0.09 for the best drug (paroxetine) to 3.42 for the worst drug (citalopram). For the efficacy rank, reboxetine, paroxetine, doxepin and duloxetine were among the most efficacious treatments, the cumulative probabilities of which were 100%, 85.7%, 83.2%, 62.4%, respectively. With respect to the acceptability rank, paroxetine, placebo, sertraline and nortriptyline were among the most acceptable treatments, the cumulative probabilities of which were 92.4%, 63.5%, 57.3%, 56.3%.

CONCLUSION

After weighing the efficacy and acceptability, we conclude that paroxetine might be the best choice when starting acute treatment for PSD, and fluoxetine might be the worst choice.

TRIAL REGISTRATION NUMBER

This systematic review has been registered in the Prospective Register of Systematic Review Protocols (PROSPERO) public database (CRD42017054741; http://www.crd.york.ac.uk/PROSPERO).

Fractional amplitude of low-frequency fluctuations (fALFF) in post-stroke depression

Depression is a common outcome following stroke, associated with reduced quality of life and poorer recovery. Despite attempts to associate depression symptoms with specific lesion sites, the neural basis of post-stroke depression remains poorly understood. Resting state fMRI has provided new insights into the neural underpinnings of post-stroke depression, but has been limited to connectivity analyses exploring interregional correlations in the time-course of activity. Other aspects of resting state BOLD signal remain unexamined. Measuring the amplitude of low frequency fluctuations allows the detection of spontaneous neural activity across the whole brain. It provides complementary information about frequency-specific local neural activity. We calculated the fractional amplitude of low frequency fluctuations (fALFF) in a group of 64 participants scanned 3 months post-stroke. Twenty showed depression symptoms when assessed with the Patient Health Questionnaire (PHQ-9). We performed analyses in both the typical 0.01-0.08 Hz range, as well as separately in the slow-5 (0.01-0.027 Hz) and slow-4 (0.027-0.073 Hz) ranges. We found significantly higher fALFF in the depressed compared to non-depressed participants in the left dorsolateral prefrontal cortex (DLPFC) and the right precentral gyrus, and a significant association between higher depression scores and higher fALFF in the left insula. The group differences were detected in the slow-5 fluctuations, while the association with depression severity was observed in the slow-4 range. We conclude that post-stroke depression can be characterised by aberrant spontaneous local neural activity, which in small samples could be a more sensitive measure than lesion volume and location.

Oral administration of corticosterone at stress-like levels drives microglial but not vascular disturbances post-stroke

Exposure to chronic stress following stroke has been shown, both clinically and pre-clinically, to impact negatively on the recovery process. While this phenomenon is well established, the specific mechanisms involved have remained largely unexplored. One obvious signaling pathway through which chronic stress may impact on the recovery process is via corticosterone, and its effects on microglial activity and vascular remodeling. In the current study, we were interested in examining how orally delivered corticosterone at a stress-like concentration impacted on microglial activity and vascular remodeling after stroke. We identified that corticosterone administration for two weeks following stroke significantly increased tissue loss and decreased the weight of the spleen and thymus. We also identified that corticosterone administration significantly altered the expression of the key microglial complement receptor, CD11b after stroke. Corticosterone administration did not alter the expression of the vessel basement membrane protein, Collagen IV after stroke. Together, these results suggest that corticosterone is likely to represent only one of the major stress signals responsible for driving the negative impacts of chronic stress on recovery.

Prevalence of Depressive Disorder in Persons With Type 2 Diabetes: A National Population-Based Cohort Study 2000-2010

BACKGROUND

Diabetes mellitus, a chronic and disabling disease, is epidemic worldwide. Depressive disorder affects the productivity of workers and leads to disability.

OBJECTIVE

This study investigated the prevalence of depressive disorder among persons with type 2 diabetes in Taiwan.

METHODS

We extracted service claims data for subjects who had at least 2 ambulatory care service claims or 1 inpatient service claim with a principal diagnosis of type 2 diabetes and at least 1 ambulatory or inpatient service claim with a principal diagnosis of depressive disorder from Taiwan's National Health Insurance Database.

RESULTS

From 2000-2010, the prevalence of depressive disorder increased from 3.50-4.07% in people with type 2 diabetes, and from 1.05-2.27% in the general population. The higher prevalence of depressive disorder in persons with type 2 diabetes was associated with being female; residence in central, southern, and eastern Taiwan; residence in urban areas; the comorbidities of hemiplegia or paraplegia, cerebrovascular disease, and anxiety disorder; Charlson Comorbidity Index scores ≥1; diabetes duration >9 years; and the use of rapid-acting insulin injection therapy.

CONCLUSIONS

The prevalence of depressive disorder is higher among persons with type 2 diabetes than the general population. Consequently, more public health attention should be devoted to the prevention and treatment of this debilitating disease in persons with type 2 diabetes, especially those with the earlier mentioned risk factors.

The Casson Memorial Lecture 2000: Reflect on the Past to Shape the Future

The Casson Memorial Lecture 2000, given on 21 July at the 24th Annual Conference of the College of Occupational Therapists, held at the University of Keele.

Consulting Service Users: The Stroke Association Home Therapy Project

In 1999, the Stroke Association set up a project to promote home-based occupational therapy for patients who had had a stroke and been discharged home from hospital. As part of the service evaluation, focus groups for service users and carers were set up in two of the sites to consult users about the changes in their quality of life during the period of the home therapy. A total of 11 service users and 9 carers attended the groups, representing 30% of the service users and 27% of the carers involved in the project. The group discussion was taped and transcribed and then analysed using a framework approach.

The group members described their personal experiences of recovery from and limitations after the stroke and reported improvements in life issues during the period of their home therapy. The content and organisation of the service and the relationships with project staff were felt to influence the effectiveness of the occupational therapy. Other issues that affected the perceived outcome for the service users included individual choice, age, stroke consequences, other rehabilitation and community services and social limitations. This consultation process allowed the service users to describe the strengths and weaknesses of the service and provided valuable feedback that could be used to design the content and application of future home therapy services.

Coping with Chronic Illness and Disability through Creative Needlecraft

Chronic illness and impairment commonly restrict the individual's access to work and leisure activities. Furthermore, if increasingly dependent upon family care, the individual may experience loss of valued roles and self-esteem. The present study enquired into the role of a creative leisure pursuit in long-term coping with illness and disability. The qualitative study examined the written narratives of 35 women, aged 18 to 87 years. All had acquired a disability or a chronic illness in adulthood and shared needlecraft as a common leisure pursuit.

In these accounts, the women described the circumstances in which needlecraft had been adopted as a leisure pursuit and the personal benefits experienced. The accounts showed that most of the women had taken up this activity in adulthood to cope with the crisis of illness. Needlecraft activities were commonly viewed as providing a means of managing pain and unstructured time, as well as facilitating self-esteem and reciprocal social roles. The women's accounts suggest that creative activity may be helpful for patients learning to cope with chronic conditions.

Poststroke agitation and aggression and social quality of life: a case control study

BACKGROUND AND OBJECTIVE

Aggression and agitation are common after a stroke. The association between agitation/aggression following stroke and Health-Related Quality of Life (HRQoL) in stroke survivors is unknown. This study aimed to examine the association between agitation/aggression and HRQoL in Chinese stroke survivors.

METHODS

Three hundred and twenty-four stroke patients entered this cross-sectional study. Agitation/aggression was assessed using the Chinese version of Neuropsychiatric Inventory (CNPI). HRQoL was measured with the Stroke Specific Quality of Life (SSQoL).

RESULTS

Three months after the index stroke, agitation/aggression was found in 60 (18.5%) patients. In the agitation/aggression group, 44 patients (73.3%) showed passive agitation/aggression, whereas 16 (26.7%) displayed passive and active agitation/aggression. No patients showed only active agitation/aggression. Patients with agitation/aggression were more likely to have history of diabetes and greater severity of depression, as well as lower SSQoL total score and Personality Changes and Social Role scores. Controlling for diabetes and depression severity did not alter the above results. The Energy and Thinking scores of the SSQoL were significantly lower in the passive/active agitation/aggression group relative to the passive agitation/aggression group (adjusted for CNPI aggression/agitation score).

CONCLUSION

In this study sample, agitation/aggression was preponderantly of the passive type and was associated with poorer HRQoL independently from depression or medical conditions. Patients with both passive and active agitation/aggression had lower Quality of Life (QoL) than patients with only passive agitation/aggression. The causality of the association between low QoL and agitation/aggression needs to be explored in future studies.

Emotional Distress Following Stroke: Interpretive Limitations of the SCL-90-R

Evaluation of affective status in medical patients is frequently hampered by the uncertain validity, questionable relevance, or both, of certain items on measures used for this purpose. In this study, we examined the validity of the Symptom Checklist-90-Revised (SCL-90-R) as a measure of psychological distress in stroke patients. Those SCL-90-R symptoms (N = 19) that were designated by at least 8 of 10 expert raters as "usual consequences of stroke" were labeled "stroke symptoms." These items loaded primarily on the Somatization, Obsessive-Compulsive, and Depression scales. Among a sample of 30 patients hospitalized for acute rehabilitation following unilateral stroke, average scores fell at or above the 70th percentile (relative to normative data given in the manual) on five of the nine symptom dimensions and on all three summary indices of distress. Significantly elevated rates of endorsement were found in the stroke group on 12 of the 19 "stroke symptoms" and on 20 of the remaining symptoms as well. Participants with right-hemisphere lesions generally reported higher levels of distress than did the smaller group of patients with left hemisphere involvement. Our study suggests that at least some portion of SCL-90-R elevations is likely to be attributable to endorsement of phenomena that comprise part of the "natural history" of stroke. Our findings underscore the need for clinicians to examine individual responses of neurological patients on such self-report measures, as simple interpretation of summary scale scores can be highly misleading.

Quality of Life Following Stroke: Negotiating Disability, Identity, and Resources

Residual physical and cognitive impairments following a stroke can pose a significant threat to a survivor’s quality of life. Yet, there is not always a direct one-to-one correlation between functional disability and subjective quality of life. This research investigated the complexity of factors that influence quality of life after stroke, using qualitative interviews. Results indicate that a stroke has a significant impact on the quality of life of survivors, but some individuals find ways to adapt to their functional disabilities and report a high quality of life. Common elements of this process consist of reordering priorities to focus on those activities considered most salient to an individual’s identity; then drawing on existing resources, including health services and social supports, to maintain a customary activity, even in a modified form, retaining salient aspects of the individual’s identity and maintaining a sense of continuity in his or her life.

The global impact of non-communicable diseases on macro-economic productivity: a systematic review

Non-communicable diseases (NCDs) have large economic impact at multiple levels. To systematically review the literature investigating the economic impact of NCDs [including coronary heart disease (CHD), stroke, type 2 diabetes mellitus (DM), cancer (lung, colon, cervical and breast), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD)] on macro-economic productivity. Systematic search, up to November 6th 2014, of medical databases (Medline, Embase and Google Scholar) without language restrictions. To identify additional publications, we searched the reference lists of retrieved studies and contacted authors in the field. Randomized controlled trials, cohort, case-control, cross-sectional, ecological studies and modelling studies carried out in adults (>18 years old) were included. Two independent reviewers performed all abstract and full text selection. Disagreements were resolved through consensus or consulting a third reviewer. Two independent reviewers extracted data using a predesigned data collection form. Main outcome measure was the impact of the selected NCDs on productivity, measured in DALYs, productivity costs, and labor market participation, including unemployment, return to work and sick leave. From 4542 references, 126 studies met the inclusion criteria, many of which focused on the impact of more than one NCD on productivity. Breast cancer was the most common (n = 45), followed by stroke (n = 31), COPD (n = 24), colon cancer (n = 24), DM (n = 22), lung cancer (n = 16), CVD (n = 15), cervical cancer (n = 7) and CKD (n = 2). Four studies were from the WHO African Region, 52 from the European Region, 53 from the Region of the Americas and 16 from the Western Pacific Region, one from the Eastern Mediterranean Region and none from South East Asia. We found large regional differences in DALYs attributable to NCDs but especially for cervical and lung cancer. Productivity losses in the USA ranged from 88 million US dollars (USD) for COPD to 20.9 billion USD for colon cancer. CHD costs the Australian economy 13.2 billion USD per year. People with DM, COPD and survivors of breast and especially lung cancer are at a higher risk of reduced labor market participation. Overall NCDs generate a large impact on macro-economic productivity in most WHO regions irrespective of continent and income. The absolute global impact in terms of dollars and DALYs remains an elusive challenge due to the wide heterogeneity in the included studies as well as limited information from low- and middle-income countries.

Costs of hospitalization for stroke patients aged 18-64 years in the United States

BACKGROUND

Estimates for the average cost of stroke have varied 20-fold in the United States. To provide a robust cost estimate, we conducted a comprehensive analysis of the hospitalization costs for stroke patients by diagnosis status and event type.

METHODS

Using the 2006-2008 MarketScan inpatient database, we identified 97,374 hospitalizations with a primary or secondary diagnosis of stroke. We analyzed the costs after stratifying the hospitalizations by stroke type (hemorrhagic, ischemic, and other strokes) and diagnosis status (primary and secondary). We employed regressions to estimate the impact of event type and diagnosis status on costs while controlling for major potential confounders.

RESULTS

Among the 97,374 hospitalizations (average cost: $20,396 ± $23,256), the number with ischemic, hemorrhagic, or other strokes was 62,637, 16,331, and 48,208, respectively, with these types having average costs, in turn, of $18,963 ± $21,454, $32,035 ± $32,046, and $19,248 ± $21,703. A majority (62%) of the hospitalizations had stroke listed as a secondary diagnosis only. Regression analysis found that, overall, hemorrhagic stroke cost $14,499 more than ischemic stroke (P < .001). For hospitalizations with a primary diagnosis of ischemic stroke, those with a secondary diagnosis of ischemic heart disease (IHD) had costs that were $9836 higher (P < .001) than those without IHD.

CONCLUSIONS

The costs of hospitalizations involving stroke are high and vary greatly by type of stroke, diagnosis status, and comorbidities. These findings should be incorporated into cost-effective strategies to reduce the impact of stroke.

Stroke Social Network Scale: development and psychometric evaluation of a new patient-reported measure

Objective:

To describe the development and psychometric evaluation of a new patient-reported measure that assesses a person’s social network in the first six months post stroke. Although it is known that the social networks of those with stroke and aphasia are vulnerable to change, there is currently no social network scale that has been validated for this population.

Design and setting:

Repeated measures psychometric study, evaluating internal consistency, construct validity, and responsiveness to change of the Stroke Social Network Scale. Participants were interviewed two weeks, three months and six months following a first stroke.

Measures:

Stroke Social Network Scale; Medical Outcomes Studies (MOS) Social Support Survey; National Institute of Health Stroke Scale; Stroke and Aphasia Quality of Life Scale-39g; Frenchay Aphasia Screening Test.

Results:

87 participants were recruited, of whom 71 were followed up at six months. Factor analysis was used with the Stroke Social Network Scale to derive five subdomains: satisfaction; children; relatives; friends; and groups, which explained 63% of variance. There was good evidence for the scale’s internal consistency (α = 0.85); acceptability; and convergent (r = 0.34; r = 0.53) and discriminant validity (r = −0.10; r = −0.19). It differentiated between those with high versus low perceived social support ( p = 0.01). Moderate changes from two weeks to six months supported responsiveness (d = 0.32; standardised response mean (SRM) = 0.46), with the friends factor, as expected, showing more change than the children’s factor (friends factor: d = 0.46; SRM = 0.50; children’s factor: d = 0.06; SRM = 0.19).

Conclusions:

The Stroke Social Network Scale is a new measure that demonstrates good internal consistency, validity and responsiveness to change.

Post-stroke depression: mechanisms, translation and therapy

The interaction between depression and stroke is highly complex. Post-stroke depression (PSD) is among the most frequent neuropsychiatric consequences of stroke. Depression also negatively impacts stroke outcome with increased morbidity, mortality and poorer functional recovery. Antidepressants such as the commonly prescribed selective serotonin reuptake inhibitors improve stroke outcome, an effect that may extend far beyond depression, e.g., to motor recovery. The main biological theory of PSD is the amine hypothesis. Conceivably, ischaemic lesions interrupt the projections ascending from midbrain and brainstem, leading to a decreased bioavailability of the biogenic amines – serotonin (5HT), dopamine (DA) and norepinephrine (NE). Acetylcholine would also be involved. So far, preclinical and translational research on PSD is largely lacking. The implementation and characterization of suitable animal models is clearly a major prerequisite for deeper insights into the biological basis of post-stroke mood disturbances. Equally importantly, experimental models may also pave the way for the discovery of novel therapeutic targets. If we cannot prevent stroke, we shall try to limit its long-term consequences. This review therefore presents animal models of PSD and summarizes potential underlying mechanisms including genomic signatures, neurotransmitter and neurotrophin signalling, hippocampal neurogenesis, cellular plasticity in the ischaemic lesion, secondary degenerative changes, activation of the hypothalamo-pituitary-adrenal (HPA) axis and neuroinflammation. As stroke is a disease of the elderly, great clinical benefit may especially accrue from deciphering and targeting basic mechanisms underlying PSD in aged animals.

The association between major depression, health behaviors, and quality of life in adults with stroke

AIM

The study aims to examine the association between major depression, healthcare behaviors, and quality of life indices among adults with stroke.

METHODS

Data from 5869 participants with stroke in the 2006 Behavioral Risk Factor Surveillance Survey were examined. Multiple logistic regression was used to assess the independent association between depression status, self-care and preventive health behaviors, and quality of life indices, after accounting for relevant covariates.

RESULTS

In multivariate models, individuals with major depression were less likely to engage in physical activity (odds ratio 0·41; 95% confidence interval 0·29, 0·56) than those without major depression. Women with major depression were also less likely to have received a mammogram in the past two-years (odds ratio 0·61; 95% confidence interval 0·40, 0·96 for women ≥ age 40 and odds ratio 0·58; 95% confidence interval 0·36, 0·72 for women ≥ age 50) and a pap smear in the past three-years (odds ratio 0·40; 95% CI 0·22, 0·72). In comparisons of quality of life, individuals with major depression were less likely to perceive their health as excellent/very good/good (odds ratio 0·36; 95% confidence interval 0·25, 0·53), to report being satisfied with life (odds ratio 0·13; 95% confidence interval 0·08, 0·20), and to report receiving needed social support (odds ratio 0·42; 95% confidence interval 0·28, 0·63). Individuals who were depressed were also more likely to report one or more poor physical and poor mental health days in the past 30 days (odds ratio 4·56; 95% confidence interval 3·08, 6·76 and odds ratio 10·97; 95% confidence interval 7·75, 15·52, respectively).

CONCLUSIONS

In adults with stroke, major depression is associated with decreased engagement in stroke-specific and gender-specific self-care and preventive health behaviors, as well as a broad range of quality of life indices.

Why do people lose their friends after a stroke?

BACKGROUND

It is well-known that people lose friends after a stroke; what is less well understood is why this occurs.

AIMS

This study explored why people lose contact with their friends, and whether there are any protective factors. It also examined how friendship loss and change is perceived by the individual.

METHODS AND PROCEDURES

Participants with a first stroke were recruited from one acute stroke unit in the UK. In-depth qualitative interviews took place between 8 and 15 months post stroke.

OUTCOMES AND RESULTS

29 participants were recruited of whom 10 had aphasia. The main reasons given for losing friends were: loss of shared activities, reduced energy levels, physical disability, aphasia, unhelpful responses of others, environmental barriers, and changing social desires. The subset of participants who experienced the most extensive loss of friends were those who described a sense that they were 'closing in' on themselves leading to a withdrawal from social contact and a new preference for meeting only close friends and family. Those with aphasia experienced the most hurtful negative responses from others and found it more difficult to retain their friends unless they had strong supportive friendship patterns prior to the stroke. The factors which helped to protect friendships included: having a shared history, friends who showed concern, who lived locally, where the friendship was not activity-based, and where the participant had a 'friends-based' social network prior to the stroke.

CONCLUSIONS AND IMPLICATIONS

Given the link between depression and loss of friends post stroke, supporting an individual in maintaining a social network is likely to be beneficial. For intervention to be effective, however, it may need to take into account not only the impact of new physical and language disabilities, but also changing social desires.

Ambient experience in restitutive treatment of aphasia

One of the greatest challenges to language rehabilitation is reconciling the fact that the same therapeutic intervention, provided to different individuals with similar types of stroke-induced aphasia, may result in divergent outcomes. In this paper, the authors reviewed existing literature to identify relevant ambient factors – those outside the control of the clinician – that may potentially influence functional language recovery in aphasia and response to treatment. The goal was to develop a clinical history-taking tool to assist clinicians in gathering information germane to each individual's unique circumstances and environment, elements that may have previously been underestimated, to provide a complete inventory of potentially potent prognostic factors. First, two of the authors, speech–language pathologists experienced in aphasia rehabilitation, identified and categorized factors that seemed likely to influence aphasia outcomes. Then, a wide range of literature was reviewed in an effort to identify factors empirically found to be potent influences on aphasia recovery. Where studies relating these factors to aphasia were not found, relevant research from allied fields that examined recovery from brain injury is reported. Moreover, some factors thought to be potentially potent have yet to be examined. Finally, the ambient factors supported by evidence were categorized as facilitators or barriers to functional improvement, and the Ambient Influences on Outcome Checklist (AOC) was developed, including only those factors shown to be potent in the recovery process. It is hoped that this checklist can be used to more broadly assess potential prognostic influences in aphasia restitution, as well as spawn further research.

Poststroke depression: a review

OBJECTIVE

To review the world's (English-language) publications related to depression following stroke.

METHOD

The databases from MEDLINE and PubMed were reviewed for articles related to poststroke depression (PSD), depression and cerebral vascular accident, depression and cerebral vascular disease, and depression and cerebral infarction.

RESULTS

Most studies examined prevalence rates of depression and the clinical correlates of depression. Based on pooled data, the overall prevalence of major depression was 21.7% and minor depression was 19.5%. The strongest single correlate of depression was severity of impairment in activities of daily living. However, the existence of depression at baseline was found to be associated with greater impairment at follow-up, ranging from 6 weeks to 2 years in 83% of studies. Further, depression following acute stroke was also associated with greater cognitive impairment and increased mortality. PSD has been shown in 6 double-blind controlled studies to be effectively treated with antidepressants, and 1 study has recently shown that PSD can be effectively prevented.

CONCLUSIONS

During the past 20 years, significant progress has been made in the identification and treatment of depression following stroke. In the future, antidepressant treatment will likely play an increasing role in the management of patients with acute stroke. Further research is needed to identify the mechanisms of depression and why antidepressants lead to improved physical and cognitive recovery and decreased mortality.

Psychological distress after stroke and aphasia: the first six months

Objective: We explored the factors that predicted psychological distress in the first six months post stroke in a sample including people with aphasia.

Design: Prospective longitudinal observational study.

Setting and subjects: Participants with a first stroke from two acute stroke units were assessed while still in hospital (baseline) and at three and six months post stroke.

Main measures: Distress was assessed with the General Health Questionnaire-12. Other measures included: NIH Stroke Scale, Barthel Index, Frenchay Aphasia Screening Test, Frenchay Activities Index, MOS Social Support Scale and social network indicators. Logistic regression was used to identify predictors of distress at each stage post stroke; and to determine what baseline factors predicted distress at six months.

Results: Eighty-seven participants were able to self-report on measures used, of whom 32 (37%) had aphasia. 71 (82%) were seen at six months, including 11 (16%) with aphasia. Predictors of distress were: stroke severity at baseline; low social support at three months; and loneliness and low satisfaction with social network at six months. The baseline factors that predicted distress at six months were psychological distress, loneliness and low satisfaction with social network (Nagelkerke R2 = 0.49). Aphasia was not a predictor of distress at any time point. Yet, at three months post stroke 93% of those with aphasia experienced high distress, as opposed to 50% of those without aphasia (χ2 (1) = 8.61, P<0.01).

Conclusions: Factors contributing to distress after stroke vary across time. Loneliness and low satisfaction with one’s social network are particularly important and contribute to long-term psychological distress.

Return to work in stroke patients

PURPOSE

To present the current state of knowledge regarding return to work (RTW) following stroke.

METHOD

A comprehensive review of the current stroke rehabilitation literature pertaining to prognostic and treatment factors for RTW following stroke.

RESULTS

Stroke is a major healthcare problem and one of the most expensive diseases in modern society. Stroke results not only in impairment and limitation in basic daily activities; it also impacts on participation in community activities, such as returning to work. Return to work in post-stroke patients has been reported to range between 19% and 73%. Various studies report on return to work in diverse populations, using different follow-up periods, while utilizing variable definitions of stroke and successful work outcomes. The factors positively related to RTW in stroke patients, as found in the literature, are age less then 65 years, high education level and white-collar employment. The significant negative predictor is the severity of stroke. This is indicated by neurological parameters including functional measures of the presence and extent of motor and cognitive impairment. Significantly, the side of the brain damaged and stroke location were not found to be correlated with RTW. Social and financial factors also significantly influence RTW.

CONCLUSIONS

RTW in stroke patients should be considered one of the indicators of a successful rehabilitation as it influences self-image, well-being and life satisfaction. There is still a considerable lack of knowledge regarding effective assessments and interventions in vocational rehabilitation in stroke patients.

Understanding the experience of stroke: a mixed-method research agenda

The use of both quantitative and qualitative strategies to examine a single research question has been a subject of considerable controversy and still remains a largely uncommon practice in the sociology of health and illness. Yet, when seeking to understand the meaning of a chronic disabling condition in later life from a social psychological perspective, a mixed-method approach is likely to provide the most comprehensive picture. This article provides an overview of the usefulness and appropriateness of a mixed-method approach to understanding the stroke experience. I comment on the current state of research on the experience of stroke, including epistemological and ontological orientations. Using real data examples, I address paradigmatic assumptions, methods of integration, as well as challenges and pitfalls in integrating methods. I conclude by considering future directions in this field of research.

The beneficial effects of the herbal medicine Free and Easy Wanderer Plus (FEWP) and fluoxetine on post-stroke depression

OBJECTIVES

Depression occurs frequently in post-stroke patients and appears to be associated with impairment of their rehabilitation and functional recovery. In this study, we evaluated the efficacy and tolerability of the herbal drug, Free and Easy Wanderer Plus (FEWP), in patients affected by post-stroke depression (PSD).

METHODS

One hundred fifty (150) moderately to severely depressed patients as determined by a score >20 on the Hamilton Depression Scale (HDS) after a single ischemic or hemorrhagic stroke were randomly divided into the FEWP group (n = 60), the fluoxetine group (n = 60), and the placebo group (n = 30). The FEWP, fluoxetine, and placebo were administered to the patients over a period of 8 weeks. Depression was evaluated by HDS and the Barthel Index (BI) before, during, and after the treatment.

RESULTS

Significantly higher clinical response rates were observed in both the FEWP and fluoxetine groups compared to the placebo group (60% and 65.5% versus 21.4%, chi(2) = 15.9, p < 0.01) and there was no difference in the response rates between the FEWP group and the fluoxetine group at the end of this study (60% versus 65.5%, chi(2) = 0.38, p > 0.05). Compared to fluoxetine, FEWP produced significantly greater improvement in depression at week 2 (15% versus 3.3%, chi(2) = 4.9, p < 0.05). Furthermore, FEWP produced significantly greater improvement in the activities of daily living (ADL) than fluoxetine at the end of this trial (BI: 43.8 +/- 5.6 versus 40.7 +/- 3.7, p < 0.01).

CONCLUSIONS

FEWP showed good efficacy, safety, and tolerability in PSD patients. We conclude that FEWP is well tolerated and may be a useful therapeutic option in patients with PSD.

Assistive control system using continuous myoelectric signal in robot-aided arm training for patients after stroke

In some stroke rehabilitation programs, robotic systems have been used to aid the patient to train. In this study, a myoelectrically controlled robotic system with 1 degree-of-freedom was developed to assist elbow training in a horizontal plane with intention involvement for people after stroke. The system could provide continuous assistance in extension torque, which was proportional to the amplitude of the subject's electromyographic (EMG) signal from the triceps, and could provide resistive torques during movement. This study investigated the system's effect on restoring the upper limb functions of eight subjects after chronic stroke in a twenty-session rehabilitation training program. In each session, there were 18 trials comprising different combinations of assistive and resistive torques and an evaluation trial. Each trial consisted of five cycles of repetitive elbow flexion and extension between 90 degrees and 0 degrees at a constant velocity of 10 degrees/s. With the assistive extension torque, subjects could reach a more extended position in the first session. After 20 sessions of training, there were statistically significant improvements in the modified Ashworth scale, Fugl-Meyer scale for shoulder and elbow, motor status scale, elbow extension range, muscle strength, and root mean square error between actual elbow angle and target angle. The results showed that the twenty-session training program improved upper limb functions.

Antidepressant therapy in post-stroke depression

BACKGROUND

About 40% of patients with stroke will develop depression at some stage after the acute event. Post-stroke depression (PSD) is associated with a poor prognosis. Depressed patients have more severe deficits in activities of daily living, a worse functional outcome, more severe cognitive deficits and increased mortality as compared to stroke patients without depression.

OBJECTIVE

This review will focus on available controlled trials of treatment for PSD.

METHODS

An unsystematic review of recent studies for the treatment of PSD.

RESULTS

Randomized controlled trials have demonstrated the efficacy of sertraline, citalopram and nortriptyline to treat post-stroke depression. Whether antidepressant medication may help to prevent post-stroke depression and decrease post-stroke mortality will require further controlled studies.

Changes in quality of life over the first year after stroke: findings from the Sunnybrook Stroke Study

PURPOSE

The purpose of this study was to investigate the longitudinal patterns of recovery of quality of life over the first year after stroke to understand the factors that are influential in this process.

METHOD

A sample of 116 stroke survivors with mild to moderate impairment was followed-up at 3 months and at 1 year after stroke onset. Changes in scores on a quality of life measure were assessed in association with changes in impairment and disability over this 9-month period. The use of rehabilitation services over the first year was also documented.

RESULTS

The quality of life of these survivors improved over the first year after stroke. Improvements in motor disability and depressive symptoms were found to be associated with improvements in quality of life. Additionally, survivors receiving rehabilitation therapy reported an improvement in quality of life that was independent of changes in disability and depressive symptoms.

CONCLUSIONS

Opportunities to enhance the quality of life of stroke survivors exist throughout the first year of recovery. Improvements in functional ability and depression are important for long-term improvements in quality of life. Rehabilitation therapy is a potentially important resource.