Social isolation poststroke: relationship between race/ethnicity, depression, and functional independence

Inter-relationships of depression and insomnia symptoms with life satisfaction in stroke and stroke-free older adults: Findings from the Health and Retirement Study based on network analysis and propensity score matching

BACKGROUND

Depression and insomnia are common co-occurring psychiatric problems among older adults who have had strokes. Nevertheless, symptom-level relationships between these disorders remain unclear.

OBJECTIVES

In this study, we compared inter-relationships of depression and insomnia symptoms with life satisfaction among older stroke patients and stroke-free peers in the United States.

METHODS

The study included 1026 older adults with a history of stroke and 3074 matched controls. Data were derived from the US Health and Retirement Study. Depression, insomnia and life satisfaction were assessed. Propensity score matching was employed to identify demographically-similar groups of stroke patients and controls. Central and bridge symptoms were assessed using Expected influence (EI) and bridge EI, respectively.

RESULTS

The prevalence of depression in the stroke group (25.0 %) was higher than that of controls (14.3 %, P < 0.001). In stroke group, "Feeling depressed" (CESD1; EI: 5.80), "Feeling sad" (CESD7; EI: 4.67) and "Not enjoying life" (CESD6; EI: 4.51) were the most central symptoms, while "Feeling tired in the morning" (JSS4; BEI: 1.60), "Everything was an effort" (CESD2; BEI: 1.21) and "Waking up during the night" (JSS2; BEI: 0.98) were key bridge symptoms. In controls, the most central symptoms were "Lack of happiness" (CESD4; EI: 6.45), "Feeling depressed" (CESD1; EI: 6.17), and "Feeling sad" (CESD7; EI: 6.12). Furthermore, "Feeling tired in the morning" (JSS4; BEI: 1.93), "Everything was an effort" (CESD2; BEI: 1.30), and "Waking up too early" (JSS3; BEI: 1.12) were key bridge symptoms. Life satisfaction had the most direct associations with "Not enjoying life" (CESD6) and "Feeling lonely" (CESD5) in the two groups, respectively.

CONCLUSION

Older adults with stroke exhibited more severe depression and insomnia symptoms. Interventions targeting central and bridge symptoms may help to mitigate the co-occurrence of these symptoms.

Dynamics of Perceived Social Isolation, Secondary Conditions, and Daily Activity Patterns Among Individuals With Stroke: A Network Analysis of Ecological Momentary Assessment Data

OBJECTIVE

To assess contemporaneous and temporal dynamics of perceived social isolation (PSI), secondary conditions, and daily activity patterns in individuals post-stroke.

DESIGN

Longitudinal observational study using ecological momentary assessment (EMA) as a real-time assessment of an individual's lived experiences. We conducted dynamic network analyses to examine longitudinal associations among EMA variables.

SETTINGS

Home and Community.

PARTICIPANTS

202 individuals with mild-to-moderate chronic stroke (median age=60 years; 45% women; 44% black; 90% ischemic stroke; median NIHSS score=2; N=202).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

EMA questions measured PSI, secondary conditions (pain, tiredness, stress, anxiety, worthlessness, difficulty concentrating, and cheerfulness), and daily activity patterns (being at home, being alone, and participating in productive activities).

RESULTS

The median EMA response rate was 84%. The contemporaneous model showed that PSI was associated with being home, alone, and all symptoms except pain. The temporal model revealed a pathway indicating that feelings of worthlessness predicted PSI (regression coefficient=0.06, P=.019), followed by stress (regression coefficient=0.06, P=.024), and then by being not at home (regression coefficient=-0.04, P=.013).

CONCLUSION

Implementing dynamic network analyses on EMA data can uncover dynamic connections among PSI, secondary conditions, and daily activity patterns after stroke. This study found a significant temporal association between PSI and negative emotions. Feeling isolated was followed by feeling stressed, which was followed by a tendency to be out of home, indicating adaptive behaviors in individuals with stroke. These findings highlight the importance of engaging in out-of-home or outdoor activities to mitigate PSI and negative emotions.

Neurologic morbidity and functional independence in adult survivors of childhood cancer

OBJECTIVE

To examine associations between neurologic late effects and attainment of independence in adult survivors of childhood cancer treated with central nervous system (CNS)-directed therapies.

METHODS

A total of 7881 survivors treated with cranial radiation therapy (n = 4051; CRT) and/or intrathecal methotrexate (n = 4193; IT MTX) ([CNS-treated]; median age [range] = 25.5 years [18-48]; time since diagnosis = 17.7 years [6.8-30.2]) and 8039 without CNS-directed therapy reported neurologic conditions including stroke, seizure, neurosensory deficits, focal neurologic dysfunction, and migraines/severe headaches. Functional independence was assessed using latent class analysis with multiple indicators (independent living, assistance with routine and personal care needs, ability to work/attend school, attainment of driver's license, marital/partner status). Multivariable regression models, adjusted for age, sex, race/ethnicity, and chronic health conditions, estimated odds ratios (OR) or relative risks (RR) for associations between neurologic morbidity, functional independence, and emotional distress.

RESULTS

Among CNS-treated survivors, three classes of independence were identified: (1) moderately independent, never married, and non-independent living (78.7%); (2) moderately independent, unable to drive (15.6%); and (3) non-independent (5.7%). In contrast to 50% of non-CNS-treated survivors and 60% of siblings, a fourth fully independent class of CNS-treated survivors was not identified. History of stroke (OR = 2.50, 95% CI: 1.70-3.68), seizure (OR = 9.70, 95% CI: 7.37-12.8), neurosensory deficits (OR = 2.67, 95% CI: 2.16-3.31), and focal neurologic dysfunction (OR = 3.05, 95% CI: 2.40-3.88) were associated with non-independence among CNS-treated survivors. Non-independence was associated with emotional distress symptoms.

INTERPRETATION

CNS-treated survivors do not attain full independence comparable to non-CNS-treated survivors or siblings. Interventions to promote independence may be beneficial for survivors with treatment-related neurological sequalae.

An enriched environment reduces hippocampal inflammatory response and improves cognitive function in a mouse model of stroke

An enriched environment is used as a behavioral intervention therapy that applies sensory, motor, and social stimulation, and has been used in basic and clinical research of various neurological diseases. In this study, we established mouse models of photothrombotic stroke and, 24 hours later, raised them in a standard, enriched, or isolated environment for 4 weeks. Compared with the mice raised in a standard environment, the cognitive function of mice raised in an enriched environment was better and the pathological damage in the hippocampal CA1 region was remarkably alleviated. Furthermore, protein expression levels of tumor necrosis factor receptor-associated factor 6, nuclear factor κB p65, interleukin-6, and tumor necrosis factor α, and the mRNA expression level of tumor necrosis factor receptor-associated factor 6 were greatly lower, while the expression level of miR-146a-5p was higher. Compared with the mice raised in a standard environment, changes in these indices in mice raised in an isolated environment were opposite to mice raised in an enriched environment. These findings suggest that different living environments affect the hippocampal inflammatory response and cognitive function in a mouse model of stroke. An enriched environment can improve cognitive function following stroke through up-regulation of miR-146a-5p expression and a reduction in the inflammatory response.

The influence of a virtual reality entertainment program on depressive symptoms and sedentary behaviour in inpatient stroke survivors: a research protocol for a pilot randomized controlled trial

Background

Sedentary behaviour among stroke inpatients may be due to high rates of depressive symptoms after stroke. Thus, efforts to address depressive symptoms among stroke inpatients are warranted to in turn lessen sedentary behaviour. Despite evidence that virtual reality (VR) is emerging as a method to help with depression, the use of VR to improve depression among inpatient stroke survivors has yet to be studied. In this paper, we report on the protocol investigating the feasibility of a VR entertainment system at improving depressive symptoms among stroke survivors receiving inpatient rehabilitation.

Methods

In this single-blind randomized controlled trial, 30 inpatient stroke survivors from the rehabilitation unit at Kelowna General Hospital will be randomized to either (1) intervention: 3 times per week of VR entertainment for duration of inpatient rehabilitation or (2) control: usual care. Individuals will be included if they have a confirmed diagnosis of stroke, are 19 years of age or older, able to provide informed consent, have physician clearance to participate in the study (medically stable or fit), or are able to understand English. Outcome measures to address depressive symptoms (primary outcome), sedentary behaviour, motivation, anxiety, stress, and happiness (secondary outcome) will be administered at two timepoints: (1) baseline (T1) and (2) post-intervention (T2). Study analyses will consider study feasibility indicators and clinical (statistical) outcomes. Means and standard deviations (for continuous variables) and frequencies and proportions (for categorical variables) will be used to summarize the variables. Feasibility indicators will be dichotomized into either ‘success’ if they meet the a priori criteria, or ‘revise’ if they do not meet the criteria. Intervention effects post-intervention (T2) for the primary and secondary clinical outcomes will be estimated using linear regression including baseline (T1) controlling for age and sex.

Discussion

The results of this trial will add to our understanding of depression and sedentary behaviour among individuals receiving inpatient stroke rehabilitation as well as the feasibility of a VR entertainment program to improve depressive symptoms, which will in turn may lessen sedentary behaviour in inpatient stroke survivors.

Trial registration

ClinicalTrials.gov Identifier: NCT04011202 . First posted July 8, 2019 (study postponed from March 2020 to July 2021 due to COVID-19).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01189-8.

Exploring the poststroke experiences and unmet needs of South Asian communities in high-income countries: a scoping review protocol

INTRODUCTION

South Asian groups experience a higher burden of stroke and poorer functional outcomes after stroke than their White counterparts. However, within the stroke literature, there has been little focus on the unique poststroke needs of the South Asian community and opportunities for community-based services to address these needs.

RESEARCH QUESTION

What is the current knowledge base related to the experiences and needs, including unmet needs of people living with stroke and their caregivers from South Asian communities living in high-income countries?

AIMS

This is a protocol for a review that intends to synthesise existing studies of the poststroke experiences and needs of individuals from South Asian communities to uncover opportunities for community-based resources to address these needs.

METHODS AND ANALYSIS

This scoping review methodology will be guided by modified Arksey and O'Malley (2005) and Joanna Briggs Institute frameworks. A search on OVID Medline, OVID Embase, OVID PsycINFO, EBSCO CINAHL, the Cochrane Library, Scopus and Global Index Medicus will be conducted to synthesise existing peer-reviewed literature (all study designs). Grey literature will be searched through detailed hand searching. Literature focusing on the poststroke experiences and needs of South Asian groups impacted by stroke residing in high-income countries will be included. Study descriptors will be extracted (eg, study location, type, methodology). Data will be analysed descriptively and thematically. Team meetings will provide opportunities for peer debriefing, thereby enhancing analytic rigour.

CONCLUSION AND IMPLICATIONS

Findings will enhance knowledge of the poststroke experiences and needs of South Asian communities living in high-income countries and identify actionable opportunities for community-based resources to address needs.

ETHICS AND DISSEMINATION

Ethics approval was not required for this scoping review protocol. Community-based organisations will be consulted to provide insights into the analysis and assist with dissemination. Dissemination of findings will also occur through a publication and academic presentations.

A Conceptual Review of Loneliness in Adults: Qualitative Evidence Synthesis

The paper reports an evidence synthesis of how loneliness is conceptualised in qualitative studies in adults. Using PRISMA guidelines, our review evaluated exposure to or experiences of loneliness by adults (aged 16+) in any setting as outcomes, processes, or both. Our initial review included any qualitative or mixed-methods study, published or unpublished, in English, from 1945 to 2018, if it employed an identified theory or concept for understanding loneliness. The review was updated to include publications up to November 2020. We used a PEEST (Participants, Exposure, Evaluation, Study Design, Theory) inclusion criteria. Data extraction and quality assessment (CASP) were completed and cross-checked by a second reviewer. The Evidence of Reviews of Qualitative Research (CERQual) was used to evaluate confidence in the findings. We undertook a thematic synthesis using inductive methods for peer-reviewed papers. The evidence identified three types of distinct but overlapping conceptualisations of loneliness: social, emotional, and existential. We have high confidence in the evidence conceptualising social loneliness and moderate confidence in the evidence on emotional and existential loneliness. Our findings provide a more nuanced understanding of these diverse conceptualisations to inform more effective decision-making and intervention development to address the negative wellbeing impacts of loneliness.

Assessing factors associated with social connectedness in adults with mobility disabilities

BACKGROUND

People with mobility disabilities are likely to report limitations in community participation and social connectedness for a variety of reasons, including inaccessible physical environments, health issues, transportation barriers, and limited financial resources. Improving social connectedness is a public health issue and research shows its relation to overall health and life expectancy.

OBJECTIVE

The purpose of this study was to (1) assess social activity, isolation, and loneliness among people with mobility disabilities compared to those with non-mobility disabilities and (2) understand factors associated with social connectedness among people with mobility disabilities.

METHODS

An observational, cross-sectional analysis was conducted using data from Wave 2 of the National Survey on Health and Disability (NSHD) to test for differences between adults age 18-64 with mobility disabilities (n = 621) and those with other disabilities (n = 1535), in addition to tests within the mobility disability group.

RESULTS

Adults with mobility disabilities were less likely than respondents from other disability groups to report feeling isolated (30.2% versus 35.2%), but these groups did not differ on measures of social activity or loneliness. Within the mobility disability group, being unemployed and in fair or poor health were predictive of greater loneliness, more isolation, and less satisfaction with social activity.

CONCLUSIONS

Social connectedness is an important public health issue. This research helps to inform service providers and medical professionals about the personal factors affecting social connectedness among people with mobility disabilities.

The Impact of the COVID-19 Public Health Crisis on Communication and Quality of Life: Insights From a Community of Stroke and Brain Trauma Survivors

Purpose The COVID-19 pandemic has led to stay-at-home orders and social distancing guidelines that have the potential to greatly impact individuals' behavior and social engagement. Adults recovering from stroke or other brain trauma, who often have communication difficulties and other long-term challenges, are a population already at risk of isolation and lower quality of life. We investigated the impact of public health guidelines and related behavioral changes on self-perceptions of communication abilities and psychosocial factors in this population. Method The Stroke Comeback Center, a community-based center for stroke and other brain trauma survivors with communication impairments, disseminated an online survey to current members to investigate changes in communication, social engagement, and quality of life. Results Participants (N = 50) reported a number of changes in their day-to-day activities that reflect the current social distancing guidelines, such as reduced outings into the community and fewer in-person conversations with those living outside one's home. Overall, feelings of connectedness to others and overall quality of life were reported to be decreased when compared to before the COVID-19 pandemic, whereas receptive language abilities and technology skills were reported to have improved. Perhaps most interestingly, certain behavioral changes (including healthy movement activities and participation in virtual programs) had specific relationships with perceived communication abilities and social engagement. Conclusions Changes in daily life resulting from the COVID-19 pandemic have had a tangible impact on self-perceived psychosocial elements (e.g., quality of life) and communication abilities among stroke and other brain trauma survivors. Clinicians and researchers may consider these perceived changes when engaging with this population as the effects of the pandemic continue and in the period of community re-entry that may follow. Supplemental Material https://doi.org/10.23641/asha.14830881.

Examining components of community psychosocial stroke interventions using concept mapping

BACKGROUND

Stroke impacts psychosocial well-being and engagement in occupation. Psychosocial interventions reduce depression and anxiety but may not impact occupation. Knowledge of key processes and components of community psychosocial stroke interventions can inform future intervention development.

AIM/OBJECTIVE(S)

To determine the essential elements common to three psychosocial interventions for stroke survivors.

MATERIAL(S) AND METHOD(S)

Concept maps were created for three community psychosocial stroke interventions based on published literature and communication with researchers who tested the intervention with stroke survivors. The concept maps were then compared to identify common elements. Ongoing communication with researchers ensured accurate representation of each respective intervention.

RESULTS

Similarities in intervention processes and components included support for autonomy; individualized information exchange; coping, life skill development and adaptation support; competence development; and the incorporation of goals. Differences included intervention delivery (individual versus group), and the avenues in which psychosocial needs are addressed (occupation versus dialogue).

CONCLUSIONS

Concept mapping identified similarities among the three interventions that can be best understood using self-determination theory. Clinicians may utilize findings revealed in the process to inform evidence-based psychosocial stroke interventions.

SIGNIFICANCE

Knowledge of key 'active ingredients' for psychosocial community stroke interventions, can be used to guide clinical reasoning and inform development of interventions.

Older migrants' experience of existential loneliness

Background:

With rapidly ageing population worldwide, loneliness among older adults is becoming a global issue. Older migrants are considered being a vulnerable population and ethical issues are often raised in care for elderly. A deeper sense of loneliness, existential loneliness is one aspect of loneliness also described as the ultimate loneliness. Making oneself understood or expressing emotions, have shown to be particularly challenging for older migrants which could lead to experience of existential loneliness. Ageing and being a migrant are potential triggers for experiencing existential loneliness. There appears to be, however, little known about being a migrant experiencing existential loneliness in old age.

Aim:

This study explored older migrants’ experience of existential loneliness.

Research design:

Qualitative study.

Participants and research context:

Data were collected through interviews (n = 15) with older (>65) migrants’ in Swedish nursing homes or senior citizen centres. A thematic analysis was performed to analyse the data.

Ethical considerations:

The study was conducted in accordance with the principles of research ethics.

Findings:

The result was described in terms of three themes: (1) Choices made in life, (2) seeking reconciliation with life and (3) thoughts about death and dying in a foreign country.

Discussion:

Ethical reflection and knowledge about how older migrants’ life story can lead to experiencing existential loneliness, could be of use in care for older migrants’.

Conclusion:

This study indicates that the experience of existential loneliness derived from being a migrant is a long-term and significant process. Migration was a hope of creating a meaningful life, the experience of existential loneliness occurred as migrants sought reconciliation with life, reflected upon their past choices, and thought about death and dying in a foreign country.

Exercise-based interventions for post-stroke social participation: A systematic review and network meta-analysis

BACKGROUND

Resuming participation in society is an important goal of post-stroke rehabilitation. Exercise-based interventions have been shown to be effective non-pharmacological methods for improving social participation in post-stroke survivors, however it is unclear what the most effective types of exercise interventions are.

OBJECTIVE

To assess the comparative effects and ranks of all exercise-based interventions in improving social participations in patients after a stroke.

METHODS

A random-effects network meta-analysis was performed to identify evidence from relevant randomized control trials. We searched MEDLINE, CINAHL, EMBASE, PsycINFO, CINHAL, Cochrane Library, AMED, SPORTDiscus, Web of Science and Clinical Trials.gov from their earliest records to January 2020. Included trials must include at least one types of exercise for patients with stroke. The primary e was social participation. Bias will be assessed according to the revised Cochrane risk of bias tool. Data were analysed using Stata v14.0. Registration number of this study is CRD42020152523.

RESULTS

A total of 16 randomized control trials involving 1704 patients and 12 intervention arms were included in our study. We performed three subgroup analyses divided based on follow up time (1 to <6 months post-treatment, and ≥6 months post-treatment), and intervention adherence. Based on the ranking probabilities, motor relearning programme was ranked as the most effective among all exercise interventions (surface under cumulative ranking curve values [SUCRCV]: 95.6%, standardized mean difference [SMD]: 2.72, 95% confidence interval [CI]: 1.76 to 3.69) in overall and short-term treatment efficacy. In the long-term subgroup, home-based combined exercise ranked the best for the efficacy of social participation improvements among stroke survivors (SUCRCV: 71.8%, SMD: -0.23, 95% CI: -0.61 to 0.15). In the analysis of all interventions with adherence of >90%, cognitive-based exercise ranked the best (SUCRCV: 100%, SMD: 2.64, 95% CI: 1.62 to 3.66).

CONCLUSIONS

Interventions that emerged with the highest ranks in our analysis might be considered in practice when resources allow. More large, well-designed multicentre trials are needed to support the conclusion of this study.

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.

Perceived participation and its determinants among young and middle-aged stroke survivors following acute care one month after discharge

PURPOSE

To describe the perceived participation and assess its determinants among young and middle-aged stroke patients following acute care one month after discharge in mainland China.

METHODS

Two hundred and twenty-three patients were consecutively recruited from two tertiary hospitals and were followed up 1 month after discharge in the outpatient department or their communities to assess their participation by using the Impact on Participation and Autonomy Questionnaire, with 23 patients lost to follow-up. Determinants (i.e., sociodemographic, diseased-related, physical, psychological, and social factors) of participation were identified in four domains: indoor autonomy; outdoor autonomy; family role; and social life.

RESULTS

The overall perceived participation of our respondents was good to fair. Forty-six (23.0%), 32 (16.0%), 13 (6.5%), and 19 (9.5%) perceived their participation as "very good" in the domains of indoor autonomy, family role, outdoor autonomy and social life, respectively. Stroke severity, depressive symptoms, and social support were the common determinants of participation for all the domains, with stroke severity being the strongest correlate. Activities of daily living was associated with indoor autonomy, family role, and outdoor autonomy, but not associated with social life.

CONCLUSIONS

The perceived participation of our respondents is relatively optimistic. Physical health along with mental and social status can affect participation. Tailored strategies should be implemented early in the rehabilitation phase to promote stoke survivors' participation in all the domains.Implications for rehabilitationAlthough the overall perceived participation of young and middle-aged stroke patients was fair to good, attention should be paid to their family roles.The strategies should be mainly focused on reducing the stroke severity to improve patients' participation.Improving patients' depressive symptom and social support can also be helpful for improving their participation.

Prediction of life-space mobility in patients with stroke 2 months after discharge from rehabilitation: a retrospective cohort study

Purpose: To determine the predictors of life-space mobility among patients with stroke 2 months after discharge from a post-acute rehabilitation unit.Materials and methods: The study population was 1023 patients discharged from a post-acute rehabilitation unit in Japan. We assessed the relationships between life-space mobility 2 months after discharge and age, sex, length of hospital stay, cognition and motor function (Functional Independence Measure), severity of hemiparesis, falls efficacy, physical function (Timed Up and Go (TUG) test), walking distance ability and social support from family and friends.Results: Bivariate and multiple regression analyses showed that life-space mobility was predicted by sex, age, cognitive score at discharge, TUG score <15 s, length of hospital stay and falls efficacy at discharge. Taken together, these factors accounted for 54% of the variability in life-space mobility. A predictive formula was determined for clinical use.Conclusions: The predictive formula provides an objective measure of life-space mobility for stroke patients after discharge. The clinical application of this formula could help health care professionals working in stroke rehabilitation to prepare patients for discharge and to set concrete goals for in-hospital rehabilitation to improve life-space mobility after discharge.Implications for rehabilitationAccurate prediction of the prognosis for life-space mobility 2 months after discharge is useful in establishing clear goals for community-based rehabilitation.Long-term life-space mobility in the community is not only affected by physical function, but also by sex, age, cognitive ability and falls efficacy at discharge.Life-space mobility in female patients is affected by factors reflecting physical function, whereas life-space mobility in male patients is affected by both physical and cognitive function.Prediction of life-space mobility after stroke is important to determine unique mobility goals in rehabilitation and the required use of adaptive equipment after discharge (e.g., returning to work, engaging in a hobby or travelling beyond the immediate neighbourhood).

Association Between Anxiety, Depression, and Post-traumatic Stress Disorder and Outcomes After Ischemic Stroke

Background: Stroke patients are known to be at risk of developing anxiety, depression, and post-traumatic stress disorder (PTSD). Objective: To determine the overlap between anxiety, depression, and PTSD in patients after stroke and to determine the association between these disorders and quality of life, functional status, healthcare utilization, and return to work. Methods: A cross-sectional telephone survey was conducted to assess for depression, anxiety, PTSD, and health-related outcomes 6-12 months after first ischemic stroke in patients without prior psychiatric disease at a single stroke center. Results: Of 352 eligible subjects, 55 (16%) completed surveys. Seven subjects (13%) met criteria for probable anxiety, 6 (11%) for PTSD, and 11 for depression (20%). Of the 13 subjects (24%) who met criteria for any of these disorders, 6 (46%) met criteria for more than one, and 5 (39%) met criteria for all three. There were no significant differences in baseline characteristics, including stroke severity or neurologic symptoms, between those with or without any of these disorders. Those who had any of these disorders were less likely to be independent in their activities of daily living (ADLs) (54 vs. 95%, p < 0.001) and reported significantly worse quality of life (score of 0-100, median score of 50 vs. 80, p < 0.001) compared to those with none of these disorders. Conclusions: Anxiety, depression, and PTSD are common after stroke, have a high degree of co-occurrence, and are associated with worse outcomes, including quality of life and functional status.

Hyperforin improves post-stroke social isolation‑induced exaggeration of PSD and PSA via TGF-β

Stroke survivors often experience social isolation, which can lead to post-stroke depression (PSD) and post-stroke anxiety (PSA) that can compromise neurogenesis and impede functional recovery following the stroke. The present study aimed to investigate the effects and mechanisms of post-stroke social isolation-mediated PSD and PSA on hippocampal neurogenesis and cognitive function. The effects of the natural antidepressant hyperforin on post-stroke social isolation-mediated PSD and PSA were also investigated. In the present study, a model of PSD and PSA using C57BL/6J male mice was successfully established using middle cerebral artery occlusion combined with post-stroke isolated housing conditions. It was observed that PSD and PSA were more prominent in the isolated mice compared with the pair-housed mice at 14 days post-ischemia (dpi). Mice isolated 3 dpi exhibited decreased transforming growth factor-β (TGF-β) levels and impairment of hippocampal neurogenesis and memory function at 14 dpi. Intracerebroventricular administration of recombinant TGF-β for 7 consecutive days, starting at 7 dpi, restored the reduced hippocampal neurogenesis and memory function induced by social isolation. Furthermore, intranasal administration of hyperforin for 7 consecutive days starting at 7 dpi improved PSD and PSA and promoted hippocampal neurogenesis and memory function in the isolated mice at 14 dpi. The inhibition of TGF-β with a neutralizing antibody prevented the effects of hyperforin. In conclusion, the results revealed a previously uncharacterized role of hyperforin in improving post-stroke social isolation-induced exaggeration of PSD and PSA and, in turn, promoting hippocampal neurogenesis and cognitive function via TGF-β.

Depressive Symptoms in Individuals after Stroke in a Home-Based Rehabilitation Setting

Poststroke depression has been shown to affect rehabilitation progress. This study evaluated patients after stroke who actively participated in a home-based rehabilitation program to determine variables that correlated with depressive symptoms in this population. A retrospective review of patients who were provided rehabilitation by Community Stroke Rehabilitation Team clinicians between January 1, 2009, and September 30, 2015, was completed. Logistic regression analysis was conducted to determine which demographic and outcome variables (Functional Independence Measure [FIM™] and Reintegration to Normal Living Index [RNLI]) were independently associated with depressive symptoms, as defined by Patient Health Questionnaire (PHQ-9) scores. 889 patients (53.2% male, mean age = 69.8 years) were included. Based on PHQ-9 scores, 89.7% of patients presented with no or mild depressive symptoms (PHQ-9 < 10) and 10.3% were considered to have moderate to severe depressive symptoms (PHQ-9 ≥ 10). The regression demonstrated that referral from outpatient, community care access centre, or community settings (OR = 1.89, p = 0.04), low RNLI scores (OR = 0.92; p = 0.001), and younger age (OR = 0.96; p < 0.001) predicted patients having moderate to severe depressive symptoms. Given the impact of poststroke depression on rehabilitation, clinicians should consider the potential impact of referral source, community reintegration, and age when monitoring and treating depressive symptoms.

Racial and ethnic disparities in stroke outcomes: a scoping review of post-stroke disability assessment tools

Purpose: To identify how post-stroke disability outcomes are assessed in studies that examine racial/ethnic disparities and to map the identified assessment content to the International Classification of Functioning, Disability, and Health (ICF) across the time course of stroke recovery. Methods: We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria. Results: We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature. Conclusions: A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US. Implications for Rehabilitation An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery. Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias. Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.

African American elders' psychological-social-spiritual cultural experiences across serious illness: an integrative literature review through a palliative care lens

Disparities in palliative care for seriously ill African American elders exist because of gaps in knowledge around culturally sensitive psychological, social, and spiritual care. The purpose of this integrative literature review is to summarize the research examining African American elders' psychological, social, and spiritual illness experiences. Of 108 articles, 60 quantitative, 42 qualitative, and 6 mixed methods studies were reviewed. Negative and positive psychological, social, and spiritual experiences were noted. These experiences impacted both the African American elders' quality of life and satisfaction with care. Due to the gaps noted around psychological, social, and spiritual healing and suffering for African American elders, palliative care science should continue exploration of seriously ill African American elders' psychological, social, and spiritual care needs.

Post-stroke depression inhibits improvement in activities of daily living in patients in a convalescent rehabilitation ward

[Purpose] There have been no investigations into the improvement of activities of daily living among patients suffering from post-stroke depression on admission to convalescent rehabilitation wards in Japan. This study aimed to assess the improvement of activities in daily living in patients with or without post-stroke depression at the time of admission to a convalescent rehabilitation ward. [Subjects and Methods] This retrospective study included 108 stroke patients divided into two groups according to their Geriatric Depression Scale 15-item short form scores. Activities of daily living were assessed using the Functional Independence Measure. The degree of improvement on the Functional Independence Measure was defined as the difference between scores on admission and at discharge. [Results] The Functional Independence Measure gain score was significantly different from the Functional Independence Measure total score. There was a significant interaction between time period and post-stroke depression factors for the Functional Independence Measure total score. A multiple regression analysis revealed a significant association between Geriatric Depression Scale score and Functional Independence Measure total score. [Conclusion] The present study suggests that post-stroke depression has a negative impact on recovery of activities of daily living and on rehabilitation outcomes in a convalescent rehabilitation ward setting.

A study in persons later after stroke of the relationships between social participation, environmental factors and depression

OBJECTIVE

To explore the impacts of social participation and the environment on depression among people with stroke.

DESIGN

Cross-sectional survey.

SETTING

Structured interviews in the participants' homes.

SUBJECTS

Community-dwelling persons with stroke in the rural areas of China ( N = 639).

INTERVENTIONS

Not applicable.

MAIN MEASURES

Depression (Hamilton Rating Scale for Depression-6), activity and social participation (Chinese version of the World Health Organization's Disability Assessment Schedule 2.0), environmental barriers (Craig Hospital Inventory of Environmental Factors), neurological function (Canadian Neurological Scale).

RESULTS

A total of 42% of the variance in depression was explained by the environmental barriers, neurological function, activity, and social participation factors studied. Social participation, services/assistance, and attitudes/support were directly related to depression; their standardized regression coefficients were 0.530, 0.162, and 0.092, respectively ( p ⩽ 0.01). The physical environment, policies, and neurological function indirectly impacted depression. Depression influences social participation in turn, with a standardized regression coefficient of 0.29 ( p ⩽ 0.01).

CONCLUSIONS

Depression and social participation are inversely related. The physical environment, services/assistance, attitudes/support, and policies all impact post-stroke depression.

Neuropsychiatric sequelae of stroke

Stroke survivors are often affected by psychological distress and neuropsychiatric disturbances. About one-third of stroke survivors experience depression, anxiety or apathy, which are the most common neuropsychiatric sequelae of stroke. Neuropsychiatric sequelae are disabling, and can have a negative influence on recovery, reduce quality of life and lead to exhaustion of the caregiver. Despite the availability of screening instruments and effective treatments, neuropsychiatric disturbances attributed to stroke are currently underdiagnosed and undertreated. Stroke severity, stroke-related disabilities, cerebral small vessel disease, previous psychiatric disease, poor coping strategies and unfavourable psychosocial environment influence the presence and severity of the psychiatric sequelae of stroke. Although consistent associations between psychiatric disturbances and specific stroke locations have yet to be confirmed, functional MRI studies are beginning to unveil the anatomical networks that are disrupted in stroke-associated psychiatric disorders. Evidence regarding biochemical and genetic biomarkers for stroke-associated psychiatric disorders is still limited, and better understanding of the biological determinants and pathophysiology of these disorders is needed. Investigation into the management of these conditions must be continued, and should include pilot studies to assess the benefits of innovative behavioural interventions and large-scale cooperative randomized controlled pharmacological trials of drugs that are safe to use in patients with stroke.

The association of an inability to form and maintain close relationships due to a medical condition with anxiety and depressive disorders

BACKGROUND

While low social support is a risk factor for mental illness, anxiety and depression's relationship with social impairment specifically resulting from a medical condition is poorly understood. We hypothesize that when a medical illness makes it difficult for people to form and maintain close relationships with others, they will be at increased risk for anxiety and depression.

METHODS

Two nationally representative surveys, the National Comorbidity Survey-Replication and National Latino and Asian American Study, included 6805 adults with at least one medical illness and information on social impairment attributed to a medical condition. The Composite International Diagnostic Interview evaluated a 12-month history of anxiety and depressive disorders.

RESULTS

8.2% of our sample had at least moderate difficulty in forming and maintaining close relationships due to a medical condition. In bivariate analyses, younger age, Latino ethnicity, less education, worse financial status, more chronic illnesses, physical health and discomfort, and problems with mobility, home management, and self-care were associated with this social impairment. In multivariable analyses accounting for possible confounders, there was a dose-dependent relationship between social impairment and the prevalence of anxiety and depression.

LIMITATIONS

Data are cross-sectional and our analyses are therefore unable to determine cause-and-effect relationships.

CONCLUSIONS

Among adults with one or more medical conditions, social impairment attributed to medical illness was associated with a significantly greater odds of anxiety and depression. Further clarification of this relationship could inform more targeted, personalized interventions to prevent and/or alleviate mental illness in those with chronic medical conditions.

The relationship between post-stroke depression and physical recovery

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Pair housing reverses post-stroke depressive behavior in mice

Social isolation (SI) has been linked epidemiologically to high rates of morbidity and mortality following stroke. In contrast, strong social support enhances recovery and lowers stroke recurrence. However, the mechanism by which social support influences stroke recovery has not been adequately explored. The goal of this study was to examine the effect of post-stroke pair housing and SI on behavioral phenotypes and chronic functional recovery in mice. Young male mice were paired for 14 days before a 60 min transient middle cerebral artery occlusion (MCAO) or sham surgery and assigned to various housing environments immediately after stroke. Post-stroke mice paired with either a sham or stroke partner showed significantly higher (P<0.05) sociability after MCAO than isolated littermates. Sociability deficits worsened over time in isolated animals. Pair-housed mice showed restored sucrose consumption (P<0.05) and reduced immobility in the tail suspension test compared to isolated cohorts. Pair-housed stroked mice demonstrated significantly reduced cerebral atrophy after 6 weeks (17.5 ± 1.5% in PH versus 40.8 ± 1.3% in SI; P<0.001). Surprisingly, total brain arginase-1, a marker of a M2 "alternatively activated" myeloid cells was higher in isolated mice. However, a more detailed assessment of cellular expression showed a significant increase in the number of microglia that co-labeled with arginase-1 in the peri-infarct region in PH stroke mice compared to SI mice. Pair housing enhances sociability and reduces avolitional and anhedonic behavior. Pair housing reduced serum IL-6 and enhanced peri-infarct microglia arginase-1 expression. Social interaction reduces post-stroke depression and improves functional recovery.

Life changed existentially: a qualitative study of experiences at 6-8 months after mild stroke

PURPOSE

To explore experiences of mild-stroke survivors in the context of early supported discharge. The meanings patients attributed to activities and participation in the home recovery process were our main interest.

METHODS

Eight participants (45-80 years) from a randomised controlled study were selected for this sub-study. This purposive sample had received rehabilitation in their homes in the post-stroke acute phase of recovery as part of the larger study. Extensive interview data were analysed using an interpretive strategy and systematic text condensation. Coping theory was included in later stages of analysis.

FINDINGS

The mild-stroke survivors' stories revealed that life had changed profoundly. Differences and similarities in experienced changes were related to: self-perceived health, the body, practical activities, taking part in society, and self-perception. The findings showed the ways in which life changed for mild-stroke survivors, experienced challenges, and survivors' thoughts about the future.

CONCLUSIONS

Mild-stroke rehabilitation should focus more strongly on basic concerns related to self-perceived health, self-perception, and body, since these dimensions seem to complicate daily activities and close relationships. Professionals should also be aware of patients who experience an uncertain situation and unresolved rehabilitation needs, which still can be present 6-8 months after the stroke.

IMPLICATIONS FOR REHABILITATION

When living with mild stroke, entrance to practical and social activities seemed founded on the patients' perception of the body and self as comprehensible or not. Comprehending their own changed body and sense of self seem to be a long-term process when living with mild stroke. It is suggested that long-term follow-up be incorporated in home rehabilitation service, also in the context of early supported discharge. This may contribute to help patient cope more optimally with activities and participation of importance to them.

Clinical features of adults with seven-valent-conjugated-vaccine-serotype pneumococcal pneumonia

BACKGROUND

Despite the reduction in adult invasive pneumococcal disease through 'herd protection' consequent to the introduction of childhood pneumococcal conjugate vaccination (PCV), a significant proportion of adults continue to develop pneumococcal pneumonia caused by one of the seven serotypes included in the seven-valent conjugated pneumococcal vaccine (PCV7). The clinical features and outcomes of these adults have not been previously reported.

METHODS

Adults recruited over a three year period to a large prospective cohort study of community acquired pneumonia (CAP) were investigated for pneumococcal serotypes using a validated multiplex immunoassay (Bio-plex). The baseline characteristics and outcomes of adults with PCV7-serotype CAP in comparison to those with non-PCV7-serotype CAP were established.

RESULTS

Pneumococcal aetiology was identified in 415 of 1166 (35.6%) individuals, and a serotype determined in 287 (69.2%). Following exclusion of three individuals with both a PCV7 and non-PCV7 serotype, 77 of the remaining 284 (27.1%) adults had CAP due to PCV7 serotypes. Adults with PCV7-serotype CAP were older (median years (inter-quartile range) 73.3 (60.8-84.4) versus 65.0 (46.1-78.0); p=0.001) and were more likely to have a World Health Organisation performance status ≥1 (odds ratio (OR) 2.05, 95% confidence interval (CI) 1.21-3.50).The presence of stroke (adjusted OR 2.84, 95% CI 1.36-5.95) and dementia (adjusted OR 3.55, 95% CI 1.26-9.94) as underlying co-morbid illnesses were independently associated with PCV7-serotype CAP; 30-day mortality was significantly greater in adults with PCV7-serotype CAP (adjusted OR 4.38, 95% CI 1.85-10.34).

CONCLUSION

A significant proportion of adults continue to develop PCV7-serotype CAP in the era of childhood pneumococcal conjugate vaccination. These adults are more likely to have stroke and dementia as underlying co-morbid illnesses, and have a higher 30-day mortality. A combination of pneumococcal transmission factors, host factors and pneumococcal serotype specific characteristics are likely to explain these findings.

Predictors of depressive symptoms among community-dwelling stroke survivors

BACKGROUND

Depression is a common yet often unrecognized consequence of stroke, affecting between 25% and 70% of all survivors. Untreated depression post-stroke leads to a poorer prognosis and increased mortality. However, the pattern and profile of post-stroke depression in chronic stroke are poorly understood.

OBJECTIVE

The aim of this study was to examine the independent predictors of depressive symptoms in chronic stroke.

METHODS

Community-dwelling stroke survivors (n = 100) completed the Center for Epidemiological Studies-Depression (CES-D) scale, Multidimensional Scale of Perceived Social Support, Medical Outcomes Study Short Form-36, and the Pittsburgh Sleep Quality Index. Functional disability and cognitive impairment were assessed using standardized procedures. Multiple linear regression was conducted to explore potential independent predictors of depressive symptoms.

RESULTS

Subjects were, on average, 70 ± 10 years old and 39 ± 49 months post-stroke. The majority were white/European-American (78%), college educated (79%), and retirees (77%). Annual income was $50 000 or greater for 32%. Hemiparesis was common (right side, 39%; left side, 42%); 35% had a Center for Epidemiological Studies-Depression scale score of 16 or higher, and 21% had a history of major depression. Approximately 64% of the variance in depressive symptoms could be explained by the independent variables in the model: quality of life, sleep quality, social support, cognitive impairment, functional disability, months post-stroke, age, gender, history of major depression, and lesion location (R = 0.64, F12,87 = 12.97, P < .01). Only poor quality of life (t1,87 = -6.99, P < .01) and low social support (t1,87 = -2.14, P = .04) contributed uniquely and significantly to the severity of depressive symptoms among these stroke survivors.

CONCLUSION

Depressive symptoms are prevalent in chronic stroke survivors, even among an educated and economically advantaged population. Our findings are similar to reports by others that poor quality of life and low social support are major contributors to depressive symptoms in chronic stroke and should be routinely assessed and monitored to improve long-term rehabilitation efforts and promote wellness and community reintegration.

Physical, cognitive and social activity levels of stroke patients undergoing rehabilitation within a mixed rehabilitation unit

OBJECTIVE

To determine physical, cognitive and social activity levels of stroke patients undergoing rehabilitation, and whether these changed over time.

DESIGN

Observational study using behavioural mapping techniques to record patient activity over 12 hours on one weekday and one weekend day at baseline (week 1) and again two weeks later (week 2).

SETTING

A 20-bed mixed rehabilitation unit.

SUBJECTS

Fourteen stroke patients.

INTERVENTIONS

None.

MAIN MEASURES

Percentage of day spent in any activity or physical, cognitive and social activities. Level of independence using the Functional Independence Measure (FIM) and mood using the Patient Health Questionniare-9 (PHQ-9).

RESULTS

The stroke patients performed any activity for 49%, social activity for 32%, physical activity for 23% and cognitive activity for 4% of the day. Two weeks later, physical activity levels had increased by 4% (95% confidence interval (CI) 1 to 8), but levels of any activity or social and cognitive activities had not changed significantly. There was a significant: (i) positive correlation between change in physical activity and change in FIM score (r = 0.80), and (ii) negative correlation between change in social activity and change in PHQ-9 score (r = -0.72). The majority of activity was performed by the bedside (37%), and most physical (47%) and cognitive (54%) activities performed when alone. Patients undertook 5% (95% CI 2 to 9) less physical activity on the weekends compared with the weekdays.

CONCLUSIONS

Levels of physical, cognitive and social activity of stroke patients were low and remained so even though level of independence and mood improved. These findings suggest the need to explore strategies to stimulate activity within rehabilitation environments.

Impaired social decision making in patients with major depressive disorder

Research on how depression influences social decision making has been scarce. This study investigated how people with depression make decisions in an interpersonal trust-reciprocity game. Fifty female patients diagnosed with major depressive disorders (MDDs) and 49 healthy women participated in this study. The experiment was conducted on a one-to-one basis. Participants were asked to play the role of a trustee responsible for investing money given to them by an anonymous female investor playing on another computer station. In each trial, the investor would send to a participant (the trustee) a request for a certain percentage of the appreciated investment (repayment proportion). Since only the participant knew the exact amount of the appreciated investment, she could decide to pay more (altruistic act), the same, or less (deceptive act) than the requested amount. The participant's money acquired in the trial would be confiscated if her deceptive act was caught. The frequency of deceptive or altruistic decisions and relative monetary gain in each decision choice were examined. People with depression made fewer deceptive and fewer altruistic responses than healthy controls in all conditions. Moreover, the specific behavioral pattern presented by people with depression was modulated by the task factors, including the risk of deception detection and others' intentions (benevolence vs. malevolence). Findings of this study contribute to furthering our understanding of the specific pattern of social behavioral changes associated with depression.