Impact of Persistent Poor Sleep Quality on Post-Stroke Anxiety and Depression: A National Prospective Clinical Registry Study

Association of plasma neurofilament light protein concentration with sleep disturbance after intracerebral hemorrhage

Background

Intracerebral hemorrhage (ICH) represents a critical subtype of stroke characterized by substantial morbidity and mortality. Emerging research indicates that neurofilament light protein (NfL), a biomarker indicative of neuronal damage, may offer valuable prognostic information regarding outcomes and recovery trajectories post-ICH. This study seeks to elucidate the relationship between plasma NfL (pNfL) concentrations and long-term patient outcomes, with a particular focus on sleep disturbances following ICH.

Methods

We conducted a cohort study comprising 26 healthy controls and 49 patients who had experienced ICH. The Glasgow Coma Scale (GCS) was assessed upon admission. Plasma samples were collected at admission and on 3, 7, and 14 days post-ICH. Then pNfL levels were quantified using Enzyme-Linked Immunosorbent Assay (ELISA). Clinical outcomes were evaluated at 6 months post-ICH using the Glasgow Outcome Scale-Extended (GOSE) and the Pittsburgh Sleep Quality Index (PSQI). Receiver operating characteristic (ROC) curves and the areas under the ROC curves (AUC) were utilized to determine the accuracy of hemorrhage volume and pNfL levels in identifying sleep disturbances.

Results

pNfL levels were elevated in patients with ICH compared to healthy controls. Longitudinal analysis indicated an increasing trend in pNfL levels over the initial 7 days post-admission. pNfL levels demonstrated an AUC for distinguishing ICH patients from controls (admission for 0.92, post-ICH 3d for 0.98). In ICH patients, pNfL levels showed a positive correlation with hemorrhage volume and PSQI, and a negative correlation with GCS and GOSE. The AUCs for pNfL levels and hemorrhage volume, which were indicative of sleep disturbances, were 0.82 and 0.75, respectively. Furthermore, the combined assessment of pNfL levels and hemorrhage volume exhibited superior predictive performance compared to the evaluation of each factor individually.

Conclusion

pNfL represents a promising biomarker for predicting functional outcomes and evaluating sleep disturbances in patients following ICH. Elevated levels of NfL at admission are associated with poorer prognoses and increased sleep-related issues, indicating that monitoring pNfL could be valuable for prognostication and the implementation of targeted interventions.

Daily Bidirectional Associations Between Sleep and Fatigue, Depression, and Anxiety in Stroke Survivors: A 7-Day Intensive Longitudinal Study

OBJECTIVE

To examine the bidirectional relationship between sleep quality and mood states including fatigue, depression, and anxiety in stroke survivors.

DESIGN

A prospective observational study using ecological momentary assessment (EMA) surveys conducted 3 times daily over a 7-day period.

SETTING

A tertiary-level, class A hospital.

PARTICIPANTS

Thirty-four stroke survivors (N=34).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

EMA measures of mood symptoms (fatigue, depression, anxiety) and sleep, including subjective and objective total sleep time (TST), sleep onset latency (SOL), total wake after sleep onset (WASO), number of awakenings (NWK), sleep efficiency (SE), and sleep quality.

RESULTS

Multilevel models revealed that more frequent NWK and increased TST were associated with greater fatigue, whereas higher SE was linked to lower depression levels. EMA analyses showed that greater daytime fatigue and evening anxiety were unexpectedly associated with improved same-night sleep quality, whereas better sleep quality was linked to increased next-day fatigue. No significant associations were found between sleep quality and next-day depression or anxiety. Fatigue and anxiety peaked in the morning and decreased significantly by evening, whereas depression showed reductions in the afternoon and evening compared with morning levels. However, no significant interaction was observed between sleep quality and time of day in their effects on mood.

CONCLUSIONS

This study provides preliminary evidence of the intricate and dynamic relationship between sleep and mood in stroke survivors, highlighting the bidirectional associations and time of day effects. These findings emphasize the need for targeted, personalized, and multifaceted interventions to improve both sleep and mood in stroke patients. Further research is necessary to validate these observations and explore mechanisms underlying these associations.

Poor sleep quality and its determinants among stroke survivors in Northwest Ethiopia

Sleep disorders are highly prevalent and linked bidirectionally to stroke as risk factors for stroke to worsen the outcomes. To date, most of the studies on post-stroke sleep were conducted in Western countries. Quality of sleep among stroke patients is masked by other physical and medical complications and limited attention is given in Ethiopia. To address this gap the current study aims to estimate the incidence of poor sleep quality and its determinants among stroke survivors in Northwest Ethiopia. A prospective cohort study was conducted in three public referral hospitals from June 2022 to December 2022. The study included 403 stroke survivors at the three-month follow-up. We conducted analyses of bivariable and multivariable logistic regression to look into the relationship between the outcome and the explanatory variables. Statistics were given as odds ratios and 95% confidence intervals, with a significance level of p < 0.05. The overall incidence of poor sleep quality was 50.1%, with a mean Global Sleep Quality (GSQ score) of 5.15 (SD ± 0.16). According to Pittsburgh Sleep Quality Index (PSQI) data, the mean sleep hour was 6.15. History of alcohol consumption, complications during admission, and time between the onset of symptoms and hospital arrival were predictors of sleep quality. Sleep quality was observed in half of stroke survivors. The study's findings point to the significance of screening for sleep quality following a stroke and further research is needed including admitted and non-admitted stroke patients.

The Role of Mature Brain-Derived Neurotrophic Factor and Its Precursor in Predicting Early-Onset Insomnia in Stroke Patients Experiencing Early Neurological Deterioration

Background

The investigation and management of early-onset insomnia (EOI) in patients undergoing early neurological deterioration (END) appear to be insufficiently prioritized in clinical practice. Brain-derived neurotrophic factor (mBDNF) and its precursor, proBDNF, play essential roles in neuroplasticity and may be involved in the pathophysiological mechanisms underlying EOI. This study aimed to investigate the associations of serum mBDNF, proBDNF, and the mBDNF/proBDNF ratio with EOI in stroke patients experiencing END.

Methods

In a prospective cohort study from October 2021 to December 2023, 232 stroke patients with END and 56 healthy controls (HCs) were enrolled. Serum levels of mBDNF and proBDNF were quantified using enzyme-linked immunosorbent assays. EOI was diagnosed according to the International Classification of Sleep Disorders, Third Edition (ICSD-3). Patients with END were categorized into subgroups based on the presence or absence EOI.

Results

Serum levels of mBDNF, proBDNF, and the mBDNF/proBDNF ratio were significantly lower in END patients compared to those in HCs (all p < 0.05). Among the 232 END patients, 82 (35.3%) developed EOI. Those with EOI had significantly lower levels of mBDNF and the mBDNF/proBDNF ratio compared to those without EOI (all p < 0.001). Multivariate logistic regression analysis revealed that male gender (p = 0.026), Hamilton Depression Rating Scale (HAMD) scores (p < 0.001), mBDNF (p = 0.009), and the mBDNF/proBDNF ratio (p < 0.001) were independent predictors of EOI in END patients. The areas under the curve (AUC) for mBDNF and the mBDNF/proBDNF ratio were 0.686 and 0.778, respectively.

Conclusion

Our study identified a correlation between reduced mBDNF levels and a decreased mBDNF/proBDNF ratio with the development of EOI in END patients. In addition, the mBDNF/proBDNF ratio may provide greater insight as a promising biomarker for EOI than mBDNF or proBDNF alone.

Behavioral Monitoring in Transient Ischemic Attack and Stroke Patients: Exploratory Micro- and Macrostructural Imaging Insights for Identifying Post-Stroke Depression with Accelerometers in UK Biobank

To examine the association between post-stroke depression (PSD) and macrostructural and microstructural brain measures, and to explore whether changes in accelerometer-measured physical activity (PA) are associated with PSD, we conducted an exploratory study in UK Biobank with dementia-free participants diagnosed with at least one prior stroke. Eligible participants (n = 1186) completed an MRI scan. Depression was classified based on positive depression screening scores (PHQ-2 ≥ 3). Multivariate linear regression models assessed the relationships between depression and structural and diffusion measures generated from brain MRI scans. Logistic regression models were used to examine the relationship between accelerometer-measured daily PA and future depression (n = 367). Depression was positively associated with total white matter hyperintensities (WMHs) volume (standardized β [95% CI]-0.1339 [0.012, 0.256]; FDR-adjusted p-value-0.039), periventricular WMHs volume (standardized β [95% CI]-0.1351 [0.020, 0.250]; FDR-adjusted p-value-0.027), and reduced MD for commissural fibers (standardized β [95% CI]--0.139 [-0.255, -0.024]; adjusted p-value-0.045). The odds of depression decreased by 0.3% for each daily minute spent in objectively measured light PA, while each minute spent in sleep from midnight to 6:00 AM was associated with a 0.9% decrease in the odds of depression. This early-stage analysis using a population cohort offers a scientific rationale for researchers using multimodal data sources to investigate the heterogenous nature of PSD and, potentially, identify stroke patients at risk of poor outcomes.

Inclusion of hypocretin-1 improved performance of poor sleep quality prediction for elderly patients with acute ischemic stroke: a prospective cohort study

Background

Hypocretin-1 is a vital neurotransmitter in regulating the sleep-wake cycle and provides neuroprotection against cerebral ischemia. We aims to develop a poor sleep quality predictive model for elderly population with acute ischemic stroke.

Methods

A total of 183 consecutively elderly patients were included in the prospective cohort study. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI). Cerebrospinal fluid samples were taken within 24 h of acute ischemic stroke onset. After selecting optimal predictors via univariate analysis and bootstrapped stepwise logistic regression, the predictive model was developed. The models were internally validated and evaluated comprehensively via discrimination, calibration, and clinical utility.

Results

The prevalence of poor sleep (PSQI >7) was 64.5% among elderly individuals experiencing acute ischemic stroke. The study developed a predictive model using hypocretin-1, hypertension, stroke history, the National Institutes of Health Stroke score, and depression. Adding hypocretin-1 (as continuous variable) significantly improved the model performance greatly, as the area under the receiver operating characteristic curve increased from 0.799 to 0.845 (p < 0.001). The optimal cutoff value for hypocretin-1 was 74.94 pg/mL. Adding hypocretin-1 (as binary variable) significantly improved the model performance greatly, as the AUC increased from 0.799 to 0.857 (p < 0.001).

Conclusion

Reduced cerebrospinal fluid levels of hypocretin-1 at admission were an independent poor sleep quality predictor and the model demonstrated superior performance. The combination of hypocretin-1 could offer valuable prognostic information for post-stroke sleep quality in elderly patients with acute ischemic stroke.

Multi-dimensional factors associated with adequate social participation among stroke survivors based on the social ecological model: A cross-sectional study on the gender and living place differences

This cross-sectional study aimed to investigate the multi-dimensional factors associated with adequate social participation among stroke survivors based on the social ecological model, and to identify the gender and living place differences. A total of 470 stroke survivors were recruited through convenience sampling method in two northern tertiary hospitals in China. Stepwise multiple logistic regression models showed that multi-dimensional factors (except for political factors) accounted for 10.10 % of the variance in adequate social participation. Intrapersonal (i.e., anxiety, motivation) and physical environmental factors (i.e., healthcare service accessibility) were strong associated determinants. Health condition (i.e., stroke sequelae) was one of significant determinants of perceiving adequacy in participation only for females. Interpersonal (i.e., social support) and organizational factors (i.e., frequency of community activities) were significant predictors of participation only for males and people living in rural. Comprehensive interventions addressing negative emotions, improving social support and integrating community resources are necessary for full social participation among stroke survivors.

Efficacy of non-invasive brain stimulation for post-stroke sleep disorders: a systematic review and meta-analysis

Objective

This study aimed to systematically assess the clinical efficacy of non-invasive brain stimulation (NIBS) for treating post-stroke sleep disorders (PSSD).

Methods

We conducted thorough literature search across multiple databases, including PubMed, Web of Science, EmBase, Cochrane Library, Scopus, China Biology Medicine (CBM); China National Knowledge Infrastructure (CNKI); Technology Periodical Database (VIP), and Wanfang Database, focusing on RCTs examining NIBS for PSSD. Meta-analyses were performed using RevMan 5.4 and Stata 14.

Results

Eighteen articles were reviewed, including 16 on repetitive Transcranial Magnetic Stimulation (rTMS), one on Theta Burst Stimulation (TBS), and two on transcranial Direct Current Stimulation (tDCS). Meta-analysis results indicated that rTMS within NIBS significantly improved the Pittsburgh Sleep Quality Index (PSQI) score (MD = -1.85, 95% CI [-2.99, -0.71], p < 0.05), the 17-item Hamilton Depression Rating Scale (HAMD-17) score [MD = -2.85, 95% CI (-3.40, -2.30), p < 0.05], and serum brain-derived neurotrophic factor (BDNF) levels [MD = 4.19, 95% CI (2.70, 5.69), p < 0.05], while reducing the incidence of adverse reactions [RR = 0.36, 95% CI (0.23, 0.55), p < 0.05]. TBS significantly improved the PSQI score in patients with PSSD (p < 0.05). Conversely, tDCS significantly improved the HAMD-17 score in PSSD patients [MD = -1.52, 95% CI (-3.41, -0.64), p < 0.05]. Additionally, rTMS improved sleep parameters, including Stage 2 sleep (S2%) and combined Stage 3 and 4 sleep (S3 + S4%) (p < 0.05), while tDCS improved total sleep time (TST) and sleep efficiency (SE) (p < 0.05).Subgroup analysis results indicated: (1) Both LF-rTMS and HF-rTMS improved PSQI scores (p < 0.05). (2) Both rTMS combined with medication and rTMS alone improved PSQI scores (p < 0.05). Compared to the sham/blank group, the rTMS group showed improvements in SE, sleep latency (SL), S1%, S3 + S4%, and REM sleep (REM%). The rTMS combined with medication group showed improved SL compared to the medication-only group (p < 0.05).

Conclusion

NIBS effectively improves sleep quality, structure, depression levels, and BDNF levels in PSSD patients, while also being safe. Further investigations into the potential of NIBS in PSSD treatment may provide valuable insights for clinical applications.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, CRD42023485317.

Bidirectional temporal associations between sleep and affect and cognitive symptoms among community-dwelling stroke survivors: An ecological momentary assessment study

INTRODUCTION

Sleep plays a critical role in daily functioning and stroke recovery but receives little attention in stroke rehabilitation. Sleep disturbances are linked to affective and cognitive impairments, but temporal associations between sleep and affect and cognitive symptoms are less clear. Understanding these temporal associations may inform new directions in intervention and prevention to support continued stroke recovery.

OBJECTIVE

To examine the bidirectional temporal associations between sleep and affect and cognitive symptoms among community-dwelling stroke survivors.

DESIGN

A secondary analysis of a longitudinal observational study involving 7 days of ecological momentary assessment (EMA), during which participants completed eight EMA surveys and a sleep diary per day. Multilevel modeling was used to analyze data.

SETTING

Community.

PARTICIPANTS

Community-dwelling stroke survivors (N = 40).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

EMA measures of depressed affect, cheerful affect, and cognitive symptoms. Sleep quality and duration as measured using a sleep diary.

RESULTS

Between-person sleep quality was negatively associated with next-day depressed affect (B = -.16; p = .028) and positively associated with next-day cheerful affect (B = .63; p < .001). Inversely, between-person depressed affect was negatively associated with next night sleep quality (B = -.77; p = .015), and vice versa for cheerful affect (between-person: B = .45; p < .001; within-person: B = .09; p = .008). Long sleep (>9 hours) was positively associated with next-day cognitive symptoms (B = .13; p = .002), whereas cognitive symptoms were associated with a higher odds of long sleep the following night (odds ratio [OR] = 0.25; p = .047).

CONCLUSIONS

This study identified the bidirectional associations of sleep with affect and cognitive symptoms in the context of the everyday life of stroke survivors. The findings suggest that interventions addressing sleep quality and duration may impact affect and cognitive symptoms, and vice versa.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Associations between Life's Essential 8 and post-stroke depression and all-cause mortality among US adults

BACKGROUND

Depression is the common mental disease after stroke. Our objective was to investigate the correlation of Life's Essential 8 (LE8), the recently updated evaluation of cardiovascular health, with the occurrence of post-stroke depression (PSD) and all-cause mortality among United States (US) adults.

METHODS

Participants with stroke were chosen from the National Health and Nutrition Examination Survey (NHANES) between 2005 and 2018. The relationship between LE8 and the risk of PSD was assessed through weighted multiple logistic models. A restricted cubic spline was employed for the examination of correlations. To demonstrate the stability of the results, sensitivity analysis and subgroup analysis were carried out. Furthermore, Cox regression models were used for the correlation between LE8 and all-cause mortality.

RESULTS

In this study, a total of 1071 participants were included for analysis. It was observed that LE8 score and PSD risk shared an inverse relationship in per 10 points increase [OR = 0.62 (0.52-0.74, P < 0.001)] in logistic regression models. The analysis of restricted cubic spline demonstrated approximately a noticeable inverse linear association between LE8 score and PSD risk. Sensitivity analysis verified the stability of the findings. Moreover, no statistically significant interactions were identified in subgroup analysis. A reverse association between LE8 score and all-cause mortality was also observed with a 10-point increase [HR = 0.85 (0.78-0.94, P < 0.001)] in cox regression models.

CONCLUSIONS

A negative correlation was discovered between LE8 score and PSD and all-cause mortality risk among US adults. We need to conduct large-scale prospective studies to further validate our results.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Examining the Role of GLU/GABA to GLN Metabolic Cycle in the Pathogenesis of Post-Stroke Depressive Disorder and Insomnia

OBJECTIVE

This study aims to elucidate the potential links between the GLU/GABA to GLN metabolic cycle disruptions and the onset of depressive and insomnia disorders following a stroke. We particularly focus on understanding if these disorders share a common underlying pathogenic mechanism.

METHODS

We examined 63 patients with post-stroke insomnia, 62 patients with post-stroke depression, and 18 healthy individuals. The study involved assessing insomnia using the Acute Insomnia Scale (AIS) and depression using the Hamilton Depression Rating Scale. We measured serum concentrations of GLN, GLU, and GABA and analyzed their correlations with AIS and HAMD scores.

RESULTS

Our results indicate no significant difference in the serum levels of GLN, GLU, and GABA between the post-stroke insomnia and depression groups. However, these levels were notably lower in both patient groups compared to the healthy control group. A negative correlation between AIS scores and GABA levels was observed in the post-stroke insomnia group, suggesting a potential link between GABAergic disturbances and insomnia. Conversely, no significant correlation was found between Hamilton Depression Rating Scale scores and the levels of GABA, GLU, or GLN in the post-stroke depression group.

CONCLUSION

The study highlights that abnormalities in the GLU/GABA to GLN metabolic cycle, particularly the levels of GLN, GABA, and GAD, might be intricately linked to the pathogenesis of post-stroke insomnia and depression. Our findings suggest that GABAergic imbalances could be indicative of post-stroke insomnia, serving as potential biological markers for differential diagnosis in clinical settings. Further research is warranted to explore these relationships in greater depth, potentially leading to new diagnostic and therapeutic approaches for post-stroke neuropsychiatric disorders.

Predicting the relationship between anxiety and health-related quality of life in post-stroke patients: The role of sleep duration

OBJECTIVES

Sleep and psychological disorders are common complaints in stroke survivors. The effectiveness of sleep duration in post-stroke on mental well-being and health outcomes has been reported recently. This study aimed to investigate the mediating effect of sleep duration on the relationship between anxiety and health-related quality of life in Chinese post-stroke; MATERIALS AND METHODS: We conducted a quantitative, cross-sectional study with participants recruited through a multistage, stratified, probability proportional to size sampling method. Anxiety, health-related quality of life, and sleep duration were measured by Zung Self-rating Anxiety Scale, World Health Organization Quality of Life Questionnaire, and a self-administered, structured questionnaire. A multiple linear regression analysis was conducted to identify the association between anxiety, sleep duration, and quality of life. The direct and indirect effects of sleep duration on health-related quality of life was assessed using the bootstrap method via Model 4 (parallel mediation) of SPSS PROCESS macro; RESULTS: A total of 856 post-stroke patients participated in the study, and incidence of anxiety symptom amongst post-stroke was 33.53%. Sleep duration mainly plays partial mediating roles in the relationship between mild-to-moderate anxiety and quality of life in physical, psychological, and environment domains, with sleep duration of 7-8h playing a major role; CONCLUSIONS: A significant relationship among anxiety, sleep duration, and quality of life in post-stroke was found in this study. The sleep duration partially mediated the association between anxiety and quality of life. Suitable prevention methods and early interventions for sleep duration may improve the quality of life for post-stroke anxiety.

Sleep disturbances and associated factors amongst stroke survivors in North Central, Nigeria

Introduction

Sleep disturbance is common in persons with stroke and when unrecognised and untreated may hinder rehabilitation efforts and lead to poor functional outcome. It may also result in increased risk for stroke recurrence.

Aim

We investigated the frequency and associated factors of sleep disturbances amongst stroke survivors.

Methodology

One hundred and ten stroke survivors attending the neurology outpatient clinics of two tertiary hospitals, from February 2021 to January 2022, were interviewed after obtaining ethical approval and informed consent. We used a structured questionnaire to obtain their socio-demographic, clinical characteristics and sleep disturbances. Excessive daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Data were analysed with statistical significance set at P < 0.05.

Results

Eighty (72.7%) patients were males with a mean age of 61.4 ± 11.8, slightly older than the females (30, 27.3%) with a mean age of 60.9 ± 2.9. Their median follow-up duration was 7.5 months. Majority (84, 76.4%) had ischaemic stroke, and the frequency of sleep disturbances was 37 (33.6%) consisting of insomnia (19, 17.3%), hypersomnia (10, 9.0%), sleep-disordered breathing (5, 4.5%) and sleep-related movement disorder (3, 2.7%), respectively. Using the ESS score, 22 (20.0%) had mild, 10 (9.0%) had moderate and 7 (6.4%) had severe ESS scores, respectively. Univariate analysis showed depression to be significantly associated with ESS (P = 0.006) whereas multivariate analysis revealed age and sex as significant associated factors (P = 0.008 and P = 0.009) of ESS.

Conclusion

More than one-third of participants reported sleep disturbances with depression, age and gender as associated factors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sleep Quantity and Quality During Inpatient Rehabilitation After Stroke

OBJECTIVE

To identify sleep patterns and their association with recovery after stroke during inpatient rehabilitation, and to determine if clinical outcomes are different between participants demonstrating abnormal sleep patterns as compared to those with normal sleep patterns.

METHODS

Cohort study in which participants were undergoing inpatient rehabilitation after a stroke. Sleep quantity and quality was measured using an actigraph that participants wore for up to 7 nights during the first week of inpatient rehabilitation. Medicare Quality Indicators (GG code), Barthel Index, gait speed, and Berg balance scale were collected at admission and discharge. Participants were categorized into groups based on meeting or not meeting recommended sleep quantity and quality guidelines. Association between sleep patterns and outcomes were assessed using Pearson correlation and differences in outcomes and length of stay between participants who met or did not meet sleep quantity and quality guidelines were determined using independent sample t-test.

RESULTS

69 participants were in the study. Sleep quantity and quality was poor for all the participants. None of the participants met all the sleep quantity and quality guidelines. There were moderate to small associations (-0.42 to 0.22) between some sleep quantity and quality parameters and clinical outcomes. Participants who's sleep efficiency (SE) was <85% had a significantly longer length of stay compared to those who's SE was >=85% (17.4 vs. 21.5 days, p<0.05).

CONCLUSIONS

People with stroke undergoing inpatient rehabilitation have poor sleep quantity and quality. There is a small to moderate association between sleep patterns and clinical outcomes and participants with poor sleep quality had longer length of stay compared to those with good sleep quality. Further research is necessary to better understand the complex relationship between sleep and recovery after stroke.

IMPACT

Sleep is associated with functional recovery during inpatient rehabilitation after stroke.

Association of a low vitamin D status with risk of post-stroke depression: A meta-analysis and systematic review

BACKGROUND

Although post-stroke depression (PSD) affects one-third of patients following an acute stroke, pooled evidence addressing the correlation between a low vitamin D status and the risk of PSD remains inconclusive.

METHODS

Comprehensive database search of Medline, EMBASE, Cochrane library, and Google Scholar was performed from inception to December 2022. The primary outcome was the association of PSD risk with a low vitamin D status, while the secondary outcomes included the relationship between PSD and other risk factors.

RESULTS

Analysis of seven observational studies published between 2014 and 2022 with 1,580 patients showed pooled incidences of vitamin D deficiency (defined as 25[OH] D levels < 50 nmol/L) and PSD of 60.1 and 26.1%, respectively. Patients with PSD had a lower circulating vitamin D concentration compared to those without [mean difference (MD) =-13.94 nmol/L, 95% CI: -21.83 to -6.05, p = 0.0005, I 2 = 91%, six studies, 1,414 patients]. Meta-analysis also demonstrated a correlation between a low vitamin D level and an increased PSD risk [odd ratio (OR) = 3.25, 95% CI: 1.57-6.69, p = 0.001, I 2 = 78.7%, 1,108 patients], the heterogeneity of which was found to be associated with the incidence of vitamin D deficiency but not female proportion on meta-regression. Besides, female gender (OR = 1.78, 95% CI: 1.3-2.44, p = 0.003, I 2 = 31%, five studies, 1,220 patients), hyperlipidemia (OR = 1.55, 95% CI: 1.01-2.36, p = 0.04, I 2 = 0%, four studies, 976 patients), and high National Institutes of Health Stroke Scale (NIHSS) scores (MD = 1.45, 95% CI: 0.58-2.32, p = 0.001, I 2 = 82%, five studies, 1,220 patients) were potential risk factors for PSD. For the primary outcome, the certainty of evidence was very low. Regarding secondary outcomes, the certainty of evidence was low for BMI, female gender, hypertension, diabetes, and stroke history, and very low for age, level of education, hyperlipidemia, cardiovascular disease, and NIHSS scores.

CONCLUSION

The results suggested an association of a low circulating vitamin D level with an increased risk of PSD. Besides, female gender, hyperlipidemia, high NIHSS score were related to an increased risk or occurrence of PSD. The current study may imply the necessity of routine circulating vitamin D screening in this population.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42022381580.