Temporal Evolution of Poststroke Cognitive Impairment Using the Montreal Cognitive Assessment.

BACKGROUND AND PURPOSE: The Montreal Cognitive Assessment (MoCA) is nowadays recommended for the screening of poststroke cognitive impairment. However, little is known about the temporal evolution of MoCA-assessed cognition after stroke. The objective of this study was to examine the temporal pattern of overall and domain-specific cognition at 2 and 6 months after stroke using the MoCA and to identify patient groups at risk for cognitive impairment at 6 months after stroke. METHODS: Prospective cohort study in which 324 patients were administered the MoCA at 2 and 6 months post stroke. Cognitive impairment was defined as MoCA<26. Differences in cognitive impairment rates between 2 and 6 months post stroke were analyzed in different subgroups. Patients with MoCA score <26 at 2 months, who improved by ≥2 points by 6 months, were defined as reverters. Logistic regression analyses were used to identify determinants of (1) cognitive impairment at 6 months post stroke and (2) reverter status. RESULTS: Between 2 and 6 months post stroke, mean MoCA score improved from 23.7 (3.9) to 24.7 (3.5), P<0.001. Prevalence of cognitive impairment at 2 months was 66.4%, compared with 51.9% at 6 months (P<0.001). More comorbidity and presence of cognitive impairment at 2 months were significant independent predictors of cognitive impairment 6 months post stroke. No significant determinants of reverter status were identified. CONCLUSIONS: Although cognitive improvement is seen ≤6 months post stroke, long-term cognitive deficits are prevalent. Identifying patients at risk of cognitive impairment is, therefore, important as well as targeting interventions to this group.

Quality of Life during the First Two Years Post Stroke: The Restore4Stroke Cohort Study.

BACKGROUND: Little information is available about the course of quality of life (QoL) post stroke and how dependency on activities of daily living (ADL) influences this course. The aim of this study was therefore to describe the course of QoL from 2 months up to 2 years post stroke and to study the influence of ADL dependency in the first week post stroke. METHODS: This is a multicenter prospective longitudinal cohort study in which 368 stroke patients were included and data were collected at 1 week, 2 months, 6 months, 12 months and 24 months post stroke. QoL assessment included measures of health-related quality of life (HRQoL) (short stroke-specific Quality of Life Scale), emotional functioning (Hospital Anxiety and Depression Scale), participation (Utrecht Scale for Evaluation of Rehabilitation-Participation), and life satisfaction (2LS). Dependency on ADL was defined as having a Barthel Index score ≤ 17 four days post stroke. Generalized Estimating Equations analyses were performed to examine the course of the 4 domains of QoL. Furthermore, the possible confounding effect of age, gender, marital status, level of education and discharge destination was examined. RESULTS: Results showed that HRQoL, participation and life satisfaction improved during the first year post stroke, with most changes occurring in the first 6 months. Furthermore, patients dependent in ADL scored consistently lower on all 4 QoL domains and test occasions compared to ADL-independent patients. In both patient groups separately, no changes over time were found in emotional functioning. ADL-independent patients improved in HRQoL (p = 0.002), participation (p < 0.001) and life satisfaction (p = 0.020) between 2 and 6 months and in life satisfaction (p = 0.003) between 6 and 12 months also. ADL-dependent patients improved in HRQoL (p = 0.009) between 2 and 6 months and in participation between 2 and 6 months (p = 0.001) and between 6 and 12 months (p = 0.031). Furthermore, they experienced no changes in life satisfaction. No confounding effect was found after adding age, gender, marital status, level of education and discharge destination. CONCLUSIONS: Most improvement in QoL occurred up to 6 months post stroke and showed different patterns for specific domains of QoL and for patients with and without dependency in ADL in the first week post stroke. It is therefore important to differentiate between these different domains of QoL when the long-term perspective is considered. Furthermore, patients dependent in ADL consistently scored lower on all QoL domains and did not reach the level of QoL of patients independent of QoL.

Risk Factors for Symptoms of Depression and Anxiety One Year Poststroke: A Longitudinal Study.

OBJECTIVE: To estimate the relative contribution of psychological factors next to sociodemographic and premorbid/stroke-related factors to the risk of developing symptoms of depression and anxiety after stroke. DESIGN: Multicenter, longitudinal cohort study. SETTING: Patients after stroke from 6 general hospitals. PARTICIPANTS: Patients (N=331) were included at stroke onset and followed up 2 and 12 months after stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sociodemographic and premorbid/stroke-related information was recorded during hospital admission, whereas psychological characteristics were determined with postal questionnaires 2 months poststroke. Symptoms of depression and anxiety were assessed with the Hospital Anxiety and Depression Scale (HADS) 2 and 12 months poststroke. Multivariable logistic analysis was performed to analyze the influence of sociodemographic, premorbid/stroke-related, and psychological characteristics on depressive symptoms (depression subscale of HADS >7) and symptoms of anxiety (anxiety subscale of HADS >7) 1 year after stroke. RESULTS: Early depression, stroke severity, posterior cerebral artery stroke, and neuroticism independently explained the variance of depressive symptoms 1 year poststroke (discriminative power, 83%; adjusted R(2) value, 36%). Neuroticism and early anxiety independently explained the variance of symptoms of anxiety 1 year poststroke (discriminative power, 88%; adjusted R(2) value, 44%). Based on these predictive models, nomograms were constructed to visually reflect the individual contribution of each risk factor to the development of long-term mood disorders after stroke. CONCLUSIONS: Psychological characteristics are important risk factors for poststroke symptoms of depression and anxiety.

Does the frequency of participation change after stroke and is this change associated with the subjective experience of participation?

OBJECTIVE: To investigate changes in the frequency of participation 6 months poststroke compared with prestroke; and to establish whether the change is associated with participation restrictions and satisfaction with participation 6 months poststroke. DESIGN: Inception cohort study. Prestroke frequency of participation was measured retrospectively in the first week poststroke. Frequency, participation restrictions, and satisfaction with participation were assessed 6 months poststroke. SETTING: General hospitals and home residences. PARTICIPANTS: Patients with stroke (N=325; 65.5% men; mean age, 66.9±12.2y) admitted to 1 of 6 participating general hospitals. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Utrecht Scale for Evaluation of Rehabilitation-Participation (0-100), which consists of 3 scales: frequency, restrictions, and satisfaction. The frequency scale consists of 2 parts: vocational activities (work, volunteer work, education, household activities) and leisure and social activities. RESULTS: Vocational activities showed a large decrease (effect size: 0.6) poststroke; leisure and social activities showed a small decrease (effect size: 0.13) poststroke. In multiple regression analyses, both the frequency of participation in vocational activities 6 months poststroke and the decrease in vocational activities compared with before the stroke were significantly associated with the participation restrictions experienced and satisfaction with participation after controlling for age, sex, level of education, dependency in activities of daily living, cognitive functioning, and presence of depressive symptoms. The presence of depressive symptoms showed the strongest association with the subjective experience of participation. CONCLUSIONS: The frequency of participation decreased after a stroke, and this decrease was associated with participation restrictions experienced and satisfaction with participation. Resuming vocational activities and screening and, if applicable, treatment of depressive symptoms should be priorities in stroke rehabilitation.

Psychological factors determine depressive symptomatology after stroke.

OBJECTIVE: To identify psychological factors related to poststroke depressive symptoms. DESIGN: Cross-sectional study, with patients assessed at 2 months poststroke. SETTING: Patients with stroke from 6 general hospitals. PARTICIPANTS: Stroke patients (N=344; mean age ± SD, 66.9±12.3y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The presence of clinical depressive symptoms was determined with the depression subscale of the Hospital Anxiety and Depression Scale 2 months poststroke. Psychological factors assessed were extraversion, neuroticism, optimism, pessimism, self-efficacy, helplessness, acceptance, perceiving benefits, proactive coping, and passive coping. RESULTS: Bivariate correlations and multivariate backward logistic regression were used to analyze associations between psychological factors and poststroke depressive symptoms, accounting for demographic and stroke-related factors. More neuroticism, pessimism, passive coping, and helplessness, and less extraversion, optimism, self-efficacy, acceptance, perceived benefits, and proactive coping were bivariately associated with the presence of depressive symptoms. Multivariate logistic regression analysis showed that more helplessness (odds ratio [OR]=1.17) and passive coping (OR=1.19) and less acceptance (OR=.89) and perceived benefits (OR=.89) were independently significantly associated with the presence of poststroke depressive symptoms (Nagelkerke R(2)=.49). CONCLUSIONS: We found a relationship between psychological variables and the presence of depressive symptoms 2 months poststroke. It is important to take these factors into account during poststroke rehabilitation.

Psychological factors after stroke: Are they stable over time?

OBJECTIVE: Psychological factors influence stroke outcomes, such as participation and quality of life. Although important for clinical practice, not much is known about the temporal stability of these factors. This study explored whether psychological factors are stable post-stroke. METHODS: Prospective longitudinal cohort study. The following psychological factors were assessed using self-report questionnaires at 2 months and at 2 years post-stroke: proactive coping, self-efficacy, extraversion, optimism, passive coping, neuroticism and pessimism. Changes over time, associations and dimensions among psychological factors were considered. RESULTS: Data for 324 participants were available. Only passive coping scores showed no change between 2 months and 2 years post-stroke. Participants showed less proactive coping, lower self-efficacy, less extraversion, less optimism, more neuroticism and more pessimism over time. All but one inter-correlation of psychological factors, r = [-0.14; 0.71], and all correlations over time, r = [0.42-0.64], were significant. At both time-points, the psychological factors clustered into an "adaptive psychological factor" (proactive coping, self-efficacy, extraversion) and a "maladaptive psychological factor" (passive coping, neuroticism). CONCLUSION: Across all psychological factors, changes toward less favourable scores were found. Clinicians should pay attention to adaptive and maladaptive psychological factors among stroke patients during long-term care.

Long-term restrictions in participation in stroke survivors under and over 70 years of age.

PURPOSE: This study aims to (1) assess differences in participation restrictions between stroke survivors aged under and over 70 years and (2) identify predictors associated with favorable and unfavorable long-term participation in both age groups. METHODS: Prospective cohort study in which 326 patients were assessed at stroke onset, two months and one year after stroke. The Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-Participation) was used to measure participation restrictions one year after stroke. Bivariate and multivariate logistic regression analyses were performed including demographic factors, stroke-related factors, emotional functioning and comorbidity as possible predictors. RESULTS: Stroke survivors aged over 70 years perceived more participation restrictions in comparison to stroke survivors aged under 70 years one year after stroke. Independently significant predictors for unfavorable participation outcomes were advancing age, more severe stroke and anxiety symptoms in patients aged over 70 years, and female gender, more severe stroke, impaired cognition and depression symptoms in patients aged under 70 years. Lower age was the only independent predictor associated with favorable participation after one year in stroke survivors aged over 70 years. CONCLUSIONS: This study emphasizes the need to pay more attention to participation restrictions in elderly stroke survivors. Implications for rehabilitation More attention in the rehabilitation process should be paid to restrictions in participation of stroke survivors aged older than 70 years, taking into account the different participation needs and predictors of older stroke survivors. Early screening on the presence of anxiety symptoms could potentially prevent long-term restrictions in participation in stroke survivors aged over 70-year old. Stroke survivors experience considerable restrictions in physical activity and mobility after one year, highlighting the need for the development of community-based exercise programs for stroke survivors.

Caregiver burden and emotional problems in partners of stroke patients at two months and one year post-stroke: Determinants and prediction.

OBJECTIVES: (a) To determine levels of and factors explaining partners' burden, anxiety and depressive symptoms at two months post-stroke, (b) to predict partners' burden, anxiety and depressive symptoms at one year post-stroke based on patient and partner characteristics available at two months post-stroke. METHODS: Prospective cohort study. Partners of stroke patients (N=183) were included. Main outcome measures were the Caregiver Strain Index and the Hospital Anxiety and Depression Scale. RESULTS: Many partners experienced high burden, anxiety and depressive symptoms. At two months post-stroke, these outcomes were associated with the partner variables: age, relationship satisfaction, pro-active coping, self-efficacy, everyday social support, burden, anxiety and depressive symptoms; and the patient variables: stroke severity and depressive symptoms. Partner outcomes at one year post-stroke were mainly predicted by the level of these outcomes at two months post-stroke. CONCLUSIONS: Partner outcomes at two months post-stroke predict to a large degree partner outcomes at one year post-stroke. PRACTICE IMPLICATIONS: Measuring partners' burden and anxiety and depressive symptoms in the post-acute phase is recommended to trace partners at risk of long-term burden and emotional problems.

A longitudinal cohort study on quality of life in stroke patients and their partners: Restore4Stroke Cohort.

BACKGROUND: Stroke is a major cause of disability in the Western world. Its long-term consequences have a negative impact on the quality of life of both the patients and their partners. AIM: The aim of the Restore4Stroke Cohort study is to investigate the changes in quality of life of stroke patients and their partners over time, and to determine factors predicting quality of life in several domains, especially personal and environmental factors. METHOD: Multicentre prospective longitudinal cohort study. Inclusion and the first assessment take place during hospital stay in the first week post-stroke. Follow-up assessments take place at two months, six months, one year, and two years post-stroke. Recruitment of 500 patients from stroke units in six participation hospitals is foreseen. If the patient has a partner, he or she is also asked to participate in the study. OUTCOMES: The main outcome is quality of life, considered from a health-related quality of life and domain-specific quality of life perspective. Factors predicting long-term quality of life will be determined by taking into account the health condition (pre-stroke health condition and stroke-related health condition), personal factors (e.g. coping and illness cognitions), and environmental factors (e.g. caregiver burden and social support). DISCUSSION: This study is expected to provide information about the changes in quality of life of stroke patients and their partners over time. Furthermore, the identification of factors predicting quality of life can be used to improve rehabilitation care and develop new interventions for stroke patients and their partners.

The influence of psychological factors on health-related quality of life after stroke: a systematic review.

BACKGROUND AND PURPOSE: Many stroke patients experience problems with health-related quality of life, but much of the variance of health-related quality of life after stroke remains unexplained. Health-related quality of life may be influenced by psychological factors, as these factors reflect the way people approach situations and react to stressful situations. The aim of this study was to systematically examine the relationship between psychological factors and health-related quality of life after stroke. SUMMARY OF REVIEW: A systematic literature search was conducted in online databases PubMed, Embase, PsycINFO, and CINAHL in November 2011. A total of nine studies were included. Personality (i.e., problems of temperament and personality functions and neuroticism) was moderately negatively associated with health-related quality of life (r = 0.26-0.49). Coping (i.e., situational and personal adaptation), internal locus of control, self-worth (i.e. self-esteem and self-efficacy), and hope and optimism were moderately positively associated with health-related quality of life (r = 0.026-0.81). No evidence was found for an association between extraversion and health-related quality of life. CONCLUSIONS: There is still a paucity of studies on psychological determinants of poststroke health-related quality of life. The reviewed studies supported the importance of psychological factors, but further research is needed to supplement the available evidence and to examine how psychological factors can be modified to improve health-related quality of life, and at what moment after the stroke these interventions should be given.

Associations between social support and stroke survivors' health-related quality of life--a systematic review.

OBJECTIVE: Social support to stroke survivors has been recognized as an important determinant of their health-related quality of life (HRQoL), but this relationship is not clarified to date. More insight in the relationships between various types (i.e. emotional, instrumental, or informational support) and sources (i.e. partner, children) of social support and HRQoL might target post-stroke educational and counseling interventions to strengthen patient's social networks and supportive relationships. METHODS: Systematic review. RESULTS: 11 original articles could be included. Most of these articles studied the overall perceived social support without further specification of type or source. They show a positive relation between perceived social support and stroke survivors' HRQoL. Relations between perceived social support and HRQoL seems to be more often significant and were stronger than relationships between specific social support types or sources and HRQoL. CONCLUSION: Due to the small number of studies and the heterogeneity in methods of assessing social support, a clear statement about the specific influence of social support source or type could not be made. PRACTICE IMPLICATIONS: Attention should be paid to promoting social support on the short and long term. Further research is needed to clarify the influence of social support type and source.