Explanatory factors for the association between depression and long-term physical disability after stroke.

OBJECTIVES: To identify explanatory factors for the association between depression at 3 months after stroke and physical disability at 3 years. METHODS: Data from the South London Stroke Register (1998-2013) were used. Patients (n = 3,612) were assessed at stroke onset. Follow-up at 3 months included assessment for depression with the Hospital Anxiety and Depression scale (scores ≥ 7 = depression), physical disability (Barthel index) cognitive function, smoking habit, selective serotonin reuptake inhibitors (SSRIs) use, perception of recovery and social support. Physical disability was reassessed at 3 years. The associations between depression at 3 months and physical disability at 3 years were estimated with multinomial regression adjusting for age, gender, ethnicity, stroke severity and possible explanatory factors for the association (introduced in the models first individually and then sequentially): pre-stroke medical history and physical disability, cognitive function, smoking, SSRIs, perception of recovery and social support at 3 months. RESULTS: One thousand three hundred and seven survivors were assessed at 3 months, of which 418 (32.0%) had depression. Survivors with depression had a higher physical disability rate at 3 years. These associations remained significant after adjustment for individual explanatory factors but were not significant after adjustment for combined explanatory factors. Physical disability at 3 months was a relevant explanatory factor for this association. SSRIs were associated with severe, relative risk: 6.62 (2.92-15.02) P < 0.001, and moderate physical disability, relative risk: 3.45 (1.58-7.52) P = 0.002, at 3 years. CONCLUSION: The association between depression and physical disability appears to be multifactorial. The use of SSRIs after stroke requires further research.

Natural history, predictors and associated outcomes of anxiety up to 10 years after stroke: the South London Stroke Register.

BACKGROUND: evidence on the long-term natural history, predictors and outcomes of anxiety after stroke is insufficient to inform effective interventions. This study estimates within 10 years of stroke: (i) the incidence, cumulative incidence, prevalence, and time of onset of anxiety. (ii) Predictors of anxiety and its association with depression. (iii) The association between anxiety 3 months after stroke and mortality, stroke recurrence, disability, cognitive impairment and quality of life (QoL) at follow-up. METHODS: data from the South London Stroke Register (1995-2010). Patients were assessed at the time of the stroke, at 3 months, 1 year and then annually for up to 10 years. Baseline data included socio-demographics and stroke severity. Follow-up data included assessments for anxiety and depression (hospital anxiety and depression scale), disability, cognition and QoL. Multivariate regression was used to investigate predictors and associated outcomes of anxiety. RESULTS: incidence of anxiety up to 10 years ranged from 17 to 24%. Cumulative incidence: 57%. Prevalence range: 32-38%. Amongst patients with anxiety, 58% were anxious at 3 months. 57-73% of patients with anxiety had co-morbid depression. Predictors of anxiety included age under 65, female gender, inability to work, depression treatment, smoking and stroke severity. Anxiety at 3 months was associated with lower QoL at follow-up. CONCLUSIONS: anxiety is a frequent problem affecting stroke survivors in the long term. Clinicians should pay attention to patients at risk of anxiety since it is associated with lower QoL and depression.

Evaluation of the Hospital Anxiety and Depression Scale (HADS) in screening stroke patients for symptoms: Item Response Theory (IRT) analysis.

BACKGROUND: Variations have been reported in the number of underlying constructs and choice of thresholds that determine caseness of anxiety and /or depression using the Hospital Anxiety and Depression scale (HADS). This study examined the properties of each item of HADS as perceived by stroke patients, and assessed the information these items convey about anxiety and depression between 3 months to 5 years after stroke. METHODS: The study included 1443 stroke patients from the South London Stroke Register (SLSR). The dimensionality of HADS was examined using factor analysis methods, and items' properties up to 5 years after stroke were tested using Item Response Theory (IRT) methods, including graded response models (GRMs). RESULTS: The presence of two dimensions of HADS (anxiety and depression) for stroke patients was confirmed. Items that accurately inferred about the severity of anxiety and depression, and offered good discrimination of caseness were identified as "I can laugh and see the funny side of things" (Q4) and "I get sudden feelings of panic" (Q13), discrimination 2.44 (se = 0.26), and 3.34 (se = 0.35), respectively. Items that shared properties, hence replicate inference were: "I get a sort of frightened feeling as if something awful is about to happen" (Q3), "I get a sort of frightened feeling like butterflies in my stomach" (Q6), and "Worrying thoughts go through my mind" (Q9). Item properties were maintained over time. LIMITATIONS: Approximately 20% of patients were lost to follow up. CONCLUSION: A more concise selection of items based on their properties, would provide a precise approach for screening patients and for an optimal allocation of patients into clinical trials.

The effect of definitions of activities of daily living on estimates of changing ability among older people.

Physical functioning status is often assessed using scales of activities of daily living and instrumental activities of daily living. Different ways of defining change in adequacy of performance of both activities of daily living and instrumental activities of daily living tasks may be used, including increasing difficulty in performance, the need for assistance and inability to do tasks. In this prospective study, we investigated the effect of different definitions of decline on estimates of physical function, and explored the relationships between decline in each activity of daily living individually and potential predictors. The study was based on a sample of 999 individuals aged 65 years or more who participated in a national survey of quality of life, of whom 531 (68% of those eligible for follow up) responded 12-18 months later. Different definitions of decline were used and the prevalence of decline was, depending on the individual activities of daily living item, used as an outcome in logistic regression models. The results showed that the strength of association with chronic diseases, demographic, psychological and environmental factors varied by altering the activities of daily living item used. Decline in ability to walk 400 yards was strongly associated with respiratory problems (odds ratio 3.5 [95% confidence interval 1.3-9.0]) while decline in ability to get on a bus was associated with musculoskeletal problems (odds ratio 2.8 [95% confidence interval 1.4-5.6]). In conclusion, the prevalence of decline varies by definition, and summary measures which are customarily used to describe disability, may be inadequate for the assessment and identification of predictors of decline in functional ability.

The natural history of depression and trajectories of symptoms long term after stroke: The prospective south London stroke register.

BACKGROUND: The natural history of depression in stroke patients is complex and the mechanism of change in symptoms over time is not fully understood. We hypothesise that there are different trajectories of symptoms after stroke. METHODS: The primary analysis comprised 761 patients who completed 5 years follow up, obtained from the prospective South London Stroke Register (1998-2013). The Hospital Anxiety and Depression scale (HADs) was used to screen patients for depression symptoms at 3 months after stroke, then annually. Trajectories of depression symptoms were detected using group based trajectory modelling (GBTM). RESULTS: Four patterns of symptoms (Groups I-IV) were identified: 6.31% of patients had severe symptoms, improved slightly in early years then worsen (predicted mean HADs score, 15.74 (se=1.06)); 28.65% had moderate symptoms, a tendency to get worse over time, predicted mean score 7.36 (se=0.35); 49.54% had mild symptoms and a tendency of getting worse, predicted mean 3.89 (se=0.30), and 15.51% of the cohort, had no symptoms and remained so over time. The lowest rate of Selective serotonin reuptake inhibitors (SSRI) use, over 5 years after stroke was 1.1% for group (I) and highest was 35% for group (IV). Sensitivity analyses were used to assess the robustness of the findings using several inclusion criteria and findings agreed with the primary results. LIMITATIONS: There is loss to follow up of around 20%. CONCLUSIONS: The study identified 4 trajectories of depression symptoms, providing useful information for the long term management of stroke patients and for the implementation of cost effective personalized interventions.