Course and Predictors of Subjective Cognitive Complaints During the First 12 Months after Stroke.

BACKGROUND: Subjective Cognitive Complaints (SCC) are common after stroke. This study documents the prevalence and course of SCC in the first year after stroke and determines which patient characteristics in the first 3 months predict subsequent SCC at 1-year follow-up. METHODS: Using a longitudinal design, 155 patients (mean age 64.0 ± 11.9 years; 69.7% men) were assessed at 3 and 12 months after stroke. SCC were assessed using the Checklist for Cognitive and Emotional consequences following stroke (CLCE) inventory (content component [CLCE-c] and worry component [CLCE-w]). Potential predictors of 12 months SCC included demographics, stroke severity, objective cognitive impairment, psychological factors (depression, anxiety, perceived stress, fatigue, personality traits, coping style), and activities of daily life functioning assessed at 3 months poststroke. Multiple hierarchical linear regression analyses were used to determine predictors of SCC at 12 months poststroke. RESULTS: SCC remained stable from 3 to 12 months over time (CLCE-c from 3.3 ± 2.4 to 3.3 ± 2.6; CLCE-w: from 1.9 ± 2.2 to 2.1 2.5). Independent predictors of SCC at 12 months were baseline CLCE-c (ß = 0.54) and perceived stress (ß = 0.23) for content, and baseline CLCE-w (ß = 0.57) and depressive symptoms (ß = 0.23) for worry. CONCLUSIONS: Patients who report SCC at 3 months after stroke are likely to continue having these complaints at 1 year follow-up. Perceived stress and depressive symptoms additionally increase the likelihood of having SCC at 12 months, independent of SCC at 3 months poststroke. Rehabilitation programs that target reduction of stress and depression in the first months after stroke might reduce sustained SCC and improve well-being.

Psychological factors and subjective cognitive complaints after stroke: Beyond depression and anxiety.

Subjective Cognitive Complaints (SCC) are common after stroke and adversely affect quality of life. In the present study, we determined the associations of depression, anxiety, perceived stress and fatigue with post-stroke SCC, and whether these associations were independent of objective cognitive functioning, stroke characteristics and individual differences in personality traits and coping styles. Using a cross-sectional design, SCC and psychological measures were obtained in 208 patients (mean 3.3 ± 0.5 months after stroke; 65.9% men; mean age 64.9 ± 12.4 years). SCC were assessed using the Checklist for Cognitive and Emotional consequences following stroke (CLCE) inventory. Validated questionnaires were used to measure depression and anxiety (Hospital Anxiety and Depression Scale), perceived stress (Perceived Stress Scale), fatigue (Fatigue Assessment Scale), personality traits (Eysenck Personality Questionnaire Revised Short Scale) and coping style (Utrecht Coping List). Multivariate hierarchical linear regression analyses were used to adjust for covariates. Depression (ß = 0.35), anxiety (ß = 0.38), perceived stress (ß = 0.39), and fatigue (ß = 0.39) were associated with CLCE scores, independent of demographic, cognitive performance and stroke-related covariates. After including personality traits and coping styles in the model, independent associations with CLCE scores were found for fatigue (ß = 0.26, p = .003) and neuroticism (ß = 0.21, p = .05). Interventions aimed at improving psychological resilience and increasing energy levels might be a worthwhile addition to stroke rehabilitation programmes by reducing SCC and improving quality of life.

Quality of Life after Young Ischemic Stroke of Mild Severity Is Mainly Influenced by Psychological Factors.

BACKGROUND: Long-term prognosis in terms of quality of life (QoL) in young stroke patients is of importance because they usually have a long life expectancy and extensive daily life demands. We aimed at determining which medical and psychological factors influence the QoL in young stroke patients (<50 years), after long-term follow-up. METHODS: Young ischemic stroke patients admitted to the St. Elisabeth Hospital and the TweeSteden Hospital, Tilburg, the Netherlands, between 2000 and 2010 were included. One hundred seventy patients and 61 controls filled out the following questionnaires: (1) the Hospital Anxiety and Depression Scale, (2) the Fatigue Assessment Scale, and (3) the shortened World Health Organization Quality of Life scale. Using linear multiple regression analysis, we assessed the factors influencing QoL. RESULTS: QoL did not differ significantly between patients (median modified Rankin Scale score at follow-up, 0) and controls after a mean follow-up of 4.5 (standard deviation, 2.8) years. The presence of excessive fatigue was associated with lower scores on all domains of the QoL (P ≤ .003), but not for general health domain (P = .010). Similarly, depression was associated with worse QoL on the physical (P = .004) and psychological (P = .001) domains and anxiety with lower scores on the psychological (P < .001) QoL domain. No relationship was found between stroke-specific factors and QoL. CONCLUSIONS: Fatigue and to a lesser extent depression and anxiety affect the QoL in young adults after ischemic stroke of mild severity. Therefore, young stroke patients should be informed about, screened, and, if possible, treated for fatigue, depression, and anxiety.

Prevalence and Profile of Poststroke Subjective Cognitive Complaints.

BACKGROUND: Subjective cognitive complaints (SCCs) are common after stroke, but detailed information about how SCCs differ between patients with stroke versus stroke-free individuals is not available. We evaluated the prevalence and profile of the 2 SCC components (content and worry) in patients 3 months after stroke versus controls using both a generic and a stroke-specific instrument. METHODS: Using a cross-sectional design, 142 patients were compared to 135 controls (matched at group level on age, sex, and estimate of premorbid intelligence quotient). SCC-content and SCC-worry were assessed using the Cognitive Failures Questionnaire (CFQ) and the Checklist of Cognitive and Emotional Consequences after stroke (CLCE-24). Univariate and multivariate linear (for continuous scores) and logistic (for dichotomous scores) regression analyses were used to explore differences between patients and controls on both instruments. RESULTS: Based on the CLCE, patients reported more SCC-content (standardized ß = .21, p.001) and SCC-worry (standardized ß = .18, p.02) than controls in multivariate analyses. Profiles indicated that stroke was associated in particular with SCC-content on the domains of memory, attention, executive functioning, expressive language, and with attention-related SCC-worry. In contrast, no group differences were found on SCC-content and SCC-worry assessed by the CFQ. CONCLUSIONS: The prevalence and profile of SCC-content and SCC-worry differ between patients and controls 3 months after stroke. The instrument used may, however, determine prevalence estimates. Stroke-specific inventories that differentiate between SCC-content and SCC-worry are preferable when attempting to determine SCC after stroke.

Long-term cognitive outcome of ischaemic stroke in young adults.

BACKGROUND: Long-term prognosis in terms of cognition in young stroke patients is very important because these patients usually still have a long life expectancy and rather extensive daily life demands. However, little is known on cognitive deficits in these patients. We aimed to evaluate cognitive function in young stroke patients (<50 years) after long-term follow-up. METHODS: Young adults with first-ever ischaemic stroke admitted to St. Elisabeth Hospital or the TweeSteden Hospital, Tilburg, the Netherlands, between January 2000 and December 2010 were included. Patients with severe aphasia or pre-existent cognitive impairment were excluded. Cognitive functioning was assessed using a neuropsychological examination focussing on the following cognitive domains: visual perception, visual and verbal memory, mental speed, and executive functioning. Raw scores were compared to the scores of 61 controls using a multivariate analysis of variance with adjustment for education level. RESULTS: The 96 participants (median age at index event 43.0 years; 45.8% male) performed worse than controls on the Stroop Color-Word Test Part 1 (p < 0.001) and on the Symbol-Digit Substitution Task (p < 0.001), both assessing mental speed. Patients had significantly lower scores on the learning slope of the Word Pair test (p = 0.002) assessing verbal memory. Patients performed better on the Rey-Osterrieth Complex Figure than controls (p < 0.001). CONCLUSIONS: In young patients with ischaemic stroke, mental slowness is present even up to 10 years after stroke. When counselling these patients, doctors should actively try to assess the presence of cognitive deficits, also after a long period of follow-up.

Subjective cognitive complaints after stroke: a systematic review.

BACKGROUND: Most studies to date have assessed poststroke cognitive impairment objectively, whereas less attention is paid to subjective cognitive complaints (SCC). We, therefore, systematically searched the literature to summarize and evaluate the current knowledge about poststroke SCC. METHODS: Articles were included in this review if the study evaluated SCC in adult stroke survivors, and the publication was an original empirical article from which the full text was available. There were no year or language restrictions. RESULTS: Twenty-six studies were found on poststroke SCC. There is a huge heterogeneity among these studies with respect to stroke sample, SCC definitions, and instruments used, but they all showed that SCC are very common after stroke. Other main findings are that SCC tend to increase over time and that there is moderate agreement between patients and their proxies on prevalence and severity of patients' SCC. Furthermore, SCC are inconsistently associated with current depressive symptoms and objective cognitive performances, whereas they may predict future emotional and cognitive functioning. CONCLUSIONS: This review highlights that poststroke SCC are highly prevalent and that clinicians should take such complaints seriously. More research is, however, needed to gain further insight into poststroke SCC, to be able to accurately inform patients and relatives, and to develop adequate treatment programs. Based on the limitations of the studies to date, suggestions are made on how both future research and ultimately patient-centered care may be improved in stroke survivors.

The COMPlaints After Stroke (COMPAS) study: protocol for a Dutch cohort study on poststroke subjective cognitive complaints.

BACKGROUND: Although many studies have assessed poststroke objective cognitive impairment, only a few have evaluated patients' subjective cognitive complaints (SCC). Although these SCC are found to be common in the early and chronic phases after stroke, knowledge about their risk factors, course over time, differences with healthy controls and their diagnostic relevance is limited. The aim of the COMPlaints After Stroke (COMPAS) study is therefore to determine the possible risk factors, prognosis, time course and predictive value of SCC in the first 2 years after stroke. METHODS AND DESIGN: A prospective cohort study is conducted in which patients are compared to non-stroke controls at 3, 6, 12 and 24 months after stroke. Approximately 300 patients are recruited from the stroke units of three hospitals in the Netherlands, while 300 controls are sought among the relatives (spouses excluded) and social networks of participants. A wide range of subjective and objective variables is assessed in both groups using interviews, questionnaires and neuropsychological assessment. The primary outcomes include SCC and objective cognitive impairment, whereas secondary outcomes are quality of life, subjective recovery and daily life functioning. ETHICS AND DISSEMINATION: The study is being carried out in agreement with the Declaration of Helsinki and the Medical Research Involving Human Subjects Act. The protocol has been approved by the medical ethics committees of the participating centres and all participants give written informed consent. The results will be published in peer-reviewed journals and disseminated to the medical society and general public. DISCUSSION: The COMPAS study is the first to systematically evaluate poststroke SCC in a prospective longitudinal design, taking a wide range of subjective and objective variables into account. The results obtained can be used to accurately inform patients and their families, as well as to develop patient-tailored intervention programmes to ultimately improve stroke patient care.

Delirium in acute stroke: a predictor of subsequent cognitive impairment? A two-year follow-up study.

OBJECTIVE: Delirium is an independent risk factor for cognitive impairment and development of dementia in medical patients. It has never been thoroughly studied whether this association is also present in the stroke population. Our aim was to evaluate the effects of delirium in the acute phase after stroke on cognitive functioning two years later. METHODS: Two years after stroke, 50 patients (22 with and 28 without delirium in the acute phase) were assessed on two screening instruments for dementia and a neuropsychological test battery. RESULTS: Delirium was an independent predictor for development of dementia as assessed by the Clinical Dementia Rating Scale (odds ratio (OR) 4.7; 95% confidence interval (CI) 1.08 to 20.42) and by the Rotterdam-CAMCOG (OR 7.2, 95% CI 1.88 to 27.89). Cognitive domains most affected in patients with previous delirium were memory, language, visual construction and executive functioning. CONCLUSIONS: Delirium in the acute phase after stroke is an independent predictor for severe cognitive impairment two years after stroke. These findings emphasize the importance of both rapid detection and treatment of delirium after stroke. Furthermore, periodic monitoring and evaluation of cognitive functioning in these vulnerable patients in the years after stroke is strongly recommended.