Antero Leppävuori

Frequency and Clinical Determinants of Poststroke Depression

BACKGROUND AND PURPOSE Previous studies have shown a large variation concerning the frequency of poststroke depression. This variation is caused by differences in patient populations, psychiatric assessment methods, and diagnostic criteria. In this study, we evaluated the frequency and clinical correlates of poststroke depression in a large well-defined stroke cohort. METHODS We studied a consecutive series of 486 patients with ischemic stroke aged from 55 to 85 years. Of these, 277 patients underwent a comprehensive psychiatric evaluation, including the Present State Examination, from 3 to 4 months after ischemic stroke. The criteria of the Diagnostic and Statistical Manual of Mental Disorders, edition 3, revised (DSM-III-R), were used for the diagnosis of depressive disorders. RESULTS The frequency of any depressive disorder was 40.1% (n=111). Major depression was diagnosed in 26.0% (n=72) and minor depression in 14.1% (n=39). Major depression with no other explanatory factor besides stroke was diagnosed in 18.0% (n=49) of the patients. Comparing depressed and nondepressed patients, we found no statistically significant difference in sex, age, education, stroke type, stroke localization, stroke syndrome, history of previous cerebrovascular disease, or frequency of DSM-III-R dementia. According to the multiple logistic regression model, dependency in daily life correlated with the diagnosis of depression (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1 to 3.1) and with the diagnosis of major depression (OR, 2.9; 95% CI, 1.6 to 5.5). A history of previous depressive episodes also correlated with the diagnosis of depression (OR, 2.3; 95% CI, 1.3 to 4.4) and with the diagnosis of major depression (OR, 2.9; 95% CI, 1.6 to 5.5), whereas solely stroke-related major depression correlated only weakly with stroke severity as measured on the Scandinavian Stroke Scale (OR, 1.1; 95% CI, 1.0 to 1.1). CONCLUSIONS Clinically significant depression is frequent after ischemic stroke. We emphasize the importance of the psychiatric examination of poststroke patients, especially those with a significant disability and with a history of prior depressive episodes.

Depression is an independent predictor of poor long-term functional outcome post-stroke.

The influence of depression on the long‐term outcome of stroke patients was examined among 390 of 486 consecutive patients aged 55–85 years. They completed, at 3 months after ischaemic stroke, a detailed medical, neurological, and radiological stroke evaluation, structured measures of emotion (Beck’s Depression Inventory, BDI), handicap (Rankin scale, RS), and assessment of activities of daily living (Barthel Index, BI). Further RS and BI was evaluated at 15‐month follow‐up from these 390 patients and BDI in 276 patients. A group of 256 patients completed, in addition to the 15‐month follow‐up, a comprehensive psychiatric evaluation, including the Present State Examination 3 months after stroke. The DSM‐III‐R criteria were used for diagnosis of the depressive disorders. BDI identified depression (cut‐off point ≥ 10 for depression) in 171 (43.9%) of 390 and in 123 (44.6%) of 276 patients at 3‐ and 15‐month follow‐up. DSM‐III‐R major depression was diagnosed in 66 (25.8%), and minor depression in 32 (12.5%), of 256 patients 3 months after stroke. Patients with BDI ≥ 10, or major, but not minor, depression more often had poor functional outcome (RS > II and BI < 17) at 15 months. Poor functional outcome at 3 months also correlated with depression at 15 months. In logistic regression analysis, depression at 3 months (Beck ≥ 10) correlated with poor functional outcome at 15 months (RS > II) (OR 2.5, 95% CI 1.6–3.8). More careful examination and treatment of depression in stroke patients is emphasized.

Post-stroke depression, executive dysfunction and functional outcome.

The early diagnosis of vascular cognitive impairment has been challenged and executive control function has been suggested to be a rational basis for the diagnosis of vascular dementia. We sought to examine the correlates of executive dysfunction in a well‐defined stroke cohort. A group of 256 patients from a consecutive cohort of 486 patients with ischaemic stroke, aged 55–85 years, was subjected to a comprehensive neuropsychological examination 3–4 months after ischaemic stroke and 188 of them in addition to detailed psychiatric examination. Basic and complex activities of daily living (ADLs) (bADLs and cADLs) post‐stroke were assessed. The DSM‐III‐R criteria were used for the diagnosis of the depressive disorders. Altogether 40.6% (n=104) of the patients had executive dysfunction. The patients with executive dysfunction were older, had lower level of education, were more often dependent, did worse in bADLs and cADLs, had more often DSM‐III dementia, had worse cognition as measured by Mini Mental State Examination (MMSE) and were more depressed as measured by the BECK depression scale, but not with the more detailed psychiatric evaluation. They had more often stroke in the anterior circulation and less often in the posterior circulation. The independent correlates of executive dysfunction were cADLs (OR 1.1, 95% CI 1.03–1.16), each point of worsening in cognition by MMSE (OR 1.7, 95% CI 1.42–1.97) and stroke in the posterior circulation area (OR 0.4, 95% CI 0.18–0.84). Clinically significant executive dysfunction is frequent after ischaemic stroke and is closely connected with cADLs and to overall cognitive status but could be distinguished from depression by detailed neuropsychological examination. Executive measures may detect patients at risk of dementia and disability post‐stroke.

Insomnia in Ischemic Stroke Patients

This is the first study that focuses on insomnia in stroke patients. A subgroup of 277 patients from a consecutive series of 486 stroke patients aged 55–85 years was subjected to a comprehensive psychiatric evaluation 3–4 months after ischemic stroke. Of 277 patients, 56.7% reported any insomnia complaint and 37.5% fulfilled the DSM-IV criteria of insomnia. In 38.6%, insomnia complaint/insomnia had already been present prior to the stroke and in 18.1%, it was a consequence of the stroke. Independent correlates of any insomnia complaint/insomnia were anxiety (Zung Anxiety Scale) and the use of psychotropic drug. Independent correlates of poststroke-onset insomnia complaint/insomnia were disability after stroke (Barthel Index), dementia, anxiety and use of psychotropic drug. Insomnia should be taken into consideration in treating and rehabilitating stroke patients.

MRI correlates of executive dysfunction in patients with ischaemic stroke

Executive dysfunction (ED) may lead to problem behaviour and impaired activities of daily living in many neuropsychiatric disorders, but the neuroanatomical correlates of ED are still not well known. Different aspects of executive functions were studied by widely used neuropsychological tests in 214 elderly patients 3 months after ischaemic stroke, and a sum score of eight different measures was counted in each patient. The number and site of brain infarcts as well as severity and location of white matter lesions (WMLs) and brain atrophy on magnetic resonance imaging were recorded and compared between patients with and without ED. ED was present in 73 (34.1%) of the 214 patients. The mean frequency of brain infarcts in the brain and in the left hemisphere was higher in the patients with ED. Lesions affecting the frontal‐subcortical circuits (e.g. pallidum, corona radiata or centrum semiovale) were more frequent in patients with ED than in those without. Also, patients with pontine brain infarcts frequently had ED, but this may have been due to more extensive ischaemic changes in these patients in general. Mean number of brain infarcts affecting the pons and posterior centrum semiovale on the left side, moderate to severe medial temporal atrophy, the Fazekas white matter score, the Mini‐Mental State Examination score and low education were independent correlates of ED. Brain infarcts and WML affecting the frontal‐subcortical circuits or the pons may increase risk for ED in stroke patients.

Depression-executive dysfunction syndrome in stroke patients.

OBJECTIVE It has been suggested that executive dysfunction could be the core defect in patients with geriatric or vascular depression, and that this depression-dysexecutive syndrome (DES) might be related to frontal-subcortical circuit dysfunction. The authors tested this hypothesis in 158 poststroke patients, of whom 21 had both depression and executive dysfunction. METHODS In this cross-sectional cohort study, a neurological, psychiatric, and neuropsychological examination was carried out 3 months after ischemic stroke, and brain infarcts, white-matter changes, and brain atrophy were recorded by MRI. RESULTS The 21 patients with DES had significantly more brain infarcts affecting their frontal-subcortical circuit structures than the 137 patients without DES, or the 41 patients with depression but without executive dysfunction. Patients with DES also had more severe depressive symptoms and worse psychosocial functioning, and they coped less well in complex activities of daily living. CONCLUSIONS DES is a valid concept and may define a subgroup of poststroke patients with frontal-subcortical pathology and with distinct prognosis and treatment options.

Generalized Anxiety Disorders Three to Four Months after Ischemic Stroke

Background and Objective: The main objective of our study was to detail the frequency and clinical determinants of poststroke generalized anxiety disorders in a large, well-defined stroke cohort. Methods: A total of 277 stroke patients aged 55–85 were subjected to a comprehensive psychiatric evaluation between 3 and 4 months after ischemic stroke. Primary generalized anxiety disorder or generalized anxiety disorder due to stroke were diagnosed according to DSM-IV symptom criteria. Results: The frequency of any generalized anxiety disorder was 20.6% (n = 57). According to a logistic model, any generalized anxiety disorder was associated with a history of epilepsy, comorbid depressive disorder, severity of depression, severity of anxiety, and the use of anxiolytic drugs. A discriminant analysis identified four factors that distinguished the two diagnostic subgroups from one another: the level of psychosocial functioning (worse score in patients with generalized anxiety due to stroke), a history of migraine, anterior circulation stroke localization (more frequent in patients with generalized anxiety disorder due to stroke), and a history of insomnia (more frequent in patients with primary generalized anxiety disorder). Conclusions: Clinically significant anxiety is common in ischemic stroke patients and may hamper their rehabilitation.

Suicidal Ideas in Stroke Patients 3 and 15 Months after Stroke

Patients with stroke may have an increased risk of suicide. We sought to examine the frequency and clinical correlates of suicidal ideas 3 and 15 months after stroke. The study group comprised 286 of 486 consecutive patients aged 55–85 years who at 3 and 15 months after ischemic stroke completed a detailed medical, neurological and radiological stroke evaluation, structured measures of cognition (Mini Mental State Examination), emotion (Beck Depression Inventory, BDI), disability (Rankin scale), and assessment of dependent living. Suicidal ideas were present in 9.8% (n = 28) at 3 months’ follow-up and in 14.0% (n = 40) at 15 months’ follow-up. The patients with suicidal ideas were more depressed measured by BDI both at 3 (17.0 vs. 7.9, p < 0.001) and 15 months (20.5 vs. 8.5, p < 0.001) after stroke compared to the patients without suicidal ideas. Patients with suicidal ideas had more often a history of a stroke already before the index stroke (35 vs. 18.3%, p = 0.0154), right-sided stroke (60.0 vs. 41.9%, p = 0.0323), they were more disabled according to the Rankin scale (2.4 vs. 1.9; p = 0.0035) and more dependent in living (45.0 vs. 27.2%, p = 0.023) 15 months after stroke. An independent correlate of suicidal ideas 15 months after stroke was history of prior stroke (OR 2.4; 95% CI 1.14–4.97) in logistic regression analysis. The frequency of suicidal ideas increased with the time elapsed from stroke. Recurrent strokes, depressive symptoms, more disabling stroke and right-sided stroke correlated to suicidal ideas at 15 months after stroke. Early identification of these risk factors may lead to effective therapeutic intervention.

Cognitive Functions and Depression as Predictors of Poor Outcome 15 Months after Stroke

The prognostic predictors of poor outcome, as defined by death between 3 and 15 months and dependent living at 15 months, were examined in the Helsinki Stroke Aging Memory (SAM) study cohort. Death between 3 and 15 months was registered from the whole study group of 486 consecutive patients aged 55–85 years. Altogether 286 of the 486 patients went through a detailed follow-up examination both 3 and 15 months after stroke, including structured measures of emotion (Beck’s Depression Inventory, BDI), cognition (Mini-Mental State Examination, MMSE), dementia assessment according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), and handicap (Rankin scale, RS). The only independent correlate of death between 3 and 15 months was dependent living at 3 months (OR 2.6, 95% CI 1.2–5.8), which also had the most powerful association with dependent living at 15 months (OR 5.8, 95% CI 2.6–13.1). Also, both worsening in cognition (change in MMSE, OR for each point of worsening 1.2, 95% CI 1.1–1.3) and worsening of depression (change in BDI, OR for each point of worsening 1.1, 95% CI 1.02–1.12), between 3 and 15 months follow-up, had an independent effect on dependent living 15 months after ischemic stroke. This challenges the care and rehabilitation of these items even at the stable period after stroke.

Post-stroke delirium in relation to dementia and long-term mortality

Delirium is a frequent post‐stroke complication that compromises effective rehabilitation and has been associated with poor outcome. We aimed to investigate whether delirium is associated with increased risk of post‐stroke dementia and long‐term mortality once confounding is taken into account.