Lara Caeiro

Delirium in the first days of acute stroke.

Abstract.Background and Purpose:Delirium is an acute, transient disorder of cognition and consciousness with fluctuating intensity. The aim of this study was to investigate the presence and the risk factors for delirium in the first days after stroke onset.Patients and methods:We assessed delirium prospectively in a sample of 218 consecutive patients (mean age 57 years) with an acute (≤ 4 days) stroke (28 subarachnoid haemorrhages, 48 intracerebral haemorrhages, 142 cerebral infarcts) and in a control group of 50 patients with acute coronary syndromes with the Delirium Rating Scale (DRS) (cut-off score ≥ 10).Results:29 (13%) acute stroke patients (mean DRS score = 13.2, SD = 2.3) and only one (2 %) acute coronary patient had delirium (χ2 = 5.2, p = 0.02). In nine patients delirium was secondary to stroke without any additional cause, in 10 patients there were also medical complications and in the remaining 10 there were multiple potential causes for delirium. Delirium was more frequent after hemispherical than after brainstem/cerebellum strokes (p = 0.02). No other statistically significant associations with stroke locations were found. Medical complications (OR = 4.3; 95% CI = 1.8 to 10.2), neglect (OR = 3.5; 95% CI = 1.3 to 9.2), intracerebral haemorrhage (OR = 3.1; 95% CI = 1.3 to 7.5) and age ≥ 65 (OR = 2.4; 95% CI = 1.0 to 5.8) were independent factors to the development of delirium in stroke patients.Conclusion:Delirium was more frequent in stroke than in coronary acute patients. Among stroke patients, delirium was most frequent in older patients, in those with neglect, with medical complications and with intracerebral haemorrhages. These findings indicated that delirium in acute stroke patients 1) is not a non-specific consequence of acute disease and hospitalisation and 2) is secondary to hemisphere brain damage and to metabolic disturbances due to medical complications.

Apathy Secondary to Stroke: A Systematic Review and Meta-Analysis

Background: Apathy is a disturbance of motivation, frequent in survivors of stroke. Several studies have evaluated the rate of apathy secondary to stroke and risk factors. Different conclusions and contradictory findings have been published. We aimed to perform a systematic review and meta-analysis of all studies evaluating apathy secondary to stroke to better estimate its rate and risk factors, and explore associations with poorer outcomes. Methods: We searched PubMed, Cochrane Library, PsychINFO and PsycBITE databases and screened references of included studies and review articles for additional citations. Search results and data extraction was performed independently. We systematically reviewed available publications reporting investigations on ischemic and intracerebral hemorrhagic stroke and apathy. Quality assessment of the studies was performed independently. Subgroup analyses were performed according to stroke phase (acute and post-acute), stroke past history (first-ever and any-stroke) and patient age (younger and older patients). Pooled odds ratios (OR) and standardized mean difference, and 95% confidence intervals (CI), were derived by random-effects meta-analysis. Heterogeneity was assessed with I2 test. Results: From the initial 1,399 publications, we included 19 studies (2,221 patients). The pooled rate of apathy was 36.3% (95% CI 30.3–42.8; I2 = 46.8), which was similar for acute [39.5% (95% CI 28.9–51.1)] and post-acute phase [34.3% (95% CI 27.8–41.4)], and about three times higher than the rate of depression [12.1% (95% CI 8.2–17.3)]. Apathetic patients were on average 2.74 years older (95% CI 1.25–4.23; I2 = 0%). No gender differences were found. Depression (OR 2.29; 95% CI 1.41–3.72; I2 = 44%) and cognitive impairment (OR 2.90; 95% CI 1.09–7.72; I2 = 14%) were more frequent and severe in apathetic patients. Apathy rate was similar for ischemic and hemorrhagic stroke type and for left- and right-sided hemispheric lesions. Clinical global outcome was similar between apathetic and nonapathetic patients. Conclusion: Apathy secondary to stroke is a more frequent neuropsychiatric disturbance than depression. Apathetic patients are more frequently and severely depressed and cognitively impaired. A negative impact of apathy secondary to stroke on clinical global outcome cannot be ascribed. Future research should properly address its predictor factors and evaluate the impact of apathy treatment options in stroke patients.

Poststroke Emotional and Behavior Impairment: A Narrative Review

Emotional and behavioral disturbances are a frequent complication in stroke survivors. They are underdiagnosed, have a high impact on quality of life and are often a precipitant of institutionalization. For the caregivers of stroke survivors, these disturbances are a main cause of exhaustion. Health professionals have an insufficient training in their diagnosis and management which demands qualified skills and dedication of a multiprofessional team. In this article, we update some of the most common or relevant poststroke emotional and behavioral disturbances, including poststroke mania and poststroke depression, poststroke anxiety disorders, posttraumatic stress disorder, personality changes with focus on apathy and disturbances of emotional expression control. Significant advances in the management of poststroke emotional and behavioral disturbances will need the use of comparable instruments and methods and multicenter collaboration.

Delirium in acute stroke.

Delirium is the presenting feature in a few stroke patients, but can complicate the clinical course of acute stroke in up to 48% of cases. Old age, extensive motor impairment, previous cognitive decline, metabolic and infectious complications, and sleep apnoea are all predisposing conditions for delirium. Patients with delirium have longer hospitalizations and a poorer prognosis, and are at increased risk of developing dementia. The identification of the patients at risk and non‐pharmacological preventative interventions are the key measures in the management of delirium. Curr Opin Neurol 15:51–55.

Delirium in acute stroke: a preliminary study of the role of anticholinergic medications

The pathogenesis of delirium in acute stroke is incompletely understood. The use of medications with anticholinergic (ACH) activity is associated with an increased frequency of delirium. We hypothesized that the intake of medications with ACH activity is associated with delirium in acute stroke patients. Delirium was assessed using the DSM‐IV‐TR criteria and the Delirium Rating Scale, in a sample of consecutive patients with an acute (≤4 days) cerebral infarct or intracerebral haemorrhage (ICH). We performed a gender and age matched case–control study. Twenty‐two delirious stroke patients (cases) and 52 non‐delirious patients (controls) were compared concerning the intake of ACH medications (i) before stroke, (ii) during hospitalization but before the assessment. The variables associated with delirium on bivariate analysis were entered in a stepwise logistic regression analysis. The final regression model (Nagelkerke R2 = 0.65) retained non‐neuroleptics ACH medication during hospitalization (OR = 24.4; 95% CI = 2.18–250), medical complications (OR = 20.8; 95% CI = 3.46–125), ACH medication taken before stroke (OR = 17.5; 95% CI = 1.00–333.3) and ICH (OR = 16.9; 95% CI = 2.73–100) as independent predictors of delirium. This preliminary result indicates that drugs with subtle ACH activity play a role in the pathogeneses of delirium in acute stroke. Medication with ACH activity should be avoided in acute stroke patients.

Apathy in acute stroke patients.

Background and purpose:  Apathy is a frequent disturbance in stroke patients. The aim of this case–control study was to elucidate whether apathy: (i) was secondary to stroke or related to hospitalization, (ii) was related to thalamic and striatocapsular stroke lesions, (iii) was independent from cognitive impairment and depression in the acute phase of stroke, (iv) was associated with clinical and demographical variables and (v) was associated with a worse functional outcome at discharge.

Mania and Stroke: A Systematic Review

Background: Mania is a rare consequence of stroke and according to the sparse published information it is difficult to describe its demographic, clinical and prognostic characteristics. Methods: We performed a systematic review of all cases of mania and stroke to describe those characteristics. Studies were identified from comprehensive searches of electronic databases, reference lists of the studies collected and handbooks. Two authors independently assessed abstracts, and collected and extracted data. Results: From 265 abstracts, 139 were potentially relevant. For the first analysis, which tries to answer the clinical question of the relationship between mania and stroke, 49 studies met the inclusion criteria and described 74 cases. For the second analysis, we looked for an explicit temporal and causal relationship between manic symptoms and stroke, and selected 32 studies describing 49 cases. In both analyses, the typical patient was male, without a personal or family history of psychiatric disorder, with at least one vascular risk factor, but without subcortical atrophy and had suffered a right cerebral infarct. The majority of patients (92%) presented elevated mood as the first symptom. The other frequent symptoms were an increased rate or amount of speech (71%), insomnia (69%) and agitation (63%). Conclusions: Post-stroke mania should be considered in any manic patient who presents concomitant neurological focal deficits and is older than expected for the onset of primary mania. The results of a systematic study of mania in acute stroke with subsequent follow-up and data from diffusion MR or perfusion CT in a multicenter study with a central database would be relevant.

Anger, hostility and aggression in the first days of acute stroke

In acute stroke patients, anger can disturb management and rehabilitation and creates a stressful situation for family, health‐care providers and other patients. We aim to describe the presence of anger and its association with demographic, clinical, psychiatric, lesion variables and functional outcome in acute stroke patients. We screened anger prospectively in 202 consecutive acute stroke patients (≤4 days) using eight items from three psychiatric scales (Catastrophic Reaction Scale, Mania Rating Scale and Comprehensive Psychopathological Rating Scale). Anger was present if the patient scored in at least one item. Anger was detected in 71 (35%) patients and 26 of these were severely angry (≥4 points). There was no association between anger and the considered variables. Analysis of the items extracted two factors: (i) the emotional‐cognitive and (ii) the behavioural components of anger. These components were independent of each other in 26 patients. In 38 patients we found a dissociation between clinical observation and patients’ subjective expression. Anger was frequent in acute stroke patients. Anger was probably triggered by the brain lesion, which interfered with the emotional control. The lack of an association with clinical and imaging variables suggests a contribution of psychological/psychosocial dimensions.

Temperament in Portuguese university students as measured by TEMPS-A: Implications for professional choice

BACKGROUND The structure of temperament displays subaffective traits as attributes of adaptive value. There are few studies on how different professions compare on temperaments. Our aim was to examine the relationship between the choices of Portuguese students in their fields of study, and their respective temperaments. METHODS The sample included 1386 students from six different universities (law, engineering, arts, medicine, psychology, and nursing), of both genders (67% female), and ages between 17 and 58 (X + or - SD = 21 + or - 3.4). RESULTS Law and art students presented a cyclothymic or irritable temperament. Engineering students presented a hyperthymic temperament. Psychology and nursing students presented predominantly depressive and anxious temperaments. Medicine students were least extreme in temperament scores or frequencies. LIMITATIONS Nursing students came largely from one university located in a Portuguese city (northeast from Lisbon) which could be a potential limitation to be confirmed. CONCLUSIONS Distinct temperamental profiles of students enrolled in different professional fields could be identified in our sample taking into account the presence or absence of excessive temperaments. Future physicians did not present a predominant temperament, future lawyers and artists presented predominantly a cyclothymic or irritable temperament, future engineers presented a hyperthymic temperament and, future psychologists and nurses presented predominantly depressive and anxious temperaments.

Neuropsychiatric disturbances in acute subarachnoid haemorrhage

Background:  Acute and unexpected neuropsychiatric disturbances can herald subarachnoid haemorrhage (SAH). We investigated the risk factors for neuropsychiatric disturbances in acute SAH and analysed the relation between neuropsychiatric disturbances and location and amount of haematic densities and hydrocephalus.