Risto Vataja

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.

Clinical Determinants of Poststroke Dementia

BACKGROUND AND PURPOSE Frequency of poststroke dementia is high, and stroke considerably increases the risk of dementia. The risk factors for dementia related to stroke are still incompletely understood. We sought to examine clinical determinants of poststroke dementia in a large well-defined stroke cohort. METHODS The study group comprised 337 of 486 consecutive patients aged 55 to 85 years who 3 months after ischemic stroke completed a comprehensive neuropsychological test battery and MRI, including structured medical, neurological, and laboratory evaluations; clinical mental status examination; interview of a knowledgeable informant; detailed history of risk factors; and evaluation of stroke type, localization, and syndrome. The DSM-III definition for dementia was used. RESULTS Frequency of any poststroke dementia was 31.8% (107/337), that of stroke-related dementia (mixed Alzheimers disease plus vascular dementia excluded) was 28.4% (87/306), and that of dementia after first-ever stroke was 28.9% (79/273). The patients with poststroke dementia were older and more often had a low level of education, history of prior cerebrovascular disease and stroke, left hemispheric stroke (reflecting laterality), major dominant stroke syndrome (reflecting laterality and size), dysphasia, gait impairment, and urinary incontinence. The demented patients were also more frequently current smokers, had lower arterial blood pressure values, and more frequently had an orthostatic reaction compared with the nondemented stroke patients. The correlates of dementia in logistic regression analysis were dysphasia (odds ratio [OR], 5.6), major dominant stroke syndrome (OR, 5.0), history of prior cerebrovascular disease (OR, 2.0), and low educational level (OR, 1.1). When we excluded those with cerebrovascular disease plus Alzheimers disease or those with recurrent stroke, the order of correlates remained the same. When the patients with dysphasia (n=30) were excluded, the correlates were major dominant syndrome (OR, 4.6) and low educational level (OR, 1.1). CONCLUSIONS Our data suggest that a single explanation for poststroke dementia is not adequate; rather, multiple factors including stroke features (dysphasia, major dominant stroke syndrome), host characteristics (educational level), and prior cerebrovascular disease each independently contribute to the risk.

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.

Comparison of Stroke Features and Disability in Daily Life in Patients With Ischemic Stroke Aged 55 to 70 and 71 to 85 Years

BACKGROUND AND PURPOSE This study compared stroke features and poststroke disability in two age groups of patients with ischemic stroke: younger (55 to 70 years) and older (71 to 85 years). Stroke has an impact on daily living in many areas, but whether risk factors, stroke features, and poststroke disability differ between young and old patients with stroke is not so well established. METHODS A cohort of 486 ischemic stroke patients aged 55 to 85 years admitted consecutively to the Helsinki University Central Hospital (Finland) between December 1, 1993, and March 31, 1995, were examined 3 months after the index stroke. Structured medical, neurological, and radiological (MRI or CT) examinations, mental status, and emotional examination and interview of a close informant were done. Prestroke and poststroke activities of daily living were assessed with five scales: the Index of ADL, Instrumental Activities of Daily Living Scale, Functional Activities Questionnaire, Blessed Functional Activities Scale, and Barthel Index. RESULTS History of cardiac failure (P < .001), atrial fibrillation (P < .001), and cardioembolic stroke (P = .011) was more frequent in the older age group, whereas stroke due to large-artery atherosclerosis (P = .048) was more common in the younger age group. The older patients more often had major dominant stroke syndrome (P = .018). Comparison of activities of daily living before and after stroke showed that the older age group deteriorated significantly more than the younger age group after adjustment for sex, education, and living conditions (Barthel Index, P = .005; other scales, P < .0001). CONCLUSIONS The stroke patients in young and old age groups had different risk profiles and stroke features. The older stroke patients were more dependent and disabled beforehand, and after stroke they were relatively even more dependent than the patients in the younger age group. Because older patients already constitute the majority of stroke victims, the importance of early active diagnosis, treatment, rehabilitation, and guidance is stressed.

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.

Cognitive impairment predicts poststroke death in long-term follow-up

Background: Poststroke global cognitive decline and dementia have been related to poor long-term survival. Whether deficits in specific cognitive domains are associated with long-term survival in patients with ischaemic stroke is not known in detail. Methods: Patients with acute stroke subjected to comprehensive neuropsychological evaluation were included in the study (n = 409) and followed up for up to 12 years. Results: In Kaplan–Meier analysis, impairments in following cognitive domains predicted poor poststroke survival (estimated years): executive functions (48.2%) (5.8 vs 10.1 years, p<0.0001), memory (59.9%) (6.8 vs 9.3 years, p = 0.009), language (28.9%) (5.3 vs 8.6 years, p = 0.004) and visuospatial/constructional abilities (55.2%) (5.6 vs 10.1 years, p<0.0001). Low Mini Mental Status Examination (MMSE) ⩽25 (30.5%) (4.4 vs 9.3 years, p<0.0001), low education (<6 years) (31.8%) (6.4 vs 8.2 years, p = 0.003) and poor modified Rankin score (39.9%) (3.9 vs 9.7 years, p<0.0001) were also related to poor survival. In Cox regression proportional hazards analyses including age, sex and years of education as covariates, deficits in executive functions (hazard ratio (HR) 1.59, p<0.0001), memory (HR 1.31, p = 0.042), language (HR 1.33, p = 0.036) and visuospatial/constructional abilities (HR 1.82, p<0.0001) were significant predictors of poor poststroke survival. Of these, executive functions (HR 1.33, p = 0.040) as well as visuospatial/constructional abilities (HR 1.53, p = 0.004) remained as significant predictors after addition of MMSE⩽25 and poor modified Rankin score as covariates. Furthermore, cognitive impairment no dementia (CIND) was also an independent predictor of poor poststroke survival (HR 1.63, p = 0.0123). Conclusions: In patients with ischaemic stroke, cognitive impairment, particularly in executive functions, and visuospatial/constructional abilities relate to poor survival.

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.