Early cognitive impairment predicts long-term depressive symptoms and quality of life after stroke

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Abstract

Objective

The aim of the present study was to examine the predictive value of cognitive impairment in the acute phase after stroke as a risk factor for long-term (six to ten months after stroke) depressive symptoms (DS) and a reduced quality of life (QOL), independent of demographic and neurological predictors.

Methods

We evaluated 143 patients within the first 3 weeks post-stroke. Predictor variables included domain-specific cognitive function, demographic data, vascular risk factors, lesion characteristics, and clinical factors. Predictor variables associated with long-term DS (Montgomery ?sberg Depression Rating Scale ≥ 7) and QOL (Stroke-Specific Quality of Life Scale) were identified with multiple logistic and linear regression.

Results

Long-term DS were independently predicted by cognitive impairment at baseline, DS at baseline, female sex, diabetes mellitus, and previous TIA(s). Cognitive impairment, increasing age, and functional dependence predicted a reduced QOL, whereas hypercholesterolaemia predicted a better QOL. Among all cognitive disorders, unilateral neglect was the greatest risk factor for DS after 6 months, whereas a disorder in visual perception and construction affected QOL the most.

Conclusions

Cognitive impairment and vascular risk factors are important predictors of long-term DS and QOL after stroke. The prognostic value of cognition suggests a reactive component in the development or continuation of long-term DS.

Introduction

Depression is a common complication after stroke and is associated with increased mortality [1], poor functional outcome [2], and decreased quality of life [3]. Over the past 20 years conflicting findings have been reported regarding the association between cognitive impairment and depressive pathology after stroke. Whereas most studies have reported an association with cognitive impairment [4], [5], [6], others did not find such an association [7], or were able only to show that this association held in patients with left hemisphere damage [8], [9], [10]. The majority of these studies have assessed post-stroke depression based on the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and/or using self-rating scales such as the Beck Depression Inventory. However, communication difficulties and severe cognitive impairment may complicate the assessment of depression in patients who recently suffered a stroke. Consequently, the diagnostic approach often has resulted in the exclusion of patients with severe cognitive impairment (e.g. [6], [11]). This emphasises the importance of administering observational methods in acute stroke patients with cognitive impairment. One recent study demonstrated that the presence of observer-rated depressive symptoms at 6 months post-stroke is closely related to the presence of dementia at 6 months [5]. Currently, it is still unclear whether cognitive impairment early after stroke is a risk factor of depressive symptoms in the longer term, independent of other well-known medical and demographic predictors.

In addition to emotional and cognitive disturbances, stroke patients frequently report a reduced subjective health perception or ‘quality of life’ (QOL) [3]. In the few studies that examined the relative contribution of cognitive performance in the prediction of QOL after stroke, either no significant association was found [12], or a selective association with aphasia was reported [13]. However, none of these studies examined cognitive functioning by means of an extensive neuropsychological examination tapping distinct cognitive functions, although specific cognitive disorders might affect quality of life after stroke differently.

In the present study, we aimed (i) to test whether acute cognitive impairment is an independent risk factor of DS 6 months after stroke, and (ii) to examine its relation with long-term QOL. Furthermore, we examined which specific cognitive deficits in the early phase of stroke were associated with DS and a reduced QOL after 6 months. To this end, we used a sensitive neuropsychological examination covering a broad range of cognitive domains, which has been shown to demonstrate a good predictive validity with respect to long-term domain-specific cognitive impairment [14].

Section snippets

Subjects

The patient population in this study was selected from consecutive patients with a first-ever symptomatic stroke admitted to stroke units of three hospitals in The Netherlands (University Medical Centre Utrecht, Tweesteden Hospital Tilburg, St.-Elisabeth Hospital Tilburg) between February 2002 and January 2003 (see also [14], [15] for two studies on the same cohort). Only patients with a first-ever ischaemic stroke or primary intracerebral haemorrhage were included. Diagnosis of stroke was

Potential selection bias

Of the 143 patients included at baseline, 91 (64%) were re-examined at follow-up. Patients not included at follow-up were significantly older [t(141) = 2.4; p < 0.05], and more of these patients demonstrated white matter lesions [÷2(1) = 7.04; p < 0.01] than the included patients. No difference was found with respect to other demographic factors, vascular risk factors, or the prevalence of DS or cognitive impairment at baseline. Characteristics of patients included for follow-up are shown in Table 1.

Discussion

A first important finding of this study is that cognitive impairment in the early phase of stroke is an independent risk factor of DS and a reduced QOL after 6 months. Until now, acute cognitive impairment after stroke has been studied mainly with global screening instruments intended to detect dementia, e.g. the Mini-Mental State Examination [28] or the CAMCOG [29]. Whereas antidepressant treatment has been shown to reduce cognitive impairment after stroke suggesting that depression causes a

Acknowledgements

This study was funded by the Netherlands Heart Foundation (NHS 2000.023).

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