Research report
Depressive symptoms in stroke patients: A 13 month follow-up study of patients referred to a rehabilitation unit

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Abstract

Background

Although depression is known to be frequently associated with stroke, it is nonetheless underdiagnosed and under-treated in this patient population. Its effect on outcome for stroke patients is thought to be substantial, but prediction is complicated by other pre- and post stroke factors. The aims of this study was to describe changes in depressive symptoms in elderly stroke patients across a timespan of one year, to examine risk factor for such changes and to explore whether depressive symptoms have any independent impact upon one year mortality and nursing home placement.

Methods

194 patients diagnosed with an ischaemic or hemorrhagic stroke was recruited from the Stroke Rehabilitation Unit, Ullevaal University Hospital, Oslo, Norway during the period between March 2005 and August 2006 and followed up for a period of 13 months. Pre-stroke assessment was accomplished by means of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), the Frenchay Activities Index (FAI), the Barthel ADL Index and patient's medical history. Post-stroke assessment at inclusion and follow-up examination was performed with the Mini Mental State Examination (MMSE), the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), the Star Cancellation Test, the Barthel ADL Index, the modified Rankin Scale (mRS) and the National Institute of Health Stroke Scale (NIHSS). Information was collected from the patients' records.

Results

Institutionalization at 13 months was predicted by more depression (MADRS) and cognitive impairment (RBANS) at baseline, together with lower pre-stroke social activity levels (FAI). Two factors predicted death at 13 months: Cognitive impairment (MMSE) and greater age. The prevalence of depression was relatively unchanged from baseline (56%) to 13 month follow-up (48%). Among the patients who were depressed at baseline 55% still had MADRS score above six (persistent depression) at 13 months, while 35% in the non-depressed group at baseline had developed depression (incident depression). Persistent depression was significantly predicted by lower pre-stroke social activity levels (FAI) together with a more severe stroke (NIHSS) and worse overall function (mRS) at baseline. Incident depression was predicted by receipt of municipal home help before the stroke and a lower score on the delayed memory tasks on RBANS at baseline.

Section snippets

Subjects

The study sample consists of 194 patients diagnosed with an ischaemic or a hemorrhagic stroke through clinical examination and/or computed tomography (CT), consecutively recruited at a mean of 18.3 days (SD 13.4) after admission to the Stroke Rehabilitation Unit at Ullevaal University Hospital, Oslo, Norway, between March 2005 and August 2006. Mean age (and standard deviation, s.d.) was 76.9 (10.5) years; 95 (49%) were women. Mean age for women was 79.4 (9.6) years, for men 74.5 (10.9) years.

Pre-stroke information and medical history

Pre-stroke cognitive function was assessed by the Norwegian version of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). The IQCODE is a structured questionnaire consisting of 26 items assessing cognitive changes suffered by an informant over the past 10 years. It has been widely used for the screening of dementia (Jorm, 2004). A score above three indicates a decline in cognition.

Functioning in the activities of daily living (ADL) was assessed with the Barthel ADL Index

Results

The mean age of the 126 patients followed up at 13 months was 75.0 (s.d 11.3) years; 58 (46%) were women. The mean age of the women was 78.8 (s.d 9.9) years, whereas the mean age of the men was 74.8 (s.d. 11.2) years.

Discussion

The prevalence of clinically significant depressive symptoms defined as a score on MADRS above six was relatively unchanged from baseline (56%) to the 13 month follow-up stage (48%). We found a relatively high prevalence of depression, but still within the 18% to 61% prevalence range described in two systematic reviews (Aben et al., 2001, House, 1987). Differences in diagnostic methods, time of assessment and subject samples may explain the general discrepancy between post-stroke prevalence

Role of funding source

Funding for this study was provided by the Eastern Norway Regional Health Authority and Norwegian Centre for Dementia Research, Centre for Ageing and Health; they had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Lasse Farner (sign).

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgements

Authors thank Eastern Norway Regional Health Authority and Norwegian Centre for Dementia Research, Centre for Ageing and Health for their financial support.

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