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Influence of post-stroke delirium on mental health problems during the follow-up period in univariate and multivariate logistic regression models.
Source publication
Background:
Stroke patients are particularly vulnerable to delirium episodes, but very little is known about its subsequent adverse mental health outcomes. The author's objective was to explore the association between in-hospital delirium and depression, anxiety, anger and apathy after stroke.
Methods:
A total of 750 consecutive patients with ac...
Contexts in source publication
Context 1
... univariate analyses, delirium was a risk factor for depression, anxiety and hostility at the hospital and after 3 months, for aggression during hospitalization and for apathy during all of the observation period (see Supplementary Materials: Tables S2-S5). In multivariable logistic regression analysis, delirium was an independent risk factor for depression and aggression during hospitalization, anxiety after 3 months and apathy during all follow-up periods. ...Context 2
... multivariable logistic regression analysis, delirium was an independent risk factor for depression and aggression during hospitalization, anxiety after 3 months and apathy during all follow-up periods. Table 2 shows the final results. The detailed results of all outcome measures during the follow-up period are available in Supplementary Data (Table S6). ...Context 3
... seems to be the most connected mental health complication with in-hospital delirium among stroke patients. Table S1: Prevalence of depression, apathy, anxiety and aggression/hostility in hospital, at 3-month follow-up and 12-month follow-up in no-delirium and delirium groups, Table S2: Influence of post-stroke delirium on the incidence of depression in hospital, at 3-month follow-up and 12-month follow-up in univariate and multivariate logistic regression models, Table S3: Influence of post-stroke delirium on the incidence of apathy in hospital, at 3-month follow-up and 12-month follow-up in univariate and multivariate logistic regression models, Table S4: Influence of post-stroke delirium on the incidence of anxiety in hospital, at 3-month follow-up and 12-month follow-up in univariate and multivariate logistic regression models, Table S5: Influence of post-stroke delirium on the incidence of aggression/hostility in hospital, at 3-month follow-up and 12-month follow-up in univariate and multivariate logistic regression models, Table S6: Influence of post-stroke delirium on the incidence of depression, apathy, anxiety and aggression/hostility in hospital, at 3-month follow-up and 12-month follow-up in univariate and multivariate logistic regression models. ...Citations
... These factors are further associated with both post-stroke dementia [19] and depression [20,21]. Furthermore, several studies have found relationships between acute delirium and psychiatric symptoms in the general hospital population [22], but the research on the effect of post-stroke delirium on psychiatric symptoms is sparse with divergent findings [23,24]. Whether delirium in the acute phase of stroke predisposes for later psychiatric symptoms therefore emerges as a relevant topic. ...
... Other studies examining the effect of acute delirium on psychiatric symptoms have varying findings. In their study, Kowalska et al. [24] found an effect of delirium during admission and three months post-stroke, but not 12 months post-stroke, and suggesting that the effect disappears over time. Similarly, Chan et al. [23] used HADS to examine stroke patients at one, six and 12 months post-stroke, finding no difference in scores on both HADS-A and HADS-D between patients experiencing delirium in the acute phase and non-delirious patients. ...
... In addition, Davydow (24) indicated that depression and anxiety may result from delirium, meaning that there could be a bidirectional relationship between delirium and affective disorders. It has been observed that delirium generally gives rise to depressive symptoms, although studies investigating the relationship between delirium and anxiety symptoms have reported conflicting results (25)(26)(27)(28). While no significant differences in terms of the anxiety and depression scores were observed between the two groups in this study, the depression scores of the delirium group were higher than those of the control group, whereas the anxiety scores of the two groups were similar. ...
... The diagnosis of delirium followed the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [20] and was based on clinical observations and structural assessments by a neurologist/neuropsychologist and ward nurses. All details of the in-hospital assessment of post-stroke delirium have been described elsewhere [21,22]. ...
Introduction
With increasing life expectancy and the rising incidence of stroke in young adults, it is important to know the long-term prognosis of this condition. Post-stroke delirium and post-stroke dementia are common complications of stroke that negatively affect prognosis. The purpose of this study was to evaluate five-year mortality from stroke and to assess the influence of post-stroke delirium and post-stroke dementia on mortality and disability over the five-year period.
Methods
Consecutive patients admitted to the stroke unit for acute stroke or transient ischemic attacks were screened for in-hospital delirium. At the three- and twelve-month follow-up, the same patients underwent neurocognitive testing. Diagnoses of in-hospital delirium and dementia after three and twelve months based on DSM-5 criteria. Five years after stroke surviving patients were reevaluated. Outcome assessment included place of stay, current functional status assessed by the modified Rankin Scale (mRS), or death.
Results
At the five-years of follow-up, data were collected from 575 of 750 patients originally included in the study (76.67%). The mortality rate was 51.65%. In-hospital post-stroke delirium and post-stroke dementia diagnosed three and twelve months after stroke were independent risk factors for death and an increase in mRS score of ≥ 1 or ≥ 2 points. There was no significant association with institutionalization rate.
Conclusions
More than half of post-stroke patients die within five years of follow-up. Post-stroke delirium and post-stroke dementia are associated with an increased risk of death and disability.
... In addition to our study, some studies reported that stroke patients experience high anxiety, especially in the first two weeks, which affects many aspects of their lives (Rafsten et al., 2018). Therefore, the thought of death undeniably influences these patients' lives, resulting in a crisis, psychological distress, and even the loss of meaning in life, making spiritual care more important (Kowalska et al., 2020). Meanwhile, theorists support the idea that patients can cope with the idea of dying through various mechanisms. ...
... 42 Regarding psychiatric outcomes, only limited work has been done: one study did not find an impact of PSD on measures of anxiety and depression over the course of 1 year 40 , while another found a higher rate of depression in delirious patients during the acute stroke phase, higher rate of anxiety at 3 months, and higher rate of apathy at all times points. 43 More work is needed to better understand the impact of delirium on these important rehabilitative outcomes. ...
Introduction:
Post-stroke delirium (PSD) is a common yet underrecognized complication following stroke, with its effect on stroke rehabilitation being the subject of limited attention. The objective of this narrative review is to provide an overview of core issues in PSD including epidemiology, diagnostic challenges, and management considerations, with an emphasis on the rehabilitation phase.
Methods:
Ovid Medline and Google Scholar were searched through February 2023 using keywords related to delirium, rehabilitation, and the post-stroke period. Only studies conducted on adults (≥18 years) and written in the English language were included.
Results:
PSD affects approximately 25% of stroke patients, and often persists well into the post-acute phase, with a negative impact on rehabilitation outcomes including lengths of stay, function, and cognition. Certain stroke and patient characteristics can help predict risk for PSD. The diagnosis of delirium becomes more challenging when superimposed on stroke deficits (such as attentional impairment or other cognitive, psychiatric, or behavioural disorders), leading to underdiagnosis, overdiagnosis, or misdiagnosis. Particularly in patients with post-stroke language or cognitive disorders, common screening tools are less accurate. The multidisciplinary rehabilitation team should be involved in management of PSD as rehabilitative activities can be beneficial for patients who can participate safely. Addressing barriers to effective delirium care at various levels of the health care system can improve rehabilitation trajectories for these patients.
Conclusions:
PSD is a disease entity commonly encountered in the rehabilitation setting, but it is challenging to diagnose and manage. New delirium screening tools and management approaches specific for the post-stroke and rehabilitation settings are needed.
... Stroke may have unexpected long-term effects on a patient's life, such as limited social activity, disability, depression, and emotional issues (Kowalska et al., 2020). Stroke is the second-leading cause of mortality and the third-leading cause of disability and death. ...
This study sought to examine the effect of a spiritual program on the hope of stroke patients in Iran. The present study was a randomized controlled trial that included 108 stroke patients referred to Besat Hospital, Hamadan, Iran, in 2021. Participants were randomized to either the intervention group (n = 54) or control group (n = 54). The data were collected before the intervention by using the demographic information form, Snyder's Adult Hope Scale (AHS), the Modified Rankin Scale (MRS), and after the intervention, the Snyder's Adult Hope Scale (AHS). The intervention group received four sessions of 45–60 min (one session per week) that included a spiritual needs assessment, religious care, spiritual supportive care, and evaluation of benefits. After the intervention, a significant between-group difference was observed (p < 0.001). There was also a significant increase in the mean of hope scores in the intervention group from baseline to follow-up (within-group difference) (p < 0.001), while there was no significant difference between baseline and follow-up in the control group (p = 0.553). (IRCT 20160110025929N36 and date: 2021/09/27).
... Moreover, these behaviors generally subside over time along with the disappearance of other delirious or aphasic symptoms. 4,5 Thus, the aggressive behaviors shown in these patients are unlikely to be an anger based on true emotion disturbances. ...
... 3. I am a hotheaded person. 4. I get angry when I am slowed down by others' mistakes. ...
Post-stroke mood and emotional disturbances are frequent and diverse in their manifestations. Among them, post-stroke depression is the best known. Although post-stroke anger (PSA) has been studied relatively less, it can be as frequent as depression. Manifestations of PSA range from overt aggressive behaviors (including hitting or hurting others) to becoming irritable, impulsive, hostile, and less tolerable to family members. The possible pathophysiological mechanisms of PSA include neurochemical dysfunction due to brain injury, frustration associated with neurological deficits or unfavorable environments, and genetic predisposition. PSA causes distress in both patients and their caregivers, negatively influences the patient’s quality of life, and increases the burden on caregivers. It can be treated or prevented using various methods, including pharmacological therapies. In addition, anger or hostility may also be a risk or triggering factor for stroke. The hazardous effects of anger may be mediated by other risk factors, including hypertension or diabetes mellitus. The identification of anger as a result or cause of stroke is important because strategic management of anger may help improve the patient’s quality of life or prevent stroke occurrence. In this narrative review, we describe the phenomenology, prevalence, factors or predictors, relevant lesion locations, and pharmacological treatment of PSA. We further describe the current evidence on anger as a risk or triggering factor for stroke.
... This would imply that the anxiety levels in patients with delirium are of clinical importance at 18 and 36 months (Mean (SD): 5.6 (1.2) and 6.2 (1.3) respectively). Though Kowalska et al. [54] recently found delirium to be a risk factor for anxiety 3 months after stroke, our findings suggest that the subsequent anxiety symptoms can be present or even increase over a longer timeframe. ...
Objective
Delirium, a common complication after stroke, is often overlooked, and long-term consequences are poorly understood. This study aims to explore whether delirium in the acute phase of stroke predicts cognitive and psychiatric symptoms three, 18 and 36 months later.
Method
As part of the Norwegian Cognitive Impairment After Stroke Study (Nor-COAST), 139 hospitalized stroke patients (49% women, mean (SD) age: 71.4 (13.4) years; mean (SD) National Institutes of Health Stroke Scale (NIHSS) 3.0 (4.0)) were screened for delirium with the Confusion Assessment Method (CAM). Global cognition was measured with the Montreal Cognitive Assessment (MoCA), while psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Data was analyzed using mixed-model linear regression, adjusting for age, gender, education, NIHSS score at baseline and premorbid dementia.
Results
Thirteen patients met the criteria for delirium. Patients with delirium had lower MoCA scores compared to non-delirious patients, with the largest between-group difference found at 18 months (Mean (SE): 20.8 (1.4) versus (25.1 (0.4)). Delirium was associated with higher NPI-Q scores at 3 months (Mean (SE): 2.4 (0.6) versus 0.8 (0.1)), and higher HADS anxiety scores at 18 and 36 months, with the largest difference found at 36 months (Mean (SE): 6.2 (1.3) versus 2.2 (0.3)).
Conclusions
Suffering a delirium in the acute phase of stroke predicted more cognitive and psychiatric symptoms at follow-up, compared to non-delirious patients. Preventing and treating delirium may be important for decreasing the burden of post-stroke disability.
... In the meta-analysis by Hackett and Pickles [1], the pooled data showed that depression was present in 31% of stroke survivors at any time up to five-years post stroke, however its frequency varied across studies from 5% at two to five days after stroke to 84% at three months after stroke. Our data on PSD, among Polish patients with stroke, showed that PSD occurs in 54.58% of patients at the hospital, in 58.51% three months, and in 54.75% 12 months after the stroke [2]. ...
Post-stroke depression (PSD) is the most frequent neuropsychiatric consequence of stroke. The nature of the relationship between PSD and mortality still remains unknown. One hypothesis is that PSD could be more frequent in those patients who are more vulnerable to physical disability, a mediator variable for higher level of physical damage related to higher risk of mortality. Therefore, the authors’ objective was to explore the assumption that PSD increases disability after stroke, and secondly, that mortality is higher among patients with PSD regardless of stroke severity and other neuropsychiatric conditions. We included 524 consecutive patients with acute stroke or transient ischemic attack, who were screened for depression between 7–10 days after stroke onset. Physical impairment and death were the outcomes measures at evaluation check points three and 12 months post-stroke. PSD independently increased the level of disability three (OR = 1.94, 95% CI 1.31–2.87, p = 0.001), and 12 months post-stroke (OR = 1.61, 95% CI 1.14–2.48, p = 0.009). PSD was also an independent risk factor for death three (OR = 5.68, 95% CI 1.58–20.37, p = 0.008) and 12 months after stroke (OR = 4.53, 95% CI 2.06–9.94, p = 0.001). Our study shows the negative impact of early PSD on the level of disability and survival rates during first year after stroke and supports the assumption that depression may act as an independent mediator for disability leading to death in patients who are more vulnerable for brain injury.
Anger or aggression is prevalent during the acute and subacute stages of stroke. Thus, along with depression, anger/aggression appears to be one of the main emotional symptoms observed in patients with stroke. Post-stroke anger (PSA) is associated with neurological deficits, depression, and emotional incontinence. Although the study results are heterogeneous, lesions involving the frontal-lenticular-brainstem pathway appear to be related to PSA. Considering this, PSA seems to be, at least in part, related to neurochemical (e.g., serotonin) changes secondary to brain damage. However, patients’ frustration associated with their functional deficits, hostile environments, and genetic predisposition may also play a role in PSA development. Antidepressants, particularly SSRIs, are considered the management of choice. The recognition of PSA is important because not only does it deteriorate patients’ quality of life and increase caregivers’ burden but it is also treatable. However, several limitations need to be addressed. First, a standardized method for diagnosing or measuring PSA severity has not yet been established. Second, in most PSA studies, patients with severe aphasia or cognitive impairment were excluded. Thus, PSA prevalence is probably underestimated. Third, data from different continents (e.g., Europe, North America, and Asia) may generate further confounders because of the possible differences in the healthcare system across countries. Finally, studies involving large populations, appropriate controls, and well-designed clinical trials are rare. Thus, further research is needed to improve the understanding and management of PSA.
