Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
BMC Neurology
Published in: BMC Neurology 1/2023

Open Access 01-12-2023 | Stroke | Research

Long-term psychological outcomes following stroke: the OX-CHRONIC study

Authors: Andrea Kusec, Elise Milosevich, Owen A. Williams, Evangeline G. Chiu, Pippa Watson, Chloe Carrick, Bogna A. Drozdowska, Avril Dillon, Trevor Jennings, Bloo Anderson, Helen Dawes, Shirley Thomas, Annapoorna Kuppuswamy, Sarah T. Pendlebury, Terence J. Quinn, Nele Demeyere

Published in: BMC Neurology | Issue 1/2023

Login to get access

Abstract

Background

Stroke survivors rate longer-term (> 2 years) psychological recovery as their top priority, but data on how frequently psychological consequences occur is lacking. Prevalence of cognitive impairment, depression/anxiety, fatigue, apathy and related psychological outcomes, and whether rates are stable in long-term stroke, is unknown.

Methods

N = 105 long-term stroke survivors (M [SD] age = 72.92 [13.01]; M [SD] acute NIH Stroke Severity Score = 7.39 [6.25]; 59.0% Male; M [SD] years post-stroke = 4.57 [2.12]) were recruited (potential N = 208). Participants completed 3 remote assessments, including a comprehensive set of standardized cognitive neuropsychological tests comprising domains of memory, attention, language, and executive function, and questionnaires on emotional distress, fatigue, apathy and other psychological outcomes. Ninety participants were re-assessed one year later. Stability of outcomes was assessed by Cohen’s d effect size estimates and percent Minimal Clinically Important Difference changes between time points.

Results

On the Montreal Cognitive Assessment 65.3% scored < 26. On the Oxford Cognitive Screen 45.9% had at least one cognitive impairment. Attention (27.1%) and executive function (40%) were most frequently impaired. 23.5% and 22.5% had elevated depression/anxiety respectively. Fatigue (51.4%) and apathy (40.5%) rates remained high, comparable to estimates in the first-year post-stroke. Attention (d = -0.12; 85.8% stable) and depression (d = 0.09, 77.1% stable) were the most stable outcomes. Following alpha-adjustments, only perceptuomotor abilities (d = 0.69; 40.4% decline) and fatigue (d = -0.33; 45.3% decline) worsened over one year. Cognitive impairment, depression/anxiety, fatigue and apathy all correlated with worse quality of life.

Conclusion

Nearly half of participants > 2 years post-event exhibited psychological difficulties including domains of cognition, mood, and fatigue, which impact long-term quality of life. Stroke is a chronic condition with highly prevalent psychological needs, which require monitoring and intervention development.
Appendix
Available only for authorised users
Footnotes
1
Activity monitor data will be reported elsewhere.
 
Literature
1.
Van De Port IGL, Kwakkel G, Van Wijk I, et al. Susceptibility to deterioration of mobility long-term after stroke: a prospective cohort study. Stroke. 2006;37(1):167–71.PubMedCrossRef
2.
Jaillard A, Naegele B, Trabucco-Miguel S, et al. Hidden dysfunctioning in subacute stroke. Stroke. 2009;40(7):2473–9.PubMedCrossRef
3.
Nys GM, Van Zandvoort MJ, De Kort PL, et al. Cognitive disorders in acute stroke: prevalence and clinical determinants. Cerebrovasc Dis. 2007;23(5–6):408–16.PubMedCrossRef
4.
Seminog OO, Scarborough P, Wright FL, Rayner M, Goldacre MJ. Determinants of the decline in mortality from acute stroke in England: linked national database study of 795 869 adults. BMJ. 2019;22:365.
5.
Johnson CO, Nguyen M, Roth GA, Nichols E, Alam T, Abate D, Abd-Allah F, Abdelalim A, Abraha HN, Abu-Rmeileh NM, Adebayo OM. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):439–58.CrossRef
6.
Lin BL, Mei YX, Wang WN, Wang SS, Li YS, Xu MY, Zhang ZX, Tong Y. Unmet care needs of community-dwelling stroke survivors: a systematic review of quantitative studies. BMJ Open. 2021;11(4):e045560.PubMedPubMedCentralCrossRef
7.
Lo JW, Crawford JD, Desmond DW, Godefroy O, Jokinen H, Mahinrad S, Bae HJ, Lim JS, Köhler S, Douven E, Staals J. Profile of and risk factors for poststroke cognitive impairment in diverse ethnoregional groups. Neurology. 2019;93(24):e2257–71.PubMedPubMedCentralCrossRef
8.
9.
10.
11.
12.
Mole JA, Demeyere N. The relationship between early post-stroke cognition and longer term activities and participation: a systematic review. Neuropsychol Rehabil. 2020;30(2):346–70.PubMedCrossRef
13.
14.
Andrew NE, Kilkenny M, Naylor R, Purvis T, Lalor E, Moloczij N, Cadilhac DA, National Stroke Foundation. Understanding long-term unmet needs in A ustralian survivors of stroke. Int J Stroke. 2014;9:106–12.PubMedCrossRef
15.
Abrahamson V, Wilson PM. How unmet are unmet needs post-stroke? A policy analysis of the six-month review. BMC Health Serv Res. 2019;19:1–9.CrossRef
16.
17.
18.
19.
Tang EY, Amiesimaka O, Harrison SL, Green E, Price C, Robinson L, Siervo M, Stephan BC. Longitudinal effect of stroke on cognition: a systematic review. J Am Heart Assoc. 2018;7(2):e006443.PubMedPubMedCentralCrossRef
20.
21.
Demeyere N, Riddoch MJ, Slavkova ED, Bickerton WL, Humphreys GW. The Oxford Cognitive Screen (OCS): validation of a stroke-specific short cognitive screening tool. Psychol Assess. 2015;27(3):883.PubMedCrossRef
22.
23.
24.
25.
Baylan S, Griffiths S, Grant N, Broomfield NM, Evans JJ, Gardani M. Incidence and prevalence of post-stroke insomnia: a systematic review and meta-analysis. Sleep Med Rev. 2020;1(49):101222.CrossRef
26.
Fulk GD, Boyne P, Hauger M, Ghosh R, Romano S, Thomas J, Slutzky A, Klingman K. The impact of sleep disorders on functional recovery and participation following stroke: a systematic review and meta-analysis. Neurorehabil Neural Repair. 2020;34(11):1050–61.PubMedCrossRef
27.
Caeiro L, Ferro JM, eMelo TP, Canhão P, Figueira ML. Post-stroke apathy: an exploratory longitudinal study. Cerebrovascular Dis. 2013;35(6):507–13.CrossRef
28.
29.
Williams OA, Demeyere N. Association of depression and anxiety with cognitive impairment 6 months after stroke. Neurology. 2021;96(15):e1966–74.PubMedCrossRef
30.
31.
Skogestad IJ, Kirkevold M, Larsson P, Borge CR, Indredavik B, Gay CL, Lerdal A. Post-stroke fatigue: an exploratory study with patients and health professionals to develop a patient-reported outcome measure. J Patient-Reported Outcomes. 2021;5(1):1–1.CrossRef
32.
Ezekiel L, Collett J, Mayo NE, Pang L, Field L, Dawes H. Factors associated with participation in life situations for adults with stroke: a systematic review. Arch Phys Med Rehabil. 2019;100(5):945–55.PubMedCrossRef
33.
Carnes-Vendrell A, Deus J, Molina-Seguin J, Pifarré J, Purroy F. Depression and apathy after transient ischemic attack or minor stroke: prevalence, evolution and predictors. Sci Rep. 2019;9(1):16248.PubMedPubMedCentralCrossRef
34.
Demeyere N, Sun S, Milosevich E, Vancleef K. Post-stroke cognition with the Oxford Cognitive Screen vs Montreal Cognitive Assessment: a multi-site randomized controlled study (OCS-CARE). AMRC Open Res. 2019;13(1):12.CrossRef
35.
36.
Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–9.PubMedCrossRef
37.
Kaplan E. The Assessment of Aphasia and Related Disorders. Philadelphia: Lippincott Williams & Wilkins; 1983.
38.
Mack WJ, Freed DM, Williams BW, et al. Boston naming test: shortened versions for use in Alzheimer’s disease. J Gerontol. 1992;47(3):P154–8.PubMedCrossRef
39.
Delis DC, Kaplan E, Kramer JH. Delis-Kaplan executive function system. San Antonio (USA): Pearson; 2001.
40.
Burgess P, Shallice T. The Hayling and Brixton tests. Bury St Edmunds (GB):Thames Valley Company; 1997.
41.
Demeyere N, Haupt M, Webb SS, et al. Introducing the tablet-based Oxford Cognitive Screen-Plus (OCS-Plus) as an assessment tool for subtle cognitive impairments. Sci Rep. 2021;11(1):8000.PubMedPubMedCentralCrossRef
42.
Wechsler D, Edition WM. Wechsler Memory Scale-III. San Antonio (USA): Pearson; 1997.
43.
Wilson B, Cockburn J, Halligan PW. Behavioural inattention test thames valley test company: Titchfield. Hampshire. 1987.
44.
Osterrieth PA. Le test de copie d'une figure complexe; contribution a l'etude de la perception et de la memoire. Arch de psychologie. 1944;30:206–356.
45.
Broadbent DE, Cooper PF, FitzGerald P, Parkes KR. The cognitive failures questionnaire (CFQ) and its correlates. Br J Clin Psychol. 1982;21(1):1–6.PubMedCrossRef
46.
Nucci M, Mapelli D, Mondini S. Cognitive Reserve Index questionnaire (CRIq): a new instrument for measuring cognitive reserve. Aging Clin Exp Res. 2012;24:218–26.PubMedCrossRef
47.
Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, Van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19(5):604–7.PubMedCrossRef
48.
Nouri FM, Lincoln NB. An extended activities of daily living scale for stroke patients. Clin Rehabil. 1987;1(4):301–5.CrossRef
49.
Ellul J, Watkins C, BArer D. Estimating total Barthel scores from just three items: the European Stroke Database ‘minimum dataset’for assessing functional status at discharge from hospital. Age Ageing. 1998;27(2):115–22.PubMedCrossRef
50.
Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–70.PubMedCrossRef
51.
Yesavage JA. Geriatric depression scale. Psychopharmacol Bull. 1988;24(4):709–11.PubMed
52.
Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989;46(10):1121–3.PubMedCrossRef
53.
Marin RS, Biedrzycki RC, Firinciogullari S. Reliability and validity of the Apathy Evaluation Scale. Psychiatry Res. 1991;38(2):143–62.PubMedCrossRef
54.
Espie CA, Kyle SD, Hames P, et al. The sleep condition indicator: a clinical screening tool to evaluate insomnia disorder. BMJ Open. 2014;4(3):e004183.PubMedPubMedCentralCrossRef
55.
Herdman M, Gudex C, Lloyd A, et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res. 2011;20(10):1727–36.PubMedPubMedCentralCrossRef
56.
Jenkinson C, Fitzpatrick R, Crocker H, Peters M. The Stroke Impact Scale: validation in a UK setting and development of a SIS short form and SIS index. Stroke. 2013;44(9):2532–5.PubMedCrossRef
57.
Whoqol Group. Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med. 1998;28(3):551–8.CrossRef
58.
Al-Janabi HN, Flynn T, Coast J. Development of a self-report measure of capability wellbeing for adults: the ICECAP-A. Qual Life Res. 2012;21:167–76.PubMedCrossRef
59.
60.
Brown LM, Schinka JA. Development and initial validation of a 15-item informant version of the geriatric depression scale. Int J Geriatr Psychiatry. 2005;20(10):911–8.PubMedCrossRef
61.
Jorm AF, Jacomb PA. The informant questionnaire on cognitive decline in the elderly (IQCODE): sociodemographic correlates, reliability, validity and some norms. Psychol Med. 1989;19(4):1015–22.PubMedCrossRef
62.
63.
Van Buuren S, Groothuis-Oudshoorn K. mice: multivariate imputation by chained equations in R. J Stat Softw. 2011;12(45):1–67.
64.
Shi D, Chen X, Li Z. Diagnostic test accuracy of the Montreal Cognitive Assessment in the detection of post-stroke cognitive impairment under different stages and cutoffs: a systematic review and meta-analysis. Neurol Sci. 2018;39:705–16.PubMedCrossRef
65.
Janssen MF, Pickard AS, Shaw JW. General population normative data for the EQ-5D-3L in the five largest European economies. Eur J Health Econ. 2021;22(9):1467–75.PubMedPubMedCentralCrossRef
66.
Wu CY, Hung SJ, Lin KC, Chen KH, Chen P, Tsay PK. Responsiveness, minimal clinically important difference, and validity of the MoCA in stroke rehabilitation. Occup Ther Int. 2019;2019(2517658):662–73.
67.
Dromerick AW, Edwards DF, Diringer MN. Sensitivity to changes in disability after stroke: a comparison of. J Rehabil Res Dev. 2003;40(1–4):1–8.PubMedCrossRef
68.
Chen P, Lin KC, Liing RJ, Wu CY, Chen CL, Chang KC. Validity, responsiveness, and minimal clinically important difference of EQ-5D-5L in stroke patients undergoing rehabilitation. Qual Life Res. 2016;25:1585–96.PubMedCrossRef
69.
Lemay KR, Tulloch HE, Pipe AL, Reed JL. Establishing the minimal clinically important difference for the hospital anxiety and depression scale in patients with cardiovascular disease. J Cardiopulm Rehabil Prev. 2019;39(6):E6-11.PubMedCrossRef
70.
Vinkers DJ, Gussekloo J, Stek ML, Westendorp RG, Van Der Mast RC. The 15-item Geriatric Depression Scale (GDS-15) detects changes in depressive symptoms after a major negative life event. The Leiden 85-plus Study. Int J Geriatric Psychiatry. 2004;19(1):80–4.CrossRef
71.
Rooney S, McFadyen A, Wood L, Moffat F, Paul L. Minimally important difference of the fatigue severity scale and modified fatigue impact scale in people with multiple sclerosis. Multiple Sclerosis Relat Disord. 2019;1(35):158–63.CrossRef
72.
Espie CA, Farias Machado P, Carl JR, Kyle SD, Cape J, Siriwardena AN, Luik AI. The Sleep Condition Indicator: reference values derived from a sample of 200 000 adults. J Sleep Res. 2018;27(3):e12643.PubMedCrossRef
73.
Douiri A, Rudd AG, Wolfe CD. Prevalence of poststroke cognitive impairment: South London stroke register 1995–2010. Stroke. 2013;44(1):138–45.PubMedCrossRef
74.
Mahon S, Parmar P, Barker-Collo S, Krishnamurthi R, Jones K, Theadom A, Feigin V. Determinants, prevalence, and trajectory of long-term post-stroke cognitive impairment: results from a 4-year follow-up of the ARCOS-IV study. Neuroepidemiology. 2017;49(3–4):129–34.PubMedCrossRef
75.
Sensenbrenner B, Rouaud O, Graule-Petot A, Guillemin S, Piver A, Giroud M, Béjot Y, Jacquin-Piques A. High prevalence of social cognition disorders and mild cognitive impairment long term after stroke. Alzheimer Dis Assoc Disord. 2020;34(1):72–8.PubMedCrossRef
76.
Rohde D, Gaynor E, Large M, Mellon L, Bennett K, Williams DJ, Brewer L, Hall P, Callaly E, Dolan E, Hickey A. Cognitive impairment and medication adherence post-stroke: a five-year follow-up of the ASPIRE-S cohort. PLoS One. 2019;14(10):e0223997.PubMedPubMedCentralCrossRef
77.
Delavaran H, Jönsson AC, Lövkvist H, Iwarsson S, Elmståhl S, Norrving B, Lindgren A. Cognitive function in stroke survivors: a 10-year follow-up study. Acta Neurol Scand. 2017;136(3):187–94.PubMedCrossRef
78.
Barker-Collo S, Starkey N, Lawes CM, Feigin V, Senior H, Parag V. Neuropsychological profiles of 5-year ischemic stroke survivors by Oxfordshire stroke classification and hemisphere of lesion. Stroke. 2012;43(1):50–5.PubMedCrossRef
79.
Schaapsmeerders P, Maaijwee NA, van Dijk EJ, Rutten-Jacobs LC, Arntz RM, Schoonderwaldt HC, Dorresteijn LD, Kessels RP, de Leeuw FE. Long-term cognitive impairment after first-ever ischemic stroke in young adults. Stroke. 2013;44(6):1621–8.PubMedCrossRef
80.
Turunen KE, Laari SP, Kauranen TV, Uimonen J, Mustanoja S, Tatlisumak T, Poutiainen E. Domain-specific cognitive recovery after first-ever stroke: a 2-year follow-up. J Int Neuropsychol Soc. 2018;24(2):117–27.PubMedCrossRef
81.
Nys GM, Van Zandvoort MJ, De Kort PL, Jansen BP, Van der Worp HB, Kappelle LJ, De Haan EH. Domain-specific cognitive recovery after first-ever stroke: a follow-up study of 111 cases. J Int Neuropsychol Soc. 2005;11(7):795–806.PubMedCrossRef
82.
Ayerbe L, Ayis S, Crichton S, Wolfe CD, Rudd AG. The natural history of depression up to 15 years after stroke: the South London Stroke Register. Stroke. 2013;44(4):1105–10.PubMedCrossRef
83.
Lapin BR, Thompson NR, Schuster A, Katzan IL. Magnitude and variability of stroke patient-proxy disagreement across multiple health domains. Arch Phys Med Rehabil. 2021;102(3):440–7.PubMedCrossRef
84.
85.
86.
Hinkle JL, Becker KJ, Kim JS, Choi-Kwon S, Saban KL, McNair N, Mead GE. Poststroke fatigue: emerging evidence and approaches to management: a scientific statement for healthcare professionals from the American Heart Association. Stroke. 2017;48(7):e159–70.PubMedCrossRef
87.
88.
89.
Baylor C, Yorkston KM, Jensen MP, Truitt AR, Molton IR. Scoping review of common secondary conditions after stroke and their associations with age and time post stroke. Top Stroke Rehabil. 2014;21(5):371–82.PubMedCrossRef
90.
Ilse IB, Feys H, De Wit L, Putman K, De Weerdt W. Stroke caregivers’ strain: prevalence and determinants in the first six months after stroke. Disabil Rehabil. 2008;30(7):523–30.PubMedCrossRef
91.
Rigby H, Gubitz G, Phillips S. A systematic review of caregiver burden following stroke. Int J Stroke. 2009;4(4):285–92.PubMedCrossRef
92.
Denham AM, Wynne O, Baker AL, Spratt NJ, Loh M, Turner A, Magin P, Bonevski B. The long-term unmet needs of informal carers of stroke survivors at home: a systematic review of qualitative and quantitative studies. Disabil Rehabil. 2022;44(1):1–2.PubMedCrossRef
93.
Calamia M, Markon K, Tranel D. Scoring higher the second time around: meta-analyses of practice effects in neuropsychological assessment. Clin Neuropsychol. 2012;26(4):543–70.PubMedCrossRef
94.
95.
Lugtmeijer S, Lammers NA, de Haan EH, de Leeuw FE, Kessels RP. Post-stroke working memory dysfunction: a meta-analysis and systematic review. Neuropsychol Rev. 2021;31:202–19.PubMedCrossRef
96.
97.
98.
99.
100.
101.
102.
Lammers NA, Van Wanrooij LL, van Dalen JW, van Gool WA, Schmand B, Moll van Charante EP, de Haan EH, Van de Beek D, Nederkoorn PJ, Richard E. The course of post-stroke apathy in relation to cognitive functioning: a prospective longitudinal cohort study. Aging Neuropsychol Cogn. 2021:1–2.
103.
104.
Ward NS, Brander F, Kelly K. Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme. J Neurol Neurosurg Psychiatry. 2019;90(5):498–506.PubMedCrossRef
105.
106.
107.
Webb SS, Carrick C, Kusec A, Demeyere N. Introducing the Tele-OCS: A validated remotely administered version of The Oxford Cognitive Screen. Health Open Res. 2023;5(8):8.CrossRef
108.
Chapman JE, Gardner B, Ponsford J, Cadilhac DA, Stolwyk RJ. Comparing performance across in-person and videoconference-based administrations of common neuropsychological measures in community-based survivors of stroke. J Int Neuropsychol Soc. 2021;27(7):697–710.PubMedCrossRef
Metadata
Title
Long-term psychological outcomes following stroke: the OX-CHRONIC study
Authors
Andrea Kusec
Elise Milosevich
Owen A. Williams
Evangeline G. Chiu
Pippa Watson
Chloe Carrick
Bogna A. Drozdowska
Avril Dillon
Trevor Jennings
Bloo Anderson
Helen Dawes
Shirley Thomas
Annapoorna Kuppuswamy
Sarah T. Pendlebury
Terence J. Quinn
Nele Demeyere
Publication date
01-12-2023
Publisher
BioMed Central
Published in
BMC Neurology / Issue 1/2023
Electronic ISSN: 1471-2377
DOI
https://doi.org/10.1186/s12883-023-03463-5

Other articles of this Issue 1/2023

BMC Neurology 1/2023 Go to the issue

Research

The value of elevated cerebrospinal fluid lactate concentrations in post-neurosurgical bacterial meningitis

Case report

A case report on recurrent alternating Tolosa-Hunt syndrome due to bacterial sphenoid sinusitis: rediscussing the diagnostic terminology and classification

Research

Underlying causes of cryptogenic stroke and TIA in the nordic atrial fibrillation and stroke (NOR-FIB) study – the importance of comprehensive clinical evaluation

Research

Elevated RANTES levels are associated with increased risk of cerebral atherosclerotic stenosis

Research

Investigating cognitive reserve, symptom resolution and brain connectivity in mild traumatic brain injury

Review

Current evidence for J147 as a potential therapeutic agent in nervous system disease: a narrative review