A cohort study on anxiety and perceived recovery 3 and 12 months after mild to moderate stroke

BackgroundAnxiety is a common complication of stroke, affecting one in every three stroke survivors. Stroke recovery is a dynamic process, with most recovery occurring within the first 3 months. However, how anxiety affects this dynamic remains unknown. Therefore, this study aimed to investigate how anxiety affects perceived recovery at 3 and 12 months after stroke. Additionally we also examined the change in perceived stroke recovery from 3 to 12 months and its relationship with anxiety.MethodsIn this longitudinal study patients with stroke were enrolled at Sahlgrenska University Hospital, Gothenburg, Sweden. The Hospital Anxiety and Depression Scale was used to assess anxiety, and the Stroke Impact Scale was used to assess perceived recovery 3 and 12 months after the stroke. The difference in perceived stroke recovery between the anxiety and no-anxiety groups at 3 and 12 months was analyzed. Changes in perceived stroke recovery were calculated and trichotomized from 3 to 12 months based on clinically significant positive changes (+10 points or more), clinically important negative changes (−10 points or less), or no changes (±9). At 3 and 12 months after the stroke, negative and positive recovery was compared to no change in recovery regarding anxiety scores.ResultsThis study included 99 patients (44.4% female, median age, 77 years). At 3 and 12 months after the stroke, the median recovery score was 80 out of 100. At 3- and 12-months 17.6 and 15.7% of the patients experienced anxiety, respectively. At both time points, there was a significant association between anxiety and lower perceived stroke recovery (at 3 months: p < 0.001; and 12 months p = 0.002). Among participants with anxiety at 3 or 12 months after stroke, a positive change in recovery from 3 to 12 months was identified (3 months, p = 0.004 and 12 months, p = 0.0014).ConclusionAnxiety symptoms following a stroke are associated with lower levels of perceived stroke recovery for at least 1 year after the stroke. Identifying patients with anxiety early after stroke may be beneficial for identifying those at risk of lower recovery.Clinical trial registration:ClinicalTrials.gov, identifier [NCT01622205]. Registered on June 19, 2012 (retrospectively registered)

Feasibility of Cognitive Functions Screened With the Montreal Cognitive Assessment in Determining ADL Dependence Early After Stroke

Objective: To investigate the feasibility of assessing cognitive function using the Montreal Cognitive Assessment (MoCA) given 36–48 h post stroke to explain dependence in activities of daily living (ADL).Methods: This is a cross-sectional, exploratory study. Cognitive function and basic ADL were assessed with the MoCA and the Barthel Index (BI), respectively, within 36–48 h of admission. Neurological functions were assessed with the National Institute of Health Stroke Scale (NIHSS) upon admittance to the hospital. Binary logistic regression analyses were performed to assess the feasibility of the MoCA in explaining ADL dependence.Results: Data were available for 550 patients (42% females, mean age 69 years). Moderate correlations (rs > +0.30, p < 0.001) were found between the total score on the BI, MoCA, and visuospatial/executive functions. The regression analysis model including only MoCA as an independent variable had a high sensitivity for explaining ADL dependence. However, the model with independent variables of MoCA, NIHSS, and age had the best area under the curve value (0.74).Conclusions: Cognitive functions assessed with the MoCA partly explain ADL dependence 36–48 h post stroke. Stroke-related neurological deficits and age should be additional considerations

Postural balance, anxiety and motor function after stroke, at a very early supported discharge with continued rehabilitation

The overall aim of this thesis was to investigate postural balance, anxiety and motor function the first year after stroke and whether postural balance, anxiety and motor function was different at the intervention of Very Early Supported Discharge (VESD) com-pared to routine discharge during the first year post stroke. Methods. In paper I a systematic review and a meta-analysis was performed in order to study presence of anxiety after stroke. Papers II and IV included material from the GOTVED-study (Gothenburg Very Early Supported Discharge study), a random-ised controlled study where 140 patients with stroke admitted to a stroke unit at Sahlgrenska University Hospital were consecutively included. Paper II investigated whether VESD affects the anxiety assessed with the Hospital Anxiety and Depression Scale (HADS) and the overall disability measured with the modified ranking scale (mRS) for the stroke patient compared with ordinary discharge routines. In paper III data from two different data sources was merged to investigate if there was any association between function in the affected arm and postural balance. The dependent variables were Berg Balance Scale (BBS) and Timed Up and Go (TUG). As in-dependent variable was Fugl-Meyer assessment-Upper extremity (FMA-UE) scale was used. In Paper IV the correlation between self-confidence in postural balance, observer assessed postural balance and anxiety during the first year after stroke was investi-gated. The impact of the intervention on the correlation was also examined. The self-confidence in postural balance was measured using the Fall Efficacy Scale (FES(S)). Postural balance was as-sessed with Berg Balance Scale (BBS) and Time Up and Go (TUG). Anxiety was assessed with HADS. Assessments were made 5 days after stroke onset, 1 day and 1 month after discharge, 3- and 12 months post stroke. Main results. The systematic review showed that the overall pooled prevalence of anxiety after stroke was 29.3 %. There was no difference in anxiety if you received VESD or ordinary rehabili-tation, but the VESD led to a faster improvement of overall disa-bility compared to ordinary rehabilitation. The motor function in the affected arm significantly correlated with the postural balance the first year post-stroke. There was a significant correlation be-tween self-confidence in postural balance and observer assessed postural balance. Between anxiety and self-confidence in postural balance, there was only a small correlation. Conclusions and clinical implications. Anxiety is common af-ter stroke with about a third of patients experiencing it in the first year. Since anxiety influence quality of life and is a predictor of depression, routine screening would be worth considering in the stroke care. VESD did not show any harm or unintendent effects, but on the contrary led to a faster improvement in overall disabil-ity. We therefore suggest that coordinated VESD for patients with mild to moderate stroke should be considered as part of the ser-vice from a stroke unit. The result that motor function in the af-fected arm associated with the postural balance in a late stage after stroke can be of clinical importance to be aware of in assessment and planning the rehabilitation of postural balance. Patients with mild stroke seemed able to assess their confidence in postural bal-ance, involved in daily activity performance, in line with observer assessed postural balance. Assessment of self-confidence can pro-vide important information useful in rehabilitation planning and support patients regarding physically active after discharge

Gothenburg very early supported discharge study (GOTVED) NCT01622205 : a block randomized trial with superiority design of very early supported discharge for patients with stroke

BACKGROUND: Stroke is the disease with the highest costs for hospital care and also after discharge. Early supported discharge (ESD) has shown to be efficient and safe and the best results with well-organised discharge teams and patients with less severe strokes. The aim is to investigate if very early supported discharge (VESD) for stroke patients in need for on-going individualised rehabilitation at home is useful for the patient and cost effective. METHODS/DESIGN: A randomized controlled trial comparing VESD with ordinary discharge. Inclusion criteria: confirmed stroke, >18 years of age, living within 30 min from the stroke unit, on day 2 0-16 points on the National institute of health stroke scale (NIHSS) and 50-100 points on the Barthel Index (BI), with BI 100 then the patient can be included if the Montreal Cognitive Assessment is < 26. Exclusion criteria are: NIHSS >16, BI < 50, life expectancy < 1 year, inability to speak or to communicate in Swedish. The inclusion occurs on day 4 and in block randomization of 20 and with blinded assessor. Primary outcome: levels of anxiety and depression. Secondary outcomes: independence, security, level of function, quality of health, needs of support in activities of daily living and caregiver burden. Power calculation is based on the level of anxiety and with a power of 80%, p-value 0.05 (2 sided test) 44 persons per group are needed. Data is gathered on co-morbidity, re-entry to hospital, mortality and a health economic analysis. Interviews will be accomplished with a strategic sample of 15 patients in the intervention group before discharge, within two weeks after homecoming and 3 months later. Interviews are also planned with 15 relatives in the intervention group 3 months after discharge. DISCUSSION: The ESD studies in the Cochrane review present hospital stays of a length that no longer exist in Sweden. There is not yet, to our knowledge, any study of early supported discharge with present length of hospital stay. Thus it is not clear if home rehabilitation nowadays without risks, is cost effective, or with the same patient usefulness as earlier studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT01622205