Predictors of health-related quality of life and participation after brain injury rehabilitation: The role of neuropsychological factors.

The aims of this longitudinal study were: (1) to assess associations between neuropsychological factors and health-related quality of life (HRQoL) and participation three months after discharge from inpatient acquired brain injury (ABI) rehabilitation; and (2) to determine the best neuropsychological predictor of HRQoL and participation after controlling for demographic and injury-related factors. Patients with ABI (n = 100) were assessed within approximately two weeks of enrolment in inpatient rehabilitation. Predictor variables included demographic and injury-related characteristics and the following neuropsychological factors: active and passive coping, attention, executive functioning, verbal memory, learning potential, depressive symptoms, motivation, extraversion, neuroticism and self-awareness. Bivariate analyses revealed that passive coping, executive functioning, depressive symptoms, extraversion, and neuroticism were significantly associated with HRQoL and/or participation. Neuropsychological factors significantly explained additional variance in HRQoL (18.1-21.6%) and participation (6.9-20.3%) after controlling for demographic and injury-related factors. However, a higher tendency towards passive coping was the only significant neuropsychological predictor (ß = -0.305 to -0.464) of lower HRQoL and participation. This study shows that neuropsychological functioning, and in particular passive coping, plays a role in predicting HRQoL and participation after inpatient ABI rehabilitation and emphasises the importance of addressing patients' coping styles in an early phase of ABI rehabilitation.

Course of cognitive functioning during stroke rehabilitation.

The aim of the study was to determine the course of cognitive functioning within the subacute phase (< 4 months) after stroke during rehabilitation. Stroke patients admitted to a rehabilitation centre were submitted to a neuropsychological examination on admission (1 month post-stroke) and upon discharge (4 months post-stroke). Cognitive domains studied were attention, executive functioning, memory, and visual attention. Forty-two patients (mean age = 57.1 years; SD = 7.7) participated. At admission more than half of the patients showed deficits in attention and memory. Patients improved significantly on these domains; the largest improvement was seen in the domain of visual attention, while executive functioning did not improve significantly. A differential course of cognitive functioning was found in the subacute phase after stroke. The prognosis of visual attention is the most prominent.

Depressive symptoms and executive functioning in stroke patients: a follow-up study.

BACKGROUND: Cognitive and emotional sequellae are commonly observed in stroke patients and these symptoms often co-occur. Diagnosis can be difficult since symptoms of depression and executive dysfunction overlap. OBJECTIVE: To study the longitudinal relationship between depressive symptoms and executive dysfunction in stroke patients. METHODS: The study comprises of 116 first-ever stroke patients who were followed-up for 2 years and who were assessed for emotional and cognitive sequellae after 1, 6, 12, and 24 months. Emotional disturbances were evaluated using the SCL-90 depression subscale. Executive functions were assessed using compound scores of a combination of the interference scores of the Stroop Colour Word Test and the Concept Shifting Test. RESULTS: Twenty-five patients suffered from both depressive symptoms and executive dysfunction, 28 patients were depressed with no signs of executive dysfunction, and 13 patients showed executive dysfunction with no depressive symptoms. Patients with executive dysfunction had higher mean SCL-90-D scores compared to patients with no executive dysfunction (30.9 (SD 11.7) versus 26.2 (SD 11.1, p = 0.037). Depressive symptoms were predictive for executive dysfunction in a regression analysis corrected for age, sex, and diabetes mellitus but not after additional correction for pre-existent brain damage and other vascular risk factors. After 2 years 66.6 and 53.3% of patients with both depressive symptoms and executive dysfunction at baseline still had depressive symptoms and executive dysfunctions respectively and had worse prognostic outcome than patients with depressive symptoms or executive dysfunction alone. CONCLUSIONS: Symptoms of depression and executive dysfunction are highly prevalent in stroke patients and often co-occur. These patients are more at risk for poor stroke outcome, chronic depression, and cognitive deterioration.

A one-year follow-up study into the course of depression after stroke.

BACKGROUND: Stroke patients commonly suffer from neuropsychiatric disorders, such as depression, that negatively influence stroke outcome. Diagnosis, treatment and prevention of post-stroke psychiatric disorders including depression are under debate. OBJECTIVE: To study the course of depression after stroke. METHODS: One hundred and ninety first-ever stroke patients were screened for depressive symptoms at 1, 3, 6, 9, and 12 months after stroke. Diagnosis of depression was made according to the DSM-IV criteria of major and minor depression. RESULTS: Follow-up was completed in 138 patients. The cumulative incidence of post-stroke depression (PSD) in 1 year was 36.2%. One month after stroke the prevalence of PSD was 18.8%. Thirty percent of patients who were depressed in the first three months did not reach cut-off levels on depression screening instruments at the following assessments. In 44% of these patients symptoms recurred. Recurrent cases were older than patients with limited disease. In 40% of PSD patients depression persisted for at least two consecutive following follow-up visits. Persistent cases were more disabled and suffered more often from major depression. CONCLUSION: Half of PSD patients become depressed within the first month after stroke. Although most patients recover, a clinician has to be aware that symptoms can recur especially in older patients and that in patients with major depression symptoms may be persistent. In these patients treatment should be considered, whereas in patients with limited disease an observational approach may suffice.

The effect of the APOE-epsilon4 allele and ACE-I/D polymorphism on cognition during a two-year follow-up in first-ever stroke patients.

BACKGROUND: Cognitive impairment is commonly observed after stroke and has a negative impact on survival and rehabilitation. Some stroke patients deteriorate in cognitive functioning whereas others do not. Environmental and demographic risk factors cannot fully explain this. There is growing evidence that a genetic predisposition plays a role in the pathogenesis of post-stroke cognitive decline. OBJECTIVE: To study the influence of the APOE-epsilon4 allele and the ACE-I/D polymorphism on cognitive functioning after stroke. METHODS: We included 194 first-ever stroke patients of whom information about APOE genotyping and ACE-I/D polymorphism was available in 92 and 129 patients, respectively. Patients were cognitively assessed at 1, 6, 12 and 24 months after the event. Linear mixed models with slope estimates were used to study the influence of the APOE-epsilon4 allele and the ACE-I/D polymorphism on the MMSE score, CAMCOG, executive functioning, psychomotor speed, and verbal memory function during follow-up. RESULTS: Patients carrying the APOE-epsilon4 allele more often suffered a lacunar infarction than non-carriers. The APOE-epsilon4 allele had no effect on cognitive functioning during the follow-up. ACE-DD homozygosity was associated with a worse performance in executive functioning compared to patients with neither an APOE-epsilon4 allele nor the ACE-DD genotype. There was no interaction between the APOE-epsilon4 allele and the ACE-DD phenotype in the prediction of cognitive decline. CONCLUSION: The ACE-DD genotype may be associated with post-stroke cognitive decline while the APOE-epsilon4 allele is not. Further research is needed to examine the role of genetic risk factors for post-stroke cognitive decline and to determine why some patients deteriorate cognitively after stroke but others do not.

Effectiveness of a low intensity outpatient cognitive rehabilitation programme for patients in the chronic phase after acquired brain injury.

The aim of this prospective cohort study was to examine the effectiveness of a low intensity outpatient cognitive rehabilitation programme for patients with acquired brain injury in the chronic phase. Twenty-seven patients with acquired brain injury (i.e., stroke, traumatic brain injury, subarachnoid haemorrhage; 52% male) with a mean age of 49.5 (SD 9.2) years and 25 relatives with a mean age of 48.8 (SD 8.8) years were recruited to the study. Mean time since injury in the patient group was 1.9 years (SD 2.0). The group programme consisted of 15 weekly sessions of 2.5 hours and included cognitive strategy training, social skills training, and psycho-education. Patients also received homework. Relatives were invited to attend twice. Repeated measurements were taken: prior to treatment (baseline, T0); directly after treatment (T1, 21 weeks); and at follow-up (T2, 45 weeks). Primary outcome measures were individualised goals (GAS), cognitive failures (CFQ), and quality of life (SA-SIP). Patients did improve significantly on individual goals (p < .05) between T0 and T1 and the level of attainment remained stable between T1 and T2. Goals were mostly set in the cognitive and behavioural domains. There were no significant differences between the measurements (T0-T1-T2) on the CFQ and the SA-SIP. The programme had a positive effect on the individual goals set by the patients. However, this did not result in a higher participation level or a better quality of life. This may be due to the low intensity and short duration of the programme.

The symptomatology of post-stroke depression: comparison of stroke and myocardial infarction patients.

BACKGROUND: Depression is a frequent problem in stroke patients but, all too often, the problem goes unrecognized. How depression-like symptoms in post-stroke depression (PSD) should be interpreted is still subject to debate. If PSD has a distinct symptom profile of depression accompanying other chronic vascular somatic conditions then this could imply that PSD is a specific disease entity. OBJECTIVE: To study whether depressed stroke patients exhibit other signs and symptoms than patients suffering from depression after myocardial infarction (MI). METHODS: Depressive signs and symptoms were measured using the Hospital Anxiety and Depression Scale and the 17-item Hamilton Depression Rating Scale. The results of 190 stroke patients were compared with the results of 198 MI patients every 3 months during the first year after the event. RESULTS: Depressed stroke patients exhibited more loss of interest, psychomotor retardation, and gastro-intestinal complaints as compared to depressed MI patients. However, in multivariate analyses including both depressed and non-depressed stroke and MI patients, no specific symptom profile was found to differentiate between the two depressive syndromes by looking at the modifying effect of stroke vs MI on the occurrence of specific symptoms in depression. CONCLUSION: Although in their clinical presentation, depressed stroke patients exhibit a symptom profile different from depressed MI patients, this is not due to differences in the depressive syndrome in these two patient groups but it reflects differences between stroke and MI patients in general.

Cognitive-behavioural intervention for depression after stroke: five single case studies on effects and feasibility.

The purpose of the study was to investigate whether or not a cognitive-behavioural intervention for depression after stroke has an effect and is feasible. A single-subject quasi experimental design (SSED) was used with an AB design and follow-up. The participants were five first episode stroke patients attending outpatient rehabilitation in a rehabilitation centre in The Netherlands. Mood and quality of life were measured on four occasions over four weeks (baseline phase A). During the eight week intervention phase (B) a visual analogue measure of mood was administered three times a week. Immediately after the intervention, and one and three months later, the baseline measures were repeated. The intervention (phase B) was based on cognitive-behavioural principles: recognising negative thoughts and challenging them, learning principles of relaxation, and planning of pleasurable activities. Following intervention three patients reported they had improved, three patients reported a minor improvement in quality of life, and four patients reported a more positive mood. Three months later three patients reported fewer depressive symptoms. Both patients and therapist were positive about the intervention and three months later, in daily life, all patients still applied the strategies. It was concluded that despite some ambiguous results, it seems that the cognitive-behavioural intervention has an effect on patients' mood. The intervention was rated as feasible by both patients and therapists.

Vascular mild cognitive impairment is highly prevalent after lacunar stroke but does not increase over time: a 2-year follow-up study.

UNLABELLED: Although ample research has been done into cognitive disorders occurring after stroke, relatively few data are available on the development and the course of vascularmild cognitive impairment (VMCI) after first-ever lacunar stroke. METHODS: A cohort of 95 patients with a first-ever symptomaticlacunar infarct, older than 40 years, MMSE>or=15 and no other neurological or major psychiatric deficits were included. Patients were assessed (clinically and with a neuropsychological test battery) at 1 and 24 months after stroke, and CT was repeated. VMCI was diagnosed when patients had a deficit in at least one cognitive domain, in the absence of dementia. RESULTS: Approximately 75% of the patients had VMCI at 1 month; this percentage was somewhat lower at 2 years. Only initial stroke severity was an independent predictor of VMCI after stroke. CONCLUSION: VMCI is highly prevalent after lacunar stroke, but does not increase during the first 2 years thereafter.

Checklist for cognitive and emotional consequences following stroke (CLCE-24): development, usability and quality of the self-report version.

OBJECTIVE: In this paper a new checklist (CLCE-24) for identification of cognitive and emotional problems after stroke is presented. The CLCE-24 is intended to support a clinical interview by health care professionals other than the trained (neuro)psychologist. METHODS: Patients were interviewed with the CLCE-24, 6 months post stroke. Usability was determined by interviews. Quality of the self-report version was determined using reference instruments (MMSE, CAMCOG). RESULTS: Sixty-nine patients participated in the study (37 men; mean age 66 years). Both patients and assessors were positive about the use of the CLCE-24. Eighty percent of the patients had cognitive and/or emotional problems (73% cognitive; 51% emotional problems). Patients with complaints on the CLCE-24 also showed problems on the MMSE and the CAMCOG (p<0.05). The CLCE-24 was a predictor of the MMSE and CAMCOG (Adj. R(2)=0.13 and 0.16, respectively) at 12 months post stroke. Internal consistency of the CLCE-24 was good (alpha of 0.81). CONCLUSIONS: The CLCE-24 is a usable and valid instrument for cognitive screening by health care professionals in the stroke service in the chronic phase after stroke.

Long-term neuropsychological performance in a cohort of children and adolescents after severe paediatric traumatic brain injury.

OBJECTIVE: The purpose of the present study was to evaluate progress in neuropsychological performance in children and adolescents with severe paediatric traumatic brain injury (TBI), from admission to the rehabilitation centre up to 3-12 years after the trauma. METHODS: Children and adolescents (n = 31, mean age at injury 11.8 years, SD = 3.8; at follow-up 18.8 years; SD = 4.5) who all had suffered a TBI participated. A comprehensive neuropsychological test battery was administered at the start of rehabilitation (T1), around discharge (T2) and in the long-term (at least 3 years after rehabilitation; T3). T1 and T2 were clinical assessments; T3 was executed as a follow-up measurement for this study. RESULTS: At T1 and T2, most problems were in the domains of attention, memory and executive functioning. At the start of rehabilitation most deficits were with performal intelligence (61%); at discharge (mean length of stay 411 days) considerably less children had severe deficits on the intelligence domain (23%). At long-term follow-up, most problems were in the domains attention, mental speed and memory. From admission to discharge 42% of the children improved on two or more cognitive tests; from discharge to follow-up this percentage was 13%. CONCLUSIONS: In this unique study a clinical cohort of children with severe TBI was followed for many years after injury. Most cognitive deficits were found in the early phase of rehabilitation. Most children did improve on cognitive functioning (40%) during the first year after their injury, whereas at follow-up most children had not changed. At follow-up, more than half of the children (54%) attended a regular school or had a regular job, corresponding to their age and pre-morbid functioning.

[Checklist for the detection of cognitive and emotional consequences after stroke (CLCE-24)]. / CheckLijst voor het opsporen van cognitieve en emotionele gevolgen na een beroerte (CLCE-24).

BACKGROUND AND PURPOSE: Cognitive and emotional problems are common after stroke and screening is essential. In this paper a new screening instrument is presented and its usability is investigated. METHODS: A group of stroke patients (N = 69) were interviewed using the new instrument, the CLCE-24, six months post stroke. Moreover extensive neuropsychological testing was conducted (including MMSE/CAMCOG). RESULTS: Patients, relatives and assessors (a psychologist) were positive about its use. The interview with the CLCE-24 took 11.1 minutes on average (5-35 minutes). Eighty percent of the patients had complaints; 73% had cognitive problems, while 51% had emotional problems. Patients with at least one complaint on the CLCE-24 scored lower on the MMSE (t=2.5; p = 0.01) and the CAMCOG (t= 2.5; p= 0.02) compared to patients without complaints. CONCLUSIONS: The CLCE-24 can be applied by professionals in primary care for identification of cognitive and emotional complaints after stroke. Further research and implementation in clinical practice and the stroke service is recommended.

Cognitive performance after first ever stroke related to progression of vascular brain damage: a 2 year follow up CT scan study.

BACKGROUND: Stroke is one of the most common causes of cognitive impairment in the elderly. Ischaemic brain damage (white matter lesions and silent infarcts) progresses in a substantial number of stroke patients. The aim of this study was to investigate whether the progression of ischaemic brain damage is associated with cognitive functioning after first ever stroke. METHODS: A total of 101 stroke patients were followed up for 2 years. Neuropsychological functioning was assessed at 1, 6, 12, and 24 months after stroke. Computed tomography was performed on all patients at baseline and 2 years after stroke. Progression in white matter lesions and (silent) infarcts was recorded. RESULTS: Patients with progressive vascular brain damage performed worse on cognitive tasks, both 1 and 24 months after stroke, yet change in cognitive functioning was not different from that of patients without progressive vascular damage. During the follow up, improvement was noticed on most cognitive domains. CONCLUSIONS: Although patients with progressive vascular brain damage after a first stroke performed somewhat worse on cognitive tests than those without such damage, both groups showed an improved or stable performance 2 years later. Thus, there is not a simple relation between progression of ischaemic brain damage and decline in cognitive functioning after first ever stroke.

The effect of different diagnostic criteria on the prevalence and incidence of post-stroke dementia.

There is little agreement about the prevalence and incidence of vascular dementia (VaD) mainly because investigators have used different diagnostic criteria. The aim of this study was to examine the influence of different diagnostic criteria on the prevalence and cumulative incidence of VaD in first-ever stroke patients (n = 194) clinically evaluated at 1, 6, 12, and 24 months after stroke. Post-stroke VaD was diagnosed using the DSM-III, DSM-III-R, DSM-IV, ICD-10-NA, NINDS-AIREN, and ADDTC criteria. The prevalence of dementia was highest at 1 month; ranging from 11.3% with the NINDS-AIREN to 20.1% with the ICD-10-NA. The incidence was highest at 6 months, ranging from 2.6% with the ADDTC to 5.2% with the ICD-10-NA. Agreement among diagnostic criteria was high, with the exception of the ADDTC. In conclusion, both the prevalence and incidence of dementia are highest directly after stroke, but exact rates are influenced by the diagnostic criteria used.

Predictors of reversible mild cognitive impairment after stroke: a 2-year follow-up study.

UNLABELLED: Many studies have investigated mild cognitive impairment (MCI) in the context of prodromal dementia, but few have investigated recovery from MCI. The aim of this study was to determine the prevalence of reversible MCI after stroke and to identify factors related to recovery. METHODS: One hundred and eighteen patients with a first ever cerebral stroke were followed up for 2 years. Neuropsychological assessment was performed at 1, 6, 12, and 24 months poststroke. Possible predictors of reversible MCI were demographic variables, baseline MMSE scores, presence of stroke risk factors, and CT variables. Poststroke MCI was diagnosed when there was a deficit in at least one cognitive domain, without their being demented. Recovery was considered when MCI was no longer present. RESULTS: Twenty-four (20.3%) patients were classified as having permanent reversible MCI and were compared with patients without recovery. Most patients recovered from MCI between the first and second assessments (19.7% versus 13.1% and 2.0% later on). Higher baseline MMSE scores and female sex were independent predictors of recovery (OR(High MMSE)=9.9; OR(female sex)=2.8). Neither stroke-related risk factors nor CT variables were predictors of favorable outcome. CONCLUSION: About 20% of patients with poststroke MCI recover from MCI. Higher MMSE scores at baseline and female sex are independent predictors of this recovery.

Predictive accuracy of MCI subtypes for Alzheimer's disease and vascular dementia in subjects with mild cognitive impairment: a 2-year follow-up study.

AIM: The aim of this study was to investigate the prognostic accuracy of different subtypes of mild cognitive impairment (MCI): amnestic MCI, multiple domain MCI, and single non-memory domain MCI, for the development of Alzheimer's dementia (AD) and vascular dementia (VaD). PATIENTS: Nondemented patients from a memory clinic cohort (n = 118), and a stroke cohort (n = 80, older than 55 years and with a cognitive impairment). RESULTS: 'Multiple domain MCI' had the highest sensitivity for both AD (80.8%) and VaD (100%), and 'amnestic MCI' had the highest specificity (85.9% for AD, 100% for VaD). The positive predictive value was low for all subtypes (0.0-32.7%), whereas the negative predictive value was high (72.8-100%). DISCUSSION: The subtype 'multiple domain MCI' has high sensitivity in identifying people at risk for developing AD or VaD. The predictive accuracy of the MCI subtypes was similar for both AD and VaD.

Demographic and CT scan features related to cognitive impairment in the first year after stroke.

OBJECTIVE: Little is known about the relation between stroke related features and cognitive performance over time when stroke patients with dementia or less severe cognitive disorders are considered separately. We aimed to study the features (computed tomography (CT) scan and demographic) that could be related to vascular cognitive impairment one, six, and 12 months after stroke. METHODS: A total of 176 patients with a first-ever brain infarct, a Mini Mental State Examination score > or = 15, age older than 40 years, and without pre-stroke dementia and other neurological or psychiatric disorders participated in this study. The following CT scan features were recorded: side of infarct, lacunar or territorial infarct, white matter lesions, silent infarcts, and brain atrophy. The demographic features studied were: age, level of education, and sex. Univariate and multivariate logistic regression analyses were performed to compare the three groups of patients (patients with dementia, patients with vascular cognitive impairment (VCI), and patients with vascular mild cognitive impairment (MCI)) with patients without cognitive disorders. RESULTS: At one month none of the variables were predictors of dementia; at six months older age (odds ratio (OR) 9.4), low education (OR 14.7), and territorial infarct (OR 10.6) predicted dementia; and at 12 months low education (OR 8.7) and pre-stroke cerebrovascular damage (OR 7.4) predicted dementia. Predictors of VCI were low education (OR 3.4) and territorial infarct (OR 2.4) at one month post stroke; older age (OR 4.3) and low education (OR 4.1) at six months; and older age (OR 3.5) at 12 months. Predictors of vascular MCI were low education (OR 4.96) and territorial infarct (OR 3.58) at one month; and older age and lower education at six months (OR 3.4 and 3.7, respectively) and at 12 months (OR 3.5 and 2.28, respectively). CONCLUSIONS: Territorial infarct, older age, and low educational level are predictors of cognitive disorders after stroke.

Vascular cognitive disorders: memory, mental speed and cognitive flexibility after stroke.

This study investigated the occurrence of cognitive disorders 1 and 6 months after stroke in a cohort of patients with a first-ever stroke. In addition, it was investigated whether age, sex and level of education are risk factors for vascular cognitive disorders. Memory, simple speed, cognitive flexibility and overall cognitive functioning were examined in 139 patients at 1 and 6 months post-stroke. Inclusion criteria on admission were first cerebral stroke, age>/=40, no other neurological or psychiatric disorders and ability to communicate. Mean age was 69.3 years (S.D.=12.3). Patients were compared with a healthy control group matched for age, sex and level of education. A large group of patients who, at 1 month after stroke, scored below the cutoff on cognitive domains, scored above the cutoff on most of these cognitive domains at 6 months. For overall cognitive functioning, 16 out of 39, for memory, 13 out of 26 and for cognitive flexibility, 15 out of 49 patients, who at 1 month scored below the cutoff, scored above the cutoff at 6 months. Simple speed did not change; 12 patients scored above the cutoff and 7 patients scored below the cutoff at 6 months after stroke. Speaking in terms of improvement or deterioration, most people remained stable on the four cognitive domains (ranging from 37.6% to 83.5%), and a substantial group improved (ranging from 12.9% to 52.1%). Older and female patients had more cognitive disturbances. Overall, the conclusion is that the prognosis of cognitive functioning after stroke is general favourable, especially in younger patients.

Psychobiological research on Dissociative Identity Disorder (DID): A methodological note.

BACKGROUND: To a large extent, discussions about dissociative identity disorder (DID) revolve around the way in which identity states (alters) that are thought to be typical for this condition should be interpreted: are they metaphors or are they genuine actors? Recent literature offers some fine examples of studies demonstrating that alters differ in their physiological profile. On the basis of this type of evidence, some authors have concluded that alters are more than just metaphors. OBJECTIVE: Drawing upon an experimental example, we argue that such a line of reasoning is highly problematic. METHOD & RESULTS: Our example demonstrates that normal subjects are perfectly able to simulate alters such that these alters are accompanied by different physiological profiles. This is especially true for subjects scoring high on fantasy proneness. CONCLUSIONS: Psychobiological research on DID should include normal controls, preferably controls who are fantasy prone. Unless such a strategy is adopted, psychobiological research on alter activity will not be very informative.