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CME / ABIM MOC / CE

Can Worsening Depression Precede Stroke in Older Adults?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 9/9/2022
  • Valid for credit through: 9/9/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

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    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, family medicine/primary care clinicians, internists, psychiatrists, neurologists, nurses/nurse practitioners, physician assistants, and other members of the healthcare team for patients with depression who may be at increased risk for stroke.

The goal of this activity is for learners to be better able to describe the trajectory of depressive symptoms several years before and after incident stroke, measured with the Center for Epidemiologic Studies Depression Scale (CES-D 8), according to an analysis of data from the English Longitudinal Study of Ageing (ELSA).

Upon completion of this activity, participants will:

  • Describe the trajectory of depressive symptoms several years before and after incident stroke, according to an analysis of data from ELSA
  • Determine clinical implications of the trajectory of depressive symptoms several years before and after incident stroke, according to an analysis of data from ELSA
  • Outline implications for the healthcare team


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News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Megan Brooks has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Formerly owned stocks in: AbbVie Inc.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Nurse Planner

  • Lisa Simani, APRN, MS, ACNP

    Associate Director, Accreditation and Compliance, Medscape, LLC

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    Lisa Simani, APRN, MS, ACNP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Can Worsening Depression Precede Stroke in Older Adults?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 9/9/2022

Valid for credit through: 9/9/2023

processing....

Clinical Context

Depression is common among patients with stroke, with cumulative incidence 39% to 52% within 5 years of stroke and risk 2- to 8-fold higher than in a reference population; however, depressive symptom trajectories before and after stroke are still unclear.

Although increased depressive symptoms after stroke may reflect psychological reaction to stroke and associated disability, or stroke-induced brain damage, high depression rates among stroke survivors may partly reflect changes preceding stroke. Recent studies have shown depression to be an independent risk factor for stroke incidence.

Study Synopsis and Perspective

Whereas symptoms of depression are known to intensify in patients who have recently experienced an incident stroke, it might also be true in such cases that the depression actually starts to worsen in the months or years before the stroke occurs, suggests a new study of adults 50 years and older.

"Stroke seems to alter the course of depressive symptoms in more complex ways than previously thought," Maria Blöchl, PhD, University of Münster, Germany, told Medscape Medical News.

"As commonly thought, depressive symptoms surge after stroke and remain elevated for several years. But we also showed that depressive symptoms slightly increase before the stroke, perhaps indicating incipient stroke," said Blöchl, who is lead author on the study published online July 13 in Neurology, with coauthor Steffen Nestler, PhD, also from the University of Münster.

Prestroke and Poststroke Depression

About 30% of stroke survivors might experience depression at any time after the acute event. The cumulative incidence within 5 years hovers around 39% to 52%, yet little is known about how changes in depressive symptoms unfold before and after incident stroke, the report states.

To investigate, Blöchl and colleagues identified the trajectory of depressive symptoms several years before and after incident stroke in 10,797 adults (mean age, 65 years; 55% women) from the English Longitudinal Study of Ageing (ELSA), an ongoing longitudinal cohort study.

The 425 case participants (3.9%) who experienced an incident stroke during a 12-year follow-up period were propensity-score matched with 4249 stroke-free individuals.

Every 2 years in the study, participants reported past-week depressive symptoms using the 8-item version of the widely used Center for Epidemiologic Studies Depression Scale (CES-D 8), in which higher scores on a 0- to 8-point scale indicate more depressive symptoms. For this study, a CES-D 8 score of at least 3 was used to indicate probable depression.

Starting about 2 years before stroke onset, the severity of depressive symptoms increased by an average of 0.33 points (P < .001), with a further increase of 0.23 points after stroke (P < .001). Depressive symptoms remained elevated for 10 years after stroke.

In contrast, the group reports, depressive symptoms remained relatively stable over time in stroke-free individuals.

There was no statistically significant difference in prevalence of probable depression at the 2-year prestroke assessment among persons with and without stroke (29% vs 24%). At the time of stroke, however, probable depression was significantly more common in the stroke group (34% vs 24%; P < .001), a difference that persisted at the 6-year assessment.

A Predictive Marker?

Blöchl cautioned that rising symptoms of depression before stroke are mostly subtle and might not always be clinically detectable, and it remains unclear whether such prestroke changes can be used to predict who will have a stroke, "[but even slight increases in depressive symptoms, especially mood and fatigue-related symptoms, may be a signal a stroke that is about to occur."

The clinical implications of the current findings remain unclear, she noted.

"It could be envisioned that stroke might be predicted from prestroke symptoms -- depressive, cognitive, physical -- in combination with classical vascular risk factors, but that requires further research," Blöchl told Medscape Medical News.

"Depression has long been known to follow a stroke, especially in the early months of a brain attack," Shaheen E. Lakhan, MD, PhD, a neurologist and researcher from Boston, who wasn't involved in the analysis, told Medscape Medical News. 

"Newer lines of research are now showing depression itself as a risk factor for stroke," and the current study is consistent with that, he added.

Lakhan noted cited a few caveats to the analysis, however. The subjects were assessed only every 2 years "and with a depression screening tool, not diagnostic assessment," limiting our ability to draw strong conclusions.

Nonetheless, Lakhan said, the data "underscore the importance of early recognition and management of depression especially as we age."

Blöchl, Nestler, and Lakhan report no relevant disclosures.

Neurology. Published online July 13, 2022.[1]

Study Highlights

  • The investigators analyzed data from 10,797 ELSA participants without stroke history at baseline.
  • Mean age was 64.6 ± 9.9 years; 54.8% were women.
  • Participants (n = 425; 3.94%) with incident stroke during 12-year follow-up were matched to 4249 stroke-free individuals using propensity scores accounting for age, sex, education, ethnicity, and vascular risk factors.
  • Multilevel models allowed analysis of trajectories of depressive symptoms before and after stroke.
  • At prestroke assessment, participants with incident stroke had increased depressive symptoms vs matched control participants.
  • At 2-year prestroke assessment, prevalence of probable depression did not differ statistically significantly among persons with and without stroke (29.3% vs 24.3%; P = .062), but at the time of stroke, probable depression was significantly more common in the stroke group (34.1% vs 23.6%; P < .001), which persisted at 6-year assessment (34.7% vs 22.9%; P = .025).
  • Starting about 2 years before stroke onset, depressive symptom severity on CES-D 8 increased 0.33 points on average (P < .001), with further increase of 0.23 points after stroke (P < .001).
  • Depressive symptoms remained increased for 10 years after stroke whereas depressive symptoms remained relatively stable over time in stroke-free individuals.
  • Differences in depressive symptoms between stroke survivors and stroke-free control participants before and after stroke were most pronounced for mood- and fatigue-related symptoms.
  • At assessment before incident stroke, one mood-related symptom (depressed mood; P = .039) and 2 fatigue-related symptoms (everything was an effort [P = .017]; could not get going [P = .016]) were slightly more common in persons with stroke than in matched control participants.
  • These differences increased at first assessment after incident stroke: everything was an effort (P ≤ .001); could not get going (P ≤ .001); depressed mood (P = .023).
  • Patients with stroke had more sleep problems (P = .027); and less frequently endorsed positive affect (felt happy [P = .003]; enjoyed life [P ≤ .001]).
  • Even several years after stroke, fatigue-related symptoms were more common in stroke survivors than in stroke-free control participants (everything was an effort [P = .002]; could not get going [P = .007]).
  • The investigators concluded that incident stroke is associated with long-term increases in depressive symptoms; a small part of this increase occurs in the years before stroke, perhaps reflecting the incipient pathological process.
  • The findings confirm and extend previous studies by showing that small increases in depressive symptoms occur in the years before stroke, even compared with control participants with similar sociodemographic characteristics and vascular risk factors.
  • Particular attention should be paid to depressive symptoms in the long-term care of patients and especially to fatigue-related symptoms.
  • Patients with stroke are at risk for persistent increase in mood disturbances, which hinders recovery and rehabilitation and should be monitored in the long-term.
  • Although depressive symptoms change on average before stroke, prestroke frequency of probable depression did not differ from stroke-free control participants, suggesting that prestroke elevation in depressive symptoms may reflect mostly subtle, subclinical changes.
  • Prestroke increase in depressive symptoms is primarily driven by depressed mood and fatigue-related symptoms.
  • Further research is needed to clarify precise mechanisms underlying prestroke changes in depressive symptoms.
  • Accumulating evidence suggests that acute stroke follows a long period of accumulating vascular pathology associated with prodromal subtle brain damage and looming stroke symptoms, including cognitive and physical decline.
  • Despite this study’s controlling for several baseline vascular risk factors, it is still plausible that vascular brain damage accumulating before incident stroke may contribute to increased depressive symptoms.
  • Alternatively, declining prestroke cognitive and physical functioning may cause depressive symptoms.
  • Persistent increase in depressive symptoms poststroke may reflect long-term physical, cognitive, and social sequelae of stroke, or possibly stroke-induced disruptions in brain structure and function.
  • Given the multifactorial nature of depressive symptoms, it is likely that different mechanisms act at different time points following stroke.
  • The findings do not mean that depression cannot improve after stroke; effective treatments include antidepressants and psychotherapy.
  • Study limitations include long intervals between assessments, which could have missed improvements in depressive symptoms shortly after stroke; reliance on self-reported doctor-diagnosed incident stroke; and lack of accurate data on stroke onset, characteristics, and treatments.
  • Participants were mostly White, limiting generalizability to other racial-ethnic groups, in whom risk for depression and stroke is often higher.

Clinical Implications

  • Incident stroke is associated with long-term increases in depressive symptoms, a small part of which occurs in the years before stroke, perhaps reflecting the incipient pathological process.
  • Particular attention should be paid to depressive symptoms in the long-term care of patients and especially to fatigue-related symptoms.
  • Implications for the Healthcare Team: Patients with stroke are at risk for persistent increase in mood disturbances. The healthcare team should be aware that this may hinder recovery and rehabilitation and should be monitored in the long term.

 

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