Risk factors of post stroke depression in elderly patients

T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 164 RISK FACTORS OF POST STROKE DEPRESSION IN ELDERLY PATIENTS Nguyen Trung Anh1,2, Nguyen Xuan Thanh1,2, Vu Thi Thanh Huyen1,2 SUMMARY Objectives: To determine the risk factors of post-stroke depression (PSD) in elderly patients. Subjects and methods: A cross-sectional descriptive study was conducted at National Geriatric Hospital in 2019 with 187 participants aged 60 and older who were diagnosed with PSD. Depression was assessed by Geriatric Depression Scale Short Form (GDS-15). Results: The mean age was 67.83 years old. The male/female ratio was 1.63. Using the logistic regression model, communication problem, hypertension, diabetes, moderate dependence were the risk factors of PSD in elderly patients. Conclusion: There was no correlation between PSD and age (70 years old and over), living in rural, reduced role in family after stroke, facial paralysis, dysphagia, hemiplegia. * Keywords: Post-stroke; Depression; Elderly patients. INTRODUCTION Post stroke depression is classified as “mood disorder due to a general medical condition” with the specifiers of depressive features, major depressive - like episodes, manic features, or mixed features by Diagnostic and Statistical Manual (DSM) IV [1]. The epidemiological studies report a widely variable prevalence of PSD that ranges from 10 - 64% of the patients that suffered a stroke [2]. Depression aggravates the impairment of cognition, memory, spatial vision, language and can cause dementia in the elderly. Furthermore, depression exacerbates functional impairment and slows recovery during physical therapy and speech training. Depressed patients have progressed worse over the long term due to little effort of reintegration after discharge. Mood disorders reduce the ability to recover operations in daily activities and social activities. Early depression or severe decline in nerve function predict poor quality of life after 6 months. A number of studies have found several factors related to PSD, such as age, gender, educational level, daily living activities, social support and self-esteem [3]. Knowledge about risk factors for depression among post stroke elderly patients is essential to develop strategies for prevention, early detection and appropriate management, contributing to improve outcomes. Therefore, we conducted this research: To determine the factors related to PSD in elderly patients. 1Hanoi Medical University 2National Geriatric Hospital Corresponding author: Nguyen Trung Anh (trunganhvlk@gmail.com) Date received: 03/9/2020 Date accepted: 09/10/2020 T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 165 SUBJECTS AND METHODS 1. Subjects Post-stroke inpatients aged 60 years or above were treated in National Geriatric Hospital. * Inclusion criteria: Patients aged 60 years or above were diagnosed as stroke according to guideline of World Health Organization (sudden onset, nerve function damage, stroke symptoms persist for greater than 24 hours with vascular etiology). These patients were performed Magnetic Resonance Imaging (MRI) or brain CT - scan about ischemic stroke image or hemorrhagic stroke image, time of stroke onset to involment in the study at least 14 days (2 weeks). Patients and their family agreed to participate and had the physical and cognitive abilities to do a face-to-face interview. * Exclusion criteria: Patients were diagnosed with a transient ischemic attack or a previous brain injury (for example, traumatic brain injury), consciousness disorders, acute confusion due to all causes. Patients with communication problems, history of psychosis (such as severe dementia, depression, bipolar emotional disorder, schizophrenia, substance abuse). 2. Methods * Study design: A cross - sectional descriptive study. - Location: National Geriatric Hospital. - Time: from April 1st to October 15th 2019 * Variables and indicators: Variables of general information include: age (3 groups of age: 60 - 69, 70 - 79, ≥ 80 years, gender (male, female), residential area (rural, urban), family roles after stroke (change, no change), type of stroke, brain lesion location, time of stroke onset. - Depression was assessed by Geriatric Depression Scale Short Form (GDS-15). - Level of depression: Absent (0 - 4), mild (5 - 8), moderate (9 - 11), severe (12 - 15). Variables of related factors: Independence in daily activities using The Barthel Scale/Index (BI), co-morbidities (diabetes mellitus, hypertension, cardiovascular disease, peripheral vascular disease, respiratory disease, others), communication problem, disphagia, hemiplegia, family role changes after stroke, residential area. * Data processing and data analysis: The process of data coding, entry and analysis was done by using Statistical Package for Social Science (SPSS) software (version 22). Descriptive statistics were adopted to examine characteristic data: frequency, percentage, mean, standard deviation. Logistic regression was used to predict the likelihood of PSD. Statistical significance was accepted at the 95% confidence level (p < 0.05) * Ethical consideration: The study was conducted at the National Geriatric Hospital. Study subjects were explained clearly about the purpose of the study, and they were willing to participate in the study. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 166 RESULTS 1. General characteristics Table 1: Demographic characteristics. Demographic characteristics n % 60 - 69 98 52.4 70 - 79 60 32.1 Age ≥ 80 29 15.5 Male 116 62.0 Gender Female 71 38.0 Rural 81 43.3 Residential area Urban 106 56.7 Ischemic 127 67.9 Type of stroke Hemorrhagic 60 32.1 Right 79 42.2 Left 100 53.5 Brain lesion location Both sides 8 4.3 2 - 4 weeks 156 83.4 5 - 12 weeks 27 14.4 13 - 24 weeks 2 1.1 Time of stroke onset > 24 weeks 2 1.1 No change 56 29.9 Family role after stroke Change 131 70.1 Patients’s median age was 67.83 years, in which, the age group of 60 - 69 years was mainly found (52.4%). The male/female ratio was 1.63. After stroke, family roles were changed significantly, observed in 70.1% of the patients. Table 2: Co-morbidities. Co-morbidities n % Yes 48 25.6 Diabetes mellitus No 139 74.4 Yes 147 78.6 Hypertension No 40 21.4 Yes 10 5.4 Cardiovascular diseases No 177 94.6 Yes 2 1.1 Peripheral vascular diseases No 185 98.9 Yes 2 1.1 Respiratory diseases No 185 98.9 At a prevalence of 78.6%, hypertension is a common health problem in our research. The percentage of diabetes was 25.6%. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 167 * Dependence in daily living activities: The mean Barthel Index score of 187 patients was 46.75 ± 29.16 points (with median of 40 points). Table 3: Levels of dependence in activities of daily living according to Barthel Index Score. Level of dependence n % Total 48 25.7 Severe 73 39.0 Moderate 53 28.3 Mild 3 1.6 Independence 10 5.3 Most of subjects had difficulty in performing daily life activities and needed support at different levels. In particular, up to 25.7% of patients depended completely on the caregivers and 39.0% of patients had severe levels of dependency. Only 5.3% was independent. Table 4: In-hospital risk prediction for PSD. Among 10 independent variables were put into the logistic regression model, only 4 main variables had good prediction and were at major risk for the level of depression including communication problem, hypertension, diabetes, moderate dependence. In this study, communication is nearly 4 times, hypertension is nearly 5 times, diabetes is more 3 times and moderate dependence is 1.12 as high as normal value. There was no correlation between PSD and age (70 years old and over), residence, family role change after stroke, facial paralysis, difficulty swallowing, hemiplegia. 95%CI Risk prediction OR Lower Upper p Age (70 years and over) 0.17 0.77 4.6 0.17 Rural (yes/no) 3.09 1.06 8.98 0.1 Reduced role in family after stroke (yes/no) 3.49 1.08 11.36 0.12 Facial paralysis (yes/no) 1.02 0.23 2.44 0.77 Communication problem (yes/no) 3.1 1.59 9.8 0.003 Dysphagia (yes/no) 1.1 0.39 3.09 0.86 Hemiplegia (yes/no) 2.4 0.93 6.21 0.07 Hypertension (yes/no) 4.8 1.71 12.43 0.001 Diabetes (yes/no) 3.2 1.18 8.69 0.02 Moderate dependence 1.12 0.96 2.58 0.003 T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 168 DISCUSSION The pathological characteristics associated with PSD in this study are also consistent with other research. The mean time of stroke onset was 3.58 ± 3.78 weeks. Most patients suffered stroke less than 4 weeks (83.4%) while only 16.6% lasted than 4 weeks. The ischemic stroke (67.9%) and the lesion site in the left hemisphere (53.5%) accounted for the majority subjects. According to Do Tu Duy and Tran Minh Thu, 74.5% of stroke cases lasted less than 1 month and 54% had lesion in the left hemisphere [4]. According to the multivariate logistic regression model communication problems, hypertension, diabetes, moderate dependence were related factors with poor prognosis for PSD. Hypertension may also relate to depression less directly, through inflammation or other biological mechanism. Another reason for hypertension related depression is associated with medications used in the treatment of hypertention. Besides communication problem is one of main contributors to an increased risk of PSD. Patients with difficulties communication were 4 times at risk of PSD than the other group. Carod-Artal's literature review also suggests that communication difficulty is one of the risk factors for depression after stroke [5]. The associated factors of PDS were moderate dependence 1.12 higher than normal value. The current study found that the BI (the measure of need for assistance with personal ADL) was consistently associated with levels of PSD. Improvement in depressive symptoms may be associated with recovery in the ADL, although cognitive factors may also determine the level of physical functioning achieved after stroke. Intensive community- based multidisciplinary rehabilitation has been shown to improve social participation and instrumental ADL in stroke survivors [6]. A positive effect of integrated care on depressive symptoms in stroke survivors has also been reported. CONCLUSION Health care staffs and family need to pay more attention to the mental health aspects of patients, regularly evaluate and screen for early detection of PSD, especially in patients with risk factors including communication difficulties, hypertension, diabetes, moderate dependence. REFERENCES 1. 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