Dysphagia After Stroke And Depression Symptoms
Overview
The study aimed to investigate the correlation between swallowing difficulties, known as dysphagia, and symptoms of anxiety and depression following ischemic stroke. Conducted as part of the STROKE-CARD Registry study from 2020 to 2022, the research assessed dysphagia upon hospital admission, its persistence until discharge, and its impact at a 3-month follow-up using the SINGER Independency Index. Symptoms of anxiety and depression were measured using the Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS) at the 3-month mark.
Scores on the BDI, HADS-Depression (HADS-D), and HADS-Anxiety (HADS-A) scales increased with the presence or duration of dysphagia, indicating a worsening of symptoms over time. Linear regression analysis, adjusting for various factors including age, sex, comorbidities, and stroke severity, revealed significantly higher BDI and HADS-D scores in patients with dysphagia at all assessment points. Additionally, an independent association with HADS-A scores was observed specifically in patients with persistent dysphagia after 3 months.
Furthermore, patients with dysphagia were more likely to receive antidepressants, antipsychotics, or benzodiazepines at discharge and the 3-month follow-up, indicating a clinical recognition of the psychological impact of dysphagia.
In conclusion, dysphagia following ischemic stroke is prevalent and significantly impacts the psychosocial well-being of affected individuals. The study underscores dysphagia as an independent predictor for post-stroke depressive symptoms, with a lesser but still notable association with anxiety symptoms. These findings emphasize the importance of early identification and management of dysphagia to mitigate its adverse psychological effects on stroke survivors.
Introduction
The advancement of stroke care, including stroke unit care and reperfusion therapies, has notably increased survival rates among individuals affected by ischemic strokes. Despite these strides, many patients still grapple with a spectrum of complications and enduring impairments stemming from cerebral ischemia. Of particular concern is poststroke dysphagia, affecting a significant proportion of patients post-ischemic stroke, with attendant risks such as aspiration, pneumonia, and heightened mortality rates. Beyond the physical ramifications, dysphagia also exerts a profound psychosocial toll, often manifesting as reduced quality of life and social isolation, thereby underscoring the far-reaching impact of swallowing difficulties on daily functioning.
Moreover, oropharyngeal dysphagia, regardless of its underlying cause, appears intricately linked to affective symptoms such as anxiety and depression. While prior investigations predominantly explored this correlation in contexts like head and neck cancer or Parkinson’s disease, recent insights suggest that individuals grappling with stroke-induced dysphagia may be predisposed to developing poststroke depression during their hospitalization period. Notably, poststroke dysphagia presents a unique scenario compared to chronic medical conditions, as it holds the potential for swallowing function improvement over time.
The primary objective of our study is to delve into the potential association between poststroke dysphagia and symptoms of depression and anxiety within the initial three months following onset. Through an extensive analysis of a sizable representative ischemic stroke cohort drawn from the STROKE-CARD Registry, we aim to elucidate the intricate interplay between dysphagia and psychological distress during the early stages of stroke recovery.
Method
The study focused on patients enrolled in the STROKE-CARD program, implemented as standard care in December 2020 following a successful trial demonstrating its efficacy in reducing cardiovascular events and improving quality of life post-stroke. This program targeted individuals with high-risk transient ischemic attack (TIA) or ischemic stroke within the catchment area of participating centers, offering follow-up visits at 3 and 12 months to assess complications, care needs, and secondary prevention strategies.
Data from the Innsbruck study center, serving a significant population, were analyzed. Out of 1076 eligible patients, 648 were included in the analysis after exclusions. Swallowing function assessment was a crucial component, conducted through a combination of clinical records review and examination by experienced speech therapists. Diagnosis of dysphagia was established via clinical evaluation or further instrumental diagnostics if necessary, ensuring comprehensive identification of swallowing difficulties.
In addition to swallowing assessment, the study examined the prevalence of depression and anxiety post-stroke. History of depression was determined based on medication intake or digital health record documentation, while symptoms of depression and anxiety were evaluated using validated questionnaires such as the Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS). Psychiatric medication usage was also recorded to provide a holistic view of mental health status post-stroke.
Overall, the study’s rigorous methodology and comprehensive evaluation of post-stroke complications, including dysphagia and mental health, contribute valuable insights into stroke management strategies. By integrating multidimensional assessments into routine care protocols, the STROKE-CARD program aims to optimize patient outcomes and enhance quality of life for individuals recovering from stroke.
Statistical Analysis
The study employed rigorous statistical methods to analyze various characteristics, including age, sex, and other relevant factors, in relation to dysphagia. Descriptive statistics such as mean and standard deviation (SD) or median and interquartile range were utilized for continuous and ordinal data, while percentage frequencies were used for binary data. Group comparisons between individuals with and without dysphagia were conducted using appropriate statistical tests, including Pearson chi-squared for binary and nominal variables and the Mann–Whitney U-test for ordinal or continuous, non-normally distributed data. Normal distribution of continuous data was assessed using the Shapiro–Wilk and Kolmogorov–Smirnov tests.
To address the issue of multiple testing in univariate comparisons, the Bonferroni adjustment was applied. In cases where data were missing, the adjusted sample size was clearly indicated for each variable. Furthermore, multivariate linear regression analysis was performed to examine the independent association between dysphagia and depression/anxiety, while controlling for potential confounding factors such as age, sex, diabetes, dementia, and either modified Rankin Scale (mRS) or National Institutes of Health Stroke Scale (NIHSS) scores at 3 months post-stroke.
The significance level for all analyses was set at p < 0.05. The statistical procedures were carried out using the Statistical Package for the Social Sciences (SPSS) software, version 27.0.1.0, provided by IBM. These robust analytical methods ensure the reliability and validity of the study’s findings, facilitating a comprehensive understanding of the relationship between dysphagia and various clinical factors in stroke patients.
Result
The research investigated the occurrence and consequences of dysphagia in patients following acute ischemic stroke, shedding light on its prevalence, persistence, and impact on various aspects of patient health and well-being. Here’s a deeper dive into the key findings and implications of the study:
- Prevalence and Persistence of Dysphagia: The study revealed that nearly one-fifth of patients experienced dysphagia during their initial hospitalization period. This finding underscores the importance of assessing swallowing function in stroke patients early on, as dysphagia can significantly affect their recovery and prognosis. Moreover, while some patients recovered from dysphagia by the time of discharge or follow-up, a considerable proportion continued to experience swallowing difficulties, highlighting the need for ongoing monitoring and intervention.
- Demographic and Clinical Correlates: Patients with dysphagia tended to be older and had a higher prevalence of comorbid conditions such as atrial fibrillation and diabetes. They also presented with more severe strokes and greater disability compared to those without dysphagia. These associations emphasize the complex interplay between dysphagia and various clinical factors, which may influence both its onset and persistence.
- Impact on Healthcare Utilization: Patients with dysphagia experienced longer hospital stays and were more likely to be discharged to rehabilitation centers or nursing homes, indicating higher healthcare resource utilization. This underscores the economic burden associated with dysphagia post-stroke and the need for efficient care pathways to optimize patient outcomes while minimizing healthcare costs.
- Functional and Quality of Life Outcomes: Dysphagia was associated with worse functional outcomes, as evidenced by higher disability scores at discharge and follow-up. Patients with dysphagia also reported lower quality of life scores, highlighting the profound impact of swallowing difficulties on overall well-being. Moreover, dysphagia was linked to a decline in body mass index (BMI) over time, indicating potential nutritional challenges and further underscoring the multifaceted nature of its consequences.
- Psychological Well-being and Medication Use: Importantly, patients with dysphagia exhibited higher levels of depression and anxiety compared to those without dysphagia. This suggests a significant psychological burden associated with swallowing difficulties post-stroke, which may warrant targeted interventions to address mental health needs. Furthermore, patients with dysphagia were more likely to be prescribed psychiatric medications, particularly antidepressants, underscoring the importance of comprehensive management approaches to address both physical and psychological aspects of post-stroke care.
Overall, the study highlights the complex interplay between dysphagia and various clinical, functional, and psychosocial factors in stroke patients. It underscores the importance of early detection, thorough assessment, and multidisciplinary management of dysphagia to optimize patient outcomes and enhance their overall quality of life following acute ischemic stroke. Additionally, the findings underscore the need for further research to elucidate the underlying mechanisms of dysphagia post-stroke and develop targeted interventions to mitigate its impact on patient health and well-being.
Conclusion
The analysis conducted on the STROKE-CARD Registry study, a comprehensive cohort of consecutive ischemic stroke patients, sheds light on the prevalence of poststroke dysphagia during the acute phase and its subsequent recovery within the first three months. Notably, this study unveils a significant association between poststroke dysphagia and symptoms of anxiety and depression, marking a pivotal advancement in our understanding of the psychological impact of this condition.
This study is groundbreaking as it is the first to establish a clear link between poststroke dysphagia and symptoms of depression and anxiety. The severity of depressive symptoms was particularly pronounced in patients with persistent dysphagia, leading to an increased prescription of psychiatric medications such as antipsychotics, antidepressants, or benzodiazepines. Even after meticulous adjustments for various factors including age, sex, and stroke severity, the association between dysphagia and depressive symptoms remained statistically significant, underscoring the robustness of this relationship.
The etiology of poststroke dysphagia and depression has been extensively studied, with both conditions implicated in disturbances of neuronal network connectivity. While neurobiological factors play a significant role, psychosocial factors such as social isolation stemming from the inability to enjoy regular meals may exacerbate depressive symptoms in patients with dysphagia. However, further research is needed to elucidate whether appropriate treatment and management of dysphagia can mitigate mood disturbances.
Furthermore, the study reveals the prevalence and prognosis of poststroke dysphagia, emphasizing its enduring impact on patients’ psychosocial functioning. Despite varying reports on recovery rates, dysphagia remains a prevalent complication among ischemic stroke patients, necessitating comprehensive screening and management strategies.
In conclusion, poststroke dysphagia emerges as a crucial predictor of depressive symptoms following ischemic stroke. Screening for poststroke depression is imperative, particularly in patients with dysphagia, to mitigate the adverse psychological effects and improve overall patient outcomes.
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