COGNITIVE AND EMOTIONAL SYMPTOMS IN PATIENTS WITH FIRST-EVER MILD STROKE: THE SYNDROME OF HIDDEN IMPAIRMENTS

ObjectiveTo evaluate the prevalence of cognitive and emotional impairments one year after first-ever mild stroke in younger patients.DesignProspective, observational, cohort study.SubjectsA consecutive sample of 117 previously cognitively healthy patients aged 18–70 years with mild stroke (National Institutes of Health Stroke Scale score ≤ 3) were included in 2 hospitals in Norway during a 2-year period.MethodsAt 12-month follow-up, patients were assessed using validated instruments for essential cognitive domains, fatigue, depression, anxiety, apathy and pathological laughter and crying.ResultsIn total, 78 patients (67%) had difficulty with one or a combination of the cognitive domains psychomotor speed, attention, executive and visuospatial function, and memory. Furthermore, 50 patients (43%) had impairment in either one or a combination of the emotional measures for anxiety, depressive symptoms, fatigue, apathy or emotional lability. A total of 32 patients (28%) had both cognitive and emotional impairments. Only 21 patients (18%) scored within the reference range in all the cognitive and emotional tools.ConclusionHidden impairments are common after first-ever mild stroke in younger patients. Stroke physicians should screen for hidden impairments using appropriate tools.LAY ABSTRACTMany patients with minimal or no apparent neurological deficits after stroke may experience cognitive and emotional symptoms. The quality of life and functioning of these patients may be reduced. Our research group studied 117 previously cognitively healthy patients aged 70 years or younger with mild stroke 12 months after the stroke event. They were assessed for cognitive and emotional impairments using validated tests for cognitive function, fatigue, depression, anxiety, and apathy. Only 21 patients (18%) scored within the normal range in these tests. In conclusion, “hidden impairments” are common among younger stroke patients. It is important for patients, their surroundings and stroke physicians to be aware that such difficulties can occur after even a mild stroke.Key words: mild stroke, younger patients, cognitive impairment, depression, anxiety, apathy, fatigue, hidden impairments

Outcome after stroke has improved remarkably over recent years due to better prevention and improved acute treatments in the stroke units (1) and by reperfusion therapy (2).Still, independently of age and lesion size, cognitive and emotional impairments after stroke are common, with a prevalence of dementia of up to 20% and of mild cognitive impairment (MCI) of 38% in a general stroke sample one year after onset of symptoms (3), and a prevalence of depression and anxiety reaching 30% and 20–25%, respectively (4). However, the number of cognitive and emotional impairments detected after stroke vary due to heterogeneity in the cognitive instruments, used diagnostic criteria and demographic factors, such as educational level, vascular risk factors and comorbidity. Since even first-ever stroke can lead to cognitive deficits in patients who are previously cognitively intact, it has been suggested that future research on post-stroke cognitive deficits should focus on this patient group (5).Persons with minimal neurological deficits after stroke are often discharged shortly after admittance, with the observation that “everything seems to be alright”. However, on return to their everyday lives, they may realize that their quality of life and functioning has changed. These patients may face difficulties affecting their memory, concentration, attention, and commonly experience fatigue (6). Pendlebury et al. (7) showed that, in a sample of patient with minor stroke, 8.2% were diagnosed with dementia one year after stroke, which was significantly higher than for an age-matched general population. Emotional impairments, such as anxiety, depression and apathy, can also occur (6, 8). It has been suggested that younger persons are at particular risk of developing disabling cognitive and emotional impairments after stroke (9).As a consequence, patients with stroke, stroke patients’ organizations, and health professionals have introduced the concept of “hidden impairments” (10). The syndrome of hidden impairments is proposed to include cognitive and emotional impairments that are not revealed through neurological examination or cognitive and emotional screening instruments used in clinical daily routine (10). Hidden impairments may include executive dysfunction, memory impairment, language difficulties, reduced psychomotor speed, fatigue, pathological laughter and crying, anxiety, depression, and apathy. The aim of this prospective, observational, cohort study was to evaluate the prevalence of hidden impairments 12 months after first-ever mild stroke in patients aged 70 years or younger.