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Predictors and outcome of post-stroke depression among adults admitted for first stroke at referral hospitals in Dodoma, Tanzania: a protocol for a prospective longitudinal observational study

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  • Mirembe National Mental Health Hospital
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Abstract and Figures

Background Survivors of strokes are prone to disabilities, especially in underdeveloped countries. Post-stroke depression (PSD) is a common neuropsychiatric condition that exacerbates symptoms and raises the danger of stroke recurrence, disability, and mortality. Nevertheless, little is documented about PSD’s incidence, predictors, and consequences. This study aims to assess predictors and outcomes of post-stroke depression among patients admitted with the first stroke episode at referral hospitals in Dodoma, Tanzania. Methods and analysis The study is a prospective longitudinal observational design; a consecutive sampling technique will be used to attain the estimated sample size. Adults aged ≥18 years who have had their first stroke episode, within 14 days, and the stroke diagnosis will be verified through brain imaging using CT or MRI. The study will be conducted at referral hospitals in Dodoma region, Tanzania. At admission, baseline clinical parameters will be recorded, and PSD will be evaluated at one and three months after a stroke. Data will be summarised using descriptive statistics; continuous data will be reported as mean (SD) or median (IQR) while categorical data as frequencies and proportions. The PSD predictors will be determined using logistic regression analysis. The study will adhere to data-sharing guidelines and take ethical considerations into account. Ethics and dissemination The University of Dodoma’s institutional Research Review and Ethical Committee has granted permission to conduct the study with reference number MA.84/261/02. The relevant authorities granted approval for the study to be carried out at DRRH and BMH.
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Title
Predictors and outcome of post-stroke depression among adults admitted for
first stroke at referral hospitals in Dodoma, Tanzania: a protocol for a
prospective longitudinal observational study
Authors
Sadiki Mandari 1,2 Azan Nyundo 1,2,3
1Department of Psychiatry and Mental Health, School of Medicine, The
University of Dodoma, Tanzania,
2Mirembe National Mental Health Hospital, Dodoma, Tanzania,
3Department of Internal Medicine, The Benjamin Mkapa Hospital, Dodoma,
Tanzania
Corresponding author
Azan Nyundo
P O Box 395 Dodoma
1 TIBA STREET,
41218 IYUMBU, DODOMA
TANZANIA.
azannaj@gmail.com, azan.nyundo@udom.ac.tz
Metadata
Funding statement: This project did not receive any funding.
Data availability statement: Data will be available and shared as per
agreement of terms and conditions once the data collection is completed.
Competing interest statement: The authors declare there is no conflict of
interest.
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NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
Abstract
Background
Survivors of strokes are prone to disabilities, especially in underdeveloped
countries. Post-stroke depression (PSD) is a common neuropsychiatric
condition that exacerbates symptoms and raises the danger of stroke
recurrence, disability, and mortality. Nevertheless, little is documented about
PSD's incidence, predictors, and consequences.
This study aims to assess predictors and outcomes of post-stroke depression
among patients admitted with the first stroke episode at referral hospitals in
Dodoma, Tanzania.
Methods and analysis
The study is a prospective longitudinal observational design; a consecutive
sampling technique will be used to attain the estimated sample size. Adults
aged ≥18 years who have had their first stroke episode, within 14 days, and
the stroke diagnosis will be verified through brain imaging using CT or MRI. The
study will be conducted at referral hospitals in Dodoma region, Tanzania. At
admission, baseline clinical parameters will be recorded, and PSD will be
evaluated at one and three months after a stroke. Data will be summarised
using descriptive statistics; continuous data will be reported as mean (SD) or
median (IQR) while categorical data as frequencies and proportions. The PSD
predictors will be determined using logistic regression analysis. The study will
adhere to data-sharing guidelines and take ethical considerations into
account.
Ethics and dissemination
The University of Dodoma's institutional Research Review and Ethical
Committee has granted permission to conduct the study with reference
number MA.84/261/02. The relevant authorities granted approval for the
study to be carried out at DRRH and BMH.
Keywords
Predictors, Outcome, Stroke, post-stroke depression, Dodoma, Tanzania
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Introduction
Stroke is the second major cause of death globally [1] and is also linked to
the development of psychiatric symptoms and impaired quality of life[2].
Similar to the developed world where majority of stroke survivors suffer form
Ischaemic stroke, [1] approximately 80% of stroke in the develong countries is
also Ischaemic [3]. The prevalence is the highest in Sub-Saharan Africa and
other low and middle-income countries, including Tanzania; the incidence
increased by 70% from 1990 to 2019, and the prevalence increased by
85%[4]. Despite the implementation of preventive measures and risk factor
reduction similar to high-income countries, high rate of strokes is recorded in
both urban and rural areas of Tanzania[5].
Following a stroke, there is a high risk of developing neuropsychiatric
manifestations with up to a ten-fold increase in mortality rates [6]. A 20 to 50%
one-month incidence of post-stroke depression is reported and persists for
three to six months after the stroke [7]. While in high-income countries, the
prevalence of PSD ranges from 25% to 79% [8], the prevalence rates of 32%,
54%, and 89% are observed in low- and middle-income countries of Uganda,
the Democratic Republic of the Congo, and the Central African Republic,
respectively.
. Although there is a mixed evidence, several factors including female
gender, advanced age, medical and psychiatric history, social support, and
stroke-related factors, including severity and degree of disability have been
accounted for PSD. [9].
The study aims to determine the prevalence, predictors and outcome of PSD
among patients admitted with the first stroke episode at referral hospitals in
Dodoma, Tanzania.
Study aims
Aim 1
To determine the baseline prevalence of post-stroke depression at one
month among patients admitted with the first stroke episode at referral
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Hospitals in Dodoma.
Aim 2
To determine predictors of post-stroke depression among patients admitted
with the first stroke episode at referral Hospitals in Dodoma.
Aim 3
To determine the outcome of post-stroke depressive symptoms at three
months following the first stroke episode among patients admitted at referral
Hospitals in Dodoma.
Aim 4
To determine predictors of significant improvement of depressive symptoms
among patients admitted with the first episode of a stroke at referral Hospitals
in Dodoma.
Methods and analysis
Study design
The study will be a prospective longitudinal observation design.
Study setting
The study will be conducted in Dodoma's referral hospitals, the Dodoma
Regional Referral Hospital (DRRH) and Benjamin Mkapa Hospital (BMH).
Dodoma is Tanzania's capital, with a population of 3,085,625 people per the
2022 national census [10]. The coverage includes referrals from all Dodoma
districts of Mpwapwa, Bahi, Kongwa, Chemba, Kondoa and neighbouring
regions. BMH has 400 beds while DRRH has 480 bed capacities, where all
patients will be received at emergency department before being transferred
to the respective unit or ward. Stroke is among the top listed conditions
admitted at the the hospitals, with about 20 cases admitted every month in
the medical ward and intensive care unit for those requiring close
observation. Also, both BMH and DRRH has advanced radiological
investigations, including CT- scan covering patients from neighbouring
regions.
Study population
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Participants are adults aged 18 years or older admitted to the Internal
Medicine wards of either DRRH or BMH with a diagnosis of the first stroke as
per the World Health Organization, defined as "rapid development of clinical
signs of focal or global disturbance of cerebral function lasting more than 24
hours or leading to death, with no apparent cause other than vascular origin"
and confirmed by CT-scan or MRI, and the duration of symptoms lasting not
more than 14 days[11].
Inclusion criteria
Patients aged 18 years or older admitted with the first episode of stroke.
Capacity to provide informed consent or proxy consent from a close
relative or custodian in case the patient is incapable.
Patients with the first stroke episode within 14 days confirmed by CT-
scan/MRI.
Exclusion criteria
All patients with severe sensory impairment (deafness and blindness)
that will compromise the assessment of key dependent and
independent variables.
Patients with traumatic intracerebral haemorrhage.
Patients with intracerebral haemorrhage due to tumour.
Patients with transient ischemic attack (TIA).
Patients with traumatic subarachnoid haemorrhage. Patients with a
known history of chronic neurological disorders with an established risk
of psychiatric manifestations such as epilepsy, multiple sclerosis, and
neurogenerative disorders.
Sample size calculation
The sample size will be estimated utilising formula for proportion in a
prospective cohort study [12]
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Where by
r = ratio between the two groups
p1 = PSD one-month prevalence (obtained from literature)
p2 = PSD one-moth prevalence observed or expected from the study
p1 – p2 = effect size
Z = standard normal variate for statistical power
Z/2 = standard normal variate for significance level
The prevalence of PSD at 1 months is 50% [8]
The one-month prevalence in this study is expected to be 30%
Therefore;
r = 1.67
p1 = 50%
p2 = 30%
p1 – p2 = 20%
Z = 1.28 for statistical power of 90%
Z/2 = 1.96 for significance level of 95%
Considering the 30 % attrition rate [13]
Therefore, the minimum sample size estimated is 274 patients.
2
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p p
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r r
np p
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1
p rp
pr
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Sampling methods/technique
A consecutive sampling method will be used whereby the sample will be
attained by selecting every available candidate meeting the inclusion
criteria and admitted through the emergency/outpatient department to the
wards until the desired sample size is reached.
Data collection procedure/recruitment of patients
Direct interviews with the patient and/or immediate guardian will be used to
collect personal information (including sex, age, marital, and occupation),
past medical history (such as hypertension and diabetes mellitus), and
lifestyle (alcohol drinking and smoking), whereby current smoking/alcohol
use, defined as those who smoke or take alcohol within the last 12 months.
Thorough history taking on symptoms and physical examination assessing the
atrial fibrillation using ECG, Leukoaraiosis, stroke characteristics like stroke
laterality, site of lesion using CT/MRI scan and stroke severity will be evaluated
using the National Institute of Health Stroke Scale with a total score of 42-
points will be computed to categorise stroke severity. The severity will be
classified as mild stroke if the score is 1 to 4, 5 to 15 as moderate to severe
stroke, 16 to 20 as severe stroke and 21 to 42 as very severe stroke [14].
Patients who will score 5 usually indicate a strong possibility for a good
recovery with a sensitivity of 72% and specificity of 89% [15].
Clinical examination
Blood pressure (BP) readings will be taken using an automated digital
machine AD Medical Inc. brand; patient will be in a supine position with the
arm placed at the same position as the heart; a minimum of two readings will
be taken 2 minutes apart. The affected arm will be avoided in order to
reduce false results. Hypertension will be defined as BP ≥140/90 mmHg in
patients with a history of hypertension or on antihypertensive medications
[16].
The radial pulse will be measured using a finger pulse oximeter model FL –
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100, preferably on the limb unaffected for 1 minute. At least two medical
doctors will confirm the presence of arrhythmia [17].
Laboratory investigations
This study's testing will be done in accordance with accepted DRRH and BMH
standard operating procedures. A laboratory expert will request each
participant's consent to the venepuncture and finger prick before taking
blood samples. Before sample collection tubes [EDTA (K2/K3) sodium fluoride
plain, no modifications] will be labelled with the hospital registration number
corresponding to the patient, and a tourniquet is applied proximally to the
upper arm, which is about 6 cm above the elbow joint. Cleaning the region
with 70% methylated spirit in a circular motion and letting it dry for 20 seconds
before performing the venipuncture. A 10cc syringe will next be used to draw
5ml of venous blood from each arm for lipid analysis (high-density lipoprotein
(HDL), low-density lipoprotein (LDL), total cholesterol, and triglycerides). The
blood samples will be transported into a cool box to a recognised Dodoma
regional referral hospital and Benjamin Mkapa Hospital laboratory within
three hours of sample collection, but haemolysed blood will not be
processed; instead, venepuncture will be repeated. Next, the tourniquet will
be removed, and the site of venepuncture will be pressed with a cotton
swab to arrest bleeding. Centrifugation at 300 rpm for 5 minutes will be used
to separate the serum sample from whole blood. Two aliquots will then be
made, one for the lipid profile and the other for the serum electrolytes. A
sample will be stored at 20C – 80C if the analysis is expected after 2 hours from
sample collection, however, blood samples will be stored at room
temperature if the analysis is expected to be done within 2 hours from sample
collection. Using the clinical chemistry automated analyser, the sample will
be analysed. German-made Elba machine XL-180 with serial number 160239.
A high total cholesterol level of 200 mg/dL or higher, a low-density lipoprotein
cholesterol level of 130 mg/dL or higher, a triglyceride level of 150 mg/dL or
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higher, or a high-density lipoprotein cholesterol level of 40 mg/dL for women
and 50 mg/dL for males were all considered to be signs of dyslipidaemia [18].
The candidate's palm is positioned palm-side up, the index, ring, or middle
fingertip is chosen, and pressure is then applied to the fingertip to stimulate
blood flow. After that, a fingertip is cleansed with methyl alcohol before a
blood sample is drawn to measure blood sugar. This process is detailed in the
sample collection manual SM-1-03.3 of the laboratory at Benjamin Mkapa
Hospital and Dodoma Regional Referral Hospital. The finger will be held
below the level of the elbow, pricked with a brand-new, sterile lancet to
improve blood flow, and the gadget (ACCU-CHECK Active Roche
glucometer machine) will be used to collect the blood directly from the
puncture site. After the sample has been obtained, the customer will be
given a ball of cotton wool to press on the finger for 10 minutes to stop the
bleeding, and the lancet will then be disposed of in a sharp’s disposal box.
Hyperglycaemia will be defined according to American Diabetes Association
[19] for non-diabetic patients hyperglycaemia will be defined as random
blood sugar >11.1 mmol/L, or fasting blood sugar > 7.0 mmol/L and diagnosis
of diabetes will be made with a fasting blood sugar 7.0 mmol/L, or random
blood glucose 11.1 mmo/L plus symptoms of hyperglycaemia or glycated
haemoglobin 6.5 %.
When processing samples, laboratory technicians at the BMH and the DRRH
run controls in each machine daily to ensure the validity and reliability of the
results. Essential maintenance is performed once every six months, whereas
once a week is reserved for machine maintenance.
Electrocardiogram (ECG)
The investigator will carry out a 12-lead ECG and is conversant with the
manufacturer's guidelines [17] under the direction of a professional
cardiologist on each participant. Before a 12-lead ECG is taken, the patient
will be told about the procedure, their privacy will be protected, and the
environment will be kept comfortable to help the patient feel at ease and
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prevent interference with the ECG trace's clarity. The necessary tools, such as
the electrocardiograph, ECG paper, and ECG tabs, will be available to
attach the electrodes and leads to the patient. The ECG cables must be kept
from being twisted in order to prevent interference with ECG tracing. The
patient will be directed to lie down at an angle of 45degrees with his or her
head properly supported and the bed's backrest, with the inner aspect of the
patient's wrist close to but not touching the patient's waist. This is done after
entering the patient's ID number into the device and getting consent. As long
as wet gel electrodes are utilised, shaving the skin won't be necessary. The
limb electrodes will next be placed in the following manner: Right inner wrist is
red, left inner wrist is yellow, right inner leg is black just above the ankle, and
left inner leg is green just above the ankle. The chest leads will be organised
as follows: V4 is in the fifth intercostal space, mid-clavicular line, V5 is in the
anterior axillary line, and V6 is in the mid-axillary line, the same horizontal line
as V4 and V6. V1 is immediately to the right of the sternum, V2 is immediately
to the left of the sternum, V3 is halfway between V4 and V2, V4 is in the fifth
intercostal space, mid-clavicular line, and V6 is in the mid-axillary line, the
same horizontal line as V4 and V5. ECG cables should not lie to each other
and tension should be avoided to decrease artefact and increase the
accuracy and quality of ECG tracing. The calibration signal on the ECG
machine should be kept at a paper speed of 25 millimetre/second and ECG
size 1 millivolt/10-millimeter deflection. During the procedure, the patient will
be asked to remain motionless and breathe normally; the ECG trace should
be clear prior to recording. The 12-lead ECG trace will include the patient's
name, hospital identification number, date of birth, and the day and time the
ECG was taken [20]. According to the American College of Cardiology's
management guidelines for atrial fibrillation patients, the absence of P waves
and an irregular-irregular RR interval are diagnostic signs of the condition [21],
[22].
The Dutch organisation for Cardiology (2021) advises that the application
date, patient data, relevant medical use, and the existence of a pacemaker
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or implantable cardioverter-defibrillator must all be met before utilising a
Holter ECG monitor. It is important to time and record each symptom that a
patient experiences. Additionally, the patient will become aware of
alterations during the day, including variations in sleep, rest periods, and
physical activity. The Dutch organisation for Cardiology (2021) advises that
the application date, patient data, relevant medical use, and the existence
of a pacemaker or implantable cardioverter-defibrillator must all be met
before utilising a Holter ECG monitor. It is important to time and record each
symptom that a patient experiences. Also, the patient will become aware of
alterations during the day, including variations in sleep, rest periods, and
physical activity.[23].
Echocardiography
Only certain patients with ischemic stroke and additional characteristics, such
as evidence of cardiac disease on history, examination, or
electrocardiogram (ECG), suspected cardiac source of embolism (for
example, infarctions in multiple cerebral or systemic arterial territories),
suspected aortic disease, or paradoxical embolism, as well as patients with
no other options, will be advised to undergo transthoracic echocardiography
(model Vivid TM T9 made by GE Healthcare, USA, 2018)[24]
Only certain patients with ischemic stroke and additional characteristics, such
as evidence of cardiac disease on history, examination, or
electrocardiogram (ECG), suspected cardiac source of embolism (for
example, infarctions in multiple cerebral or systemic arterial territories),
suspected aortic disease, or paradoxical embolism, as well as patients with
no other options, will be advised to undergo transthoracic echocardiography
(model Vivid TM T9 made by GE Healthcare, USA, 2018)[25].
Brain imaging
To confirm the stroke diagnosis, every patient will have an acute CT scan by
SIEMENS (SOMATOM Definition Flash), and the majority will also get a brain
MRI scan by MAGNETUM SPECTRA A TIM +Dot System 3T as part of a standard
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diagnostic procedure. Within the first 14 days following a stroke, patients with
stroke-like symptoms but negative haemorrhagic stroke CT scan and
unknown ischemic stroke status will be recruited for a study-specific MRI brain
scan. The 3D-T1, axial T2, 3D-FLAIR, DWI, and SWI sequences make up the MRI
study protocol. Before brain imaging, all patients will have their renal function
status checked to lower the risk of contrast-induced nephropathy [26].The
stroke volume (hematoma/infarct volume) will be calculated using the
ellipsoid technique A+B+C/2, where A stands for the largest diameter, B for
the largest diameter perpendicular to A, and C for the product of slice
thickness and number of slices. While the volume is stated in millilitres or
centimetres three, the lengths of A, B, and C are given in centimetres. [27],
[28].
Bilateral regions of patchy or diffuse hypodensity on a CT scan or white
matter hyperintensity on an MRI will be used to define Leukoaraiosis [29]. The
global brain will be classified as absent if the third ventricle's width is less than
5 mm, mild if it is between 5 and 6 mm, moderate if it is between 6 and 7 mm,
and severe if it is greater than 7 mm [30]. All images will be downloaded to a
computer workstation with a SYNGOVIA viewer, where two radiologists with
the necessary training will review them.
Study variables and measures
Aim 1 Study Variables: The variables address the prevalence of post-stroke
depression at one month. MINI will be used for diagnosis of major depressive
disorder (MDD) while PHQ-9 will be used to screen and measure the severity
of depressive score (See Table 1 for a list of the variables with a description of
aim 1)
Aim 2 Study Variables: The variables address the predictors of post-stroke
depression at one month; these include age (in years), sex, alcohol use,
cigarette smoking history, history of diabetes mellitus, dyslipidaemia, atrial
fibrillation, post-stroke cognitive impairment and apathy, quality of life, stroke
type and characteristic (haemorrhagic/ischaemic, cortical/sub-cortical),
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stroke (infarct/hematoma) volume, presence of Leukoaraiosis or brain
atrophy (See table 2 for a list of the variables with a concise description of
Aim 2)
Aim 3 Study Variables: The variables address the outcome of post-stroke
depressive symptoms at three months, categorised as either improvement,
significant worsening, or without significant change (See Table 3 for a list of
the variables with a concise explanation for Aim 3).
Aim 4 Study Variables: The variables address the predictors of significant
improvement of depressive symptoms at three months (See Table 4 for a list
of the variables with a concise explanation for Aim 4).
Dependent variable
Post-stroke depression:
Primary dependent variable:
Post-stroke depression will be defined as per PHQ-9 criteria; those with scores
of 15 will be categorised as having major depressive disorder. Both severity
and progression of depressive symptoms can be assessed with PHQ-9 tool
[31].
Secondary dependent variable:
The outcome of PSD at three months will be evaluated by change of the
PHQ-9 scores, categorised as a significant improvement if scores decrease by
at least 5 points, significant worsening if scores increase by at least 5 points
and no significant change if the scores remain within 5 points [32], [33].
Assessment of change in Depressive symptoms
Patient Health Questionnaire (PHQ -9) will be used to assess the progress of
depressive symptoms from baseline and after the three months of follow-up.
The tool has a total score of 27, using the following nine items: little interest or
pleasure in doing things, feeling down, depressed, or hopeless, trouble falling
or staying asleep, or sleeping too much, feeling tired or having little energy,
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poor appetite or overeating, feeling bad about yourself or that you are a
failure or have let yourself or your family down, trouble concentrating on
things, such as reading the newspaper or watching television, moving or
speaking so slowly that other people could have noticed and thoughts that
you would be better off dead or of hurting yourself. Each item can score from
0-3, 0 if the participant replies (not at all), 1 if the participant responds
(several days), 2 if responds (more than half the days), and 3 if participant
responds (nearly every day). A final total score from each item is categorised
as follows: a score of 1 -4 will be regarded as minimal depression, 5 – 9 as
mild depression, 10 – 14 as moderate depression, 15 – 19 as moderately
severe depression, and 20 – 27 as severe depression. PHQ-9 has been
validated in Tanzania with a Sensitivity of 78% and a Specificity of 87%[34].
Independent variables
Age (in years), sex, marital status, occupation, level of education, alcohol
use, cigarette smoking history, diabetes mellitus, hypertension, dyslipidaemia,
atrial fibrillation, type of stroke, lesion location, severity of stroke, stroke
(infarct/hematoma) volume, presence of Leukoaraiosis, post-stroke cognitive
impairment and apathy and quality of life.
Assessment of Neurocognitive Functioning
The cognitive impairment will also be assessed using the Montreal Cognitive
Assessment (MoCA), which is used to evaluate cognitive impairment, with the
following domains: visuospatial/executive function(score of 5), naming(score
of 3), attention(score of 6), language(repeat(score of 2) and fluency( score
of 1), abstraction(score of 2), delayed recall(score of 5) and orientation(score
of 6). Where by the optimal cut-off score point will be at a score of 22 with a
sensitivity of 80% and specificity of 74%, and dementia at a score of 16, giving
a sensitivity of 90% and specificity of 80% according to the validation of the
tool done in Tanzania of which they used MoCA-5-min [35].
Assessment of Apathy
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Apathy will also be assessed using an evaluation scale which provides for
behavioural, emotional and cognitive aspects of apathy. The tool comprises
18 items with a cut-off score of 39–41 with a sensitivity 75% and a specificity of
76.2% [36].
Assessment of quality of life
Lawton-Brody Institutional Activities of Daily Living scale will be used to assess
the patient capacity to perform tasks [37]. This tool includes almost eight
domains of function like the ability to use the telephone, shopping, food
preparation, laundry, mode of transportation, responsibility for own
medications, housekeeping and ability to handle finances. Women will be
scored on all eight areas of function. In contrast, for men, the areas of food
preparation, housekeeping, and laundering will be excluded [38], with a
sensitivity of 89% and specificity of 81% [39].
Data Analysis
All data collected will be coded and entered into the computer for analysis.
Data will be analysed using the Statistical Package for Social Sciences (SPSS)
version 25.0. The data will be described by frequencies, proportions, Mean (±
SD) and Median (IQR). The Chi-square test will be used to compare the
association between post-stroke depression and the independent
categorical predictors. To determine association between the independent
variables and the post-stroke depression at one month and the outcome of
depressive symptoms at three months, binary logistic regression analysis will
be used, of which those variables with p
<
0.2 under univariable analysis will
be considered for multivariable analysis. Paired t-tests will be used to
compare the mean changes in depressive symptoms from baseline to three
months. Also, an odds ratio (OR) with a confidence interval of 95%, set at a
significance level of
<
0.05, will represent the results.
Ethical approval and data dissemination
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perpetuity.
is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint The copyright holder for thisthis version posted January 6, 2025. ; https://doi.org/10.1101/2025.01.05.25320012doi: medRxiv preprint
The ethical clearance was obtained from the institutional Research review
committee of The University of Dodoma with the reference number
MA.84/261/02 of 30/09/2022. Permission to conduct the study was provided
by the administration of Dodoma Regional Referral Hospital
(PB.22/1307/02/114) and Benjamin Mkapa Hospital (AB/150/293/01/391). All
study participants will be required to sign written informed consent forms or
proxy consent from a close relative or custodian in case the patient is
incapable, which will state clearly about the conducted study. For
confidentiality, participant names will not be utilised; only numbers will be
used. Patients with the need for psychiatric including those with post-stroke
depression will be referred for further evaluation and management will.
Study timeline
The study will be conducted for 18 months from March 2025 to July 2026.
Data collection will be for one year and three months, and follow-up for three
months.
Discussion
The prospective observation longitudinal nature of the study offers a robust
temporal association of the prevalence, progression, and associated factors
of post-stroke depression.
PHQ-9 screening tool is highly sensitive and specific in assessing the severity of
depressive symptoms and their progression.
Given the nature of the study design and patients, the study has a risk of
attrition, while has a strong capacity to elucidate the causal relationship
between dependent and outcome variables. The study is time-consuming
and expensive requiring close follow-up for accurate data collection.
The Dodoma University of Dodoma library, the study sites (Dodoma Regional
Referral Hospital and Benjamin Mkapa Hospital), and a paper ready for
submission in several peer-reviewed journals before publication will all receive
the complete findings before they are published.
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perpetuity.
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Authors’ contributions;
Conceptualisation: S.M, A.N
Data curation: S.M
Formal analysis: S.M
Investigation: A.N
Methodology: S.M, A.N
Supervision: A.N
Writing – original draft: S.M
Writing – review, supervision and editing: A.N
Acknowledgements
We would like to acknowledge the staff of Benjamin Mkapa Hospital and
Dodoma Regional referral Hospital for all the assistance and also Dr Alphonce
Baraka for his contribution in this work.
Supporting Information
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Appendix
Table 1: Aim 1 Variable
Variable
Method of
measurement
Operational
definition
Level of
measurement
Post-stroke
depression at
1month
Patient
assessment
PHQ9(1-27), were
by MDD
likelihood for
those who will
score 15
Dichotomous
Major depressive
disorder
M.I.N.I
tool/questionnaire
Yes or No
Dichotomous
Table 2; Aim 2 Variable
Variable
Operational
Level of
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Definition
Measurement
Age (years)
Age in years
Continuous
Sex
Male versus
female
Dichotomous
Alcohol use
Yes/No
Dichotomous
Smoker
Yes/No
Dichotomous
Former smoker
who abstained
from smoking for
more than 12
months (Yes/No)
Dichotomous
Current smoker
Smoking in the
past 12 months
(Yes/No)
Dichotomous
Hypertension in
(mmHg)
Previously
receiving
antihypertensive
medication or
when the patient
was previously
diagnosed with
hypertension or
detecting blood
pressure of
140/90 mm/Hg for
two
measurements
Dichotomous
Diabetes
Yes/No
Dichotomous
Hyperlipidaemia
Previous had
history
of
Continuous
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hyperlipidaemia
or using lipid-
lowering
medication or
total cholesterol
≥200 mg/dl, LDL
cholesterol ≥100
mg/ dl, and HDL-
cholesterol < 40
mg/dl for men or
< 50 mg/ dl for
women, and/or
serum triglyceride
level 150 mg/ dl
Atrial fibrillation
The absence of P
waves and
irregular-irregular
RR interval
Dichotomous
Stroke severity
NIHSS scale (1- 42)
continuous
Post-stroke cognitive
impairment
MoCA <22
Continuous
Apathy
AES > 38
Continuous
Stroke characteristics
1. Type
2. Volume of
infarct/hemato
ma
IS: hypodensity on
CT
scan/hypointense
on MRI
ICH: hyperdense
on CT
scan/hyperintense
on MRI
Stroke volume:
ellipsoid method
A+B+C/2,
Dichotomous
Continuous
Leukoaraiosis
Bilateral Areas of
patchy or diffuse
hypodensity on CT
or white matter
hyperintensity on
Dichotomous
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MRI
Brain atrophy
The width of the
third ventricle is
greater than 5
mm
Dichotomous
Type of medication
for stroke received
Name of the
medication
Nominal
Table 3: Aim 3 Variable
Variable
Method of
measurement
Operational
definition
Level of
measurement
Change in
depressive
symptoms at 3
months post-
stroke
Patient
assessment
PHQ9(1-27), 5-
point change will
be considered as
significant
change
Continuous
Table 4: Aim 4 Variable
Variable
Method of
measurement
Operational
definition
Level of
measurement
Predictors of
significant
improvement of
depressive
symptoms at 3
months
Binary logistic
regression
Which
independent
variable is
statistically
significant
associated with
significant
improvement of
depressive
symptoms
Continuous and
dichotomous
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Appendices 2
Appendix 2: Care Report Form/ questionnaire
Name……………………………………………………
Date of admission………. /…………. /……………
Hospital reg # ……………………………………….
Contacts
1…………………………2……………………………….3…………………………
1. Demographic data
1. Patient’s Identification Number…………………………………………
2. Patient’s residence: a) Urban b. Rural
3. Date of birth …………/…………/…………
4. Sex a) Male b. Female
5. Marital status a. Single b. Married c. divorced/separated d. widowed/
widower
6. Level of education a. No formal school b. Primary school c. Secondary
school d.
Tertiary school
2. Risk factors &amp; past medical history
7. Cigarette smoking a. Yes, b. No
8. If “yes” number of cigarettes per day……………...
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9. Number of years smoked …………………………
10. Pack years…………….
11. Alcohol consumption a. Yes, b. No
12. If “Yes” For how long? ………………(Years)
13. Units per day/week……………... 86
14. Hypertension a. Yes b. No
15. Diabetic Mellitus a. Yes b. No
3. Clinical presentation on admission
16. Headache
a. Yes b. No
17. Aphasia
a. Yes b. No
18. Nausea/vomiting
a. Yes b. No
19. Loss of consciousness
a. Yes, b. No
20. Focal neurological deficit/Limb weakness
a. Yes, b. No
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21. Dysarthria
a. Yes b. No
22. Seizures/ convulsion
a. Yes, b. No
23. Pupil examinations
a. Normal b. Anisocoria c. Pinpoint
4. Investigations
CT scan results
24. Type of stroke a) haemorrhagic b) ischemic (If the type of stroke is
haemorrhagic
then respond to Qn No, 25 - 26)
25. Location of haemorrhagic stroke
a) Lobar
b) Non-lobar
26. Volume of hematoma __________ cm/millilitre (if the type of stroke is
ischemic respond to Qn No, 27 – 30
27. Infarct volume __________ cm/millilitres Vital Signs 1. Heart Rate ___bpm
2.
Pulse rate ____bpm 3. Pulse deficit ____bpm 4. BP (mmHg)___/____ 5. Mental
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status (GCS)___/15 87
28. Involvement of strategic site (thalamus, angular gyrus, cingulate gyrus,
caudate,
Globus pallidus, basal forebrain, anterior limb of the internal capsule, or
hippocampus) (put a tick where appropriate) a) Yes b) No
29. Number of infarcts (give the actual number) ………………
30. If multiple, where are they located? a) dominant hemisphere b)
nondominant hemisphere c) both hemispheres d) anterior circulation e)
posterior circulation f)anterior and posterior circulation
31. Presence of Leukoaraiosis
a) Yes b) No
32. Presence of global brain atrophy
a) Yes b) No
33. ECG Results…………………………………………………………
34. Random Blood Glucose (results) …………………mmol/l
35. Cholesterol………………. mmol/l
36. LDL …………………mmol/l
37. HDL …………………mmol/l
38. Triglyceride………………...mmol/
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39. History of aspiration pneumonia (tick where appropriate)
a. Yes b. No
40. Current medications the patient is on
a. ……………………………
b. ……………………………
c. …………………………….
d. …………………………….
e. …………………………….
41. Treatment of stroke
a. ……………………………
b. ……………………………
c. ……………………………
d. ……………………………
e. ……………………………
Appendix 3 : National Institute of Health Stroke Scale NIHSS
Instructions Case definition Score
Instructions
Case definition
Score
1a. Level of Consciousness: The
0 = Alert; keenly responsive.
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Instructions
Case definition
Score
investigator must choose a
response if a full evaluation is
prevented by such obstacles as an
endotracheal tube, language
barrier, or tracheal
trauma/bandages. A 3 is scored
only if the patient does not move
(other than reflexive posturing) in
response to noxious stimulation.
1 = Not alert; but arousal by
minor stimulation to obey,
answer, or respond.
2 = Not alert; requires repeated
stimulation to attend, or is
obtunded and requires strong or
painful stimulation to make
movements (not stereotyped).
3 = Responds only with reflex
motor or autonomic effects or
unresponsive, flaccid, and
areflexic.
1b. LOC Questions: The patient is
asked the month and his/her age.
The answer must be correct - there
is no partial credit for being close.
Aphasic and stupor patients who
do not comprehend the questions
will score 2. Patients unable to
speak because of endotracheal
intubation, orotracheal trauma,
and severe dysarthria from any
cause, language barrier, or any
other problem not secondary to
aphasia are given a 1. It is
important that only the initial
answer be graded and that the
examiner not “help" the patient
with verbal or non-verbal cues.
0 = Answers both questions
correctly.
1 = Answers one question
correctly.
2 = Answers neither question
correctly.
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Instructions
Case definition
Score
1c. LOC Commands: The patient is
asked to open and close the eyes
and then to grip and release the
non-paretic hand. Substitute
another one-step command if the
hands cannot be used. Credit is
given if an unequivocal attempt is
made but not completed due to
weakness. If the patient does not
respond to the command, the task
should be demonstrated to him or
her (pantomime), and the result
scored (i.e., follows none, one, or
two commands). Patients with
trauma, amputation, or other
physical impediments should be
given suitable one-step
commands. Only the first attempt is
scored.
0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task
correctly.
2. Best Gaze: Only horizontal eye
movements will be tested.
Voluntary or reflexive
(oculocephalic) eye movements
will be scored, but caloric testing is
not done. If the patient has a
conjugate deviation of the eyes
that can be overcome by
voluntary or reflexive
activity, the score will be 1. If a
0 = Normal.
1 = Partial gaze palsy; the gaze
is abnormal in one or both eyes,
but forced deviation or total
gaze paresis is not present.
2 = Forced deviation, or total
gaze paresis not overcome by
the oculocephalic maneuverer.
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Instructions
Case definition
Score
patient has an isolated peripheral
nerve paresis (CN III, IV, or VI),
score a 1. Gaze is testable in all
aphasic patients. Patients with
ocular trauma, bandages, pre-
existing blindness, or other disorders
of visual acuity or fields should be
tested
with reflexive movements and a
choice made by the investigator.
Establishing eye contact and then
moving the patient from side to
side will occasionally clarify the
presence of partial gaze palsy.
3. Visual: Visual fields (upper and
lower quadrants) are tested by
confrontation, using finger
counting or visual threat, as
appropriate.
Patients may be encouraged, but
if they look at the side of the
moving fingers appropriately, this
can be scored as normal. If there is
unilateral blindness or nucleation,
visual fields in the remaining eye
are scored. Score 1 only if a clear-
cut asymmetry, including
quadrantanopia, is found. If the
patient is blind from any cause,
0 = No visual loss.
1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind
including cortical blindness).
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Instructions
Case definition
Score
score 3.
Double simultaneous stimulation is
performed at this point. If there is
extinction, the patient receives a 1,
and the results are used to respond
to item 11.
4. Facial Palsy: Ask or use
pantomime to encourage the
patient to show teeth or raise
eyebrows and close eyes. Score
symmetry of grimace in response to
noxious stimuli in the poorly
responsive or non-comprehending
patient. If facial trauma/bandages,
orotracheal tube, tape, or other
physical barriers obscure the face,
these should be removed to the
extent possible.
0 = Normal symmetrical
movements.
1 = Minor paralysis (flattened
nasolabial fold, asymmetry on
smiling).
2 = Partial paralysis (total or
near-total paralysis of the lower
face).
3 = Complete paralysis of one or
both sides (absence of facial
movement in the upper and
lower face).
5. Motor Arm: The limb is placed in
the appropriate position: extend
the arms (palms down) 90 degrees
(if sitting) or 45 degrees (if supine).
Drift is scored if the arm falls before
10 seconds. The aphasic patient is
encouraged to use urgency in the
voice and pantomime, but not
noxious stimulation. Each limb is
tested in turn,
Beginning with the non-paretic
0 = No drift; limb holds 90 (or 45)
degrees for a full 10 seconds.
1 = Drift; limb holds 90 (or 45)
degrees, but drifts down before
full 10 seconds; does not hit the
bed or other support.
2 = Some effort against gravity;
limb cannot get to or maintain
(if cued) 90 (or 45) degrees,
drifts down to bed but has some
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Instructions
Case definition
Score
arm. Only in the case of
amputation or joint fusion at the
shoulder, the examiner should
record the score as untestable
(UN), and write the explanation for
this choice.
effort against gravity.
3 = No effort against gravity;
limb falls.
4 = No movement.
UN = Amputation or joint fusion,
explain: _____________________
5a. Left Arm
5b. Right Arm
6. Motor Leg: The limb is placed in
the appropriate position: hold the
leg at 30 degrees (always tested
supine). Drift is scored if the leg falls
before 5 seconds. The aphasic
patient is encouraged to use
urgency in the voice and
pantomime, but not noxious
stimulation.
Each limb is tested in turn,
beginning with the non-paretic leg.
Only in the case of amputation or
joint fusion at the hip, the examiner
should record the score as
untestable (UN), and write the
explanation for this choice.
0 = No drift; leg holds 30-degree
position for full 5 seconds.
1 = Drift; leg falls by the end of
the 5 seconds but does not hit
the bed.
2 = Some effort against gravity;
leg falls to bed by 5 seconds but
has some effort against gravity.
3 = No effort against gravity; leg
falls to bed immediately.
4 = No movement.
UN = Amputation or joint fusion,
explain: ________________
6a. Left Leg
6b. Right Leg
7. Limb Ataxia: This item is aimed at
finding evidence of a unilateral
cerebellar lesion. Test with eyes
open. In case of a visual defect,
0 = Absent.
1 = Present in one limb.
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Instructions
Case definition
Score
ensure testing is done in an intact
visual field. The finger-nose-finger
and heel-shin tests are performed
on both sides, and ataxia is scored
only if present out of proportion to
weakness. Ataxia is absent in the
patient who cannot understand or
is paralyzed. Only in the case of
amputation or joint fusion, the
examiner should record the score
as untestable (UN), and write the
explanation for this choice. In case
of blindness, test by having the
patient touch the nose from an
extended arm position.
2 = Present in two limbs.
UN = Amputation or joint fusion,
explain: ________________
8. Sensory: Sensation or grimace to
pinprick when tested, or
withdrawal from noxious stimulus in
the obtunded or aphasic patient.
Only sensory loss attributed to
stroke is scored as abnormal and
the examiner should test as many
body areas (arms [not hands], legs,
trunk, face) as needed to
accurately check for hemi sensory
loss. A score of 2, “severe or total
sensory loss,” should only be given
when
a severe or total loss of sensation
0 = Normal; no sensory loss.
1 = Mild-to-moderate sensory
loss; patient feels the pinprick is
less sharp or is dull on the
affected side; or there is a loss of
superficial pain with a pinprick,
but the patient is aware of
being touched.
2 = Severe to total sensory loss;
the patient is not aware of
being touched in the face, arm,
and leg.
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Instructions
Case definition
Score
can be demonstrated. Stupors and
aphasic patients will, therefore,
probably score 1 or 0. The patient
with brainstem stroke who has
bilateral loss of sensation
is scored 2. If the patient does not
respond and is quadriplegic, score
2. Patients in a coma (item 1a=3)
are automatically given a 2 on this
item.
9. Best Language: A great deal of
information about comprehension
will be obtained during the
preceding sections of the
examination. For this scale item,
the patient is asked to describe
what is happening in the attached
picture, to name the items on the
attached naming sheet, and to
read from the attached list of
sentences.
Comprehension is judged from
responses here, as well as to all of
the commands in the preceding
general neurological exam. If visual
loss interferes with the tests, ask the
patient to identify objects placed
in the hand, repeat, and produce
speech. The intubated patient
0 = No aphasia; normal.
1 = Mild-to-moderate aphasia;
some obvious loss of fluency or
facility of comprehension,
without significant limitation on
ideas expressed or form of
expression. Reduction of speech
and/or comprehension,
however, makes the
conversation about provided
materials difficult or impossible.
For example, in a conversation
about provided materials, the
examiner can identify picture or
naming card content from the
patient’s response.
2 = Severe aphasia; all
communication is through
fragmentary expression; great
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Instructions
Case definition
Score
should be asked to write. The
patient in a coma (item 1a=3) will
automatically score 3 on this item.
The examiner must choose a score
for the patient with a stupor or
limited cooperation, but a score of
3 should be used only if the patient
is mute and follows no one-step
commands.
need for inference, questioning,
and guessing by the listener. The
range of information that can
be exchanged is limited; the
listener carries the burden of
communication. The examiner
cannot identify the materials
provided from the patient's
response.
3 = Mute, global aphasia; no
usable speech or auditory
comprehension.
10. Dysarthria: If the patient is
thought to be normal, an
adequate sample of speech must
be obtained by asking the patient
to read or repeat words from the
attached list. If the patient has
severe aphasia, the clarity of
articulation of spontaneous speech
can berated. Only if the patient is
intubated or has other physical
barriers to producing speech, the
examiner should record the score
as untestable (UN), and write an
explanation for this choice. Do not
tell the patient why he or she is
being tested.
0 = Normal.
1 = Mild-to-moderate dysarthria;
patient slurs at least some words
and, at worst, can be
understood with some difficulty.
2 = Severe dysarthria; patient's
speech is so slurred as to be
unintelligible in the absence of
or out of proportion to any
dysphasia, or is mute/anarthria.
UN = Intubated or another
physical barrier,
explain:
_____________________________
11. Extinction and Inattention
0 = No abnormality.
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Instructions
Case definition
Score
(formerly Neglect): Sufficient
information to identify neglect may
be obtained during the prior
testing. If the patient has a severe
visual loss preventing visual double
simultaneous stimulation, and the
cutaneous stimuli are normal, the
score is normal. If the patient has
aphasia but does appear to
attend to both sides, the score is
normal. The presence of visual-
spatial neglect or anosognosia
may also be taken as evidence of
abnormality. Since the abnormality
is scored only if present, the item is
never untestable.
1 = Visual, tactile, auditory,
spatial, or personal inattention or
extinction to bilateral
simultaneous stimulation in one
of the sensory modalities.
2 = Profound hemi-inattention or
extinction to more than one
modality; does not recognize
own hand or orients to only one
side of space.
Tick the appropriate
1. No stroke symptoms Score 0
2. Minor stroke Scores 1- 4
3. Moderate stroke Scores 5-15
4. Moderate to severe stroke Scores 16-20
5. Severe stroke Scores 21- 42
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Appendix 4 : Apathy Evaluation Scale (AES)
Date___________________________ ID No________________________
Rate each item based on an interview of the subject. The interview should
begin with a description of the subject’s interests, activities, and daily
routine. Base your ratings on both verbal and non-verbal information.
Ratings should be based on the past 4 weeks. For each item ratings should
be judged:
Not at All
Characteristic
Slightly
Characteristic
Somewhat
Characteristic
A Lot
Characteristic
1
1
3
4
1. S/he is interested in things.
+ C Q
2. S/he gets things done during the day.
+ B Q
3. Getting things started on his/her own is important to her/him.
+ C SE
4. S/he is interested in having new experiences.
+ C Q
5. S/he is interested in learning new things.
+ C Q
6. S/he puts little effort into anything.
- B
7. S/he approaches life with intensity.
+ E
8. Seeing a job through to the end is important to her/him.
+ C SE
9. He/she spends time doing things that interest her/him.
+ B
10. Someone has to tell her/him what to do each day.
- B
11. S/he is less concerned about his/her problems than her/him
should be.
- C
12. S/he has friends.
+ B Q
13. Getting together with friends is important to her/him.
+ C SE
14. When something good happens, he/she gets excited.
+ E
15. S/he has an accurate understanding of her/his problems.
+ O
16. Getting things done during the day is important to her/him.
+ C SE
17. S/he has initiative.
+ O
18. S/he is motivated.
+ O
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Note: Items that have positive versus negative syntax are identified by +/-.
Type of item: C = cognitive; B = behaviour; E = emotional; O = other.
Appendix 5 : The Patient Health Questionnaire - 9
PATIENT HEALTH QUESTIONNAIRE-9
(PHQ-9)
Over the last 2 weeks, how often have you
been bothered by any of the following
problems? (Use “” to indicate your
answer)
Not at
all
Several
days
More
than
half
the
days
Nearly
every
day
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Trouble falling or staying asleep, or
sleeping too much
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6. Feeling bad about yourself — or that you
are a failure or have let yourself or your
family down
0
1
2
3
7. Trouble concentrating on things, such as
reading the newspaper or watching
television
0
1
2
3
8. Moving or speaking so slowly that other
people could have noticed? Or the
opposite — being so fidgety or restless that
you have been moving around a lot more
than usual
0
1
2
3
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9. Thoughts that you would be better off
dead or hurting yourself in some way
0
1
2
3
Appendix 6: Montreal Cognitive Assessment (MoCA) test
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Objective: Transthoracic echocardiography (TTE) is routinely performed as part of standard acute ischemic stroke (AIS) workup. However, the overall yield of TTE is unclear and many patients may undergo unnecessary investigations. This study aims to investigate the utility of TTE as part of AIS workup. Methods: We collected data on consecutive patients with AIS who were admitted to our institution between 07/01/2016 and 09/30/2017. Patients were included based on neuroimaging-documented AIS, age >18 and neuroimaging studies. Primary endpoint was the proportion of cases in which TTE yielded relevant finding, defined as Atrial Septa Defect or Patent Foramen Ovale, left atrial enlargement, left ventricular thrombus or ejection fraction of <35%. Secondary endpoint was the proportion of patients who had a TTE-drive change in management. Results: Among 548 AIS patients (median age 71 [59–81] years, 50% female), 482 (87%) underwent TTE. Clinically relevant findings were observed in 183 (38%) patients, leading to additional workup in 41 (8.5%). Further workup was associated with younger median age (58 [50–65] vs. 72 [62–81], p < 0.0001, and was less likely in suspected large vessel etiology (p = 0.02). Abnormal TTE lead to treatment change in 24 (5%) patients; 22/24 were started on anticoagulation. TTE results were less likely to influence treatment changes in older patients (71 [60–80] vs. 58 [49–69] years, p = 0.02) with known atrial fibrillation (p = 0.01). Conclusion: Our findings suggest that despite widespread use, the overall yield of TTE in AIS is low. Stratifying patients according to their likelihood of benefitting from it will be important toward better resource utilization.
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Background: Stroke is a leading cause of death and disability in globally and particularly in low- and middle-income countries, and this burden is increasing. The burden of stroke pathological subtypes varies in terms of incidence, disability and mortality. Previous Global Burden of Diseases, Injuries, and Risk Factors Studies (GBD) reports did not provide separate global burden and trends estimates for haemorrhagic stroke by primary intracerebral haemorrhage (PICH) and subarachnoid haemorrhage (SAH). Aim: To summarise the GBD 2017 findings for the burden and 27-year trends for ischaemic stroke (IS), intracerebral haemorrhage and SAH by age, sex and country income level in 21 world regions and associated risk factors. Methods: Data on stroke incidence, prevalence, mortality and disability-adjusted life-years (DALY) lost and the burden of IS, PICH and SAH were derived from all available datasets from the GBD 2017 studies. Data were analysed in terms of absolute numbers and age-standardised rates per 100,000 (95% uncertainty interval [UI]), with estimates stratified by age, sex and economic development level by the World Bank classification. We also analysed changes in the patterns of incidence, mortality and DALYs estimates between 1990 and 2017. Results: In 2017, there were 11.9 million incident (95% UI 11.1-12.8), 104.2 million prevalent (98.6-110.2), 6.2 million fatal (6.0-6.3) cases of stroke and 132.1 million stroke-related DALYs (126.5-137.4). Although stroke incidence, prevalence, mortality and DALY rates declined from 1990 to 2017, the absolute number of people who developed new stroke, died, survived or remained disabled from stroke has almost doubled. The bulk of stroke burden (80% all incident strokes, 77% all stroke survivors, 87% of all deaths from stroke and 89 of all stroke-related DALYs) in 2017 was in low- to middle-income countries. Globally in 2017, IS constituted 65%, PICH -26% and SAH -9% of all incident strokes. Discussion: The latest GBD estimates of stroke burden in 195 countries supersede previous GBD stroke burden findings and provide most accurate data for stroke care planning and resource allocation globally, regionally and for 195 countries. Stroke remains the second leading cause of deaths and disability worldwide. The increased stroke burden continues to exacerbate a huge pressure on people affected by stroke, their families and societies. It is imperative to develop and implement more effective primary prevention strategies to reduce stroke burden and its impact.
Article
Background Major depression has a significant impact on years lived with disability (YLD) globally. In resource-limited countries, depression may accompany daily challenges of economic security that people face, hence there is a critical need to develop depression screening tools at primary levels of health care. The overall goal of the study is to validate the PHQ-9 in Tanzania. Methods A validation study was conducted from August to October 2014 among adults accessing primary health care at public clinics in Dar es Salaam. The Mini-International Neuropsychiatric Interview (MINI) was used as the gold standard for current major depressive episode. Results Among 180 patients recruited, six were not included in the analysis since the PHQ-9 and MINI assessments were conducted more than two weeks apart (n = 174). The PHQ-9 demonstrated reasonable reliability in this setting (α = 0.83). Evidence for construct validity was observed through expected associations with female gender (r = 0.16, p = 0.04) and food insecurity (r = 0.30, p < 0.0001). Receiver Operating Characteristic analysis demonstrated good overall accuracy of the PHQ-9 (AOC = 0.87, 95%CI: 0.77, 0.96). The optimal cut-off score in this population was 9, with a sensitivity of 78% and specificity of 87%. Limitations The study sample is from a primary health care setting, hence the findings may have some limited generalizability at the community level. Conclusions The PHQ-9 demonstrated reliability and validity among adults accessing primary health care in Dar es Salaam, indicating that it can serve as a useful tool in identifying patients with depression in primary care clinics in Tanzania and similar settings.