The Triad of Pain, Fatigue and Depression in Ischemic Stroke Patients: The Bergen Stroke Study

Abstract

Background: Many patients with cerebral infarction suffer from symptoms such as pain, fatigue and depression. Most studies focus on single symptoms, but these symptoms often occur together. Whereas symptom clusters have been studied in cancer patients, little is known about different symptom clusters in patients with cerebral infarction. The aim was to evaluate clusters of co-occurring symptoms in the long term. We hypothesized that patients with cerebral infarction display distinct symptom clusters. Furthermore, we hypothesized that multiple co-occurring symptoms have an adverse effect on patients. Methods: All consecutive patients with acute stroke (the index stroke) admitted to the Stroke Unit, Department of Neurology, Haukeland University Hospital, between February 2006 and July 2008, were prospectively registered in a database. Prior risk factors (including diabetes mellitus, hypertension, smoking, coronary heart disease, atrial fibrillation and prior stroke), prior depression and stroke severity (modified Rankin Scale (mRS) score on day 7) were registered. Patients with cerebral infarction were sent a questionnaire including a visual analogue pain scale (VAS), Fatigue Severity Scale (FSS), depression subscale of the Hospital Anxiety, Depression Scale (HADS-D) and Barthel Index at least 6 months after stroke onset. Results: The questionnaire was returned by 328 patients (response rate 60%). All three symptoms were reported by 10.1%. Pain and fatigue among nondepressed patients were reported by 19.6%. Pain and depression among nonfatigued patients were reported by 2.0%. Depression and fatigue, and no pain were reported by 4.4%. Single symptoms were reported by 31% whereas 33% reported no symptoms. VAS, FSS and HADS-D score severity increased with the number of co-occurring symptoms. Logistic regression analyses showed that two or three symptoms (versus no symptoms) was associated with high mRS score on day 7 (p = 0.02), prior stroke (p = 0.002), prior diabetes mellitus (p = 0.005) and prior depression (p < 0.001). Conclusions: Symptom clusters are frequent in patients with cerebral infarction. Fatigue was associated with pain and depression whereas there was little association between depression and pain in nonfatigue patients, indicating distinct symptom clusters. The severity of symptoms increased with the number of co-occurring symptoms.

Poststroke Fatigue: Emerging Evidence and Approaches to Management: A Scientific Statement for Healthcare Professionals From the American Heart Association

“…21,24,27 One study reported that smoking cessation was associated with PSF in patients without depression, 14 suggesting that sudden abstinence of smoking may contribute to PSF. 51 Medications that are commonly used in patients with stroke such as sedatives, 27 antidepressants, 45,52 and hypnotics 17 may cause fatigue. Although studies have not implicated medications as a major cause of PSF, 14,34,47 the potential association should not be ignored.…”

“…66 Although fatigue, pain, and depression are related conditions, poststroke pain seems to be more closely associated with fatigue than depression. 52,69 Pain may somehow be involved in the persistence of fatigue over time. 26 …”

Is Poststroke Depression a Major Depression?

“…Depression also has a negative effect on social functioning and the quality of life of patients [23,24,25,26]. …”

The relationship between fatigue and participation in spinal cord injury

“…Further research to investigate the relationship between pain, fatigue and participation in community activities for individuals with SCI is warranted. Given previous attention paid to the pain-fatiguedepression symptom cluster in other populations, notably individuals with cancer 28 or post-stroke, 29 it is not surprising to see a relationship between these factors in this study. The directional nature of this cluster remains unclear and presents an opportunity for further interventional research to determine the nature of this phenomenon.…”