Previous studies have stated that both objective and subjective cognitive abilities and mental health symptoms are associated with community participation poststroke. However, there is a need to understand the direct and indirect associations among these variables in persons with stroke. The objective of this study was to investigate whether mental health symptoms mediate the associations of subjective and objective cognitive abilities with community participation poststroke. We built regression-based mediation models with 74 participants with mild to moderate stroke. Independent variables were objective and subjective cognitive abilities. The dependent variable was community participation. Mediators were mental health symptoms including depression, apathy, and anxiety. The results indicated that depression (b = .093), apathy (b = .134), and anxiety (b = .116) fully mediated the association between subjective cognitive ability (p < .05), but not objective cognitive ability (p > .05), and community participation poststroke. Our findings suggest that poor subjective cognitive ability combined with mental health symptoms should be addressed together to promote community participation poststroke.
Plain Language Summary
Mental Health Mediators for Subjective, Not Objective, Cognition, and Community Participation Poststroke
Researchers and clinicians have used both objective and subjective tools to evaluate cognitive abilities including memory, attention, and thinking. Objective cognitive ability indicates the level of cognitive ability measured using an objective tool such as pen and paper tests while subjective cognitive ability refers to self-perceived cognitive ability indicated via self-report questionnaires. Previous studies have shown that both objective and subjective cognitive abilities and mental health symptoms (depression, anxiety, and apathy) are associated with community participation in persons with stroke. However, there is a need to understand the direct and indirect associations among objective and subjective cognitive abilities, mental health symptoms, and community participation. In this context, we investigated if mental health symptoms mediated the associations of subjective and objective cognitive ability with community participation poststroke. Our results suggest that mental health symptoms fully mediated the associations between subjective cognitive ability and community participation but not the associations between objective cognitive ability and community participation poststroke. Our findings propose that rehabilitation and occupational therapy professionals should carefully monitor subjective cognitive problems with special attention to persons with poststroke depression, apathy, and anxiety to increase community participation poststroke.
AmariglioR. E.DonohueM. C.MarshallG. A.RentzD. M.SalmonD. P.FerrisS. H.KarantzoulisS.AisenP. S.SperlingR. A. (2015). Tracking early decline in cognitive function in older individuals at risk for Alzheimer disease dementia: The Alzheimer’s Disease Cooperative Study Cognitive Function Instrument. JAMA Neurology, 72(4), 446–454.
2.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (Vol. 5).
3.
Barker-ColloS.FeiginV. L.ParagV.LawesC. M. M.SeniorH. (2010). Auckland Stroke Outcomes Study. Part 2: Cognition and functional outcomes 5 years poststroke. Neurology, 75(18), 1608–1616. https://doi.org/10.1212/WNL.0b013e3181fb44c8
4.
BaronR. M.KennyD. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182.
5.
BourgetN.Deblock-BellamyA.BlanchetteA. K.BatchoC. S. (2018). Use and psychometric properties of the Reintegration to Normal Living Index in rehabilitation: A systematic review. Annals of Physical and Rehabilitation Medicine, 61(4), 262–269.
6.
BrottT.AdamsH. P.JrOlingerC. P.MarlerJ. R.BarsanW. G.BillerJ.SpilkerJ.HolleranR.EberleR.HertzbergV. J. S. (1989). Measurements of acute cerebral infarction: A clinical examination scale. Stroke, 20(7), 864–870.
7.
DelisD. C.KaplanE.KramerJ. H. (2001). Delis-Kaplan executive function system. Psychological Corporation.
8.
DelisD. C.KramerJ. H.KaplanE.HoldnackJ. (2004). Reliability and validity of the Delis-Kaplan Executive Function System: An update. Journal of the International Neuropsychological Society, 10(2), 301–303.
9.
DomensinoA. F.EvansJ.van HeugtenC. (2022). From word list learning to successful shopping: The neuropsychological assessment continuum from cognitive tests to cognition in everyday life. Applied Neuropsychology: Adult, 1–9. https://doi.org/10.1080/23279095.2022.2079087
10.
DuitsA.MunnecomT.van HeugtenC.van OostenbruggeR. J. (2008). Cognitive complaints in the early phase after stroke are not indicative of cognitive impairment. Journal of Neurology, Neurosurgery & Psychiatry, 79(2), 143–146.
11.
DuncanP. W.WallaceD.LaiS. M.JohnsonD.EmbretsonS.LasterL. J. (1999). The stroke impact scale version 2.0: Evaluation of reliability, validity, and sensitivity to change. Stroke, 30(10), 2131–2140.
12.
EbaidD.BirdL. J.McCambridgeL. J. E.WerdenE.BradshawJ.CummingT.TangE.BrodtmannA. (2022). Mood and cognitive trajectories over the first year after mild ischemic stroke. Journal of Stroke and Cerebrovascular Diseases, 31(4), Article 106323. https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106323
13.
El HusseiniN.KatzanI. L.RostN. S.BlakeM. L.ByunE.PendleburyS. T.. . . SmithE. E. (2023). Cognitive impairment after ischemic and hemorrhagic stroke: A scientific statement from the American Heart Association/American Stroke Association. Stroke, 54(6), e272–e291.
14.
FaulF.ErdfelderE.LangA. G.BuchnerA. (2007). G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175–191.
15.
GuoY.ZhangZ.LinB.MeiY.LiuQ.ZhangL.WangW.LiY.FuZ. (2021). The unmet needs of community-dwelling stroke survivors: A systematic review of qualitative studies. International Journal of Environmental Research and Public Health, 18(4), Article 2140.
16.
HayesA. F. (2017). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford.
17.
HershD.IsraelM.ShigginsC. (2022). The ethics of patient and public involvement across the research process: Towards partnership with people with aphasia. Aphasiology, 1–26. https://doi.org/10.1080/02687038.2021.1896870
18.
HillN. L.MogleJ.WionR.MunozE.DePasqualeN.YevchakA. M.ParisiJ. M. (2016). Subjective cognitive impairment and affective symptoms: A systematic review. The Gerontologist, 56(6), e109–e127.
19.
HochstenbachJ.PrigatanoG.MulderT. (2005). Patients’ and relatives’ reports of disturbances 9 months after stroke: Subjective changes in physical functioning, cognition, emotion, and behavior. Archives of Physical Medicine and Rehabilitation, 86(8), 1587–1593.
20.
JessenF.AmariglioR. E.BuckleyR. F.van der FlierW. M.HanY.MolinuevoJ. L.. . . WagnerM. (2020). The characterisation of subjective cognitive decline. Lancet Neurology, 19(3), 271–278.
21.
JessenF.AmariglioR. E.van BoxtelM.BretelerM.CeccaldiM.ChételatG.. . . WagnerM. (2014). A conceptual framework for research on subjective cognitive decline in preclinical Alzheimer’s disease. Alzheimers and Dementia, 10(6), 844–852. https://doi.org/10.1016/j.jalz.2014.01.001
22.
KimonidesS.CavuotoM. G.De SilvaL.KinsellaG. J. (2018). The role of subjective cognitive complaints and depressive symptoms in social re-integration following stroke: A mediation explanation in a cross-sectional sample. Topics in Stroke Rehabilitation, 25(7), 514–520. https://doi.org/10.1080/10749357.2018.1489570
23.
KliemE.GjestadE.RyumT.OlsenA.ThommessenB.IndredavikB.BieliauskasL.Due-TønnessenP.FladbyT.GrambaiteR. (2021). The relationship of psychiatric symptoms with performance-based and self-reported cognitive function after ischemic stroke. Journal of the International Neuropsychological Society, 28(1), 35–47. https://doi.org/10.1017/S1355617721000187
24.
KroenkeK.SpitzerR. L.WilliamsJ. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.
25.
LambF.AndersonJ.SalingM.DeweyH. (2013). Predictors of subjective cognitive complaint in postacute older adult stroke patients. Archives of Physical Medicine and Rehabilitation, 94(9), 1747–1752.
26.
LauS. C. L.ConnorL. T.BaumC. M. (2021). Subjective and objective assessments are associated for physical function but not cognitive function in community-dwelling stroke survivors. Disability and Rehabilitation, 44(26), 8349–8356. https://doi.org/10.1080/09638288.2021.2012845
27.
LeeY.NicholasM. L.ConnorL. T. (2023). Identifying emotional contributors to participation post-stroke. Topics in Stroke Rehabilitation, 30(2), 180–192.
28.
LevineD. A.GaleckiA. T.LangaK. M.UnverzagtF. W.KabetoM. U.GiordaniB.WadleyV. G. (2015). Trajectory of cognitive decline after incident stroke. JAMA, 314(1), 41–51.
29.
LöweB.KroenkeK.HerzogW.GräfeK. (2004). Measuring depression outcome with a brief self-report instrument: Sensitivity to change of the Patient Health Questionnaire (PHQ-9). Journal of Affective Disorders, 81(1), 61–66.
30.
MarinR. S. (1991). Apathy: A neuropsychiatric syndrome. Journal of Neuropsychiatry and Clinical Neurosciences, 3(3), 243–254.
31.
MarinR. S.BiedrzyckiR. C.FirinciogullariS. (1991). Reliability and validity of the Apathy Evaluation Scale. Psychiatry Research, 38(2), 143–162.
32.
MolinuevoJ. L.RabinL. A.AmariglioR.BuckleyR.DuboisB.EllisK. A.EwersM.HampelH.KlöppelS.RamiL. (2017). Implementation of subjective cognitive decline criteria in research studies. Alzheimer’s and Dementia, 13(3), 296–311.
33.
MountainA.Patrice LindsayM.TeasellR.SalbachN. M.de JongA.FoleyN.BhogalS.BainsN.BowesR.CheungD. (2020). Canadian stroke best practice recommendations: Rehabilitation, recovery, and community participation following stroke. Part two: Transitions and community participation following stroke. International Journal of Stroke, 15(7), 789–806.
34.
MukakaM. M. (2012). A guide to appropriate use of correlation coefficient in medical research. Malawi Medical Journal, 24(3), 69–71.
35.
NijsseB.van HeugtenC. M.van MierloM. L.PostM. W.de KortP. L.Visser-MeilyJ. M. (2017). Psychological factors are associated with subjective cognitive complaints 2 months post-stroke. Neuropsychological Rehabilitation, 27(1), 99–115.
36.
NysG. M. S.van ZandvoortM. J. E.van der WorpH. B.de HaanE. H. F.de KortP. L. M.KappelleL. J. (2005). Early depressive symptoms after stroke: Neuropsychological correlates and lesion characteristics. Journal of the Neurological Sciences, 228(1), 27–33. https://doi.org/10.1016/j.jns.2004.09.031
37.
PalstamA.SjödinA.SunnerhagenK. S. (2019). Participation and autonomy five years after stroke: A longitudinal observational study. PLOS ONE, 14(7), Article e0219513.
38.
RamanaiahN. V.FranzenM.SchillT. (1983). A psychometric study of the State-Trait Anxiety Inventory. Journal of Personality Assessment, 47(5), 531–535.
39.
RodakowskiJ.SkidmoreE. R.ReynoldsC. F.IIIDewM. A.ButtersM. A.HolmM. B.LopezO. L.RogersJ. C. (2014). Can performance on daily activities discriminate between older adults with normal cognitive function and those with mild cognitive impairment?Journal of the American Geriatrics Society, 62(7), 1347–1352.
40.
SörösP.HarnadekM.BlakeT.HachinskiV.ChanR. (2015). Executive dysfunction in patients with transient ischemic attack and minor stroke. Journal of the Neurological Sciences, 354(1–2), 17–20.
StephensS.KennyR.RowanE.AllanL.KalariaR.BradburyM.BallardC. (2004). Neuropsychological characteristics of mild vascular cognitive impairment and dementia after stroke. International Journal of Geriatric Psychiatry, 19(11), 1053–1057.
43.
StogmannE.MoserD.KlugS.GleissA.AuffE.Dal-BiancoP.PusswaldG.LehrnerJ. (2016). Activities of daily living and depressive symptoms in patients with subjective cognitive decline, mild cognitive impairment, and Alzheimer’s disease. Journal of Alzheimer’s Disease, 49(4), 1043–1050.
44.
StolwykR. J.MihaljcicT.WongD. K.ChapmanJ. E.RogersJ. M. (2021). Poststroke cognitive impairment negatively impacts activity and participation outcomes: A systematic review and meta-analysis. Stroke, 52(2), 748–760. https://doi.org/10.1161/strokeaha.120.032215
45.
TerroniL.SobreiroM. F.ConfortoA. B.AddaC. C.GuajardoV. D.LuciaM. C. S. d.FráguasR. (2012). Association among depression, cognitive impairment and executive dysfunction after stroke. Dementia & Neuropsychologia, 6(3), 152–157.
46.
TsaoC. W.AdayA. W.AlmarzooqZ. I.AlonsoA.BeatonA. Z.BittencourtM. S.BoehmeA. K.BuxtonA. E.CarsonA. P.Commodore-MensahY. (2022). Heart disease and stroke statistics—2022 update: A report from the American Heart Association. Circulation, 145(8), e153–e639.
47.
TuckerF. M.EdwardsD. F.MathewsL. K.BaumC. M.ConnorL. T. (2012). Modifying health outcome measures for people with aphasia. American Journal of Occupational Therapy, 66(1), 42–50. https://doi.org/10.5014/ajot.2012.001255
48.
Van Der ZeeC. H.Visser-MeilyJ. M.LindemanE.Jaap KappelleL.PostM. W. (2013). Participation in the chronic phase of stroke. Topics in Stroke Rehabilitation, 20(1), 52–61.
49.
van RijsbergenM.MarkR.KopW.de KortP.SitskoornM. (2017). The role of objective cognitive dysfunction in subjective cognitive complaints after stroke. European Journal of Neurology, 24(3), 475–482.
50.
van RijsbergenM. W.MarkR. E.de KortP. L.SitskoornM. M. (2014). Subjective cognitive complaints after stroke: A systematic review. Journal of Stroke and Cerebrovascular Diseases, 23(3), 408–420.
51.
Van RijsbergenM. W.MarkR. E.KopW. J.De KortP. L.SitskoornM. M. (2020). Course and predictors of subjective cognitive complaints during the first 12 months after stroke. Journal of Stroke and Cerebrovascular Diseases, 29(3), Article 104588.
52.
WilliamsL. S.BrizendineE. J.PlueL.BakasT.TuW.HendrieH.KroenkeK. (2005). Performance of the PHQ-9 as a screening tool for depression after stroke. Stroke, 36(3), 635–638.
53.
WilliamsO. A.DemeyereN. (2020). Cognitive impairment is differentially associated with depression and anxiety at six-months post-stroke. medRxiv.
54.
WolfT.KosterJ. (2013). Perceived recovery as a predictor of physical activity participation after mild stroke. Disability and Rehabilitation, 35(14), 1143–1148. https://doi.org/10.3109/09638288.2012.720635
55.
WolfT. J.BarbeeA. R.WhiteD. (2011). Executive dysfunction immediately after mild stroke. OTJR: Occupation, Participation and Health, 31(1_suppl), S23–S29.
56.
Wood-DauphinéeS.OpzoomerM.WilliamsJ. I.MarchandB.SpitzerW. O. (1988). Assessment of global function: The Reintegration to Normal Living Index. Archives of Physical Medicine and Rehabilitation, 69(8), 583–590.
57.
World Health Organization. (2001). International classification of functioning, disability, and health: ICF (Version 1.0).
58.
ZlatarZ. Z.MunizM.GalaskoD.SalmonD. P. (2018). Subjective cognitive decline correlates with depression symptoms and not with concurrent objective cognition in a clinic-based sample of older adults. Journals of Gerontology: Series B, 73(7), 1198–1202.
