Original Paper Received: November 4, 2013 Accepted: May 27, 2014 Published online: September 19, 2014
Eur Neurol 2014;72:223–227 DOI: 10.1159/000364902
Correlation of Fatigue During the Acute Stage of Stroke with Serum Uric Acid and Glucose Levels, Depression, and Disability Dan Wu a, b Lin Wang b Weiyu Teng a Kui Huang c Xiuli Shang a
a c
Department of Neurology, The First Affiliated Hospital, China Medical University, b Department of Neurology, Department of Gerontology, Shenyang Red Cross Hospital, Shenyang, China
Key Words Fatigue · Stroke · Uric acid · Hyperglycaemia · Depression · Disability
not associated with FSS score. Conclusions: Serum UA and glucose levels, depression, and disability are closely related to fatigue during the acute stage of ischaemic stroke. © 2014 S. Karger AG, Basel
Abstract Background: To clarify the correlation of fatigue during the acute stage of stroke with serum uric acid (UA) and glucose levels, depression, and disability. Design: Cross-sectional descriptive study. Methods: A stroke group of 312 patients and a reference group of 312 healthy controls were recruited during the same period. Fatigue was assessed using the Fatigue Severity Scale (FSS). Patients with an FSS score ≥4 points were defined as having fatigue. Depression was assessed using the Self-rating Depression Scale (SDS). Patients with an SDS score ≥50 points were defined as having depression. Stroke severity and the level of disability were assessed with the National Institutes of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (MRS). Results: The prevalence of fatigue in the stroke group was higher than that in the reference group (p < 0.001). Within the stroke group, low serum UA level, high MRS score, high serum glucose level, and high SDS score were associated with increased FSS score. The MRS score was associated most consistently with the FSS score (B = 0.411, 95% CI: 0.297, 0.525). Age, gender, chronic disease history, and NIHSS score were
© 2014 S. Karger AG, Basel 0014–3022/14/0724–0223$39.50/0 E-Mail [email protected] www.karger.com/ene
Introduction
Fatigue is a common symptom after stroke, but poststroke fatigue (PSF) is usually neglected by clinicians. Since the report by Leegaard [1] that 75% of stroke survivors experience fatigue, PSF has gradually received more attention from clinicians and researchers. Recently, an abundance of evidence has indicated that PSF is a common, long-lasting, and disabling symptom [2–4] that significantly reduces the quality of life [5], decreases the likelihood of returning to work [6], and increases mortality in stroke survivors [7]. However, the aetiology and pathogenesis of PSF are still unclear, and an effective treatment method does not still exist. PSF is complex and multi-dimensional, with numerous related causative factors. Previous PSF studies have primarily focused on demographics, co-morbidities, medications, pre-stroke fatigue (PrSF), stroke severity, stroke type, degree of disability, post-stroke depression (PSD), and lesion location. However, the results of these studies have not been consistent. Xiuli Shang Department of Neurology, The First Affiliated Hospital China Medical University Shenyang 110001 (China) E-Mail shang_zhao @ sohu.com
Table 1. FSS questionaire1
Questions
Score
1. 2. 3. 4. 5. 6. 7. 8. 9.
1 1 1 1 1 1 1 1 1
My motivation is lower when I am fatigued Exercise brings on my fatigue I am easily fatigued Fatigue interferes with my physical functioning Fatigue causes frequent problems for me My fatigue prevents sustained physical functioning Fatigue interferes with carrying out certain duties and responsibilities Fatigue is among my three most disabling symptoms Fatigue interferes with my work, family or social life
2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5
6 6 6 6 6 6 6 6 6
7 7 7 7 7 7 7 7 7
1 Individuals were asked to indicate how they felt by answering each question on a 7-point Likert scale. The score was from 1 (strongly disagree) to 7 (strongly agree). The scoring is done by calculating the average response to the questions (adding up all the answers and dividing by nine).
Recent studies have shown that the serum levels of uric acid (UA) and glucose are closely related to stroke [8, 9]. However, the relationships between serum UA and glucose levels and PSF are unknown, and the relevant data are limited. To clarify the correlations of PSF with serum glucose and UA levels, depression, and disability, we collected clinical data (age, gender, chronic disease history, stroke severity, degree of fatigue, depression, and disability), determined the PSF prevalence, and tested the serum levels of UA and glucose in first-ever stroke patients during the acute stage. Methods The study was a cross-sectional descriptive study. Study Population A stroke group of 312 patients were recruited from the Department of Neurology at Shenyang Red Cross Hospital in China between June 2012 and August 2013. The inclusion criteria were as follows: (1) first-ever stroke with CT or MRI scan upon admission and confirmed acute cerebral infarction (ACI); (2) ≥18 years of age; (3) stable temperature, pulse, respiration and blood pressure; and (4) signed informed consent. Patients were excluded for the following reasons: (1) inability to complete the scale evaluation due to communication or cognitive disorders; (2) concurrent diagnosis of cancer, systemic lupus erythematosus, or Parkinson’s disease, all of which have been shown to cause fatigue; (3) administered thrombolysis therapy; (4) PrSF (patients who reported fatigue lasting >3 months before the stroke were defined as having PrSF [10]); and (5) depression diagnosis before the stroke. A reference group of 312 healthy controls were recruited from the Health Examination Centre of Shenyang Red Cross Hospital in China during the same period. The inclusion criteria were as follows: (1) all examination results were normal; (2) no history of
224
Eur Neurol 2014;72:223–227 DOI: 10.1159/000364902
chronic diseases and chronic medication use; (3) signed informed consent; and (4) matched to the ages and genders of the stroke group on an individual-level. The exclusion criteria were as follows: (1) SDS score ≥50; or (2) a depression diagnosis. Collection of Clinical Data In the reference group, age, gender, and health examination results were obtained from the examination report. Collection of the disease history and the FSS and SDS assessments were performed during face-to-face interviews. In the stroke group, age and gender information were collected from the medical records. Collection of the disease history (hypertension, coronary heart disease, and diabetes mellitus) and assessment of scales were performed during face-to-face interviews 10–15 days after the stroke onset, when the patients were clinically stable. Based on the World Health Organization and the International Society of Hypertension guidelines (WHO/ISH) [11], hypertension was defined as systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg. Stroke severity and the level of disability were assessed with the NIHSS [12] and the MRS [13], respectively. The NIHSS contains 15 examination items and 51 raw score choices. The total score is equal to the sum of the 15 parameters. For all of the parameters, a value of 0 is normal [12]. The MRS has six grades ranging from 0 (no symptom) to 5 (severe disability). Depression was assessed with the SDS. Patients with an SDS score ≥50 points were diagnosed with depression [14, 15]. Blood samples were obtained the morning after admission, and the serum levels of UA and glucose were determined. Assessment of Fatigue We used the FSS to assess the severity of fatigue over the past week in the stroke and reference groups. The FSS was originally designed to assess the fatigue of patients with multiple sclerosis [16]. Recently, the FSS has also been frequently used to assess fatigue in stroke patients [2, 10, 17] due to its excellent internal consistency and reliability for these patients [18]. We divided the patients in the stroke group into fatigue (F group) and non-fatigue groups (NF group) based on the FSS scores. Patients with an FSS score ≥4 points were defined as having fatigue [18] (table 1).
Wu/Wang/Teng/Huang/Shang
Table 2. Characteristics of patients with and without fatigue in stroke group (n = 312)
Gender, male/female1 Age, years2 Hp (yes/no)1 CHD (yes/no)1 DM (yes/no)1 MRS score2 NIHSS score2 PSD (yes/no)1 Glucose, mmol/l2 UA, μmol/l2
F group (n = 126)
NF group (n = 186)
Statistics
p value
72/54 67.05±10.79 84/42 48/78 57/69 2.62±0.73 6.21±2.28 57/69 7.48±1.98 278.76±75.11
103/83 66.83±11.27 140/46 61/125 65/121 2.24±0.77 5.98±2.26 41/145 5.82±1.55 332.70±71.55
χ2 = 0.095 t = 0.168 χ2 = 2.745 χ2 = 0.928 χ2 = 3.341 t = 4.340 t = 0.880 χ2 = 18.758 t = 7.898 t = –6.344
0.758 0.867 0.098 0.335 0.068
Eur Neurol 2014;72:223–227 DOI: 10.1159/000364902
Correlation of Fatigue During the Acute Stage of Stroke with Serum Uric Acid and Glucose Levels, Depression, and Disability Dan Wu a, b Lin Wang b Weiyu Teng a Kui Huang c Xiuli Shang a
a c
Department of Neurology, The First Affiliated Hospital, China Medical University, b Department of Neurology, Department of Gerontology, Shenyang Red Cross Hospital, Shenyang, China
Key Words Fatigue · Stroke · Uric acid · Hyperglycaemia · Depression · Disability
not associated with FSS score. Conclusions: Serum UA and glucose levels, depression, and disability are closely related to fatigue during the acute stage of ischaemic stroke. © 2014 S. Karger AG, Basel
Abstract Background: To clarify the correlation of fatigue during the acute stage of stroke with serum uric acid (UA) and glucose levels, depression, and disability. Design: Cross-sectional descriptive study. Methods: A stroke group of 312 patients and a reference group of 312 healthy controls were recruited during the same period. Fatigue was assessed using the Fatigue Severity Scale (FSS). Patients with an FSS score ≥4 points were defined as having fatigue. Depression was assessed using the Self-rating Depression Scale (SDS). Patients with an SDS score ≥50 points were defined as having depression. Stroke severity and the level of disability were assessed with the National Institutes of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (MRS). Results: The prevalence of fatigue in the stroke group was higher than that in the reference group (p < 0.001). Within the stroke group, low serum UA level, high MRS score, high serum glucose level, and high SDS score were associated with increased FSS score. The MRS score was associated most consistently with the FSS score (B = 0.411, 95% CI: 0.297, 0.525). Age, gender, chronic disease history, and NIHSS score were
© 2014 S. Karger AG, Basel 0014–3022/14/0724–0223$39.50/0 E-Mail [email protected] www.karger.com/ene
Introduction
Fatigue is a common symptom after stroke, but poststroke fatigue (PSF) is usually neglected by clinicians. Since the report by Leegaard [1] that 75% of stroke survivors experience fatigue, PSF has gradually received more attention from clinicians and researchers. Recently, an abundance of evidence has indicated that PSF is a common, long-lasting, and disabling symptom [2–4] that significantly reduces the quality of life [5], decreases the likelihood of returning to work [6], and increases mortality in stroke survivors [7]. However, the aetiology and pathogenesis of PSF are still unclear, and an effective treatment method does not still exist. PSF is complex and multi-dimensional, with numerous related causative factors. Previous PSF studies have primarily focused on demographics, co-morbidities, medications, pre-stroke fatigue (PrSF), stroke severity, stroke type, degree of disability, post-stroke depression (PSD), and lesion location. However, the results of these studies have not been consistent. Xiuli Shang Department of Neurology, The First Affiliated Hospital China Medical University Shenyang 110001 (China) E-Mail shang_zhao @ sohu.com
Table 1. FSS questionaire1
Questions
Score
1. 2. 3. 4. 5. 6. 7. 8. 9.
1 1 1 1 1 1 1 1 1
My motivation is lower when I am fatigued Exercise brings on my fatigue I am easily fatigued Fatigue interferes with my physical functioning Fatigue causes frequent problems for me My fatigue prevents sustained physical functioning Fatigue interferes with carrying out certain duties and responsibilities Fatigue is among my three most disabling symptoms Fatigue interferes with my work, family or social life
2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4
5 5 5 5 5 5 5 5 5
6 6 6 6 6 6 6 6 6
7 7 7 7 7 7 7 7 7
1 Individuals were asked to indicate how they felt by answering each question on a 7-point Likert scale. The score was from 1 (strongly disagree) to 7 (strongly agree). The scoring is done by calculating the average response to the questions (adding up all the answers and dividing by nine).
Recent studies have shown that the serum levels of uric acid (UA) and glucose are closely related to stroke [8, 9]. However, the relationships between serum UA and glucose levels and PSF are unknown, and the relevant data are limited. To clarify the correlations of PSF with serum glucose and UA levels, depression, and disability, we collected clinical data (age, gender, chronic disease history, stroke severity, degree of fatigue, depression, and disability), determined the PSF prevalence, and tested the serum levels of UA and glucose in first-ever stroke patients during the acute stage. Methods The study was a cross-sectional descriptive study. Study Population A stroke group of 312 patients were recruited from the Department of Neurology at Shenyang Red Cross Hospital in China between June 2012 and August 2013. The inclusion criteria were as follows: (1) first-ever stroke with CT or MRI scan upon admission and confirmed acute cerebral infarction (ACI); (2) ≥18 years of age; (3) stable temperature, pulse, respiration and blood pressure; and (4) signed informed consent. Patients were excluded for the following reasons: (1) inability to complete the scale evaluation due to communication or cognitive disorders; (2) concurrent diagnosis of cancer, systemic lupus erythematosus, or Parkinson’s disease, all of which have been shown to cause fatigue; (3) administered thrombolysis therapy; (4) PrSF (patients who reported fatigue lasting >3 months before the stroke were defined as having PrSF [10]); and (5) depression diagnosis before the stroke. A reference group of 312 healthy controls were recruited from the Health Examination Centre of Shenyang Red Cross Hospital in China during the same period. The inclusion criteria were as follows: (1) all examination results were normal; (2) no history of
224
Eur Neurol 2014;72:223–227 DOI: 10.1159/000364902
chronic diseases and chronic medication use; (3) signed informed consent; and (4) matched to the ages and genders of the stroke group on an individual-level. The exclusion criteria were as follows: (1) SDS score ≥50; or (2) a depression diagnosis. Collection of Clinical Data In the reference group, age, gender, and health examination results were obtained from the examination report. Collection of the disease history and the FSS and SDS assessments were performed during face-to-face interviews. In the stroke group, age and gender information were collected from the medical records. Collection of the disease history (hypertension, coronary heart disease, and diabetes mellitus) and assessment of scales were performed during face-to-face interviews 10–15 days after the stroke onset, when the patients were clinically stable. Based on the World Health Organization and the International Society of Hypertension guidelines (WHO/ISH) [11], hypertension was defined as systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg. Stroke severity and the level of disability were assessed with the NIHSS [12] and the MRS [13], respectively. The NIHSS contains 15 examination items and 51 raw score choices. The total score is equal to the sum of the 15 parameters. For all of the parameters, a value of 0 is normal [12]. The MRS has six grades ranging from 0 (no symptom) to 5 (severe disability). Depression was assessed with the SDS. Patients with an SDS score ≥50 points were diagnosed with depression [14, 15]. Blood samples were obtained the morning after admission, and the serum levels of UA and glucose were determined. Assessment of Fatigue We used the FSS to assess the severity of fatigue over the past week in the stroke and reference groups. The FSS was originally designed to assess the fatigue of patients with multiple sclerosis [16]. Recently, the FSS has also been frequently used to assess fatigue in stroke patients [2, 10, 17] due to its excellent internal consistency and reliability for these patients [18]. We divided the patients in the stroke group into fatigue (F group) and non-fatigue groups (NF group) based on the FSS scores. Patients with an FSS score ≥4 points were defined as having fatigue [18] (table 1).
Wu/Wang/Teng/Huang/Shang
Table 2. Characteristics of patients with and without fatigue in stroke group (n = 312)
Gender, male/female1 Age, years2 Hp (yes/no)1 CHD (yes/no)1 DM (yes/no)1 MRS score2 NIHSS score2 PSD (yes/no)1 Glucose, mmol/l2 UA, μmol/l2
F group (n = 126)
NF group (n = 186)
Statistics
p value
72/54 67.05±10.79 84/42 48/78 57/69 2.62±0.73 6.21±2.28 57/69 7.48±1.98 278.76±75.11
103/83 66.83±11.27 140/46 61/125 65/121 2.24±0.77 5.98±2.26 41/145 5.82±1.55 332.70±71.55
χ2 = 0.095 t = 0.168 χ2 = 2.745 χ2 = 0.928 χ2 = 3.341 t = 4.340 t = 0.880 χ2 = 18.758 t = 7.898 t = –6.344
0.758 0.867 0.098 0.335 0.068
