Post-stroke Fatigue and Depressive Symptoms Are Differentially Related to Mobility and Cognitive Performance

Bradley J MacIntosh, Jodi D Edwards, Mani Kang, Hugo Cogo-Moreira, Joyce L Chen, George Mochizuki, Nathan Herrmann, Walter Swardfager, Bradley J MacIntosh, Jodi D Edwards, Mani Kang, Hugo Cogo-Moreira, Joyce L Chen, George Mochizuki, Nathan Herrmann, Walter Swardfager

Abstract

Background: Fatigue and depressive symptoms are common and often inter-related stroke sequelae. This study investigates how they are related, directly or indirectly, to mobility and cognitive outcomes within 6 months of stroke. Methods: Participants were recruited from 4 stroke centers in Ontario, Canada. Post-stroke fatigue was assessed using the Fatigue Assessment Scale (FAS). Depressive symptoms were screened using the Center for Epidemiological Studies Scale for Depression (CES-D). Factor analyses were used to construct scores from mobility (distance traveled during a 2-min walk test, Chedoke-McMaster Stroke Assessment leg score, and Berg Balance Scale total score) and cognitive (Montreal Cognitive Assessment, Trail-Making Tests A and B, and five-word free recall) tests. Direct associations were assessed in linear regression models and indirect effects were assessed in path models. Covariates were age, sex, education, antidepressant use, days since stroke, and stroke severity (National Institute of Health Stroke Severity Scale score). Results: Fatigue and depressive symptoms were highly correlated (r > 0.51, p < 0.0001). Depressive symptoms were associated with cognition (β = -0.184, p = 0.04) and indirectly with mobility, mediated by fatigue (indirect effect = -0.0142, 95% CI: -0.0277 to -0.0033). Fatigue was associated with mobility (β = -0.253, p = 0.01), and indirectly with cognition, mediated by depressive symptoms (indirect effect = -0.0113, 95% CI: -0.0242 to -0.0023). Conclusions: Fatigue and depressive symptoms are related distinctly to cognitive and mobility impairments post-stroke. Fatigue was associated with poorer lower limb motor function, and with cognition indirectly via depressive symptoms.

Keywords: cognition; depression; factor analysis; fatigue; mediation; mobility; stroke.

Figures

Figure 1
Figure 1
Initial sample from the Rehab Affiliates study, and the sub-groups that were formed to test hypotheses. Only complete records were considered in the regression models. Factor analysis was performed to generate a single composite score for mobility, and similarly a single composite score for cognition.
Figure 2
Figure 2
Composite scores for mobility and cognition were derived from 3 or 4 variables, respectively. Factor analysis produced one factor for mobility (A) and one factor for cognition (B). The numbers adjacent to the lines in (A,B) denote the factor loadings onto the composite score. The correlation matrix describes the individual correlation for the mobility data (C) and cognitive data (D). The color bars in (C,D) represent correlation coefficient values ranging from −1 to 1. The size of the ellipse indicates the degree of shared variance between each of the variables (wide ellipse, low correlation; narrow ellipse, high correlation). BBS, Berg Balance Scale; CMSA-leg, Chedoke-McMaster Stroke Assessment leg score.
Figure 3
Figure 3
Bivariate correlations for the main outcome and explanatory variables. (A) Mobility was inversely correlated with fatigue (r = −0.29). Color of data points based on CES-D (blue to cyan scale). (B) Cognitive performance was inversely correlated with depressive symptoms (r = −0.21). Color of data points based on FAS (red to yellow scale).
Figure 4
Figure 4
The results of two mediation path analysis models. One path model (A) was designed to explain between-subjects differences in mobility; the other path model (B) attempted to explain between-subjects cognitive differences. Coefficients in the path model are listed as a, b and c', where a and b are part of the indirect path and c' is the direct path adjusted for the indirect path. (A) CES-D was not directly associated with mobility (c' non-significant) but the indirect path was significant (denoted as ab). (B) FAS was not directly associated with cognition (c' non-significant) but the indirect path was significant (denoted as ab). Statistical criteria for significance are *p < 0.05 and **p < 0.01.

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