Sleep Quality and Cognitive Function after Stroke: The Mediating Roles of Depression and Anxiety Symptoms

Shuzhen Niu, Xianliang Liu, Qian Wu, Jiajia Ma, Songqi Wu, Li Zeng, Yan Shi, Shuzhen Niu, Xianliang Liu, Qian Wu, Jiajia Ma, Songqi Wu, Li Zeng, Yan Shi

Abstract

This study examined the association between post-stroke cognitive function and sleep status at 30 days post-stroke and evaluated the role of anxiety and depression as potential mediators of that association. The participants in this study were 530 acute ischemic stroke (IS) patients. Sleep disturbance at 30 days post-stroke was assessed by the Pittsburgh Sleep Quality Index. Basic patient information, cognitive function, depression, and anxiety status were assessed before discharge from the hospital. Stratified linear regression analysis models were fit to examine the associations between post-stroke sleep quality and the influencing factors. A structural equation model was developed to evaluate the role of anxiety and depression as potential mediators of sleep quality and cognitive function. At 30 days post-stroke, 58.7% of IS patients had sleep disturbance. Women and older IS patients were more likely to suffer poorer sleep quality (p < 0.05). A stratified linear regression analysis showed that the inclusion of cognitive function variables and indicators of depression and anxiety were statistically significant in predicting improvement in the sleep disturbance of AIS patients. Cognitive function, depression, anxiety, and sleep status were selected to construct a structural equation model. The total effect of cognitive function on sleep status was -0.274, with a direct effect of -0.097 and an indirect effect (through depression) of -0.177. The total effect of anxiety on sleep status was 0.235, with a direct effect of 0.186 and an indirect effect (through depression) of 0.049. IS patients often experience poor sleep quality. Depression in IS patients mediates two pathways: the pathway through which cognitive function affects sleep quality and the pathway through which anxiety affects sleep quality.

Keywords: anxiety; depression; ischemic stroke; sleep disturbances.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flowchart of participant enrollment.
Figure 2
Figure 2
Histogram of the seven components of the PSQI scores for GSQ and PSQ. C1: subjective sleep quality; C2: sleep latency; C3: sleep duration; C4: habitual sleep efficiency; C5: sleep disturbances; C6: use of sleeping medication; C7: daytime dysfunction; GSQ: good sleep quality (n = 219); PSQ: poor sleep quality (n = 311).
Figure 3
Figure 3
Mediating effects of depression (SDS score) on the relationship between cognitive function (MoCA score) and sleep quality (PSQI score) and on the relationship between anxiety (SAS score) and sleep quality (PSQI score).

References

    1. Sierra C., Coca A., Schiffrin E.L. Vascular mechanisms in the pathogenesis of stroke. Curr. Hypertens. Rep. 2011;13:200–207. doi: 10.1007/s11906-011-0195-x.
    1. Wang Y., Cui L., Ji X., Dong Q., Zeng J., Wang Y., Zhou Y., Zhao X., Wang C., Liu L., et al. The China National Stroke Registry for patients with acute cerebrovascular events: Design, rationale, and baseline patient characteristics. Int. J. Stroke. 2011;6:355–361. doi: 10.1111/j.1747-4949.2011.00584.x.
    1. Wang W., Jiang B., Sun H., Ru X., Sun D., Wang L., Wang L., Jiang Y., Li Y., Wang Y., et al. Prevalence, incidence, and mortality of stroke in China: Results from a nationwide population-based survey of 480 687 adults. Circulation. 2017;135:759–771. doi: 10.1161/CIRCULATIONAHA.116.025250.
    1. Chinese Society of Neurology Cerebrovascular Group Chinese guidelines for diagnosis and treatment of acute ischemic stroke 2018. Chin. J. Neurol. 2018;51:662–683.
    1. Thrift A.G., Thayabaranathan T., Howard G., Howard V.J., Rothwell P.M., Feigin V.L., Norrving B., Donnan G.A., Cadilhac D.A. Global stroke statistics. Int. J. Stroke. 2017;12:13–32. doi: 10.1177/1747493016676285.
    1. Pasic Z., Smajlovic D., Dostovic Z., Kojic B., Selmanovic S. Incidence and types of sleep disorders in patients with stroke. Med. Arh. 2011;65:225–227. doi: 10.5455/medarh.2011.65.225-227.
    1. Al-Dughmi M., Al-Sharman A., Stevens S., Siengsukon C.F. Sleep characteristics of individuals with chronic stroke: A pilot study. Nat. Sci. Sleep. 2015;7:139–145.
    1. Joa K.L., Kim W.H., Choi H.Y., Park C.H., Kim E.S., Lee S.J., Kim S.Y., Ko S.H., Jung H.Y. The effect of sleep disturbances on the functional recovery of rehabilitation inpatients following mild and moderate stroke. Am. J. Phys. Med. Rehab. 2017;96:734–740. doi: 10.1097/PHM.0000000000000744.
    1. Kim K.T., Moom H.J., Yang J.G., Sohn S.I., Hong J.H., Cho Y.W. The prevalence and clinical significance of sleep disorders in acute ischemic stroke patients-a questionnaire study. Sleep Breath. 2017;21:759–765. doi: 10.1007/s11325-016-1454-5.
    1. Sahlin C., Sandberg O., Gustafson Y., Bucht G., Carlberg B., Stenlund H., Franklin K.A. Obstructive sleep apnea is a risk factor for death in patients with stroke: A 10-year follow-up. Arch. Intern. Med. 2008;168:268–297. doi: 10.1001/archinternmed.2007.70.
    1. Wallace D.M., Ramos A.R., Rundek T. Sleep disorders and stroke. Int. J. Stroke. 2012;7:231–242. doi: 10.1111/j.1747-4949.2011.00760.x.
    1. Raven F., Meerlo P., Havekes R. The role of sleep in regulating structural plasticity and synaptic strength: Implications for memory and cognitive function. Sleep Med. Rev. 2018;39:3–11. doi: 10.1016/j.smrv.2017.05.002.
    1. Dzierzewski J.M., Dautovich N., Ravyts S. Sleep and cognition in older adults. Sleep Med. Clin. 2018;13:93–106. doi: 10.1016/j.jsmc.2017.09.009.
    1. Mattery P.P., Nelson E.J. Sleep disturbances, obesity, and cognitive function in childhood: A mediation analysis. Curr. Dev. Nutr. 2021;5:119–126.
    1. Guan Q., Hu X., Ma N., He H., Duan F., Li X., Luo Y., Zhang H. Sleep quality, depression, and cognitive function in non-demented older adults. J. Alzheimer’s Dis. 2020;76:1637–1650. doi: 10.3233/JAD-190990.
    1. Xu Y., Wen H., Li J., Yang J., Luo K., Chang L. The relationship between sleep disorders, anxiety, depression, and cognitive function with restless legs syndrome (RLS) in the elderly. Sleep Breath. 2022;26:1309–1318. doi: 10.1007/s11325-021-02477-y.
    1. Mason G.M., Lokhandwala S., Riggins T., Spencer R.M.C. Sleep and human cognitive development. Sleep Med. Rev. 2021;57:101472. doi: 10.1016/j.smrv.2021.101472.
    1. Quinn T.J., Dawson J., Walters M.R., Lees K.R. Functional outcome measures in contemporary stroke trials. Int. J. Stroke. 2010;4:200–205. doi: 10.1111/j.1747-4949.2009.00271.x.
    1. Quinn T.J., McArthur K., Ellis G., Stott D.J. Functional assessment in older people. BMJ Clin. Res. 2011;343:d4681. doi: 10.1136/bmj.d4681.
    1. Quinn T.J., Langhorne P., Stott D.J. Barthel index for stroke trials: Development, properties, and application. Stroke. 2011;42:1146–1151. doi: 10.1161/STROKEAHA.110.598540.
    1. Buysse D.J., Reynolds C.F., 3rd, Monk T.H., Berman S.R., Kupfer D.J. The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213. doi: 10.1016/0165-1781(89)90047-4.
    1. Liu X.C., Tang M.Q. Reliability and validity of the Pittsburgh sleep quality index. Chin. J. Psychiatry. 1996;2:103–107.
    1. Zhai S., Tao S., Wu X., Zou L., Yang Y., Xie Y., Li T., Zhang D., Qu Y., Tao F. Associations of sleep insufficiency and chronotype with inflammatory cytokines in college students. Nat. Sci. Sleep. 2021;13:1675–1685. doi: 10.2147/NSS.S329894.
    1. Ren Z., Xin Y., Wang Z., Liu D., Ho R.C.M., Ho C.S.H. What factors are most closely associated with mood disorders in adolescents during the COVID-19 pandemic? A cross-sectional study based on 1,771 adolescents in Shandong Province, China. Front. Psychiatry. 2021;12:728278. doi: 10.3389/fpsyt.2021.728278.
    1. Sun Q., Ji X., Zhou W., Liu J. Sleep problems in shift nurses: A brief review and recommendations at both individual and institutional levels. J. Nurs. Manag. 2019;27:10–18. doi: 10.1111/jonm.12656.
    1. Sun H., Qin K., Zou C., Wang H.H., Lu C., Chen W., Guo V.Y. The association of nighttime sleep duration and quality with chronic kidney disease in middle-aged and older Chinese: A cohort study. Sleep Med. 2021;86:25–31. doi: 10.1016/j.sleep.2021.08.007.
    1. Li Y.L., Qiu D., Hu C., Ouyang F.Y., He J., Zang D.F., Luo D., Xiao S.Y. Stressful life events and poor sleep quality: A cross-sectional survey in the Chinese governmental employees. Sleep Med. 2021;85:123–130. doi: 10.1016/j.sleep.2021.06.030.
    1. Wen H., Zhang Z., Niu F., Li L. The application of Montreal cognitive assessment in urban Chinese residents of Beijing. J. Gen. Intern. Med. 2008;47:36–39.
    1. Razali R., Jean-Li L., Jaffar A., Ahmad M., Shah S.A., Ibrahim N., Din N.C., Nik Jaafar N.R., Midin M., Sidi H., et al. Is the Bahasa Malaysia version of the Montreal Cognitive Assessment (MoCA-BM) a better instrument than the Malay version of the Mini Mental State Examination (M-MMSE) in screening for mild cognitive impairment (MCI) in the elderly? Compr. Psychiatry. 2014;55:70–75. doi: 10.1016/j.comppsych.2013.04.010.
    1. Zung W.W., Coppedge H.M. The Evaluation of Depressive Symptomatology. A Triadic Approach. Psychother. Psychosom. 1974;24:170–174. doi: 10.1159/000286696.
    1. Chen X., Bi H., Zhang M., Liu H., Wang X., Zu R. Research of Sleep Disorders in Patients with Acute Cerebral Infarction. J. Stroke Cerebrovasc. Dis. 2015;24:2508–2513. doi: 10.1016/j.jstrokecerebrovasdis.2015.06.033.
    1. Sterr A., Herron K., Dijk D.J., Ellis J. Time to wake-up: Sleep problems and daytime sleepiness in long-term stroke survivors. Brain Inj. 2008;22:575–579. doi: 10.1080/02699050802189727.
    1. Alfinito P.D., Chen X., Mastroeni R., Pawlyk A.C., Deecher D.C. Estradiol increases catecholamine levels in the hypothalamus of ovariectomized rats during the dark-phase. Eur. J. Pharmacol. 2009;616:334–339. doi: 10.1016/j.ejphar.2009.06.045.
    1. Gervais N.J., Mong J.A., Lacreuse A. Ovarian hormones, sleep and cognition across the adult female lifespan: An integrated perspective. Front Neuroendocrin. 2017;47:134–153. doi: 10.1016/j.yfrne.2017.08.002.
    1. Khazaei S., Ayubi E., Khazaei M. Sleep quality and related determinants among stroke patients: A cross-sectional study. Iran. J. Psychiatry. 2022;17:84–90. doi: 10.18502/ijps.v17i1.8052.
    1. Yaffe K., Blackwell T., Barnes D.E., Ancoli-Israel S., Stone K.L. Preclinical cognitive decline and subsequent sleep disturbance in older women. Neurology. 2007;69:237–242. doi: 10.1212/01.wnl.0000265814.69163.da.
    1. Lowe C.J., Safati A., Hall P.A. The neurocognitive consequences of sleep restriction: A meta-analytic review. Neurosci. Biobehav. R. 2017;80:586–604. doi: 10.1016/j.neubiorev.2017.07.010.
    1. Killgore W.D. Effects of sleep deprivation on cognition. Prog. Brain Res. 2010;185:105–129.
    1. Gerstner J.R., Yin J.C. Circadian rhythms and memory formation. Nat. Rev. Neurosci. 2010;11:577–588. doi: 10.1038/nrn2881.
    1. Guarnieri B., Sorbi S. Sleep and cognitive decline: A strong bidirectional relationship. It is time for specific recommendations on routine assess-ment and the management of sleep disorders in patients with mild cognitive impairment and dementia. Eur. Neurol. 2015;74:43–48. doi: 10.1159/000434629.
    1. Karaca B. Factors Affecting Poststroke Sleep Disorders. J. Stroke Cerebrovasc. Dis. 2016;25:727–732. doi: 10.1016/j.jstrokecerebrovasdis.2015.11.015.
    1. Saper C.B., Scammell T.E., Lu J. Hypothalamic regulation of sleep and circadian rhythms. Nature. 2005;437:1257–1263. doi: 10.1038/nature04284.
    1. Drake C.L., Pillai V., Roth T. Stress and sleep reactivity: A prospective investigation of the stress-diathesis model of insomnia. Sleep. 2014;37:1295–1304. doi: 10.5665/sleep.3916.
    1. Hackett M.L., Pickles K. Part I: Frequency of depression after stroke: An updated systematic review and meta-analysis of observational studies. Int. J. Stroke. 2014;9:1017–1125. doi: 10.1111/ijs.12357.
    1. Sonmez I., Karasel S. Poor sleep quality i related to impaired functional status following stroke. J. Stroke Cerebrovasc. Dis. 2019;28:104349. doi: 10.1016/j.jstrokecerebrovasdis.2019.104349.
    1. Davis J.C., Falck R.S., Best J.R., Chan P., Doherty S., Liu-Ambrose T. Examining the Inter-relations of Depression, Physical Function, and Cognition with Subjective Sleep Parameters among Stroke Survivors: A Cross-sectional Analysis. J. Stroke Cerebrovasc. Dis. 2019;28:2115–2123. doi: 10.1016/j.jstrokecerebrovasdis.2019.04.010.
    1. Srivastava A., Taly A.B., Gupta A., Murali T. Post-stroke depression: Prevalence and relationship with disability in chronic stroke survivors. Ann. Indian Acad. Neur. 2010;13:123–127. doi: 10.4103/0972-2327.64643.
    1. Kutlubaev M.A., Hackett M.L. Part II: Predictors of depression after stroke and impact of depression on stroke outcome: An updated systematic review of observational studies. Int. J. Stroke. 2014;9:1026–1036. doi: 10.1111/ijs.12356.
    1. Van Someren E. Brain mechanisms of insomnia: New perspectives on causes and consequences. Physiol. Rev. 2021;101:995–1046. doi: 10.1152/physrev.00046.2019.
    1. McKinley J., McCarthy A., Lynch T. Don’t lose sleep over neurodegeneration-it helps clear amyloid Beta. Front. Neurol. 2013;4:206. doi: 10.3389/fneur.2013.00206.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel