Incidence and Related Factors of Post-stroke Cognitive Impairment: a Multicenter Cross-sectional Study Based on Full-cycle Rehabilitation in Stroke

doi:10.12114/j.issn.1007-9572.2023.0784

Chinese General Practice ›› 2024, Vol. 27 ›› Issue (23): 2829-2837.DOI: 10.12114/j.issn.1007-9572.2023.0784

Special Issue: 神经系统疾病最新文章合辑；脑健康最新研究合辑；疾病康复与健康最新文章合辑

• Original Research·Stroke Rehabilitation Section • Previous Articles Next Articles

Incidence and Related Factors of Post-stroke Cognitive Impairment: a Multicenter Cross-sectional Study Based on Full-cycle Rehabilitation in Stroke

1. Institute of Rehabilitation, Fujian University of Traditional Chinese Medicine, Fuzhou 350122, China
2. Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
3. The First Affiliated Hospital of Fujian Medical University, Fuzhou 350004, China
4. National Clinical Research Center for Aging and Medicine, Shanghai 200040, China
5. National Center for Neurological Disorders, Shanghai 200040, China
6. National Regional Medical Center, Fuzhou 350000, China

Received:2023-10-12 Revised:2023-12-12 Published:2024-08-15 Online:2024-05-08
Contact: JIA Jie

脑卒中后认知障碍发病现状及相关因素分析：一项基于脑卒中全周期康复的多中心横断面研究

1．350122　福建省福州市，福建中医药大学康复医学院
2．200040　上海市，复旦大学附属华山医院康复医学科
3．350004　福建省福州市，福建医科大学附属第一医院
4．200040　上海市，国家老年疾病临床医学研究中心
5．200040　上海市，国家神经疾病医学中心
6．350000　福建省福州市，国家区域医疗中心

通讯作者: 贾杰
作者简介:
作者贡献：涂舒婷负责设计和实施研究方案、分析统计数据、撰写论文；林嘉滢、庄金阳、乡靖楠、魏栋帅、谢勇负责调查、评估并采集样本数据；贾杰负责文章的质量控制及审校，对论文负责，监督管理。
基金资助:
福建省科技创新联合资金项目(2021Y9130)

Abstract

Abstract:

Background

Post-stroke cognitive impairment (PSCI) can significantly limit the recovery of stroke patients at all stages and lead to a decline in activity participation and quality of life.

Objective

Based on the concept of full-cycle rehabilitation in stroke, by investigating the incidence of PSCI, to analyzed the differences of PSCI in different age and disease period and its potential influencing factors.

Methods

Stroke patients were hospitalized in the rehabilitation departments of 27 hospitals in different regions of China from October 2022 to July 2023 using simple random sampling method for cross-sectional analysis. A total of 402 patients were finally included according to the study criteria, and categorized into the young and middle-aged group (18-64 years old, n=234) and the elderly group (≥65 years old, n=168) according to the criteria of the National Bureau of Statistics of China, and the patients were also categorized into the acute-phase group (1-7 d, n=25), subacute-phase group (8-180 d, n=338), and the chronic-phase group (>180 d, n=39) according to the International Stroke Rehabilitation Alliance. Baseline information on patients was collected through interviews, assessments, and an electronic case system. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA), and subscores and total scores were calculated for each cognitive domain. Using the National Institute of Health Stroke Scale (NIHSS), Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Fugl-Meyer Assessment-Lower Extremity (FMA-LE), Berg Balance Scale (BBS), Modified Barthel Index (MBI), Hospital Anxiety Scale (HADS-A), and the Hospital Depression Scale (HADS-D) were used to assess the disease conditions and physical functioning of the patients. Spearman's rank correlation analysis was used to investigate the correlation between cognitive function levels and other clinical indicators at different ages and different stages of disease.

Results

The prevalence of PSCI in stroke patients was 76.4% (307/402), including 81.0% (136/168) in elderly patients and 73.1% (171/234) in young and middle-aged patients; the prevalence of PSCI in stroke patients was 56.0% (14/25) in the acute phase, 78.4% (265/338) in the subacute phase, and 71.8% (28/39) in the chronic phase. The results of grouping by age and disease period showed that the elderly group had lower visuospatial and executive function, attention, numeracy, delayed recall scores and total MoCA scores than those in the young and middle-aged group (P<0.05). Patients in the subacute-phase group had lower visuospatial and executive function, language, delayed recall scores and total MoCA scores than those in the acute-phase group (P<0.05). Correlation analysis showed that the total MoCA score was positively correlated (P<0.001) with educational level (r_s=0.314), stroke type (r_s=0.114), FMA-UE (r_s=0.245), FMA-LE (r_s=0.242), BBS (r_s=0.265), MBI (r_s=0.293), and was negatively correlated (P<0.05) with gender (r_s=-0.107), age (r_s=-0.103), history of hypertension (r_s=-0.112), hemiplegic side (r_s=-0.139), disease duration (r_s=-0.135), NIHSS (r_s=-0.107), HADS-A (r_s=-0.239), HADS-D (r_s=-0.280). Further stratified analyses showed that the young and middle-aged and elderly groups were correlated with the total MoCA score in terms of the educational level, NIHSS and physical function indicators such as FMA-UE, FMA-LE, BBS, MBI, HADS-A, and HADS-D (P<0.05). In the acute-phase group, disease duration, FMA-UE, and HADS-A were related to total MoCA score (P<0.05). In the subacute-phase group, age, education level, hypertension, history of alcohol consumption, type of stroke, hemiplegic side, disease duration, NIHSS, and physical function indicators such as FMA-UE, FMA-LE, BBS, MBI, HADS-A, HADS-D were correlated with the total MoCA score (P<0.05), and only educational level, hypertension, and HADS-D were correlated with the total MoCA score in the chronic-phase group (P<0.05) .

Conclusion

PSCI is closely related to age, disease development period, education level, physical function, balance, activities of daily living, anxiety and depression levels in stroke patients, and individualised preventive strategies and interventions should be developed for patients based on different stratified cognitive potential influencing factors, as well as increased screening and attention to cognition in the early stages of the disease to the later stages of rehabilitation.

Key words: Stroke, Cognitive function, Full-cycle, Rehabilitation, Multicenter study, Cross-sectional study, Root cause analysis, Spearman rank correlation analysis

摘要： 背景脑卒中后认知障碍（PSCI）会极大限制脑卒中患者各个阶段的康复，并导致患者活动参与能力和生活质量的下降。目的基于脑卒中全周期康复理念，通过调查PSCI的发病率，分析不同年龄及疾病时期下的PSCI差异及其潜在影响因素。方法采用简单随机抽样的方法，于2022年10月—2023年7月在全国不同地区27家医院的康复科住院抽取脑卒中患者进行横断面分析。根据研究标准最终纳入402例患者，根据我国统计局标准将患者分为青中年组（18~64岁，n=234）和老年组（≥65岁，n=168），根据国际卒中康复联盟定义的脑卒中恢复分期将患者分为急性期组（1~7 d，n=25）、亚急性期组（8~180 d，n=338）、慢性期组（>180 d，n=39）。通过访谈、评估和电子病历系统收集患者的基线资料。使用蒙特利尔认知评估量表（MoCA）评估认知功能，并计算每个认知领域的得分和量表总分。使用美国国立卫生研究院脑卒中量表（NIHSS）、Fugl-Meyer评定量表上肢部分（FMA-UE）、Fugl-Meyer评定量表下肢部分（FMA-LE）、Berg平衡量表（BBS）、改良Barthel指数（MBI）、医院焦虑抑郁量表-焦虑（HADS-A），医院焦虑抑郁量表-抑郁（HADS-D）评估患者的疾病情况和身体功能。采用Spearman秩相关分析探究不同年龄与疾病时期下PSCI与其他临床指标的相关性。结果脑卒中患者PSCI患病率为76.4%（307/402），其中老年患者PSCI患病率为81.0%（136/168），青中年患者PSCI患病率为73.1%（171/234）；脑卒中急性期患者患病率为56.0%（14/25），亚急性期患者78.4%（265/338），慢性期患者71.8%（28/39）；不同年龄与疾病时期分组结果显示：老年组患者视空间与执行功能、注意力、计算力、延迟回忆得分及MoCA总分比青中年组更低（P<0.05）；亚急性期组患者视空间与执行功能、语言、延迟回忆得分及MoCA总分低于急性期组（P<0.05）。相关性分析显示，MoCA总分与文化程度（r_s=0.314）、脑卒中类型（r_s=0.114）、FMA-UE（r_s=0.245）、FMA-LE（r_s=0.242）、BBS（r_s=0.265）、MBI（r_s=0.293）呈正相关（P<0.001），与性别（r_s=-0.107）、年龄（r_s=-0.103）、高血压史（r_s=-0.112）、偏瘫侧（r_s=-0.139）、病程（r_s=-0.135）、NIHSS（r_s=-0.107）、HADS-A（r_s=-0.239）、HADS-D（r_s=-0.280）呈负相关（P<0.05）。进一步分层分析显示：青中年组和老年组在文化程度、NIHSS以及FMA-UE、FMA-LE、BBS、MBI、HADS-A、HADS-D均与MoCA总分相关（P<0.05）。急性期患者中，病程、FMA-UE、HADS-A与MoCA总分相关（P<0.05）；亚急性期患者中，年龄、文化程度、高血压、饮酒史、脑卒中类型、偏瘫侧、病程、NIHSS以及FMA-UE、FMA-LE、BBS、MBI、HADS-A、HADS-D与MoCA总分相关（P<0.05）；慢性期患者中，文化程度、高血压、HADS-D与MoCA总分相关（P<0.05）。结论 PSCI与脑卒中患者年龄、疾病发展时期、文化程度、运动功能、平衡能力、日常生活活动能力和焦虑抑郁水平关系密切，应根据不同分层认知潜在影响因素为患者制定个性化预防策略和干预方案，并在疾病早期至康复后期提高对认知的筛查与重视。

关键词: 卒中, 认知功能, 全周期, 康复, 多中心研究, 横断面研究, 影响因素分析, Spearman秩相关分析

CLC Number:

R 743　R 338.64

TU Shuting,LIN Jiaying,ZHUANG Jinyang, et al. Incidence and Related Factors of Post-stroke Cognitive Impairment: a Multicenter Cross-sectional Study Based on Full-cycle Rehabilitation in Stroke[J]. Chinese General Practice, 2024, 27(23): 2829-2837. DOI: 10.12114/j.issn.1007-9572.2023.0784.
涂舒婷,林嘉滢,庄金阳等. 脑卒中后认知障碍发病现状及相关因素分析：一项基于脑卒中全周期康复的多中心横断面研究[J]. 中国全科医学, 2024, 27(23): 2829-2837. DOI: 10.12114/j.issn.1007-9572.2023.0784.

Figures/Tables 6

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特征	例数	患病率	χ²值	P值
性别			1.810	0.178
男	296	221（74.7）
女	106	86（81.1）
年龄			3.361	0.067
青中年	234	171（73.1）
老年人	168	136（81.0）
文化程度			11.050	0.026
小学以下	43	37（86.0）
小学	114	96（84.2）
初中	105	75（71.4）
高中及中专	87	64（73.6）
高中以上	53	35（66.0）
脑卒中类型			5.347	0.069
脑出血	139	114（82.0）
脑梗死	259	189（73.0）
均有	4	4（100.0）
疾病时期			6.974	0.031
急性期	25	14（56.0）
亚急性期	338	265（78.4）
慢性期	39	28（71.8）

特征	例数	患病率	χ²值	P值
性别			1.810	0.178
男	296	221（74.7）
女	106	86（81.1）
年龄			3.361	0.067
青中年	234	171（73.1）
老年人	168	136（81.0）
文化程度			11.050	0.026
小学以下	43	37（86.0）
小学	114	96（84.2）
初中	105	75（71.4）
高中及中专	87	64（73.6）
高中以上	53	35（66.0）
脑卒中类型			5.347	0.069
脑出血	139	114（82.0）
脑梗死	259	189（73.0）
均有	4	4（100.0）
疾病时期			6.974	0.031
急性期	25	14（56.0）
亚急性期	338	265（78.4）
慢性期	39	28（71.8）

组别	例数	视空间与执行功能	注意力	计算力	语言	抽象思维	延迟回忆	定向力	MoCA总分
青中年组	234	3.0（1.0，4.0）	6.0（4.0，6.0）	3.0（2.0，3.0）	5.0（3.0，6.0）	1.0（0，2.0）	2.0（0，4.0）	6.0（4.0，6.0）	21.0（16.0，26.0）
老年组	168	2.0（1.0，4.0）	5.0（3.0，6.0）	3.0（2.0，3.0）	5.0（3.0，6.0）	1.0（0，2.0）	1.0（0，3.0）	5.0（4.0，6.0）	18.0（13.0，24.8）
Z值		-2.070	-1.971	-2.040	-1.510	-1.192	-2.650	-1.461	-2.497
P值		0.038	0.049	0.041	0.131	0.233	0.008	0.144	0.013

组别	例数	视空间与执行功能	注意力	计算力	语言	抽象思维	延迟回忆	定向力	MoCA总分
青中年组	234	3.0（1.0，4.0）	6.0（4.0，6.0）	3.0（2.0，3.0）	5.0（3.0，6.0）	1.0（0，2.0）	2.0（0，4.0）	6.0（4.0，6.0）	21.0（16.0，26.0）
老年组	168	2.0（1.0，4.0）	5.0（3.0，6.0）	3.0（2.0，3.0）	5.0（3.0，6.0）	1.0（0，2.0）	1.0（0，3.0）	5.0（4.0，6.0）	18.0（13.0，24.8）
Z值		-2.070	-1.971	-2.040	-1.510	-1.192	-2.650	-1.461	-2.497
P值		0.038	0.049	0.041	0.131	0.233	0.008	0.144	0.013

组别	例数	视空间与执行功能	注意力	计算力	语言	抽象思维	延迟回忆	定向力	MoCA总分
急性期组	25	4.0（2.0，5.0）	6.0（5.0，6.0）	3.0（3.0，3.0）	6.0（4.5，6.0）	2.0（1.0，2.0）	3.0（2.0，4.0）	6.0（5.0，6.0）	25.0（20.5，28.0）
亚急性期组	338	2.0（1.0，4.0）^a	5.0（4.0，6.0）	3.0（2.0，3.0）	5.0（3.0，6.0）^a	1.0（0，2.0）	2.0（0，3.0）^a	5.0（4.0，6.0）	20.0（14.0，25.0）^a
慢性期组	39	2.0（1.0，5.0）	6.0（4.0，6.0）	3.0（2.0，3.0）	5.0（3.0，6.0）	2.0（1.0，2.0）	2.0（0，4.0）	5.0（4.0，6.0）	21.0（15.0，27.0）
H值		7.546	4.190	2.321	6.180	5.463	7.751	0.937	8.653
P值		0.023	0.123	0.313	0.045	0.065	0.021	0.626	0.013

Incidence and Related Factors of Post-stroke Cognitive Impairment: a Multicenter Cross-sectional Study Based on Full-cycle Rehabilitation in Stroke

脑卒中后认知障碍发病现状及相关因素分析：一项基于脑卒中全周期康复的多中心横断面研究

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项目	r_s值	P值
性别	-0.107	0.032
年龄	-0.103	0.039
文化程度	0.314	<0.001
利手	0.009	0.859
合并基础疾病
高血压	-0.112	0.025
冠心病	0.050	0.314
糖尿病	0.054	0.277
生活方式
吸烟史	0.032	0.525
饮酒史	0.098	0.049
脑卒中类型	0.114	0.022
偏瘫侧	-0.139	0.005
病程	-0.135	0.007
NIHSS评分	-0.280	<0.001
FMA-UE评分	0.245	<0.001
FMA-LE评分	0.242	<0.001
BBS评分	0.265	<0.001
MBI评分	0.293	<0.001
HADS-A评分	-0.239	<0.001
HADS-D评分	-0.280	<0.001

项目	青中年组		老年组
项目	r_s值	P值	r_s值	P值
性别	-0.080	0.223	-0.123	0.113
年龄	-0.045	0.492	0.101	0.194
文化程度	0.264	<0.001	0.340	<0.001
利手	-0.037	0.569	0.055	0.476
合并基础疾病
高血压	-0.145	0.027	-0.039	0.612
冠心病	0.099	0.133	0.051	0.509
糖尿病	-0.016	0.808	0.140	0.071
生活方式
吸烟史	0.027	0.677	-0.015	0.848
饮酒史	0.035	0.591	0.168	0.029
脑卒中类型	0.146	0.025	0.140	0.070
偏瘫侧	-0.126	0.054	-0.151	0.051
病程	-0.174	0.008	-0.117	0.133
NIHSS评分	-0.321	<0.001	-0.223	0.004
FMA-UE评分	0.285	<0.001	0.221	0.004
FMA-LE评分	0.310	<0.001	0.170	0.028
BBS评分	0.290	<0.001	0.212	0.006
MBI评分	0.314	<0.001	0.256	0.001
HADS-A评分	-0.226	<0.001	-0.259	0.001
HADS-D评分	-0.246	<0.001	-0.348	<0.001

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项目	急性期组		亚急性期组		慢性期组
项目	r_s值	P值	r_s值	P值	r_s值	P值
性别	-0.304	0.140	-0.089	0.102	-0.068	0.682
年龄	0.069	0.743	-0.144	0.008	0.032	0.848
文化程度	0.215	0.301	0.349	<0.001	0.326	0.043
利手	-0.128	0.543	-0.024	0.658	0.271	0.095
合并基础疾病
高血压	0.295	0.152	-0.113	0.037	-0.354	0.027
冠心病			0.044	0.418	0.124	0.451
糖尿病	0.163	0.437	0.024	0.657	0.079	0.633
生活方式
吸烟史	0.122	0.235	0.024	0.656	0.052	0.752
饮酒史	0.562	0.259	0.108	0.046	-0.062	0.707
脑卒中类型	0.114	0.588	0.138	0.011	-0.170	0.300
偏瘫侧	-0.017	0.937	-0.167	0.002	0.072	0.663
病程	-0.461	0.020	-0.133	0.014	-0.131	0.426
NIHSS评分	-0.073	0.727	-0.296	<0.001	-0.288	0.075
FMA-UE评分	0.435	0.030	0.243	<0.001	0.004	0.983
FMA-LE评分	0.318	0.121	0.263	<0.001	-0.085	0.609
BBS评分	0.228	0.272	0.272	<0.001	0.156	0.342
MBI评分	0.314	0.127	0.287	<0.001	0.299	0.065
HADS-A评分	-0.429	0.033	-0.199	<0.001	-0.297	0.066
HADS-D评分	-0.359	0.078	-0.237	<0.001	-0.349	0.030

项目	急性期组		亚急性期组		慢性期组
项目	r_s值	P值	r_s值	P值	r_s值	P值
性别	-0.304	0.140	-0.089	0.102	-0.068	0.682
年龄	0.069	0.743	-0.144	0.008	0.032	0.848
文化程度	0.215	0.301	0.349	<0.001	0.326	0.043
利手	-0.128	0.543	-0.024	0.658	0.271	0.095
合并基础疾病
高血压	0.295	0.152	-0.113	0.037	-0.354	0.027
冠心病			0.044	0.418	0.124	0.451
糖尿病	0.163	0.437	0.024	0.657	0.079	0.633
生活方式
吸烟史	0.122	0.235	0.024	0.656	0.052	0.752
饮酒史	0.562	0.259	0.108	0.046	-0.062	0.707
脑卒中类型	0.114	0.588	0.138	0.011	-0.170	0.300
偏瘫侧	-0.017	0.937	-0.167	0.002	0.072	0.663
病程	-0.461	0.020	-0.133	0.014	-0.131	0.426
NIHSS评分	-0.073	0.727	-0.296	<0.001	-0.288	0.075
FMA-UE评分	0.435	0.030	0.243	<0.001	0.004	0.983
FMA-LE评分	0.318	0.121	0.263	<0.001	-0.085	0.609
BBS评分	0.228	0.272	0.272	<0.001	0.156	0.342
MBI评分	0.314	0.127	0.287	<0.001	0.299	0.065
HADS-A评分	-0.429	0.033	-0.199	<0.001	-0.297	0.066
HADS-D评分	-0.359	0.078	-0.237	<0.001	-0.349	0.030