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NEW Optimizing Activity and Community Participation following Stroke
NEW Optimizing Activity and Community Participation following Stroke

2. Sleep Health and Post-Stroke Fatigue

Definitions and Descriptions

Note: Post-stroke fatigue does not appear to be correlated to the severity of stroke. Individuals who experience very mild stroke may still experience post-stroke fatigue.

Refer to the Definitions and Descriptions included in the Overview for additional information related to this section.

Recommendations and/or Clinical Considerations
2.0 General Recommendations
  1. Individuals should be monitored for post-stroke fatigue throughout the trajectory of stroke recovery as it is a common and disabling condition [Strong recommendation; Moderate quality of evidence].
  2. Healthcare professionals should anticipate the possibility of post-stroke fatigue in individuals with stroke, and mitigate fatigue through assessment, education of the individual and their family, and interventions throughout the stroke-recovery continuum [Strong recommendation; Moderate quality of evidence].
2.1 Screening and Assessment
  1. Prior to discharge from acute care or inpatient rehabilitation, individuals with stroke, their family and caregivers should be provided with information regarding sleep patterns and post-stroke fatigue [Strong recommendation; Moderate quality of evidence].
  2. Following return to the community, individuals with stroke should be periodically screened for post-stroke fatigue during follow-up healthcare visits (e.g., primary care, home care, and outpatient prevention or rehabilitation clinics) [Strong recommendation; Low quality of evidence].
  3. Individuals who experience post-stroke fatigue should be screened for common and treatable co-morbidities, conditions and for medications that are associated with and/or exacerbate fatigue or impact sleep [Strong recommendation; Low quality of evidence]. 
    1. Individuals with stroke should be screened for the possible presence of sleep apnea [Strong recommendation; Low quality of evidence].
    2. If sleep apnea is suspected, individuals with stroke should be referred to a healthcare provider with expertise in sleep health for further assessment and management to improve outcomes including ability to participate in other aspects of stroke rehabilitation [Strong recommendation; Moderate quality of evidence].

Section 2.1 Clinical Considerations 

  1. Co-morbid conditions that may impact sleep and fatigue may include signs of depression or other mood-related conditions; sleep disorders or factors (e.g. sleep apnea, pain) that decrease quality of sleep; other common post-stroke medical conditions and medications (e.g. infections such as urinary tract infections, dehydration, sedating drugs, hypothyroidism, anemia, nutritional deficiencies) that increase fatigue.
2.2 Management of Post-Stroke Fatigue
  1. Individuals with stroke should be cared for by healthcare professionals who are knowledgeable in the symptoms of fatigue and its management [Strong recommendation; Low quality of evidence].
  2. Modafinil may be considered as a treatment for post-stroke fatigue [Conditional recommendation; Low quality of evidence]. 
  3. Antidepressant medication is not recommended for the treatment of post-stroke fatigue in the absence of other co-morbid indications such as depression and anxiety [Strong recommendation; Moderate quality of evidence]. 
  4. Cognitive behavioural therapy may be considered as an adjunct treatment for post-stroke fatigue [Strong recommendation; Low quality of evidence].  
  5. Mindfulness based stress reduction may be considered as an adjunct treatment for post-stroke fatigue [Strong recommendation; Low quality of evidence]. 
  6. Progressive exercise and graded return to activity are recommended to improve deconditioning and physical tolerance [Strong recommendation; Low quality of evidence]. 
  7. Counselling and education should be provided to individuals with stroke, their family and caregivers on post-stroke fatigue, and energy conservation strategies that consider optimizing daily function in high priority activities (e.g. daily routines and modified tasks that anticipate energy needs and provide a balance of activity and rest) [Strong recommendation; Low quality of evidence]. Refer to Box 2 for additional information on energy conservation strategies. 
  8. Encourage individuals who experience post-stroke fatigue to communicate energy status and rest needs to family members, caregivers, healthcare providers, employers and social groups as a mechanism to increase self-management [Strong recommendation; Low quality of evidence].
2.3 Sleep Hygiene
  1. Counselling and education for individuals post-stroke and their family on the establishment of good sleep hygiene behaviours is recommended [Strong recommendation; Low quality of evidence].
Rationale +-

Healthy sleep patterns contribute positively to stroke rehabilitation participation and outcomes. Sleep impairments, such as post-stroke fatigue (PSF) occur frequently, affecting more than half of all individuals with stroke at some point in their recovery, and can negatively impact an individual’s ability to actively participate in rehabilitation. Post-stroke fatigue is generally under-diagnosed and not routinely assessed in individuals with stroke. While the condition is commonly associated with low mood and sleep disturbances, it can arise in their absence. Individuals experiencing PSF report common experiences including having less capacity and energy, an abnormal tiredness and an overwhelming need for long-lasting sleep, being easily fatigued, fatigue for which there was no obvious cause or explanation and increased stress sensitivity. The condition can occur in anyone who has experienced a stroke and has not been shown to be related to size, location or severity of stroke. PSF can lead to cognitive difficulties, physical limitations, and emotional disturbances, often persisting for years after the stroke. The fatigue can interfere with sleep patterns, reduce physical activity, and ultimately hinder overall recovery. Ensuring access to assessment and treatment modalities for sleep impairments and fatigue may improve mood, cognition, neurological status and mood.

Individuals with stroke report that information and awareness on post-stroke fatigue is crucial for those who have experienced a stroke, their family, caregivers, as well as for healthcare providers, to help bring understanding as to what post-stroke fatigue is, why an individual following stroke may be experiencing fatigue, and strategies that may help. Education and strategies to help manage post-stroke fatigue, such as activity pacing, sleep hygiene, and a healthy balanced diet are very important. Individuals with stroke advocate for improved follow-up care for post-stroke fatigue, as the effects of post-stroke fatigue may be most felt after returning to and participating in their community. Individuals with stroke emphasize that post-stroke fatigue can impact mental health, emotions, language and communication, and overall rehabilitation and recovery.

Performance Measures +-

System Indicators

  1. Availability of inpatient and community-based assessment services and resources for individuals with stroke experiencing post-stroke fatigue and other sleep issues.
  2. Availability of healthcare providers with expertise in post-stroke fatigue and other sleep issues.
  3. Proportion of individuals with stroke who report symptoms of post-stroke fatigue, measured at each transition point as a proportion of all individuals with stroke.

Process Indicators

  1. The proportion of individuals with stroke who return to the emergency department or are readmitted to hospital for failure to cope or other fatigue-related reasons.

Patient-Oriented Indicators   

  1. Changes in quality of life of individuals with stroke who experience post-stroke fatigue and other sleep issues, measured using a standardized scale and at regular follow-up intervals.
  2. Changes in fatigue levels for individuals with stroke who experience post-stroke fatigue and other sleep issues, measured using a standardized scale and at regular follow-up intervals.
  3. Assessment of potential depression for individuals experiencing post-stroke fatigue and other sleep issues, measured at regular intervals, transition points and when changes in health status, using standardized depression rating scales.
Implementation Resources and Knowledge Transfer Tools +-

Resources and tools listed below that are external to Heart & Stroke and the Canadian Stroke Best Practice Recommendations may be useful resources for stroke care. However, their inclusion is not an actual or implied endorsement by the Canadian Stroke Best Practices team or Heart & Stroke. The reader is encouraged to review these resources and tools critically and implement them into practice at their discretion.

Health Care Provider Information

Resources for Individuals with Stroke, Families and Caregivers 

Summary of the Evidence +-

Evidence Table and Reference List 2a

Evidence Table and Reference List 2b

Post-stroke sleep disorders

While the incidence of sleep disordered breathing, including obstructive sleep apnea is high post stroke, and is associated with an increased risk of stroke recurrence, screening for sleep apnea is uncommon post stroke and does not appear to be part of routine practice. Brown et al. 54 surveyed a group of 981 participants of the Brain Attack Surveillance program, who had sustained a stroke within the previous 90 days. Within the group, 13.6% of participants self-reported being sleepy during the day and 2.5% reported that they had stopped breathing during the night. Despite, these symptoms, less than 10% of healthcare providers asked patients about their sleep symptoms, while 5.6% were offered a sleep test. In only 2.24% of patients was a sleep test completed. 

Post-stroke fatigue

The incidence of PSF is difficult to estimate given that many patients report symptoms of pre-stroke fatigue; however, estimates of the prevalence of PSF are available from two recent systematic reviews. Zhan et al. 55 pooled the results from 66 observational studies including 11,697 participants. The mean time from stroke onset to assessment varied widely from 3 days to 10.6 years, although assessment was conducted within one year in 41 of the studies. The global pooled prevalence of PSF was 46.8% (95% CI 43.4%–50.2%). The prevalence of PSF was higher in participants with depression (48.2% vs. 42.2%) and in women (53.2% vs. 45.0%). Cumming et al. 56 included the results of 49 studies and estimated the prevalence of PSF at any point following stroke. Using the results from 22 studies that used the Fatigue Severity Scale and a cut-off level of ≥4 (or >4 in 3 studies), the prevalence of post-stroke fatigue was 50% (95% CI 43%–57%). 

The clinical course of PSF is unclear; therefore, it’s even unknown if PSF increases or decreases over time. Snaphaan et al. 57 reported that the prevalence of fatigue was 35% at two months post stroke and 33% at 18 months. 26% of patients reported fatigue at both assessment points, while 9% reported fatigue at baseline but not at follow-up, and 8% reported no fatigue at baseline but did at follow-up. In a systematic review, 58 which included the results of 9 studies, the percentage of patients reporting fatigue increased from assessment time one to time two in 7 studies, while it had decreased between assessment points in 2 studies. In contrast, Cumming et al. 56 reported the estimates of fatigue were relatively stable across time (within 3 months of stroke 55%, 95% CI 25%-85%; 1-6 months 46%, 95% CI 31%-62%; and >6 months 53%, 95% CI 48%-58%). Independent predictors of fatigue that have been identified include depression, low levels of physical functioning, and pre-stroke fatigue. 19

There are few treatments for post-stroke fatigue that have been evaluated. A Cochrane review 59 included the results from 12 RCTs, 4 evaluating pharmacological and 4 evaluating non-pharmacological approaches. In the remaining 4 trials, PSF was not the primary target of investigation, but fatigue was reported as an outcome. Treatments in these trials included continuous positive airway pressure (CPAP), a chronic-disease self-management program, tirilazad mesylate and antidepressants. Using the results from 7 trials (5 pharmacological, 2 non-pharmacological), treatment was associated with a significant reduction in fatigue scores (WMD= -1.07, 95% CI -1.93 to -0.21, p=0.014).

Pharmacological agents that have been evaluated in the treatment of PSF include selective serotonin reuptake inhibitors (fluoxetine) and modafinil, an agent that promotes wakefulness and is used to treat excessive daytime sleepiness. In the Modafinil in Debilitating Fatigue After Stroke (MIDAS) trial, 36 participants with PSF an average of 9 months post stroke, received 200 mg modafinil or placebo for 6 weeks. 60 Active treatment was associated with a significantly greater decrease in mean total Multidimensional Fatigue Inventory (MFI)-20 scores (MD= −7.38, 95% CI −21.76 to −2.99; p<0.001), mean Fatigue Severity Scale (FSS) scores (MD= -6.31, 95% CI -10.7 to -1.9, p=0.048) and a significantly greater increase in total mean Stroke-Specific Quality of Life scores (MD=11.8, 95% CI 2.3 to 21.3, p=0.015). Poulsen et al. 61 randomized 41 persons with PSF to receive 400 mg modafinil for 90 days. The results were ambiguous. At 90 days, there was no significant difference between groups in the median MFI-20 GF score (11 modafinil vs placebo 14, p=0.32), or in the median score of other MFI domains (physical fatigue, reduced activity, reduced motivation); however, median FSS and FSS-7 were significantly lower at 90 days for patients in the modafinil group (36 vs. 49.5, p=0.02 and 22 vs. 37.5, p=0.042, respectively).  Fluoxetine was examined in a trial including 83 participants with post-stroke emotional disturbances. At an average of 14 months after stroke onset, participants were randomized to receive 20 mg/day of fluoxetine (n=40) or placebo, (n=43) for 3 months. 62 At the end of treatment, there were no significant differences in the number of patients with PSF. At 6 months, 34 patients (85%) in the fluoxetine group reported PSF compared with 40 (93%) in the control group. However, at 3 months, fewer patients in the fluoxetine group reported excessive/inappropriate crying (40% vs. 62.8%, p=0.038), and at 6 months fewer patients in the fluoxetine group were identified with depression (12.5% vs. 30.2%, p=0.05). 

Among trials evaluating non-pharmacological treatments for PSF, cognitive behavioral therapy (CBT) may be an effective strategy, although it has not been well-studied. In a small RCT, Nguyen et al. 63 randomized 15 participants with post-stroke fatigue (FSS score ≥4) and/or poor sleep, whose stroke had occurred two years previously. Participants were randomized to receive CBT emphasizing specific napping schedules and re-organising activity levels as a means of energy conservation in addition to pacing and graded activity exposure or treatment as usual (control group) for two months. At the end of the intervention and at 4-month follow-up, there was significantly greater decline in the mean FSS-7 score in the CBT group; however, there was no significant difference in mean change on Brief Fatigue Inventory (BFI), at either assessment point. Zedlitz et al. 64 randomized 83 participants with severe fatigue, >4 months post stroke to participate in a 12-week program consisting of group cognitive treatment (control condition) or group cognitive treatment combined with graded activity training (COGRAT).  Cognitive treatment consisted of CBT and compensatory strategy teaching.  Those in the COGRAT group also received 24 sessions, each 2-hours in duration of graded activity training, including treadmill walking, strength training, and homework assignments. Participants who received COGRAT were significantly more likely to experience clinically relevant improvement in fatigue severity (57.9% vs. 24.4%, p=0.002). 

Mindfulness stress reduction is another non-pharmacological technique that may help to improve PSF. Johansson et al. 65 randomized 29 patients, of whom 18 were recovering from stroke (11 from traumatic brain injury) with mental fatigue to participate in an 8-week program of Mindfulness–Based Stress Reduction (MBSR), which included yoga, body scan, and sitting meditation, or to a wait list control group.  Compared with those in the wait-list control group, participants who received the MBSR program immediately reported a significantly greater decrease in Mental Fatigue Scale scores. 

There is an association between sleep-disordered breathing (SDB) and vascular morbidity and mortality. SDB independently increases the risk of stroke in the general population and is also associated with stroke recurrence. Sleep-disordered breathing is highly prevalent post stroke. Seiler et al. 66 included 86 studies with over 7,000 patients in the acute, sub acute and chronic stages of stroke. The overall prevalences of SDB with an apnea-hypopnea index (AHI) >5/hr was 71%, 40% for an AHI >20/hr, and 30% for an AHI >30/hr. The overall prevalence of central sleep apnea was lower with a pooled prevalence of 12% for AHI >5/hr. No data were available for central sleep apnea with an AHI >20/hr or >30/hr.

Sex & Gender Considerations

While women may be at higher risk of PSF, no intervention trials were reviewed that examined sex or gender as a potential determinant of outcome.

Stroke Resources
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