title: The "DOC" screen: Feasible and valid screening for depression, Obstructive Sleep Apnea (OSA) and cognitive impairment in stroke prevention clinics.
abstract: BACKGROUND
  Post-stroke Depression, Obstructive sleep apnea (OSA) and Cognitive impairment ("DOC") are associated with greater mortality, worse recovery and poorer quality of life. Best practice recommendations endorse routine screening for each condition; yet, all are under-assessed, diagnosed and treated. We seek to determine the feasibility and validity of an integrated tool ("DOC" screen) to identify stroke clinic patients at high-risk of depression, OSA, and cognitive impairment.
  
  
  METHODS
  All consecutive new referrals to a regional Stroke Prevention Clinic who were English-speaking and non-aphasic were eligible to be screened. Time for screen completion was logged. DOC screen results were compared to the neuropsychological battery and polysomnogram assessments using a modified receiver operator characteristic and area under the curve analysis. Data is reported to conform to STARD guidelines.
  
  
  RESULTS
  1503 people were screened over 2 years. 89% of eligible patients completed the screen in 5 minutes or less (mean 4.2 minutes), less than half the time it takes to complete the Montreal Cognitive Assessment (MoCA). 437 people consented to detailed testing. Of those, 421 completed the Structured Clinical Interview for Depression within 3 months of screening, 387 completed detailed neuropsychological testing within 3 months, and 88 had overnight polysomnograms. Screening scores combined with demographic variables (age, sex, education, body mass index), had excellent validity compared to gold standard diagnoses: DOC-Mood AUC 0.90; DOC-Apnea AUC 0.80; DOC-Cog AUC 0.81. DOC screen scores can reliably categorize patients in to low-, intermediate- or high-risk groups for further action and can do so with comparable accuracy to more time-consuming screens.
  
  
  CONCLUSIONS
  Systematic screening of depression, obstructive sleep apnea, and cognitive impairment in 5 minutes or less is feasible and valid in a high volume stroke clinic using the DOC screen. The DOC screen may facilitate improved identification and treatment of these comorbidities to improve function in patients after stroke and in those with other neurological diseases that share these comorbid conditions (e.g. Alzheimer's disease/mild cognitive impairment, Parkinson's disease, Traumatic Brain Injury, multiple sclerosis).
authors.affiliation: University of Toronto, Toronto, Ontario, Canada.|Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|Hurvitz Brain Sciences Research Program, Toronto, Ontario, Canada.|Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada.|University of Toronto Stroke Program, Toronto, Ontario, Canada.
authors.forename: Richard H
authors.initials: RH
authors.lastname: Swartz
authors.affiliation: Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Megan L
authors.initials: ML
authors.lastname: Cayley
authors.affiliation: University of Toronto, Toronto, Ontario, Canada.|Hurvitz Brain Sciences Research Program, Toronto, Ontario, Canada.|Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Krista L
authors.initials: KL
authors.lastname: Lanctôt
authors.affiliation: University of Toronto, Toronto, Ontario, Canada.|Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.|Hurvitz Brain Sciences Research Program, Toronto, Ontario, Canada.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Murray
authors.affiliation: St. Michael's Hospital, Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.
authors.forename: Ashley
authors.initials: A
authors.lastname: Cohen
authors.affiliation: University of Toronto, Toronto, Ontario, Canada.|St. Michael's Hospital, Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.|Dalla Lana School of Public Health, Toronto, Ontario, Canada.
authors.forename: Kevin E
authors.initials: KE
authors.lastname: Thorpe
authors.affiliation: Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Michelle N
authors.initials: MN
authors.lastname: Sicard
authors.affiliation: Department of Medicine (Neurology), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Karen
authors.initials: K
authors.lastname: Lien
authors.affiliation: McMaster University, Hamilton, Ontario, Canada.|Department of Medicine (Neurology), Hamilton Health Sciences, Hamilton, Ontario, Canada.|Hamilton General Hospital, Toronto, Ontario, Canada.
authors.forename: Demetrios J
authors.initials: DJ
authors.lastname: Sahlas
authors.affiliation: University of Toronto, Toronto, Ontario, Canada.|Hurvitz Brain Sciences Research Program, Toronto, Ontario, Canada.|Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
authors.forename: Nathan
authors.initials: N
authors.lastname: Herrmann
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D060825:Cognitive Dysfunction / Q000175:diagnosis* / Q000453:epidemiology; D015897:Comorbidity; D003863:Depression / Q000175:diagnosis* / Q000453:epidemiology; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D009483:Neuropsychological Tests; D017286:Polysomnography; D011788:Quality of Life; D020181:Sleep Apnea, Obstructive / Q000175:diagnosis* / Q000453:epidemiology; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control*; D055815:Young Adult