Women are reported to have greater mortality in the short term after stroke than men. In a review of 31 populationbased studies of short-term mortality after stroke, Appelros et al 1 reported that women had a 25% greater risk of 1-month crude mortality than men. It remains unclear what accounts for this disparity and whether these differences persist into the Background-Women are reported to have greater mortality after stroke than men, but the reasons are uncertain. We examined sex differences in mortality at 1 and 5 years after stroke and identified factors contributing to these differences. Methods and Results-Individual participant data for incident strokes were obtained from 13 population-based incidence studies conducted in Europe, Australasia, South America, and the Caribbean between 1987 and 2013. Data on sociodemographics, stroke-related factors, prestroke health, and 1-and 5-year survival were obtained. Poisson modeling was used to estimate the mortality rate ratio (MRR) for women compared with men at 1 year (13 studies) and 5 years (8 studies) after stroke. Studyspecific adjusted MRRs were pooled to create a summary estimate using random-effects meta-analysis. Overall, 16 957 participants with first-ever stroke followed up at 1 year and 13 216 followed up to 5 years were included. Crude pooled mortality was greater for women than men at 1 year (MRR 1.35; 95% confidence interval, 1.24-1.47) and 5 years (MRR 1.24; 95% confidence interval, 1.12-1.38). However, these pooled sex differences were reversed after adjustment for confounding factors (1 year MRR, 0.81; 95% confidence interval, 0.72-0.92 and 5-year MRR, 0.76; 95% confidence interval, 0.65-0.89).Confounding factors included age, prestroke functional limitations, stroke severity, and history of atrial fibrillation. Conclusions-Greater mortality in women is mostly because of age but also stroke severity, atrial fibrillation, and prestroke functional limitations. Lower survival after stroke among the elderly is inevitable, but there may be opportunities for intervention, including better access to evidence-based care for cardiovascular and general health. There have been no studies specifically designed to examine sex differences in long-term mortality after stroke. Identifying factors that explain the sex differences in mortality is important because better understanding could lead to interventions to reduce the disparities.2 In an Australian study, the 36% greater risk of death at 28 days for women compared with men was explained by age, prestroke health, stroke severity, and use of anticoagulants at discharge. 3 After adjustment in that study, women had a 17% lower short-term mortality than men. It is unknown whether these same factors account for the relative sex differences in other geographical regions or in long-term mortality.Our aims were to quantify the relative sex difference in long-term mortality and to identify factors that contribute to the greater mortality of women after stroke using a meta-analysis of pooled individual participant...

W omen experience worse outcomes after stroke than men 1 despite their lower age-adjusted incidence of stroke.2 Previous reviews of sex differences in select stroke outcomes, including activity limitations, 3-5 participation restriction, 4 poststroke depression (PSD), 3 and health-related quality of life (HRQoL), 3,4 demonstrated that women had worse outcomes than men across many of these measures. Women's greater age and stroke severity, as well as poorer prestroke function, seem to contribute to the sex difference in outcomes, but data on other contributing factors are limited.4 Existing reviews included studies published >5 years ago, and given the rapid increase in the number of studies addressing sex differences in stroke outcomes, an updated review is warranted. MethodsFull details of our methods are provided in the online-only Data Supplement. A previous review included studies up to 2007, 3 so we reviewed studies from 2007 onwards that examined sex differences in patient reported outcome measures (PROMs) at ≤12 months after stroke, including activity limitations, HRQoL, participation restriction, impaired cognition, and mood. 6 Full results tables are shown in the online-only Data Supplement. Results Activity LimitationsOf 1875 articles identified, 22 studies (3 population based) that were designed to examine sex differences (Results and Table I in the online-only Data Supplement) met criteria for inclusion. The most common instrument to assess activity limitations was the modified Rankin Scale, followed by the Barthel Index.In 8 studies including ischemic and hemorrhagic strokes, unadjusted estimates showed that women had more activity limitations than men through significantly lower odds of good outcome (odds ratio [OR] range: 0.44-0.61) 7-9 or greater odds of poor outcome (OR range: 1.29-1.62).10-14 In multivariable adjusted analyses, women had worse outcome than men with significantly lower odds of good outcome (OR range: 0.37-0.75) or greater odds of poor outcome (OR range: 1.17-1.74). 7,8,10,12,13 In 2 studies, there was no statistically significant difference between women and men.11,14 Adjustment for covariates, most commonly age, stroke severity, comorbidities, and prestroke function, reduced the associations between 9% and 20%, suggesting these factors partly explain the greater activity limitations for women after stroke.In 11 studies of ischemic stroke ( Table I in the online-only Data Supplement), women generally had worse outcome than men demonstrated by greater odds of poor outcome (mostly modified Rankin Scale ≥3 versus <3; range in ORs: 1.13-2.40) or lower odds of good outcome (eg, modified Rankin Scale ≤1 versus >1 or independent walking).15-25 Among 13 multivariable adjusted comparisons between men and women (some studies had >1 comparison), women's significantly worse outcome compared with men persisted in 7 comparisons with a greater odds of poor outcome (range, 1.30-3.40) or a higher activities of daily living score. [17][18][19][22][23][24] Common covariates included age, stro...

Summary Stroke is the second leading cause of death and the third leading cause of disability worldwide and its burden is increasing rapidly in low-income and middle-income countries, many of which are unable to face the challenges it imposes. In this Health Policy paper on primary stroke prevention, we provide an overview of the current situation regarding primary prevention services, estimate the cost of stroke and stroke prevention, and identify deficiencies in existing guidelines and gaps in primary prevention. We also offer a set of pragmatic solutions for implementation of primary stroke prevention, with an emphasis on the role of governments and population-wide strategies, including task-shifting and sharing and health system re-engineering. Implementation of primary stroke prevention involves patients, health professionals, funders, policy makers, implementation partners, and the entire population along the life course.

Aims and objectives: To review communication interventions that aim to improve regular care interactions between people with dementia and their carers in various settings; and to examine the impact of such interventions on both carer and carereceiver outcomes. Background: Effective communication is imperative to ensure quality of care for people living with dementia. Due to neurodegenerative changes, people with dementia encounter ongoing and progressive difficulties in both understanding and expressing themselves. This in turn creates challenges for carers, which highlights the need for equipping them with necessary communication skills to respond to the specific communication needs of people with dementia. Design: Systematic review and meta-analysis. Method: Medline, Embase, CINAHL, ProQuest and PsycINFO databases were searched for eligible interventions with any date of the publication. Hand searching was also conducted through reviewing the reference lists of relevant articles. The screening and selection of studies were based on the inclusion/exclusion criteria for eligibility and the methodological quality assessment checklist. Random-effects meta-analyses were conducted on comparable quantitative data. The review is reported following the PRISMA reporting guidelines. Results: Seventeen studies were included in the final review, including 12 randomised controlled trials (RCTs), three nonrandomised controlled trials (NRCTs) and two controlled before-after interventions. The intervention designs, settings and outcome measures were varied. The findings suggest that the communication training had a positive impact on both carer and care-receiver outcomes, albeit to different degrees. The intervention effects were found to be strongest on carer communication skills and knowledge. Conclusion: There is solid evidence for the positive impact of communication training on the skills and knowledge of carers. More research is needed regarding the effects of such educational interventions on carer physio-psychological outcomes and care-receiver neuropsychiatric symptoms. It is important to establish best practices in training design, develop validated outcome measures and adopt consistent reporting approaches. Relevance to clinical practice: The increasing global prevalence of people with dementia manifests across clinical and community contexts. The profound impact of dementia on communication and associated care raises the imperative for enhanced | 1051 NGUYEN Et al.

Background Women have worse outcomes after stroke than men, and this may be partly explained by stroke severity. We examined factors contributing to sex differences in severity of acute stroke assessed by the National Institutes of Health Stroke Scale. Methods and Results We pooled individual participant data with National Institutes of Health Stroke Scale assessment (N=6343) from 8 population‐based stroke incidence studies (1996–2014), forming part of INSTRUCT (International Stroke Outcomes Study). Information on sociodemographics, stroke‐related clinical factors, comorbidities, and pre‐stroke function were obtained. Within each study, relative risk regression using log‐binominal modeling was used to estimate the female:male relative risk ( RR ) of more severe stroke (National Institutes of Health Stroke Scale>7) stratified by stroke type (ischemic stroke and intracerebral hemorrhage). Study‐specific unadjusted and adjusted RR s, controlling for confounding variables, were pooled using random‐effects meta‐analysis. National Institutes of Health Stroke Scale data were recorded in 5326 (96%) of 5570 cases with ischemic stroke and 773 (90%) of 855 participants with intracerebral hemorrhage. The pooled unadjusted female:male RR for severe ischemic stroke was 1.35 (95% CI 1.24–1.46). The sex difference in severity was attenuated after adjustment for age, pre‐stroke dependency, and atrial fibrillation but remained statistically significant (pooled RR adjusted 1.20, 95% CI 1.10–1.30). There was no sex difference in severity for intracerebral hemorrhage ( RR crude 1.08, 95% CI 0.97–1.21; RR adjusted 1.08, 95% CI 0.96–1.20). Conclusions Although women presented with more severe ischemic stroke than men, much although not all of the difference was explained by pre‐stroke factors. Sex differences could potentially be ameliorated by strategies to improve pre‐stroke health in the elderly, the majority of whom are women. Further research on the potential biological origin of sex differences in stroke severity may also be warranted.

Background and Purpose— Women are reported to have poorer health-related quality of life (HRQoL) after stroke than men, but the underlying reasons are uncertain. We investigated factors contributing to the sex differences. Methods— Individual participant data on 4288 first-ever strokes (1996–2013) were obtained from 4 high-quality population-based incidence studies from Australasia and Europe. HRQoL utility scores among survivors after stroke (range from negative scores=worse than death to 1=perfect health) were calculated from 3 scales including European Quality of Life-5 Dimensions, Short-Form 6-Dimension, and Assessment of Quality of Life at 1 year (3 studies; n=1210) and 5 years (3 studies; n=1057). Quantile regression was used to estimate the median differences in HRQoL for women compared to men with adjustment for covariates. Study factors included sociodemographics, prestroke dependency, stroke-related factors (eg, stroke severity), comorbidities, and poststroke depression. Study-specific median differences were combined into pooled estimates using random-effect meta-analysis. Results— Women had lower pooled HRQoL than men (median difference unadjusted 1 year, −0.147; 95% CI, −0.258 to −0.036; 5 years, −0.090; 95% CI, −0.119 to −0.062). After adjustment for age, stroke severity, prestroke dependency, and depression, these pooled median differences were attenuated, more greatly at 1 year (−0.067; 95% CI, −0.111 to −0.022) than at 5 years (−0.085; 95% CI, −0.135 to −0.034). Conclusions— Women consistently exhibited poorer HRQoL after stroke than men. This was partly attributable to women’s advanced age, more severe strokes, prestroke dependency, and poststroke depression, suggesting targets to reduce the differences. There was some evidence of residual differences in HRQoL between sexes but they were small and unlikely to be clinically significant.

Background: Improving stroke services is critical for reducing the global stroke burden. The World Stroke Organization (WSO)-World Health Organisation (WHO)-Lancet Neurology Commission on Stroke conducted a survey of the status of stroke services in low and middle income countries (LMICs) compared to high income countries (HICs). Methods: Using a validated WSO comprehensive questionnaire, we collected and compared data on stroke services along four pillars of the stroke quadrangle (surveillance, prevention, acute stroke, and rehabilitation) in 84 countries across WHO regions and economic strata. The WHO also conducted a survey of non-communicable diseases in 194 countries in 2019. Results: Fewer surveillance activities (including presence of registries, presence of recent risk factors surveys and participation in research) were reported in low-income countries (LICs) than HICs. The overall global score for prevention was 40.2%. Stroke units were present in 91% of HICs in contrast to 18% of LICs (p<0.001). Acute stroke treatments were offered in ~60% of HICs compared to 26% of LICs (p=0.009). Compared to HICs, LMICs provided less rehabilitation services including in-patient rehabilitation, home assessment, community rehabilitation, education, early hospital discharge program, and presence of rehabilitation protocol. Conclusions: There is an urgent need to improve stroke services globally especially in LMICs. Countries with less stroke services can adapt strategies from those with better services. This could include establishment of a framework for regular monitoring of stroke burden and services, implementation of integrated prevention activities and essential acute stroke care services, and provision of interdisciplinary care for stroke rehabilitation.

Worse outcomes after stroke among women were explained mostly by age, stroke severity, and prestroke dependency, suggesting these potential targets to improve the outcomes after stroke in women.