Dementia is Associated With Poorer Quality of Care and Outcomes After Stroke: An Observational Study

Callisaya, Michele L.; Purvis, Tara; Lawler, Katherine; Brodtmann, Amy; Cadilhac, Dominique A.; Kilkenny, Monique F

doi:10.1093/gerona/glaa139

Cited by 22 publications

(30 citation statements)

References 28 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…This is consistent with what has been reported in the literature (10) and may be attributed to survival bias, since women have longer life expectancies than men on average and dementia is typically diagnosed in later years (19,20). A smaller proportion of those with pre-stroke dementia received IV tPA within 4.5 hours, which is consistent with findings from an Australian study (21). The lack of adherence may be due to barriers in patients' ability to describe their symptoms to clinicians, but it is unclear why this barrier did not impact other metrics.…”

Section: Discussionsupporting

confidence: 91%

Pre-stroke dementia and in-hospital outcomes in the Chinese Stroke Center Alliance

Liu¹,

Gu²,

Yang³

et al. 2022

Ann Transl Med

View full text Add to dashboard Cite

Background: Little is known about the impact of prevalent dementia on in-hospital outcomes of patients with incident stroke in China. Using data from the Chinese Stroke Center Alliance (CSCA), we aim to quantify the prevalence of pre-stroke dementia and whether this group is at higher risk of adverse in-hospital outcomes compared to those without pre-stroke dementia.Methods: We used multivariable logistic regression models to assess the associations between pre-stroke dementia and ambulation by day 2, in-hospital mortality, in-hospital complications, and being discharged home. Covariates included age, sex, comorbidities [dyslipidemia, atrial fibrillation, peripheral vascular disease (PVD), smoking, and alcohol use], medication history (antiplatelet drugs or lipid-lowering drugs), stroke severity [measured by the National Institute of Health Stroke Scale (NIHSS)], administration of intravenous tissue plasminogen activator (IV tPA) within 4.5 hours of stroke onset, and receipt of deep vein thrombosis (DVT) prophylaxis if indicated.Results: In the final analytic sample of 559,070 ischemic stroke patients with no prior stroke history enrolled across 1,476 hospitals, those with pre-stroke dementia (n=1,511; 0.3%) were older and more likely to be female. Despite having received similar treatment, patients with pre-stroke dementia had lower odds of ambulating by day 2 [odds ratios (OR) =0.69; 95% confidence intervals (CI): 0.62-0.78], higher odds of in-hospital mortality (OR =2.01; 95% CI: 1.35-2.99) or complications (OR =2.17; 95% CI: 1.93-2.44), and lower odds of being discharged home compared to those without pre-stroke dementia (OR =0.71; 95% CI: 0.62-0.83).Conclusions: Worse in-hospital outcomes among patients with pre-stroke dementia may be explained by pre-existing cognitive impairment that limited their ability to advocate for care needs. Further research is needed to determine whether a different care pathway or additional attention from clinicians is necessary for patients with pre-stroke dementia.

show abstract

Section: Discussionsupporting

confidence: 91%

Pre-stroke dementia and in-hospital outcomes in the Chinese Stroke Center Alliance

Liu¹,

Gu²,

Yang³

et al. 2022

Ann Transl Med

View full text Add to dashboard Cite

show abstract

“…In their initial scoping review of 76 articles, Bunn et al 15 found that in ten of the eleven articles that compared access to treatment between people with and without dementia, people with dementia were less likely to have the same level of access to or quality of care. These findings were replicated in Australia by Callisaya et al 17 While patients with dementia in Australia were thrombolyzed more often within 60 minutes than patients without dementia, patients with dementia were less often admitted to stroke units and less likely to be treated with IVT for ischemic stroke. Being admitted to a stroke unit made it more likely for a patient with dementia to receive rehabilitation and decreased the mortality rate.…”

Section: Differences In Treatment For Patients With Versus Without Di...mentioning

confidence: 73%

“…39 We found evidence that people with disabilities did not receive equitable access to treatment ranging from being admitted to stroke units to receiving post-stroke rehabilitation. 17,27,40 There is no convincing evidence of increased risk of hemorrhage or specific stroke treatment associated complications for people with disabilities, yet disability is often an exclusion criterion in treatment trials; thus, physicians lack high-quality data to guide treatment decisions for their patients who have disabilities/pre-existing impairments. 41,42 Stroke therapies must be developed in consideration of the target population.…”

Section: Discussionmentioning

confidence: 99%

“…Although some studies reported exclusion from treatment as justified on the basis that intervention was "futile" or too dangerous, most often no justification for inequitable access to treatment was given. 17 Post-stroke rehabilitation requires repetitive actions from patients. Admittance to rehabilitation programs is often based on evidence from randomized control trials (RCTs), but Nelson et al 39 observe that participants in these trials are younger, disproportionately male, and have far fewer comorbidities than the average stroke patient.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Imperfect Patients: Disparities in Treatment of Stroke Patients with Premorbid Disability

Cruise

M'Carthy

Ganesh

et al. 2022

Can. J. Neurol. Sci.

View full text Add to dashboard Cite

Background: Despite the high proportion of stroke patients with a pre-existing impairment, patients with disabilities are often excluded from stroke treatment trials. Trials are designed for “perfect patients”: patients who are functionally independent and thus generally younger with fewer comorbidities; ironically, such patients are less likely to experience stroke than those with premorbid disability. Exclusionary practices in trials may translate into disparities in stroke care in practice. Through a review of literature, our purpose is to illuminate how people with disabilities are treated across the care continuum following a stroke. Methods: We completed a qualitative systematized review of articles pertaining to the care of patients with premorbid disability and stroke and their outcomes. Using a critical disability studies' theoretical lens, we analyzed inequity across the stroke care continuum. Findings: Among 24 included studies, we found evidence that people with disabilities did not receive equitable access to treatment ranging from being admitted to stroke units to receiving post-stroke rehabilitation. However, observational studies suggest that stroke therapies may be beneficial in selected patients with disabilities when measures of success are framed more achievable (e.g. return to pre-stroke status). This leaves us concerned about how people with pre-existing impairments might be structurally disabled within current systems of stroke care. Conclusion: We use our critical disability studies' theoretical lens to argue that an intersectional approach to stroke treatment is much needed if we are to remedy structural inequities embedded throughout the care continuum.

show abstract

“…4 Aphasia and neglect, frequent after stroke, could complicate cognitive evaluation; therefore, comprehensive cognitive assessment is recommended. 5 Because risk factors for stroke are also risk factors for dementia, 6 any prestroke cognitive dysfunction or dementia (present in 10% of hospitalized stroke patients 7,8 ) must be distinguished from new poststroke impairments.…”

mentioning

confidence: 99%

Association of Ischemic Stroke Incidence, Severity, and Recurrence With Dementia in the Atherosclerosis Risk in Communities Cohort Study

et al. 2022

View full text Add to dashboard Cite

IMPORTANCE Ischemic stroke is associated with increased risk of dementia, but the association of stroke severity and recurrence with risk of impaired cognition is not well known.OBJECTIVE To examine the risk of dementia after incident ischemic stroke and assess how it differed by stroke severity and recurrence. DESIGN, SETTING, AND PARTICIPANTSThe Atherosclerosis Risk in Communities (ARIC) study is an ongoing prospective cohort of 15 792 community-dwelling individuals from 4 US states (Mississippi, Maryland, Minnesota, and North Carolina). Among them, 15 379 participants free of stroke and dementia at baseline (1987 to 1989) were monitored through 2019. Data were analyzed from April to October 2021. Associations between dementia and time-varying ischemic stroke incidence, frequency, and severity were studied across an average of 4.4 visits over a median follow-up of 25.5 years with Cox proportional hazards models adjusted for sociodemographic characteristics, apolipoprotein E, and vascular risk factors.EXPOSURES Incident and recurrent ischemic strokes were classified by expert review of hospital records, with severity defined by the National Institutes of Health Stroke Scale (NIHSS; minor, Յ5; mild, 6-10; moderate, 11-15; and severe, Ն16).MAIN OUTCOMES AND MEASURES Dementia cases adjudicated through expert review of in-person evaluations, informant interviews, telephone assessments, hospitalization codes, and death certificates. In participants with stroke, dementia events in the first year after stroke were not counted.RESULTS At baseline, the mean (SD) age of participants was 54.1 (5.8) years, and 8485 of 15 379 participants (55.2%) were women. A total of 4110 participants (26.7%) were Black and 11 269 (73.3%) were White. A total of 1378 ischemic strokes (1155 incident) and 2860 dementia cases were diagnosed 1 year or more after incident stroke in participants with stroke, or at any point after baseline in participants without stroke, were identified through December 31, 2019. NIHSS scores were available for 1184 of 1378 ischemic strokes (85.9%). Risk of dementia increased with both the number and severity of strokes. Compared with no stroke, risk of dementia by adjusted hazard ratio was 1.76 (95% CI, 1.49-2.00) for 1 minor to mild stroke, 3.47 (95% CI, 2.23-5.40) for 1 moderate to severe stroke, 3.48 (95% CI, 2.54-4.76) for 2 or more minor to mild strokes, and 6.68 (95% CI, 3.77-11.83) for 2 or more moderate to severe strokes. CONCLUSIONS AND RELEVANCEIn this study, risk of dementia significantly increased after ischemic stroke, independent of vascular risk factors. Results suggest a dose-response association of stroke severity and recurrence with risk of dementia.

show abstract

Dementia is Associated With Poorer Quality of Care and Outcomes After Stroke: An Observational Study

Cited by 22 publications

References 28 publications

Pre-stroke dementia and in-hospital outcomes in the Chinese Stroke Center Alliance

Pre-stroke dementia and in-hospital outcomes in the Chinese Stroke Center Alliance

Imperfect Patients: Disparities in Treatment of Stroke Patients with Premorbid Disability

Association of Ischemic Stroke Incidence, Severity, and Recurrence With Dementia in the Atherosclerosis Risk in Communities Cohort Study

Contact Info

Product

Resources

About