Sex differences in post-stroke cognitive decline: A population-based longitudinal study of nationally representative data

Abstract

Background Sex differences in post-stroke cognitive decline have not been systematically evaluated in a nationally representative cohort. We use a quasi-experimental design to investigate sex differences in rate of post-stroke cognitive decline. Methods Utilizing the event study design, we use the Health and Retirement Study (HRS) data (1996–2016) to evaluate the differences (percentage points [95% Confidence interval]) in the rate of change in cognitive function, measured using the modified version of the Telephone Interview for Cognitive Status (TICS-m) score, before and after incident stroke, and among patients with and without incident stroke. We estimated this event study model for the overall study population and separately fit the same model for male and female participants. Results Of 25,872 HRS participants included in our study, 14,459 (55.9%) were females with an overall mean age (SD) of 61.2 (9.3) years. Overall, 2,911 (11.3%) participants reported experiencing incident stroke. Participants with incident stroke (vs. no stroke) had lower baseline TICS-m score (15.6 vs. 16.1). Among participants with incident stroke, the mean pre-stroke TICS-m score was higher than the mean post-stroke TICS-m score (14.9 vs. 12.7). Event study revealed a significant short-term acceleration of cognitive decline for the overall population (4.2 [1.7–6.6] percentage points, p value = 0.001) and among female participants (5.0 [1.7–8.3] percentage points, p value = 0.003). We, however, found no evidence of long-term acceleration of cognitive decline after stroke. Moreover, among males, incident stroke was not associated with significant changes in rate of post-stroke cognitive decline. Conclusion Females, in contrast to males, experience post-stroke cognitive deficits, particularly during early post-stroke period. Identifying the sex-specific stroke characteristics contributing to differences in post stroke cognitive decline may inform future strategies for reducing the burden of post-stroke cognitive impairment and dementia.

Is the female sex associated with an increased risk for long-term cognitive decline after the first-ever lacunar stroke? Prospective study on small vessel disease cohort

“…Cerebral SVD burden has been strongly associated with post-stroke cognitive and functional outcomes ( 44 , 45 ). Most studies have been focusing on the early post-stroke period but also indicating that women more frequently than men experienced cognitive deficits ( 16 ). In the Health and Retirement Study, Bako et al detected a significant short-term acceleration of cognitive decline for the overall population (4.2 percentage points) and among female participants (5.0 percentage points), but no evidence of long-term acceleration of the cognitive decline after stroke was noted ( 16 ).…”

“…Most studies have been focusing on the early post-stroke period but also indicating that women more frequently than men experienced cognitive deficits ( 16 ). In the Health and Retirement Study, Bako et al detected a significant short-term acceleration of cognitive decline for the overall population (4.2 percentage points) and among female participants (5.0 percentage points), but no evidence of long-term acceleration of the cognitive decline after stroke was noted ( 16 ). We found a significant association between medium-to-long-term CI and the female sex, which is in accordance with studies reporting female sex was an independent predictor of post-stroke CI ( 13 – 15 ), although there are conflicting results as well ( 46 – 48 ).…”

“…A variable proportion of patients after a lacunar stroke had been reported to have CI of any severity (mild cognitive impairment or dementia), ranging from 24 to 47%, with most of the studies referring to early post-event assessment, which may be influenced by acute complications and interventions and may even be reversible to a certain extent ( 4 , 22 ). There is still a lack of knowledge regarding sex differences in post-stroke cognitive outcomes in the long term, as studies are few and heterogeneous in their designs ( 16 , 19 ). Therefore, we aimed to investigate sex effect on long-term outcomes in patients with clinical and MRI evidence of cerebral SVD who initially presented with first-ever lacunar stroke.…”

Stroke in Women: A Review Focused on Epidemiology, Risk Factors, and Outcomes

“…Another recent cohort study of community-dwelling adults in the US found that women experience more post-stroke cognitive deficits even after controlling for pre-stroke cognitive measures, particularly during the early post-stroke period. 131…”

“…The differences were fully attenuated after adjustment for covariates, indicating that the major contributing factors to the worse post-stroke cognitive outcomes in women were a higher prevalence of being widowed, older age at stroke onset, worse pre-stroke functional and cognitive status, and lower educational attainment. Another recent cohort study of community-dwelling adults in the US found that women experience more post-stroke cognitive deficits even after controlling for pre-stroke cognitive measures, particularly during the early post-stroke period [ 131 ].…”