Gender and the functional outcome of elderly ischemic stroke patients

Sex Differences in Stroke Hospitalization Incidence, 30-Day Mortality, and Readmission in a Regional Medical Center in the Southwestern United States

OBJECTIVES

This study explores sex differences in ischemic stroke hospitalization incidence, 30-day mortality, and 30-day readmission in a southwestern US medical center.

METHODS

Ischemic stroke admissions in a regional medical center in the southwestern United States were obtained for a 6.5-year time frame (N = 1968). Logistic regression models examine the adjusted effects of sex on 30-day mortality and 30-day readmission outcomes among individuals hospitalized for ischemic stroke.

RESULTS

Findings confirm that although women experience higher mortality than men (9.1% vs 6.7%), the sex disparity in mortality is explained by the age distribution of strokes. Women experience far more strokes and deaths because of stroke at older ages. No differences in principal procedure or 30-day readmission emerged.

CONCLUSIONS

Men experienced higher stroke hospitalization incidence, although women exhibited higher 30-day mortality. Age composition explained sex differences in mortality, but higher male stroke hospitalization incidence represents a larger public health issue that suggests the need for behavioral change at the population level. No meaningful sex differences emerged in treatment, mortality, or readmission.

Factors predicting rehabilitation outcomes after severe acquired brain injury in trauma, stroke and anoxia populations: A cohort study

Severe acquired brain injury has long-term physical and cognitive effects. Identifying patient variables predictive of recovery in different brain injury populations would generate improved prognostic information and help rehabilitation teams set appropriate therapeutic goals. This cohort study of 447 NHS neurorehabilitation inpatients aimed to identify functional and cognitive predictors of recovery following severe acquired brain injury caused by trauma, stroke and anoxia. Motor and cognitive impairment ratings were collected at admission and discharge using the Functional Independence Measure and Functional Assessment Measure (FIM+FAM), and injury-related and demographic data were collated from medical records. Predictors of physical, cognitive and overall recovery were identified via hierarchical regression analyses. Several key findings emerged. Firstly, on-admission motor skills predicted functional and overall outcomes across groups. Secondly, on-admission social interaction skills predicted cognitive discharge outcomes in stroke and trauma, and overall outcomes for stroke, but did not predict anoxia outcomes. Thirdly, age predicted all forms of recovery for stroke only. Further group-specific factors were also identified as predicting motor and cognitive recovery, indicating that factors key to the rehabilitation trajectory may differ between populations. These variables should be considered in rehabilitation goal planning, although further research is required to explore their contributions to recovery.

Racial Disparities in Stroke Recovery Persistence in the Post-Acute Stroke Recovery Phase: Evidence from the Health and Retirement Study

Background and Purpose

Blacks have a higher burden of post-stroke disability. Factors associated with racial differences in long-term post-stroke disability are not well-understood. Our aim was to assess the long-term racial differences in risk factors associated with stroke recovery.

Methods

We examined Health and Retirement Study (HRS) longitudinal interview data collected from adults living with stroke who were aged >50 years during 2000-2014. Analysis of 1,002 first-time, non-Hispanic, Black (210) or White (792) stroke survivors with data on activities of daily living (ADL), fine motor skills (FMS) and gross motor skills (GMS) was conducted. Ordinal regression analysis was used to assess the impact of sex, race, household residents, household income, comorbidities, and the time since having a stroke on functional outcomes.

Results

Black stroke survivors were younger compared with Whites (69 ± 10.4 vs 75 ± 11.9). The majority (~65%) of Black stroke survivors were female compared with about 54% White female stroke survivors (P=.007). Black stroke survivors had more household residents (P<.001) and comorbidities (P<.001). Aging, being female, being Black and a longer time since stroke were associated with a higher odds of having increased difficulty in ADL, FMS and/or GMS. Comorbidities were associated with increased difficulty with GMS. Black race increased the impact of comorbidities on ADL and FMS in comparison with Whites.

Conclusion

Our data suggest that the effects of aging, sex and unique factors associated with race should be taken into consideration for future studies of post-stroke recovery and therapy.

Prognostic significance of early urinary catheterization after acute stroke: Secondary analyses of the international HeadPoST trial

BACKGROUND

An indwelling urinary catheter (IUC) is often inserted to manage bladder dysfunction, but its impact on prognosis is uncertain. We aimed to determine the association of IUC use on clinical outcomes after acute stroke in the international, multi-center, cluster crossover, Head Positioning in Acute Stroke Trial (HeadPoST).

METHODS

Data were analyzed on HeadPoST participants (n = 11,093) randomly allocated to the lying-flat or sitting-up head position. Binomial, logistic regression, hierarchical mixed models were used to determine associations of early insertion of IUC within seven days post-randomization and outcomes of death or disability (defined as "poor outcome," scores 3-6 on the modified Rankin scale) and any urinary tract infection at 90 days with adjustment of baseline and post-randomization management covariates.

RESULTS

Overall, 1167 (12%) patients had an IUC, but the frequency and duration of use varied widely across patients in different regions. IUC use was more frequent in older patients, and those with vascular comorbidity, greater initial neurological impairment (on the National Institutes of Health Stroke Scale), and intracerebral hemorrhage as the underlying stroke type. IUC use was independently associated with poor outcome (adjusted odds ratio (aOR): 1.40, 95% confidence interval (CI): 1.13-1.74), but not with urinary tract infection after adjustment for antibiotic treatment and stroke severity at hospital separation (aOR: 1.13, 95% CI: 0.59-2.18). The number exposed to IUC for poor outcome was 13.

CONCLUSIONS

IUC use is associated with a poor outcome after acute stroke. Further studies are required to inform appropriate use of IUC.

Decannulation of tracheotomized patients after long-term mechanical ventilation - results of a prospective multicentric study in German neurological early rehabilitation hospitals

Background

In the course of neurological early rehabilitation, decannulation is attempted in tracheotomized patients after weaning due to its considerable prognostic significance. We aimed to identify predictors of a successful tracheostomy decannulation.

Methods

From 09/2014 to 03/2016, 831 tracheotomized and weaned patients (65.4 ± 12.9 years, 68% male) were included consecutively in a prospective multicentric observation study. At admission, sociodemographic and clinical data (e.g. relevant neurological and internistic diseases, duration of mechanical ventilation, tracheotomy technique, and nutrition) as well as functional assessments (Coma Recovery Scale-Revised (CRS-R), Early Rehabilitation Barthel Index, Bogenhausener Dysphagia Score) were collected. Complications and the success of the decannulation procedure were documented at discharge.

Results

Four hundred seventy patients (57%) were decannulated. The probability of decannulation was significantly negatively associated with increasing age (OR 0.68 per SD = 12.9 years, p < 0.001), prolonged duration of mechanical ventilation (OR 0.57 per 33.2 days, p < 0.001) and complications. An oral diet (OR 3.80; p < 0.001) and a higher alertness at admission (OR 3.07 per 7.18 CRS-R points; p < 0.001) were positively associated.

Conclusions

This study identified practically measurable predictors of decannulation, which in the future can be used for a decannulation prognosis and supply optimization at admission in the neurological early rehabilitation clinic.

The Impact of Comorbidity on Rehabilitation Outcome after Ischemic Stroke

SUMMARY – Comorbidity decreases survival but it still remains unknown to what extent functional recovery after ischemic stroke is affected. The aim of this research was to determine the prevalence of the most common comorbidities in patients with ischemic stroke and to examine their predictive value on the functional status and recovery. In order to obtain relevant information for this research, we conducted a prospective study over a two-year period. It included patients with acute/subacute ischemic stroke who had inhospital rehabilitation treatment in our institution. Functional status of the patients was evaluated by the following three aspects at the beginning and at the end of rehabilitation treatment: Rivermead Mobility Index was used for mobility, Barthel Index for independence in activities of daily living, and modified Rankin Scale for total disability. Modified Charlston Comorbidity Index was used to assess comorbidity. Multivariate analysis was applied to evaluate the impact of recorded comorbidities on the patient functional outcome. Independent predictors of rehabilitation success in our study were the value of modified Charlston Comorbidity Index, atrial fibrillation and myocardial infarction. Our study demonstrated that patients with more comorbidities had worse functional outcome after stroke, so it is important to consider the comorbidity status when planning the rehabilitation treatment.

Cardiovascular diseases in patients 65 years and younger with non-cardiogenic stroke

INTRODUCTION

Approximately 10-15% of patients with stroke are under 65 years of age. The aim of the study was to determine types of stroke In people below 65. We analysed the incidence and types of associated cardiovascular diseases in patients with non-cardiogenic stroke.

MATERIAL AND METHODS

In this prospective study patients (aged ≤ 65) with stroke underwent physical examination, computed tomography of the head, blood tests, electrocardiogram, echocardiography, and transcranial and carotid artery ultrasound. Classification of stroke was performed according to the ASCOD scale. Analysis considered the incidence of heart diseases in patients with non-cardiogenic stroke and the incidence of heart diseases recognised as a cause of cerebral embolism in patients with cardiogenic stroke.

RESULTS

The study included 611 patients with stroke at the age of 27-65 (mean: 57.2 ±6.7; M/F 380/231). Stroke of heterogeneous aetiology was observed in 321 patients, cardiogenic stroke in 78, and stroke caused by small vessel and carotid artery disease in 73 and 72 patients, respectively. The most common heart diseases in non-cardiogenic stroke patients included persistent foramen ovale, coronary heart disease and past myocardial infarction. The most common causes of cardiogenic embolism were cardiomyopathy, atrial fibrillation and interatrial septal defect.

CONCLUSIONS

Aetiologically heterogeneous stroke and cardiogenic stroke are the most commonly observed among young stroke patients. Cardiomyopathy and atrial fibrillation are the most common sources of cerebral embolism in young patients with cardiogenic stroke. Nearly 1/5 of patients with a non-cardiogenic stroke have congenital or acquired structural changes in the heart.

Effect of obesity on functional outcomes at 6 months post-stroke among elderly Koreans: a prospective multicentre study

OBJECTIVES

We examined whether obesity based on body mass index (BMI) was a predictor of functional independence measure (FIM) at 6 months after ischaemic stroke onset while adjusting for stroke risk factors and covariates and stratifying by age group.

DESIGN

This is an interim report of the Korean Stroke Cohort for Functioning and Rehabilitation that was designed as a nested case study within a nationwide hospital-based cohort.

SETTING

We identified all patients who were admitted to nine representative hospitals in Korea from 2012 until 2014 under a diagnosis of acute first-ever ischaemic stroke. The hospitals were selected from the metropolitan district, mid-sized cities and a small-sized city.

PARTICIPANTS

The sample included 2057 patients with acute ischaemic stroke who were at least 18 years old.

PRIMARY AND SECONDARY OUTCOME MEASURES

We divided participants into two age levels (<65 and ≥ 65 years). Participants were classified into five groups according to their baseline BMI at admission: underweight (BMI<18.5), normal (18.5 ≤ BMI<23), overweight (23 ≤ BMI<25), obese (25 ≤ BMI<30) and extremely obese (30 ≤ BMI).

RESULTS

The proportion of patients who were aged ≥ 65 years was 55.0%. The proportions of underweight, normal, overweight, obese and extremely obese patients were 2.6%, 24.3%, 29.6%, 37.2% and 6.3%, respectively, in the <65 years group and 5.5%, 34.5%, 27.9%, 28.8% and 3.3%, respectively, in the ≥ 65 years group. In a multiple linear regression, the 6-month FIM after stroke in the elderly group was significantly associated with being extremely obese (7.95, p<0.05) after adjusting for confounding variables. In the <65 years group, the 6-month FIM was not associated with any weight category.

CONCLUSIONS

This nationwide hospital-based cohort study showed that extreme obesity is a predictor of a good 6-month FIM, especially in patients with ischaemic stroke who are at least 65 years of age.

Rehabilitation Outcomes: Ischemic versus Hemorrhagic Strokes

Background. Ischemic and hemorrhagic strokes have different pathophysiologies and possibly different long-term cerebral and functional implications. Hemorrhagic strokes expose the brain to irritating effects of blood and ischemic strokes reflect localized or diffuse cerebral vascular pathology. Methods. Participants were individuals who suffered either an ischemic (n = 172) or hemorrhagic stroke (n = 112) within the past six months and were involved in a postacute neurorehabilitation program. Participants completed three months of postacute neurorehabilitation and the Mayo Portland Adaptability Inventory-4 (MPAI-4) at admission and discharge. Admission MPAI-4 scores and level of functioning were comparable. Results. Group ANOVA comparisons show no significant group differences at admission or discharge or difference in change scores. Both groups showed considerably reduced levels of productivity/employment after discharge as compared to preinjury levels. Conclusions. Though the pathophysiology of these types of strokes is different, both ultimately result in ischemic injuries, possibly accounting for lack of findings of differences between groups. In the present study, participants in both groups experienced similar functional levels across all three MPAI-4 domains both at admission and discharge. Limitations of this study include a highly educated sample and few outcome measures.

Short-term functional outcome of ischemic stroke in the elderly: a comparative study of atrial fibrillation and non-atrial fibrillation patients

The purpose of this study was to evaluate whether atrial fibrillation affects the short-term functional outcome of elderly patients with ischemic stroke, undergoing post-acute in-hospital rehabilitation. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation, out of whom 19.6% were diagnosed with atrial fibrillation. The Functional outcome of atrial fibrillation (AF) and non-atrial fibrillation (Non-AF) patients were assessed by the Functional Independence Measurement scale (FIM) at admission and discharge. Data were analyzed by t-test, Chi-square test and by multiple linear regression analysis. Compared with Non-AF, patients with AF were slightly older (p<0.001), and had lower Mini-Mental State Examination (MMSE) scores (p=0.001). Discharge total FIM scores were significantly higher in Non-AF compared with AF patients (84.34 ± 29.44 vs. 79.02 ± 30.68, p=0.031). However, total and motor FIM gains at discharge were similar in the two groups. A multiple linear regression analysis showed that age (p<0.001), admission total and motor FIM (p<0.001) and MMSE score (p<0.001) emerged as the only independent predictors of total, motor and gain FIM scores at discharge. AF was not predictive, whatsoever, of adverse FIM scores (total, motor, gain) at discharge (β=-0.024, p=0.303; β=-0.019, p=-0.455 and β=-0.04, p=0.303, respectively). The finding suggests that Non-AF ischemic stroke elderly show higher total discharge FIM scores, compared with AF patients. However, both groups achieve similar FIM gains during rehabilitation period. AF should not be considered as adversely affecting the short-term rehabilitation process of such patients.