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(Stroke. 1997;28:531-536.)
© 1997 American Heart Association, Inc.
Articles |
Stroke, Disability, and Dementia
Results of a Population Survey
From the Departments of Neurological Sciences (M.P., C.F., A.R.C., M.S., F.G.) and Experimental Medicine (F.C.), Università degli Studi "La Sapienza," Rome, Italy.
Correspondence to Massimiliano Prencipe, MD, Dipartimento di Scienze Neurologiche, Università degli Studi "La Sapienza," Viale dell'Università 30, 00185 Rome, Italy.
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Abstract |
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Background and Purpose Stroke, disability, and dementia often coexist in elderly people. We assessed the prevalence and mutual association of these disorders in an elderly rural population.
Methods We carried out a door-to-door survey on all subjects aged 65 years or over (n=1032) living in a rural community. To evaluate the associations between stroke and disability and between stroke and dementia, we compared stroke patients with all stroke-free subjects by means of two multiple logistic regression analyses. Subsequently, we performed a case-control analysis by comparing each stroke patient with two age- and sex-matched population control subjects.
Results We identified 80 stroke patients. After the exclusion of five incident cases, the prevalence of stroke was 7.3% (95% confidence interval [CI], 5.7 to 8.9). Sixty-five percent of stroke survivors and 23% of stroke-free subjects were disabled (age- and sex-adjusted odds ratio [OR], 6.3; 95% CI, 3.7 to 10.9). Thirty percent of stroke survivors and 5.7% of stroke-free subjects were demented. The OR for dementia (stroke patients versus all stroke-free subjects) was 5.8 (95% CI, 3.1 to 10.8) and became 3.4 (95% CI, 1.5 to 8.0) in the case-control analysis.
Conclusions In our population, the prevalence of stroke was higher than in previous studies. Stroke survivors were more disabled and more at risk for dementia than stroke-free subjects.
Key Words: aged • dementia • disability evaluation • stroke
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Introduction |
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Stroke is an important cause of long-term disability in most industrialized countries.1 2 3 Although incidence studies provide more accurate information on the risk of stroke, prevalence studies on stroke and stroke-related disability are useful measures for planning healthcare services. Prior population studies have found that stroke prevalence increases with age and is higher in men than women, with values ranging between 1% and 8% in persons over age 55 years.4 5 6 7 8 However, aging of the population, changes in stroke incidence and mortality, and differences in the criteria used to evaluate disability have reduced the applicability of previous data to the present time.9 10 11 12 13
Besides causing focal neurological deficits, stroke has also been associated with dementia, although the risk of dementia after a stroke is not well documented. In population studies on dementia, the percentage of demented patients affected by VaD ranges from 16% to 48%.14 15 16 However, because these studies report neither the number of nondemented stroke patients nor how many demented patients had had a stroke, they cannot be used to evaluate the risk of dementia in stroke patients. In a small cohort study, dementia was found in 30% of stroke patients examined prospectively.17 Moreover, a larger case-control study found that stroke patients had a risk of dementia 9.4 times higher than that of control subjects.18 Lastly, in a recent retrospective population study the incidence of dementia in the first year after stroke was nine times greater in stroke patients than in the rest of the general population.19
In 1992, we began a longitudinal study aimed at assessing both the prevalence and incidence of dementia and other disabling diseases in a rural population aged 65 years or over. Data on the prevalence of dementia and details on study design and case-finding procedures have been reported elsewhere.20 In this article, we report data on the prevalence of stroke and evaluate the effect of stroke on disability and dementia by comparing stroke survivors with stroke-free subjects.
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Subjects and Methods |
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All persons aged 65 years and over living in three rural villages near the town of L'Aquila (central Italy) on March 1, 1992 (prevalence day), were asked to participate in the study. Of the 1147 eligible persons, 1032 (90%) gave their informed consent and were examined between March 1992 and February 1993. There were no significant differences between participants and those who refused regarding age (Mann-Whitney U test, P=.06) and sex distribution (
2 test, P=.45).
The survey was conducted by means of a door-to-door two-phase
procedure.20 In the first phase, a trained lay interviewer
examined all participants at home, obtaining information on their
previous medical history and current health status. Furthermore, the
interviewer administered the DRS21 to all participants and
either the MMSE22 or the MSQ23 when persons
had had <3 years of education. In the second phase, a neurologist
examined at home persons with an MMSE score <28, an MSQ score <10, or
a score >1 in one of the DRS categories (mobility, continence,
domestic care, and self care). Persons with a positive history of one
or more acute cerebrovascular events were examined even if the results
of their screening tests were normal. The examination included (1) a
structured interview with each patient and a close informant to obtain
any relevant information on medical history and to evaluate the six
categories of the CDR24 scale by asking questions on
memory (facts of general knowledge, events of past and recent personal
history), orientation (temporal and spatial orientation), abstract
reasoning and judgment (similarities, differences, proverbs, ability to
handle finances, and solving of daily life problems), community affairs
(job, shopping, and social activities), home and hobby activities
(housekeeping, food preparation, responsibility for own medication,
life at home, and hobbies), and personal care (items taken from the DRS
on dressing, feeding, toileting, and continence); scores of 
0.5 in
each of the CDR categories were considered abnormal; (2) a physical and
neurological examination; and (3) a psychiatric evaluation that
included the HDRS25 . (4) In addition to memory,
orientation, abstract reasoning, and judgment, which were all evaluated
by means of the CDR scale, we assessed language (10 items on
comprehension of both verbal commands and sentences, followed by the
first 15 items of the Boston Naming Test26 with a cutoff
point of 13/14), ideative praxis (five tasks of pantomime), ideomotor
praxis,27 and visuospatial and constructional abilities
(Clock Drawing Test28 with a cutoff point of 6/7).
Persons with a positive history for stroke were considered as stroke
patients only when the event consisted of a sudden neurological deficit
lasting longer than 24 hours with no apparent cause other than that of
vascular origin.29 Consequently, persons with transient
ischemic attacks or silent infarcts (positive brain imaging examination
without reported clinical symptoms) were considered as stroke-free
subjects. In subjects with multiple vascular events, we chose the last
one as the qualifying event. A subject was considered to have arterial
hypertension if the systolic blood pressure was 140 mm Hg
and/or the diastolic blood pressure was 90 mm Hg. Subjects
taking antihypertensive medications were considered to have
hypertension regardless of their blood pressure values. Diabetes
mellitus was defined as chronic hyperglycemia (fasting blood glucose
>7.8 mmol/L) requiring diet, oral medication, or insulin
treatment. Hypercholesterolemia was defined as fasting blood total
cholesterol level >6.2 mmol/L. We defined as smokers persons who
were smoking daily at the time of survey. Ex-smokers were persons who
had smoked regularly for at least 1 year but had stopped smoking at
least 6 months before the interview. We considered as disabled all
subjects with DRS scores >2 in mobility (impossible outside house),
continence (more than occasional urine incontinence), domestic care
(requiring assistance or more help in cooking, housework, or shopping),
or self care (requiring assistance in dressing, feeding, or toileting).
In this rural community, almost all housewives performed agricultural
activities. We therefore grouped together farmers, factory workers, and
housewives in one category of manual workers.
Cognitive evaluation was postponed in all subjects affected by acute
medical diseases that could cause attention or consciousness
disturbances. Following the DSM-III-R criteria,30 dementia
was diagnosed when impairment in memory and in at least one other
cognitive domain was present. Cognitive impairment had to be severe
enough to cause a functional disability unrelated to physical deficits.
We used the CDR scale to rate severity of impairment, considering as
demented those subjects with global CDR scores of 1. We judged as
cognitively unclassifiable stroke patients affected by severe
aphasia31 and persons suffering from severe depression
(scores >15 on the HDRS) or from other severe psychiatric diseases.
Following the NINDS-AIREN guidelines,32 dementia was
classified as probable VaD when the onset of dementia was (1) abrupt,
(2) within 3 months of a stroke, and (3) in patients with either CT or
MRI examinations showing at least one ischemic lesion. Other cases of
dementia subsequent to stroke were diagnosed as possible VaD. As
previously reported,20 the interrater agreement was almost
perfect (
=0.83) for the diagnosis of dementia and substantial
(=0.68) for the diagnosis of dementia subtypes.
The prevalence rates of stroke (cases per 100 subjects) were calculated
in 10-year age groups and separately for men and women. The 95% CIs of
the percentages were calculated by using the binomial distribution for
n<10033 and the approximated formula based on the normal
distribution in all the other cases.34 We calculated the
attributable risk of disability to compare the age-related proportions
of disability in stroke and stroke-free subjects.35 The
association between disability and some predictive variables was
calculated by means of a logistic regression model that included
stroke, age (as continuous variable), sex, and education (<3 years of
education versus 3 years of education as reference group) as
independent variables. We used a similar procedure to assess the
association between dementia and stroke. In view of the multiple links
between age, sex, stroke, and dementia, we used a case-control design
to confirm the results of the previous analysis. Two population control
subjects were matched for sex and age (same year) to each case of
stroke. Control subjects were selected from among all stroke-free
participants. When more than two potential controls were available for
a given case, two were randomly selected. Because there were no
controls available for a case subject aged 94 years, we matched him
with two control subjects of 89 and 91 years.
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Results |
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The age and sex characteristics of the 1032 participants in the study are shown in Table 1
. Women outnumbered men, and
the female-to-male ratio increased from 1.2 in the 65- to 74-year age
group to 1.7 in the 85- to 96-year age group. The oldest age group
included three subjects who were 96 years old. Of the 1032
participants, 81% were manual workers, and 24% had less than 3 years
and 94% no more than 5 years of education; 63% suffered from
hypertension, 25% from hypercholesterolemia, and 14% from diabetes
mellitus; 22% were smokers and 19% ex-smokers.
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Three of the 1032 subjects died between the first and the second phase of the clinical examination; death was caused by cardiac disease in 2 patients and by cancer in 1 patient.
Of the 117 patients with a positive history for stroke, 80 (68.4%) fulfilled the diagnostic criteria of stroke, 28 (23.9%) had suffered a transient ischemic attack, and 9 (7.7%) had had symptoms that we judged insufficient for a diagnosis of cerebrovascular event. Of the 80 stroke patients, 12 (15%) had a positive history for previous cerebrovascular events, 62 (78%) were hospitalized on account of their stroke, and 68 (85%) underwent a brain imaging examination (CT or MRI) within 1 month of the stroke. At the brain imaging examinations, the lesions were ischemic in 66 and hemorrhagic in 2 patients. The 66 ischemic patients had either hemispheric (n=59) or brain stem (n=7) lesions. The hemispheric lesions were single in 27 and multiple in 32 patients. Of the 32 patients with multiple lesions, 13 had multiple infarcts, 11 had an infarct associated with one or more lacunar lesions, and 8 had multiple lacunar lesions. On the basis of all the data available, the stroke was diagnosed as ischemic in 72 patients, hemorrhagic in 3, and uncertain in the remaining 5 patients.
The time interval between stroke and neurological examination ranged from 5 months to 29 years (median, 5 years; mean, 6.1 years) without significant differences between either men and women (Mann-Whitney U test, P=.80) or the three age groups (Kruskal-Wallis test, P=.59). At the time of examination, 64% of patients had survived the stroke by more than 3 years, 46% by more than 5 years, and 15% by more than 10 years.
Five of the 80 stroke patients (4 men and 1 woman) had their stroke
after the prevalence day. After the exclusion of these incident cases,
the prevalence of stroke was 7.3% (95% CI, 5.7 to 8.9). As shown in
Table 2, the prevalence of stroke was higher in men than
in women (2 test, P=.015) and
increased with age in both sexes (2 test for
trend, P<.001).
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Stroke patients were significantly older than stroke-free subjects
(median age, 77 versus 72 years; Mann-Whitney U test,
P<.001). The proportion of men was higher
(2 test, P=.005) in stroke patients
(59%) than in stroke-free subjects (42%). Manual workers accounted
for 84% of stroke patients and 81% of stroke-free subjects
(2 test, P=.60). Subjects with <3
years of education accounted for 30% of stroke patients and 24% of
stroke-free subjects (2 test, P=.24).
The HDRS scores did not significantly differ between stroke and
stroke-free patients (median, 4.5 versus 4.0; Mann-Whitney U
test, P=.11).
Fifty-eight (72%) of the 80 stroke patients (or their caregivers)
reported that stroke worsened their functional capacity. Sixty-five
percent of stroke and 23% of stroke-free subjects scored >2 in at
least one DRS category (OR, 6.3; 95% CI, 3.7 to 10.9). As shown in
Table 3, the proportion of disabled subjects varied in
the different DRS categories. However, the percentages of disabled
subjects were higher in stroke patients than in stroke-free subjects in
all DRS categories, with ORs ranging from 4.3 in continence to 8.6 in
mobility. The proportion of bedridden or chair-bound persons was 11.3%
in stroke patients and 1.6% in stroke-free subjects (OR, 5.7; 95% CI,
2.3 to 14.1). The proportion of persons with severe disability in
domestic care activities was 48.8% in stroke patients and 10.6% in
stroke-free subjects (OR, 7.5; 95% CI, 4.3 to 13.1).
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The percentage of disabled persons increased with age in all DRS
categories (Table 4). The increase was proportionally
higher in stroke-free subjects than in stroke patients, as shown by the
age-related decrease in attributable risk.
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Dementia was present in 24 of the 80 stroke patients (30.0%) and in 54
of the 952 stroke-free subjects (5.7%; 2 test,
P<.001). We considered as cognitively unclassifiable 8
stroke patients (10%) affected by severe aphasia and 49 stroke-free
subjects (5%) suffering from severe psychiatric diseases.
Among stroke patients, 11 (23.4%) of the 47 men and 13 (39.4%) of the 33 women were demented (Fisher two-tailed test, P=.14). Demented stroke patients were older than nondemented stroke patients (median age, 80.5 versus 73.0 years; Mann-Whitney U test, P<.001). Eleven (45.8%) of the 24 demented stroke patients and 13 (23.2%) of the 56 nondemented stroke patients had <3 years of education (Fisher two-tailed test, P=.06). All demented stroke patients and 50% of nondemented stroke patients scored >2 in at least one DRS category. Mobility scores were >2 in 67% of demented and in 27% of nondemented stroke patients (Fisher two-tailed test, P=.001). The proportion of bedridden or chair-bound persons was 25% in demented and 5% in nondemented stroke patients (Fisher two-tailed test, P=.03). The proportion of persons with severe disability in domestic care activities (DRS score of 4) was 79% in demented and 36% in nondemented stroke patients (Fisher two-tailed test, P<.001).
After adjustment for the possible confounding effect of age, sex, and education, the risk of dementia was found to be significantly higher in stroke patients than in stroke-free subjects (OR, 5.8; 95% CI, 3.1 to 10.8). In addition to stroke, dementia was significantly associated with increasing age (OR, 1.16; 95% CI, 1.12 to 1.20) and low education (OR, 2.0; 95% CI, 1.2 to 3.4). When each stroke patient was compared with two age- and sex-matched control subjects, the education-adjusted OR for dementia became 3.4 (95% CI, 1.5 to 8.0).
Dementia was present before stroke in 3 (12%) of the 24 demented stroke patients: 2 of them suffered from probable Alzheimer's disease and 1 from dementia secondary to chronic renal failure. Of the other demented stroke patients, 11 (46%) had probable VaD and 10 (42%) possible VaD. In all the possible VaD patients, the deterioration in cognitive functions was reported as progressive and began no earlier than 4 months after the stroke. Three of the possible VaD patients did not undergo any brain imaging examination. Possible and probable VaD patients did not differ significantly regarding age (Mann-Whitney U test, P=.26), sex (Fisher two-tailed test, P=.20), and education (Fisher two-tailed test, P=.67).
Among the 66 stroke patients with CT or MRI examinations showing ischemic lesions, dementia was present in 18 (31%) of the 59 patients with hemispheric lesions and in none of the 7 patients with brain stem lesions (Fisher test, P=.17). Among the 18 demented stroke patients with hemispheric lesions, 7 (39%) had a single infarct, 6 (33%) had multiple infarcts, 2 (11%) had a single infarct associated with lacunae, and 3 (17%) had multiple lacunae. These percentages did not differ significantly from those observed in the 41 nondemented stroke patients.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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In agreement with data in the literature, we found that the prevalence of stroke increases with age and is higher in men than in women. Our ratios were higher than those observed in other populations of similar age.4 5 6 7 8 13 However, the prevalence would have been 6.5% instead of 7.3% had we considered all 145 refusals as stroke-free subjects. Because a neurologist examined all participants with a history for stroke and did not confirm the diagnosis of stroke in 31.6% of them, our high ratios are unlikely to be due to an overestimation of stroke cases; moreover, 85% of stroke patients underwent a brain imaging examination. We did, however, consider as stroke patients all subjects with slight focal neurological deficits and appropriate ischemic lesions at CT or MRI, even if a complete recovery was reported. In addition to the inclusion of these milder strokes, our high ratios could be explained by a different age structure of the population: in our study, 15% of the persons over 75 years were older than 85, a proportion that is likely to be higher than that of studies performed years ago. Lastly, our ratios may be higher than those previously reported as a result of an increase in incidence ratios and survival times. Some studies have reported that both stroke incidence and stroke survival have risen over the last decades.9 10 11 12 13 The risk of stroke in our population should not differ from that of other populations because prevalence ratios of common vascular risk factors are similar to or lower than those reported in the literature.36 37 38 However, we do not yet know the incidence of stroke in this population because the longitudinal phase of our study is still in progress. As regards survival time, 46% of our patients had had their last stroke more than 5 years before the prevalence day. Although this figure is marginally higher than that of the Copenhagen study4 (44%), it should be borne in mind that our stroke patients were older than theirs. Moreover, the proportion of stroke patients still alive after 5 years would have been even higher if we had considered the first rather than the last cerebrovascular event. We decided to adopt this conservative policy because the nature, severity, and time of previous events were not well defined. We cannot in any case calculate the mean survival time using these data because we do not know how many stroke patients died before the prevalence day. Therefore, we can only hypothesize that worldwide progress in medical care has increased survivorship in our population also.
In stroke survivors, disability can be the consequence not only of stroke but also of various coexisting diseases. This is particularly frequent in elderly people because of the age-related increased incidence of a number of disabling diseases. Wyller et al7 reported that 55% of stroke-free subjects aged over 80 years had moderate to severe motor impairment, and 93% of them had vocational inactivity. In the Oxfordshire study,2 43% of stroke patients aged over 85 years were affected by moderate to severe disability before the stroke. The age-related increase in disabling diseases may therefore reduce the impact of stroke-related disability. In our study, this effect was mostly evident in domestic care activities, in which attributable risk dropped from 78.7% in the 65- to 74-year age group to 12.2% in the 85- to 96-year age group. However, this comparison does not take into account the fact that stroke can worsen the functional capacity of persons who are already disabled. In our study, nearly three quarters of stroke patients (or their caregivers) reported that stroke worsened their functional capacity. Although we are aware of the subjective nature of these data, all these patients were found to suffer from neurological deficits that justified their claims.
By grouping together possible and probable VaD patients, 27% (21/78) of our demented subjects were diagnosed as VaD cases. This figure is close to the 24% reported by Fratiglioni et al14 but higher than the 16% of the Rotterdam study15 and lower than the 46% reported by Rocca et al.16 However, 30% of our stroke patients were demented, a figure close to the 26% observed by Tatemichi et al18 in a large stroke cohort study. Our stroke patients had a risk of dementia 5.8 times higher than stroke-free subjects, but this risk decreased to 3.4 times when we used the more conservative case-control analysis. These figures are lower than the 9.4 times found in a case-control study based on a hospitalized cohort.18 However, this last study included stroke patients examined within 1 year of stroke, and a recent population-based study observed that the risk of dementia started to decrease 1 year after the onset of stroke.19 We cannot compare our findings with those of other population studies on dementia because they do not report the number of nondemented stroke patients.
According to DSM-III-R criteria, the diagnosis of dementia requires the presence of a cognitive impairment (memory plus at least one other function) that is sufficiently severe to interfere with daily life activities. Unfortunately, the assessment of this condition is often difficult in stroke patients. We were unable to perform a reliable cognitive assessment in 8 stroke patients affected by severe aphasia; therefore, we judged as cognitively unclassifiable 10% of our stroke patients. On the other hand, some stroke patients, already disabled by severe mobility deficits, had both memory and cognitive impairment not directly attributable to the focal brain lesion. We considered them as demented because we found that the cognitive deficits had consistently contributed to their global disability. Because we have no definite guidelines that can help us in this decision, we do not know whether our decisions are comparable with those of other studies. Lastly, DSM-III-R criteria for dementia do not require the evaluation of executive functions, as is instead specifically requested by the DSM-IV. Therefore, we evaluated abstract reasoning (similarities, differences, proverbs, ability to handle finances, and solving of daily life problems), but we did not assess the ability to shift mental sets or to execute serial motor activities. Consequently, the impairment of these functions might have caused a functional disability that we have ascribed to other disturbances.
The problems involved in the diagnosis of VaD are different but even more difficult. Although NINDS-AIREN criteria have probably improved the sensitivity and specificity of the diagnosis of VaD, their applicability in population studies is not easy. In 10 of our 24 demented stroke patients (42%), the onset of dementia was reported as having occurred no earlier than 4 months after the stroke, with a slow and progressive cognitive decline. A similar phenomenon occurred in 33% of the patients of Tatemichi et al39 and in 41% of the patients in the Rochester study.19 Therefore, we know that these patients became demented after a stroke, but we have no other data suggesting a causal relationship between stroke and dementia. Moreover, three of our possible VaD patients did not undergo a brain imaging examination. In the other cases, the examinations were performed with different procedures and different equipment (CT or MRI), and in many cases only the radiological reports are available. Lastly, we do not have results of brain imaging examinations performed after the onset of dementia. Therefore, although these findings allow us to rule out the presence of other cerebral lesions, they do not help us to understand why the onset of dementia was reported to be slow and progressive in so many stroke patients. Only longitudinal studies will enable us to confirm the validity of these findings based on data reported by relatives. Future studies should also include serial brain imaging examinations to verify whether the cognitive decline is associated with new cerebrovascular lesions.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This study was supported by a grant from the National Research Council (CNR 95.01021.PF40). We wish to thank the lay interviewers M.L. Brocchieri, M. Cipollone, C. Giampietro, and G. Mancini for their data collection efforts.
Received July 26, 1996; revision received December 13, 1996; accepted December 14, 1996.
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