From the Department of Neurological and Psychiatric Sciences, University
of Florence (D.I., G.P., M.L., P.V., M.R.); National Research Council of
Italy, Progetto Finalizzato Invecchiamento (A. Di C.); and Health Area 10
(S.S., P.A., I.M., G.L., A.G.), Florence, Italy.
Methods—Using a proxy-informant interview based on ICD-10
criteria, we determined dementia at stroke onset and 1 year after
stroke in the 339 patients who survived, were available for follow-up,
and were not demented at stroke onset of 635 patients entered over a
1-year period in a stroke registry taken at 2 community hospitals in
Florence, Italy.
Results—Of the 339 patients, 57 (16.8%) proved to have
poststroke dementia. These patients were older, more frequently female,
and more often (multivariate odds ratio, 2.35; 95% CI,
1.21 to 4.58) had atrial fibrillation than those without dementia.
Aphasia and the clinical features expressing the severity of the stroke
event in the acute phase predicted poststroke dementia.
Conclusions—In a hospital-based nonselected series of stroke
survivors, despite the use of a method with low sensitivity for
defining dementia, our study confirms that dementia is a frequent
sequela of stroke and is mainly predicted by stroke severity. Certain
determinants could be controlled in the prestroke phase, thus reducing
its risk.
Most of the published surveys focused on first stroke or
ischemic stroke only, excluding from the study sample patients
with previous stroke or other stroke types. Moreover, because of the
difficulties in applying a comprehensive, formal neuropsychological
assessment to patients who are physically and neurologically impaired
or present with aphasia or neglect, all of these studies examined
only a subsample of the total patients registered in each setting. This
selection may contribute to patient attrition, shown to have an impact
on incidence and possibly risk factor data.8
We studied the incidence of PSD and its determinants
(demographics, vascular risk factors, and clinical features in the
acute phase), irrespective of the occurrence of a previous stroke and
of stroke type, and using an informant interview method to establish
whether patients were already demented before stroke onset or had
become demented after the acute event. Patients were those surviving at
1 year of a total sample of 635 patients with acute stroke registered
over a 1-year period in 2 community hospitals in the area of Florence,
Italy.
The 2 hospitals are first-care community hospitals, since they admit
the vast majority of patients presenting with stroke in the
geographic area served by each one. The population in both areas is
After registration, demographic and clinical information was gathered
with the forms and the criteria specified by the European Community
Stroke Project. In the present work, the possible predictors of
PSD studied are as follows: (1) baseline characteristics, including
age, sex, vascular risk factors, comorbid conditions (all listed below
with related definitions), and prestroke level of handicap, as assessed
by the Rankin Scale11; (2) clinical state at time
of maximum impairment: compromised level of consciousness, defined as
follows: 1=fully conscious, 2=somnolent, 3=semicoma, 4=coma; site of
motor deficit; severity of motor deficit, scored as follows: 1=no
deficit, 2=weakness, 3=paralysis in each of the 4 limbs, total severity
score=sum of 4 limb scores; presence of speech or swallowing problems,
urinary incontinence, confusion, or abnormal behavior; (3) specific
stroke diagnosis: cerebral hemorrhage, subarachnoid
hemorrhage, cerebral infarction, unclassified stroke; and (4)
types of cerebral infarction, classified according to the criteria of
Bamford et al12 into total anterior circulation
infarction (TACI), partial anterior circulation infarction (PACI),
posterior circulation infarction (POCI), and lacunar syndrome
(LACI).
Vascular Risk Factors
Follow-Up
Dementia Definition
Statistical Analyses
Table 1
Concerning stroke types and the risk of dementia, there were no
significant differences between the 2 groups of demented versus
nondemented patients in specific stroke diagnosis or in
ischemic stroke syndromes (according to Bamford's
classification), although LACI was more common among nondemented
patients (a difference of borderline significance) and TACI among
demented patients (a nonsignificant trend).
Table 2
When we examined by forward stepwise logistic regression
analysis (Table 3
Since aphasic patients might have been more prone to be classified as
demented, we repeated this multivariate
analysis using, instead of aphasia at stroke onset, the
presence of aphasia as determined at 1 year, concomitantly with the
assessment for dementia. Age, prestroke Rankin, atrial fibrillation,
and urine incontinence were confirmed as independent predictors of
PSD.
A variable proportion of patients who enter in a stroke registry
die, and some may be lost to follow-up. This phenomenon may also
contribute to patient attrition. Characteristics of patients who die
may vary across different study settings. To evaluate the
characteristics of this subsample of patients in our study, we examined
the differences in demographics, vascular risk factors, and acute-phase
clinical features between the patients who were seen at the 1-year
follow-up and those who were not (dead or lost at follow-up) (Table 4
We have previously indicated the main reasons for our choice of an
informant interview for defining dementia. We further justify this
choice as follows: (1) To establish the presence or absence of dementia
before stroke in a hospital-based study of PSD, the use of historical
information is the only possible method, and therefore an informant
interview was chosen. For the sake of comparability, the same method
should be used to determine the presence of dementia after stroke. (2)
As in previous studies, formal neuropsychological testing is
inapplicable in a number of patients (particularly those with severe
neurological deficits); this implies, if considered indispensable for
defining dementia, that a large number of patients must be excluded
(Table 5
The relatively low sensitivity of the method we used suggests that our
incidence figure for PSD is underestimated. The low sensitivity might
also be related to the use of ICD-10 criteria, which recently have been
demonstrated to be more specific but less sensitive than other criteria
for defining PSD.24 When dementia is
associated with progressive decline, 2 assessments over time (soon
after and 1 year after the stroke event, as in our study) may be not
sufficient to define dementia. Therefore, we have possibly failed to
count every patient with a progressive type of dementia. Additionally,
this fact might have led to underestimation of the incidence of
PSD.
Compared with other hospital-based studies and owing to the free access
and the nature of our study hospitals (first care, community-based),
our cases are more representative of all acute stroke
cases occurring in the population. To avoid further selections, all
strokes listed in our registry were included in our study sample,
independently of pathological type or first-ever/recurrent stroke.
However, in a hospital-based study, data on incidence and determinants
of PSD may vary because of the different number of patients who die in
the postacute phase or are lost to follow-up. When we examined the
effect of this selection on our study, we observed that, in the
subsample of stroke patients who died or were lost, the predictors we
have established in relation to PSD were even more present: the
consequence of this selection may be an underestimation of our
incidence figure. The determinants we found, however, seem unbiased.
The patients we lost to follow-up were few and probably did not induce
a relevant distortion.
Despite the use of a rather insensitive method for defining dementia, a
considerable proportion of acute stroke patients still appear at risk
of PSD. This risk seems higher among old and female patients. Of the
preexisting vascular risk factors, only atrial fibrillation had an
independent predictive effect on PSD. Almost all the clinical
variables expressing stroke severity in the acute phase predicted
PSD in the univariate analysis, although only
aphasia and urine incontinence maintained an independent effect after
multivariate analysis.
Data from our registry reported elsewhere showed that patients
presenting with atrial fibrillation at onset, compared with those
without, have a more severe stroke event.25 The
results of the multivariate analysis, examining
in the same model both prestroke risk factors and clinical features of
the acute phase, seem to exclude that the effect of atrial fibrillation
on PSD is dependent on stroke severity. Having suffered a previous
stroke increases the risk of dementia, but in our study this factor was
less strong than expected.
In a comparison of our results with those reported in the few previous
studies, the risk of dementia at 1 year (17.7%) among our patients
with ischemic stroke is remarkably lower than that (26.3%)
reported at 3 months in the first series of Tatemichi et
al6 of patients registered in the Stroke Data
Bank. In this study only clinical judgment was used for defining
dementia, but agreement among the observers was poor. In contrast, our
figure is almost equal to the 1-year 17.9% figure (on an actuarial
basis) reported by Tatemichi et al4 in a second
study, in which a larger patient sample was followed up, and a more
comprehensive neuropsychological examination was used to determine the
presence of dementia. Our incidence was slightly higher than that
estimated at 3 months by Censori et al5 (13.6%)
in a cohort of patients with first-ever ischemic stroke. In
that study neuropsychological testing was used for examining cognitive
functions in the majority of patients, but an informant interview had
to be used for defining dementia in aphasic patients. Our rate was
definitely lower than the 31.8% reported recently by Pohjasvaara et
al,7 who used the DSM-III criteria and an
extensive and detailed neuropsychological examination for diagnosing
dementia. Desmond et al26 obtained largely
variable incidence rates using different criteria for defining
dementia in a stroke patient cohort followed up for 3 months. Our
figure is close to that estimated by these authors when the presence of
dementia was established by clinical judgment or by clinical judgment
combined with functional impairment evaluation (16.4% in both
cases).
Regarding determinants of PSD, the results of our study confirm the
effect of age consistently reported by all previous studies.
Prior or recurrent stroke has been indicated as a risk factor for PSD
by the studies of Tatemichi et al,6 Kokmen et
al,1 and Pohjasvaara et
al.7 Recurrent stroke in patients who survived at
1 year was infrequent in our registry. However, stroke recurred in
5.3% of patients in the group of demented patients and in 1.4% of
patients in the nondemented group (odds ratio, 3.86; 95% CI, 0.84 to
17.74). Diabetes was an independent precursor in the studies of
Tatemichi et al6 and Censori et
al5 but not in the study of Woo et
al.27 In our study diabetes was associated with
PSD in the univariate but not in the
multivariate analysis. Atrial fibrillation as a
risk factor for PSD was reported by Censori et
al5 and more recently by Moroney et
al28 but was not found to be a predictor in the
other studies.
In regard to comorbid conditions, our data do not confirm the
indications of Gorelick et al29 that myocardial
infarction is an important determinant of PSD. When the possible
mechanisms underlying the effect of the 2 cardiac abnormalities, atrial
fibrillation and myocardial infarction, are considered, our results
would indirectly support the hypothesis that
cardioembolism is more important for PSD than
hypoperfusion due to cardiac pump deficit. Other vascular risk factors
such as hypertension and smoking seem irrelevant. In the study of
Pohjasvaara et al,7 significant risk factors for
PSD were age, low educational level, prior ischemic stroke, and
any prior cerebrovascular disease. Among the clinical features of
stroke, major dominant hemisphere syndrome, total score on the
Scandinavian Stroke Scale, dysphasia, gait impairment, and urinary
incontinence were all significantly associated with PSD. On logistic
regression analysis odds ratios were increased by a factor of 5
for dysphasia and major dominant hemisphere syndrome.
Our results regarding the clinical predictors of PSD appear
substantially consistent with those reported in the previous
hospital-based studies, which used more sensitive methods for defining
dementia. In our study, as in previous studies, PSD was primarily
related to the clinical severity of the stroke event (also to CT volume
of the infarct in the study of Censori et al5).
However, in contrast with the other studies, we did not find lesion
location in the dominant hemisphere to be an independent predictor of
PSD. Regarding lesion type, our data do not confirm that lacunar
infarct or any other pathological stroke subtype contributes
selectively to PSD.
In conclusion, even if a method with relatively low sensitivity was
used for defining dementia, our study confirms that PSD is a frequent
sequela of hospitalized stroke. Age, atrial fibrillation, and the
severity of stroke predict PSD. PSD should be taken into account in
evaluating the burden of care and social support of patients with
stroke. Treatable factors are involved in the risk of PSD, and adequate
prevention may reduce this burden. The observation that atrial
fibrillation is a determinant of PSD further stresses the importance of
using oral anticoagulants for stroke prevention in patients with atrial
fibrillation.
Received May 28, 1998;
revision received July 17, 1998;
accepted July 17, 1998.
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Sano M, Remien RH, Williams JBW, Mohr JP, Hauser WA, Figueroa M.
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© 1998 American Heart Association, Inc.
Original Contributions
Incidence and Determinants of Poststroke Dementia as Defined by an Informant Interview Method in a Hospital-Based Stroke Registry
Abstract
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Background and
Purpose—Inconsistent information about incidence and
determinants of poststroke dementia might be related to patient
attrition, partly because of nonapplicability of formal
neuropsychological testing to a large proportion of patients registered
in a definite setting.
Key Words: dementia • incidence • risk factors • stroke outcome
Introduction
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Information on the risk and determinants of
poststroke dementia (PSD) is important in terms of cost evaluation and
facility planning, as well as for indications about possible preventive
intervention. This information, however, is still scanty and to some
extent inconsistent. To our knowledge only a few prospective
studies have reported data on this outcome. One is a population-based
study performed in Rochester, Minn,1 whereas
others are hospital-based studies, all reported very
recently.2 3 4 5 Among these studies, risk factors
for PSD vary. In one study age, education, race, prior stroke, and
diabetes mellitus were associated with PSD, while hypertension and
cardiac disease were not.6 In another study
atrial fibrillation significantly predicted PSD.5
In a recently reported study significant predictors of PSD were age,
low educational level, and prior cerebrovascular events but not cardiac
diseases or diabetes.7 Regarding the clinical
presentation of stroke, pathological stroke subtypes
(cortical, territorial, or lacunar stroke) have been found to be
differently related to PSD.6 7
Subjects and Methods
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Setting and Patients
Index cases were all patients admitted for acute stroke to 2
general hospitals in the area of Florence, Italy, from October 1, 1993,
to September 30, 1994, and entered in a stroke registry. According to
our institutional guidelines, all patients gave informed consent. This
registry was implemented for evaluating costs of stroke care in
relation to outcome within a project supported by the European
Union (European Community Stroke
Project).9 
200 000. A collateral survey performed among general
practitioners estimated that 10% of stroke cases
occurring in these 2 areas are not hospitalized. Approximately half of
these cases are mild strokes with quick recovery; the other half are
severe strokes occurring in very old patients. Stroke was defined
according to the World Health Organization
criteria.10 Every stroke diagnosis was confirmed
by a neurologist.
Definitions for vascular risk factors were as follows: (1)
atrial fibrillation: history of chronic atrial fibrillation,
corroborated by 
1 prior ECG and/or clinical evidence or ECG positive
for atrial fibrillation on admission; (2) arterial
hypertension: previous diagnosis or current antihypertensive treatment
or blood pressure values during admission >160/90 mm Hg in
2 recordings taken after clinical stabilization; (3) diabetes
mellitus: previous diagnosis or current treatment with insulin or oral
antidiabetics or fasting serum glucose >11.1 mmol/L (>200 mg/dL)
after clinical stabilization; (4) current or previous smoking: reported
history of current smoking or previous smoking for duration of 1
year; (5) prior stroke: history of focal neurological deficits of
vascular origin of >24 hours' duration; (6) myocardial infarction:
(a) previous diagnosis, or (b) history of typical symptoms with
evidence of myocardial infarction on ECG, elevated serum enzymes levels
or atypical symptoms, unequivocal ECG signs of ischemia, or (c)
typical symptoms, signs of myocardial infarction on ECG, and absence of
normal serum enzymes level; (7) transient ischemic attacks:
history of focal neurological deficits of vascular origin of <24
hours' duration.
Three months and 1 year after the stroke event, trained
personnel contacted all registered patients by telephone. In case of
death, date and cause of death were collected and recorded. If the
patient was alive, a follow-up visit was arranged either at the
hospital or at home. All the visits were carried out by the attending
physicians assisted by neurology residents.
Assessment was performed at admission and 1 year after the
stroke event. To determine the presence of dementia we used an
interview, based on the International Classification of Diseases,
10th Revision (ICD-10) criteria for dementia
definition13 and administered to the proxy
informant. Information was gathered by the interviewer (the physician
performing the clinical assessment) with the aid of a checklist that
followed the steps and the indications of ICD-10. The presence of
dementia was established if, according to the informant, there were
memory and intellectual deficits so severe as to interfere with
everyday life activities and deterioration of both emotional control
and behavior in the absence of clouding of consciousness. Memory and
intellectual deficit had to be present for 6 months. This method
was validated by the following studies. (1) The first study assessed
sensitivity and specificity versus a standard: the subjects studied
were 39 of the first 136 (mean age, 73.4±5.2 years; mean education,
7.0±3.8 years) screened for suspected dementia in a population study
on aging (Italian Longitudinal Study on Aging)
(ILSA),14 ongoing in the areas served by the
study hospitals. First, the informant for each subject was interviewed
by a physician following the method to be used in our study on PSD. The
subjects were then assessed by a neurologist using the more extensive
method adopted by ILSA for defining dementia. This method was based on
criteria of the Diagnostic and Statistical Manual of
Mental Disorders, Revised Third Edition
(DSM-III-R)15 and also included criteria of the
National Institute of Neurological Disorders and
Stroke–Alzheimer's Disease and Related Disorders
Association,16 sections B and H of the Cambridge
Mental Disorders of the Elderly Examination
(CAMDEX),17 and the Pfeffer questionnaire
on functional activities.18 The determination of
dementia (whether present or absent) achieved by the ILSA method
was taken as the gold standard for estimating sensitivity and
specificity of the informant interview. Compared with the standard, our
method proved to be 72.2% sensitive and 90.5% specific in defining
dementia. (2) The second study assessed interobserver agreement: the
informants for 48 patients (mean age, 68.6±8.8 years; mean education,
6.6±3.3 years) consecutively presenting for a visit at the
Cerebrovascular Disease Clinic of our Neurology Department were
independently interviewed by 2 observers, 1 senior neurologist and 1
young physician. The agreement, as measured by 
statistics, was
substantial in rating memory deficit (weighted =0.92,
Z=4.22) or intellectual decline (weighted =0.94,
Z=4.16) or in the overall definition of dementia (weighted
=0.85, Z=4.85).
Differences in categorical variables among demented and
nondemented patients were compared by means of odds ratios and related
95% CIs. P values of Pearson 
2
test were also determined. To compare means of continuous variables
we used the independent samples Student's t test. A
multiple logistic regression model19 with
stepwise method for selection of variables was used to identify the
best independent predictors of dementia among all the possible
variables (either risk factors or clinical features in the acute
phase). All calculations were done with SPSS for Windows version 7.5
(SPSS Inc).
Results
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Of the 635 patients with stroke registered in the 2 hospitals
during the study period, 218 died between registration and 1-year
follow-up assessment for dementia, and 39 were lost to follow-up. After
exclusion of 39 patients who proved to be demented at entry, 339
patients remained and were assessed for PSD at 1 year. Compared with
prestroke conditions, 57 patients (16.8%) were diagnosed as newly
demented. This outcome is illustrated by the flowchart reported in the
Figure
. In each step patients with any
type of stroke and those with ischemic stroke are indicated
separately.
View larger version (17K):
[in a new window]
Figure 1. Sample attrition at different steps of the study. Numbers of
patients with ischemic stroke are in parentheses. reports the
univariate comparison according to demographics, vascular
risk factors, and prestroke handicap between the 57 patients with PSD
and the 281 of 282 patients who at 1 year were not demented (1 patient
was excluded from this analysis because of incomplete
information about risk factors). Patients with PSD were older and more
frequently female than those without dementia. Atrial fibrillation and
previous stroke were twice as frequent among demented compared with
nondemented patients. No significant difference was observed for the
other studied risk factors. A trend for smoking was observed more
frequently among nondemented patients. Prestroke handicap, as assessed
by the Rankin Scale (score >2), was 3 times more common among patients
with PSD. All these differences were confirmed when patients with
ischemic stroke only were considered.
View this table:
[in a new window]
Table 1. Predictors of PSD: Demographics, Vascular Risk
Factors, and Prestroke Rankin (Univariate Analysis) shows the differences between the
2 groups in clinical features at the time of maximum impairment in the
acute phase. In this phase patients who were demented at 1-year
follow-up were more often comatose, aphasic, and confused during the
first week and more frequently had urine incontinence than patients who
did not become demented. Moreover, patients who developed dementia had
a higher degree of motor deficit. As opposed to aphasia, patients
presenting with dysarthria had a lower probability of developing
dementia (an effect of borderline significance).
View this table:
[in a new window]
Table 2. Predictors of PSD: Clinical Features at Time of
Maximum Impairment (Univariate Analysis) ) the net
predictive effect of demographics, risk factors, and acute-phase
variables, age, prestroke Rankin, atrial fibrillation, aphasia, and
urine incontinence were all significantly and independently associated
with PSD, while previous stroke had only a borderline effect.
View this table:
[in a new window]
Table 3. Independent Predictors of PSD (Multiple Logistic
Regression Model Including Both Risk Factors and Acute-Phase Clinical
Features) ). The latter were older, more
frequently female, and more often had atrial fibrillation, aphasia or
dysarthria, swallowing problems, and urinary incontinence. In contrast,
hypertensives, diabetics, and smokers were less frequent.
View this table:
[in a new window]
Table 4. Comparison Between Followed and Nonfollowed
Patients
Discussion
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Our results confirm previous indications that PSD is a frequent
sequela of stroke. Age, prestroke disability, and certain clinical
features expressing the severity of the event at stroke onset are major
predictors of PSD. Among risk factors for stroke, atrial fibrillation
proved an independent determinant of PSD. ) or a subset of patients must be
rated differently, as was done in the study of Censori et
al.5 This may contribute to patient attrition,
shown as a potential bias of results in hospital-based PSD
studies.8 (3) The method of the informant
interview has been validated in previous
studies20 21 22 and even found superior to other
methods for defining dementia in selective settings. (4) Compared with
a more formal method for determining the presence of dementia, our
method proved highly specific and sufficiently sensitive. (5) This
method was found to be reproducible in the setting of cerebrovascular
disease patients. In contrast to the poor agreement in diagnosing
dementia by clinical judgment in the first Stroke Data Bank Study
(=0.34),23 our method was definitely more
reproducible (=0.85).
View this table:
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Table 5. Exclusions in Prior PSD Studies
Acknowledgments
This study was supported in part by the National Research
Council of Italy (grant 94.00444PF40). Participants in the European
Community Project Florence Stroke Registry were as follows: Oreste
Tofani, MD; Alessandro Rosselli, MD; Francesco Cordopatri, MD; Gianni
Giuntoli, MD; Marzio Magherini, MD; Paolo Pennati, MD; Stefano Tatini,
MD; Francesca Trucco, MD; Enrico Pieragnoli, MD; Francesco Manetti, MD;
Cristina Mugnaini, MD; Luciano Bagnoli, MD; Orazio Marrazza,
MD; Gian Paolo Menegazzo, MD (Ospedale S.M. Annunziata, Health Area 10,
Florence, Italy); Carlo Cappelletti, MD; Maria Cristina Baruffi, MD;
Marco Ricca, MD; Chiara Bianco, MD (Nuovo Ospedale S. Giovanni di Dio,
Health Area 10, Florence, Italy).
Footnotes
Reprint requests to Professor Domenico Inzitari, Dipartimento di Scienze Neurologiche e Psichiatriche, Viale Morgagni, 85–50134 Firenze, Italy.
References
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
1.
Kokmen E, Whisnant JP, O'Fallon WM, Chu CP, Beard
CM. Dementia after ischemic stroke: a population-based study in
Rochester, Minnesota (1960–1984). Neurology. 1996;46:154–159.
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