From the Department of Rehabilitation Medicine, State University of New
York at Buffalo (G.E.G.); the Department of Neurology, School of Medicine,
Boston University (P.A.W., M.K.H., C.S.K.), the Section of Preventive Medicine
and Epidemiology, Evans Memorial Department of Clinical Research and
Department of Medicine, Boston Medical Center (P.A.W.), Boston University
School of Public Health (A.B.) and Department of Mathematics, Boston
University (R.B.D.), Boston, Mass; and The Framingham Study of the National
Heart, Lung, and Blood Institute, Framingham, Mass.
Correspondence to Glen E. Gresham, MD, Professor and Chairman, Department of Rehabilitation Medicine, State University of New York at Buffalo, Erie County Medical Center, 462 Grider St, Buffalo, NY 14215.
Methods—This long-term evaluation was done with use of data from
the 1993–1995 Framingham Study Cohort Examination 23 on the 10 stroke
survivors and 20 control subjects still living to identify and compare
the host characteristics and functional status of each group. The
survival curves for both stroke survivors and controls were derived
from the ongoing Framingham Study database.
Results—Twenty-plus-year stroke survivors experienced a greater
mortality than age- and sex-matched controls (92.5% and 81%,
respectively). The slopes of the two survival curves were essentially
the same. Functional status (eg, walking and independence in activities
of daily living) of stroke survivors, however, compared very favorably
with that of the control subjects. Stroke survivors were more likely to
be female and to have a number of comorbidities, including elevated
blood pressures, greater use of medications, less use of alcohol, and
less depressive symptomology.
Conclusions—In the Framingham cohort, 20-plus-year stroke
survivors showed greater mortality than age- and sex-matched control
subjects; functionally, however, the groups were very similar and in
general quite independent.
During 1993–1995 (Framingham Study Cohort Examination 23; December 13,
1993, through June 13, 1995), approximately 20 years later, we had the
opportunity to review this original group of stroke survivors and age-
and sex-matched control subjects. We examined the survival patterns of
both stroke survivors and controls and the functional status of both
groups.
Physical evaluation and documentation for events and functional status
in the stroke survivors and control subjects were abstracted from
Framingham Study Cohort Examination 23, which took place between 1993
and 1995. Standardized tests used to document health status at
Examination 23 included the Mini-Mental State
Examination4 for cognitive function, the Center
for Epidemiologic Studies-Depression Scale5 for
depressive symptomology, and the Katz Index6 and
Rosow-Breslau scale7 for physical
functioning.
As noted in the introduction, our previous disability
study1 2 was carried out from April 1972 through
March 1975. At that time, 354 cases of stroke had been documented; 155
of these patients were still living. Seven stroke survivors (3 men and
4 women) refused to be examined. The remaining 148 (95% of the
eligible total) were the actual participants in the study. Evaluations
were done at least 6 months after the most recent stroke to minimize
the possible effects of a changing neurological status.
Each of the 148 stroke survivors evaluated was matched by sex
and age with a stroke-free member of the same cohort (except for one
80-year-old whose control was aged 82). Control subjects were evaluated
in the same manner as stroke survivors. The data from the functional
assessments were subsequently combined with those from the regular
medical and neurological examinations of the same subjects by the
Framingham Study physicians.
The significance of the difference between the frequencies for each
specific variable in the stroke survivor and control groups was
determined by the
For this 20-year follow-up study, the biennial records of the 148
original 1972–1974 stroke survivors and those of the 148 age- and
sex-matched controls were retrieved from The Framingham Heart Study
Archives. Serendipitously, those subjects still living had just been
evaluated in 1993–1995 (during Framingham Study Cohort Examination
23), and thus data on the current status of the entire study group
still living were available. The charts of the stroke survivors and
controls of the 1972–1974 cohort who were still living were reviewed
to obtain information on their functional status in the 1993–1995
examination cycle of the overall Framingham Stroke Study. The survival
curves for both stroke survivors and controls were derived from the
Framingham Study database.
As shown, only 10 (6.8%) of the 1972–1974 stroke survivors were still
living in the 1993–1995 period, compared with 20 (13.6%) of the age-
and sex-matched control subjects free of stroke in 1972–1974. The
difference in frequencies of survival status is significant at the
P=.007 level. The differential mortality between the two
groups is also displayed in Fig 1
The survival curves for the 1972–1974 stroke survivors and
controls were essentially of the same configuration with a greater
level of survival, at each point in time, for the controls (Fig 1
The host characteristics and functional status of the 10 1972–1974
stroke survivors still living in 1993–1995 (Framingham Study Cohort
Examination 23) are shown in Tables 3
As shown in Table 4
Table 5
The cohort of 675 stroke patients in the Oxfordshire Community Stroke
Project was evaluated at 2 to 6.5 years after
stroke.11 The overall survival rate was 51% at
this time. Functional status of the survivors was not given. Scmidt and
colleagues12 followed 1 538 stroke patients in
Moscow for 7 years. At that time 76.5% were dead, but 81% of the
7-year survivors were described as "independent." A 10-year
follow-up study from Poland13 reviewed 195 cases.
At the end of the 10 years, 135 (69%) had died, 15 were discharged
home, and 44 (26 females and 18 males) were "rehabilitated." Motor
improvement was described as "very good" in 21 patients. One was
lost to follow-up.
The Finnish study by Tuomilehto and colleagues14
looked at psychosocial and health status after 14 years in a cohort of
1 241 persons with stroke in 1972–1974. Of these, 241 (19.4%) were
still living (80% at home or with relatives), and 2 of 3 were
functionally independent. Ten to fifteen percent had symptoms of
depression, but half of the survivors considered their health status to
be good.
The Shibata Study15 examined a cohort of 2302
subjects for 15.5 years. Seventy-eight had strokes during this period,
for an incidence rate of 4.36 per 1000 person-years, but only risk
factors (not outcomes) were reported. Matsumoto and
colleagues16 also did a 15-year follow-up study
in Rochester, Minn, but only survival (not functional status) was
measured at that interval.
To our knowledge, ours is the first study in the English-language
literature on stroke survivors performed over 20 years after ictus, the
mean interval between onset and assessment for the survivors being 27.4
(range, 20 to 38 years). As shown in this study and others, the
progressive mortality in stroke survivors is inexorable and greater
than that of stroke-free controls, following a similar pattern at a
somewhat higher level. The fortunate few, however, who live for long
periods of time appear to enjoy relatively good functional status. In
our data, this may be related to the previously noted fact that the
20-year stroke survivors had their first stroke at a younger age than
both those stroke survivors who died of stroke and those who died of
other causes. In many instances, however, we found the functional
status of the stroke survivors to be better than that of the age- and
sex-matched controls, who were free of stroke when the 20-year period
of observation began. It will be of great interest to see whether other
controlled studies of very-long-term stroke survivors replicate these
findings.
Received October 28, 1997;
revision received December 29, 1997;
accepted January 13, 1998.
2.
Gresham GE, Phillips TF, Wolf PA, McNamara PM, Kannel
WB, Dawber TR. Epidemiologic profile of long-term stroke disability:
The Framingham Study. Arch Phys Med Rehabil. 1979;60:487–491.[Medline]
[Order article via Infotrieve]
3.
Shurtleff D. Some characteristics related to the
incidence of cardiovascular disease and death:
Framingham Study, 18-year follow-up. In: Kannel WB, Gordon T, eds.
The Framingham Study: An Epidemiological Investigation of
Cardiovascular Disease. Washington, DC: Dept of
Health, Education, and Welfare; 1974. DHEW publication NIH 74–599
(section 30).
4.
Folstein MF, Folstein SE, McHugh PR. Mini-Mental
State: a practical method for grading the cognitive state of patients
for the clinician. J Psychiatr Res. 1975;12:189–198.[Medline]
[Order article via Infotrieve]
5.
Radloff LS. The CES-D scale: a self-report depression
scale for research in the general population. Appl Psychol
Meas. 1977;1:385–401.
6.
Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW.
Studies of illness in the aged: the index of ADL: a standardized
measure of biological and psychological function. JAMA. 1963;21:914–919.
7.
Rosow I, Breslau N. A Guttman Health Scale for the
aged. J Gerontol. 1966;21:556–559.
8.
Moskowitz E, Lightbody FEH, Frietag NS. Long-term
follow-up of the post-stroke patient. Arch Phys Med Rehabil. 1972;53:167–172.[Medline]
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9.
Rankin J. Cerebral vascular accidents in patients over
the age of 60, II: prognosis. Scott Med J. 1957;2:200–215.[Medline]
[Order article via Infotrieve]
10.
Adams GF, Merrett JD. Prognosis and survival in the
aftermath of hemiplegia. Br Med J. 1961;1:309–314.
11.
Dennis MS, Burn JPS, Sandercock PAG, Bamford JM, Wade
DT, Warlow CP. Long-term survival after first-ever stroke: The
Oxfordshire Community Stroke Project. Stroke. 1993;24:796–800.
12.
Scmidt EV, Smirnov VE, Ryabova VS. Results of the
seven-year prospective study of stroke patients. Stroke. 1988;19:942–949.
13.
Wisniewska-Roszkowska K, Jedynecki A, Ziolkowski W. 10
years observation and rehabilitation of stroke disability: a
longitudinal study. Gerontol Clin. 1975;17:67–71.
14.
Tuomilehto J, Nuottimaki T, Salmi K, Aho K,
Kotila M, Sarti C, Rastenyte D. Psychosocial and health status in
stroke survivors after 14 years. Stroke. 1995;26:971–975.
15.
Nakayama T, Date C, Yokoyama T, Yoshiike N, Yamaguchi
M, Tanaka H. A 15.5 year follow-up study in stroke in a Japanese
provincial city: The Shibata Study. Stroke. 1997;28:45–52.
16.
Matsumoto N, Whisnant JP, Kurland LT, Okazaki H.
Natural history of stroke in Rochester, Minnesota, 1955 through 1969:
an extension of a previous study, 1945 through 1954. Stroke. 1973;4:20–29.
© 1998 American Heart Association, Inc.
Original Contributions
Survival and Functional Status 20 or More Years After First Stroke
The Framingham Study
Abstract
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Background and Purpose—We examined
the 20-or-more-year survival and functional levels of 148 stroke
survivors and 148 age- and sex-matched control subjects from the
Framingham Study Cohort, whom we originally studied in 1972–1974 to
ascertain the survival and disability status of stroke survivors
compared with that of controls.
Key Words: stroke outcome • mortality • follow-up studies • case-control studies • epidemiology
Introduction
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
From 1972 to 1974, we
studied all of the then-living stroke survivors in the original
Framingham Study cohort and an equal number of age- and sex-matched
control subjects who were free of stroke to determine the frequencies
of various types of disability.1 2 This group
comprised 148 persons in each category (stroke survivors and age- and
sex-matched controls). That study has been extensively cited, because
it (1) measured the frequencies of various disabilities through
objective methods and produced normative data on the prevalence of
specific disabilities in stroke survivors, (2) documented that
psychosocial disabilities after stroke were more frequent than physical
ones, (3) established that the frequency of each type of disability was
greater in stroke survivors than in control subjects, and (4) showed
that stroke survivors had a significant amount of
cardiovascular and other comorbidities that accounted
for a portion of their disabilities. The ages of the stroke survivors
at that time were 55 to 87 (mean, 73.8) years, and the mean ages at
most recent stroke were 64.3 years for the 66 men and 65.7 years for
the 82 women.
Subjects and Methods
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
The Framingham Study cohort, 5209 men and women between 30 and
62 years of age at entry in 1948 to 1950, has been examined every 2
years since the initiation of the study. The details of the study
design, implementation, and diagnostic criteria have been
published previously.3 At each examination the
participant receives a physical examination with laboratory testing.
Documentation of interim illnesses and hospitalizations are reviewed.
The records and examinations for all cardiovascular
and cerebrovascular events are reviewed and confirmed by a panel of
investigators. 
2method. Nine types of
functional disability were documented. The final set of variables
involved the presence or absence, in both stroke and control subjects,
of 14 comorbid conditions. The choice of comorbid processes to be
documented was determined by the preexisting protocol of the Framingham
Study.
Results
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
One hundred forty-seven pairs of 1972–1974 stroke survivors and
stroke-free control subjects were available for analysis in the
database (one pair from the original 148 was deleted on retrospective
review). Table 1
shows the survival
status of the 147 pairs.
View this table:
[in a new window]
Table 1. Survival Status in 1993-1995 of the 1972-1974 Cohort
of 147 Stroke Survivors and 147 Age- and Sex-Matched Controls .
View larger version (10K):
[in a new window]
Figure 1. Graph showing survival after first stroke in the original
1972–1974 Framingham Study case and control groups. Heavy line
indicates cases; thin line, controls (n=148 for each group). 
). The
age at first stroke of the 147 1972–1974 survivors is shown in Table 2. The 10 1972–1974 stroke survivors who
were still living in 1993–1995 had a mean age at first stroke of
56.0±3.4 years as opposed to 68.8±1.7 years for the 26 who died of
stroke and 65.9±0.9 years for those dying of other causes. The younger
age at first stroke of the 20-year stroke survivors is noteworthy.
Table 2 also shows that the mean total number of years of survival
after first stroke for the 1972–1974 stroke survivors who died before
1993–1995 was 14.3 (range, 0.7 to 38.3) years. The 26 1972–1974
stroke survivors who had died of stroke lived a mean of 10.7 (range,
2.5 to 31.4) years. Of the 26 individuals who died of stroke, 22 had a
least one recurrent stroke and 4 died of the original stroke. In
contrast, the 106 1972–1974 stroke survivors who died of causes other
than stroke lived for a mean of 14.8 years. The 1972–1974 stroke
survivors still living in 1993–1995 had lived an average of 27.4
(range, 20 to 38) years after their first stroke.
View this table:
[in a new window]
Table 2. 1993-1995 Survival Status of 147 1972-1974 Stroke
Survivors: Age at First Stroke and Mean Number of Years Survival
Since First Stroke and 4. One of the 10 died early in 1995,
before follow-up evaluation (Examination 23) was performed. Table 3
shows the host characteristics of the remaining 9. Their mean age was
80.3 (range, 74 to 90) years, 7 were women, and less than half were
married. The mean number of years since first stroke was 27.4 (range,
20 to 38); 5 first strokes had been atherothrombotic brain infarctions,
3 had been subarachnoid hemorrhages, and 1 was
classified as other. Of the 3 survivors who had the SAH stroke subtype,
2 did not have surgical treatment for the hemorrhages. Five had
possible coronary artery disease, and their
diastolic blood pressures ranged from 54 to 98 mm Hg
(systolic blood pressures ranged from 106 to 225 mm Hg).
None were smokers or drank alcohol. All were taking some type of
medication, and 8 of the 9 drank 1 to 2 cups of coffee per day.
View this table:
[in a new window]
Table 3. Host Characteristics of 10 1972-1974 Stroke
Survivors Still Living in 1993-1995 (From Examination 23)
View this table:
[in a new window]
Table 4. Functional Status of 10 1972-1974 Stroke Survivors
Still Living in 1993-1995 (From Examination 23) , the functional status of the 9 remaining stroke
survivors was excellent except for 1 patient who was demented
(requiring total care) and living in a nursing home. The other 8 could
still walk (although 6 required a walker or cane), all were independent
in activities of daily living (2 with assistive devices) and
instrumental activities of daily living, and all were still driving
cars. In addition, 8 of these very-long-term stroke survivors had
normal cognitive function, and only 1 showed depressive symptoms. Only
2 of the 8 had sustained falls during the previous year. Seven of the 8
were living in their own homes, 5 alone and 2 with a spouse. presents selected comparative
characteristics of the 9 stroke survivors and the 20 members of the
age- and sex-matched control group. Although the numbers are too small
to justify the use of tests for statistically significant differences,
the relative frequencies of several characteristics are worthy of note.
There were more women than men in the stroke survivor group compared
with the control group (78% and 35%, respectively). The stroke group
showed higher systolic and diastolic blood
pressures, more comorbidity (56% to 5%), greater use of medications,
less use of alcohol, and less depressive symptomology. There was little
difference in walking and independence in activities of daily
living.
View this table:
[in a new window]
Table 5. Selected Comparative Characteristics of 9 1972-1974
Stroke Survivors and 20 Control Subjects Still Living in 1993-1995
(From Examination 23)
Discussion
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Very-long-term outcome studies of stroke survivors are rare.
In our initial 1972–1974 study of this cohort, 67% of the cases were
at 20 or more months after first stroke,1 2 but
some were as close as 6 months after. The 1972 study by Moskowitz and
colleagues8 presented outcome data on 518
stroke patients collected over a 3-year period. These study subjects
were only 2 years post-onset. Both studies indicated that poststroke
disability (as opposed to survival) was not as severe as previously
believed (confirming the previous work of Rankin9
and Adams and Merrett10 ).
Acknowledgments
This study was supported by grants from the National Institute
of Neurological Disorders and Stroke (2-R01-NS-17950-15) and the
Framingham Heart Study (supported by NIH/NHLBI contract
NO1-HC-38038).
References
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
1.
Gresham GE, Fitzpatrick TE, Wolf PA, McNamara PM,
Kannel WB, Dawber TR. Residual disability in survivors of stroke: The
Framingham Study. N Engl J Med. 1975;293:954–956.[Abstract]
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