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Ouk M, Wu CY, Colby-Milley J, Fang J, Zhou L, Shah BR, Herrmann N, Lanctôt KL, Linkewich E, Law M, Swartz RH, Kapral MK, Black SE, MacIntosh BJ, Edwards JD, Swardfager W. Depression and Diabetes Mellitus Multimorbidity Is Associated With Loss of Independence and Dementia Poststroke. Stroke 2020; 51:3531-3540. [DOI: 10.1161/strokeaha.120.031068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background and Purpose:
Many patients with ischemic stroke present with multiple comorbidities that threaten survival and recovery. This study sought to determine the risks of adverse long-term stroke outcomes associated with multimorbid diabetes mellitus and depression.
Methods:
Retrospective analysis of prospectively collected data on consecutive patients without premorbid dementia admitted from the community for a first-ever acute ischemic stroke to comprehensive stroke centers across Ontario, Canada (2003–2013). Premorbid histories of diabetes mellitus and depression were ascertained within 5 years before stroke admission. Adjusted hazard ratios (aHR [95% CI]) of admission to long-term care, incident dementia, readmission for stroke or transient ischemic attack and all-cause mortality, over time among those discharged back into the community poststroke.
Results:
Among 23 579 stroke admissions, n=20 201 were discharged back into the community. Diabetes mellitus and depression were associated with synergistic hazards of admission to long-term care (X
2
=5.4;
P
=0.02) over a median follow-up of 5.6 years. This interaction was observed among women specifically; depression multimorbidity showed particularly high hazards of admission to long-term care (aHR
Depression
=1.57 [1.24–1.98]) and incident dementia (aHR
Depression
=1.85 [1.40–2.44]) among women with diabetes mellitus. In the whole cohort, diabetes mellitus and depression were associated individually with long-term care admission (aHR
Diabetes
=1.20 [1.12–1.29]; aHR
Depression
=1.19 [1.04–1.37]), incident dementia (aHR
Diabetes
=1.14 [1.06–1.23]; aHR
Depression
=1.27 [1.08–1.49]), stroke/transient ischemic attack readmission (aHR
Diabetes
=1.18 [1.10–1.26]; aHR
Depression
=1.24 [1.07–1.42]), and all-cause mortality (aHR
Diabetes
=1.29 [1.23–1.36]; aHR
Depression
=1.16 [1.05–1.29]).
Conclusions:
The risks of dementia and needing long-term care in the years after surviving a stroke were particularly elevated among women when premorbid diabetes mellitus and depression occurred together. Long-term stroke recovery strategies might target high-risk patients with mood and metabolic multimorbidity.
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Affiliation(s)
- Michael Ouk
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Department of Pharmacology and Toxicology (M.O., C.-Y.W., K.L.L., W.S.), University of Toronto, ON
| | - Che-Yuan Wu
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Department of Pharmacology and Toxicology (M.O., C.-Y.W., K.L.L., W.S.), University of Toronto, ON
| | - Jessica Colby-Milley
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Canadian Partnership for Stroke Recovery, Toronto, ON (J.C.-M., R.H.S., S.E.B., B.J.M., W.S.)
| | - Jiming Fang
- ICES, Toronto, ON (J.F., L.Z., B.R.S., R.H.S., M.K.K.)
| | - Limei Zhou
- ICES, Toronto, ON (J.F., L.Z., B.R.S., R.H.S., M.K.K.)
| | - Baiju R. Shah
- Department of Medicine and Institute for Health Policy, Management, and Evaluation, (B.R.S., M.K.K.), University of Toronto, ON
- ICES, Toronto, ON (J.F., L.Z., B.R.S., R.H.S., M.K.K.)
- Divisions of Endocrinology and Obstetric Medicine, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON (B.R.S.)
| | - Nathan Herrmann
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Department of Medicine (Psychiatry), Sunnybrook Health Sciences Centre (N.H., K.L.L.), University of Toronto, ON
| | - Krista L. Lanctôt
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Department of Pharmacology and Toxicology (M.O., C.-Y.W., K.L.L., W.S.), University of Toronto, ON
- Department of Medicine (Psychiatry), Sunnybrook Health Sciences Centre (N.H., K.L.L.), University of Toronto, ON
- University Health Network Toronto Rehabilitation Institute, Toronto, ON (K.L.L., M.L., W.S.)
| | - Elizabeth Linkewich
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Department of Occupational Science and Occupational Therapy (E.L.), University of Toronto, ON
| | - Marcus Law
- Department of Family and Community Medicine (M.L.), University of Toronto, ON
- University Health Network Toronto Rehabilitation Institute, Toronto, ON (K.L.L., M.L., W.S.)
| | - Richard H. Swartz
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Department of Medicine (Neurology), Sunnybrook Health Sciences Centre (R.H.S., S.E.B.), University of Toronto, ON
- Canadian Partnership for Stroke Recovery, Toronto, ON (J.C.-M., R.H.S., S.E.B., B.J.M., W.S.)
- ICES, Toronto, ON (J.F., L.Z., B.R.S., R.H.S., M.K.K.)
| | - Moira K. Kapral
- Department of Medicine and Institute for Health Policy, Management, and Evaluation, (B.R.S., M.K.K.), University of Toronto, ON
- ICES, Toronto, ON (J.F., L.Z., B.R.S., R.H.S., M.K.K.)
| | - Sandra E. Black
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Department of Medicine (Neurology), Sunnybrook Health Sciences Centre (R.H.S., S.E.B.), University of Toronto, ON
- Canadian Partnership for Stroke Recovery, Toronto, ON (J.C.-M., R.H.S., S.E.B., B.J.M., W.S.)
| | - Bradley J. MacIntosh
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Department of Medical Biophysics (B.J.M.), University of Toronto, ON
- Canadian Partnership for Stroke Recovery, Toronto, ON (J.C.-M., R.H.S., S.E.B., B.J.M., W.S.)
| | - Jodi D. Edwards
- University of Ottawa Heart Institute (J.D.E.), University of Ottawa, ON
- School of Epidemiology and Public Health (J.D.E.), University of Ottawa, ON
| | - Walter Swardfager
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON (M.O., C.-Y.W., J.C.-M., N.H., K.L.L., E.L., R.H.S., S.E.B., B.J.M., W.S.)
- Department of Pharmacology and Toxicology (M.O., C.-Y.W., K.L.L., W.S.), University of Toronto, ON
- Canadian Partnership for Stroke Recovery, Toronto, ON (J.C.-M., R.H.S., S.E.B., B.J.M., W.S.)
- University Health Network Toronto Rehabilitation Institute, Toronto, ON (K.L.L., M.L., W.S.)
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Lucke-Wold BP, Logsdon AF, Turner RC, Rosen CL, Huber JD. Aging, the metabolic syndrome, and ischemic stroke: redefining the approach for studying the blood-brain barrier in a complex neurological disease. ADVANCES IN PHARMACOLOGY 2014; 71:411-49. [PMID: 25307225 DOI: 10.1016/bs.apha.2014.07.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The blood-brain barrier (BBB) has many important functions in maintaining the brain's immune-privileged status. Endothelial cells, astrocytes, and pericytes have important roles in preserving vasculature integrity. As we age, cell senescence can contribute to BBB compromise. The compromised BBB allows an influx of inflammatory cytokines to enter the brain. These cytokines lead to neuronal and glial damage. Ultimately, the functional changes within the brain can cause age-related disease. One of the most prominent age-related diseases is ischemic stroke. Stroke is the largest cause of disability and is third largest cause of mortality in the United States. The biggest risk factors for stroke, besides age, are results of the metabolic syndrome. The metabolic syndrome, if unchecked, quickly advances to outcomes that include diabetes, hypertension, cardiovascular disease, and obesity. The contribution from these comorbidities to BBB compromise is great. Some of the common molecular pathways activated include: endoplasmic reticulum stress, reactive oxygen species formation, and glutamate excitotoxicity. In this chapter, we examine how age-related changes to cells within the central nervous system interact with comorbidities. We then look at how comorbidities lead to increased risk for stroke through BBB disruption. Finally, we discuss key molecular pathways of interest with a focus on therapeutic targets that warrant further investigation.
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Affiliation(s)
- Brandon P Lucke-Wold
- Department of Neurosurgery, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA
| | - Aric F Logsdon
- The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; Department of Basic Pharmaceutical Sciences, West Virginia University, School of Pharmacy, Morgantown, West Virginia, USA
| | - Ryan C Turner
- Department of Neurosurgery, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA
| | - Charles L Rosen
- Department of Neurosurgery, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA
| | - Jason D Huber
- The Center for Neuroscience, West Virginia University, School of Medicine, Morgantown, West Virginia, USA; Department of Basic Pharmaceutical Sciences, West Virginia University, School of Pharmacy, Morgantown, West Virginia, USA.
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