Racial Differences in Neurocognitive Outcomes Post-Stroke: The Impact of Healthcare Variables

Post stroke pain: Is there under-diagnosis in Black versus White patients?

Stroke incidence is higher and stroke outcomes are poorer in Black patients compared to White patients. Poststroke pain, however, is not a well understood stroke outcome. Using the National Institutes of Health All of Us Research Program database, we hypothesized that the dataset would demonstrate proportionately higher relative risk of poststroke pain in the Black poststroke patient population compared to the White poststroke patient population. However, our analysis showed that Black stroke patients were diagnosed with poststroke pain at a similar rate as White stroke patients. As our results are not consistent with other poststroke outcomes in the literature, this study identifies a potentially underdiagnosed patient population, highlighting the need for further research.

History of obstructive sleep apnea associated with incident cognitive impairment in white but not black individuals in a US national cohort study

BACKGROUND

We sought to determine if risk for obstructive sleep apnea (OSA), a history of OSA, and/or treatment of OSA has a different association with incident cognitive impairment or cognitive decline in Black individuals and White individuals.

METHODS

To determine whether the risk for OSA, a history of OSA, and/or treatment of OSA has a different association with incident cognitive impairment or cognitive decline in Black individuals and White individuals; data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) was used. Participants that completed the sleep questionnaire module, had baseline cognitive assessment, and at least one cognitive assessment during follow-up were included. Risk of OSA was determined based on Berlin Sleep Questionnaire. History of sleep apnea was determined based on structured interview questions. Optimally treated OSA was defined as treated sleep apnea as at least 4 h of continuous positive airway pressure use per night for ≥5 nights per week.

RESULTS

In 19,017 participants stratified by race, White participants with history of OSA were 1.62 times more likely to have incident cognitive impairment compared to White participants without history of OSA after adjusting for demographic characteristics, history, and lifestyle factors (OR = 1.62, 95% CI = 1.05-2.50, p-value = 0.03). This relationship was not seen in Black participants (OR = 0.92, 95% CI = 0.60-1.43, p-value = 0.72).

DISCUSSION

A previous diagnosis of OSA is associated with incident cognitive impairment in White Americans but not Black Americans. Further investigations are required to determine the mechanism for this difference.

New Onset Poststroke Dementia at one Year in Africans

BACKGROUND

There is limited information on new onset poststroke dementia (NPSD) in sub-Saharan Africa (SSA). We estimated incidence, cumulative incidence, risk factors and outcome of NPSD at 1 year in Nigerian survivors of a first-ever stroke.

METHODS

Hospital-based prospective observational study. Assessments for global cognition, learning, memory, executive and activities of daily life (ADL) functioning were conducted at 3 poststroke timepoints (Baseline, 3- and 12 months). NPSD was ascertained according to the "National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria." Outcomes were assessed using the modified Rankin Scale (mRS), center for epidemiologic studies depression scale (CES-D 10), health related quality of life in stroke patients (HRQOLISP-26) and caregivers strain index (CSI).

RESULTS

Among 144 stroke survivors who were free of dementia at baseline, we found a 1-year cumulative incidence of 4.52% (95% C.I = 3.20, 6.39). In multivariate Cox regression analyses, diabetes was associated with NPSD (Hazard Ratio = 2.10, 95% CI = 1.02, 4.35). NPSD at 3 months was independently associated with motor decline [Mean difference (MD) in mRS = 1.6, 95% C.I = 0.9, 2.3)], depression (MD in CES-D = 2.9, 95% C.I = 0.3, 5.4), caregivers burden (MD in CSI = 1.2, 95% C.I = 0.5, 1.8), and poor quality of life (MD in HRQOLISP-26 = -11.2, 95% C.I = -15.7, -6.8) at 1 year.

CONCLUSION

Approximately 4.5% of stroke survivors in Nigeria had NPSD at 1 year. Diabetes, which can be prevented, represent a primary prevention target for NPSD and its consequences in SSA.

Neurocognitive performance differences between black and white individuals with HIV disease are mediated by health literacy

Objective:Health disparities are evident for Black Americans with HIV disease, who are disproportionally affected by the epidemic in the United States. The current study investigated whether the higher rates of neurocognitive impairment in Black Americans with HIV disease may be at least partly attributable to health literacy, which is a potentially modifiable factor. Method: Participants were 61 White and 25 Black participants (ages 27-70) with HIV disease who were enrolled in studies at an urban academic center in Southern California. Neurocognitive function was assessed by an age-adjusted global score from the Cogstate battery. Health literacy was measured by a composite score derived from the Rapid Estimate of Adult Literacy in Medicine, Newest Vital Sign, and 3-Brief. Results: Bootstrap confidence interval mediation analyses showed that health literacy was a significant mediator of the relationship between race and neurocognition; that is, there were no direct ethnoracial differences in neurocognition after accounting for health literacy. A follow-up model to confirm the directionality of this association demonstrated that neurocognition was not a significant mediator of the relationship between race and health literacy. Conclusions: Low health literacy may contribute to the higher rates of neurocognitive impairment for Black Americans with HIV disease. Future studies might examine the possible mechanism of this mediating relationship (e.g., access to health information, health behaviors, socioeconomics) and determine whether culturally tailored interventions that improve health literacy also confer broader brain health benefits for Black Americans with HIV disease.

Sociodemographic, geographic and clinical factors associated with functional outcome and discharge location in US inpatient rehabilitation settings

OBJECTIVE

To assess the impact of sociodemographic factors, clinical factors and regional differences on both patients' functional outcome and discharge location in U.S. inpatient rehabilitation settings.

METHODS

Using eRehabData, 536,453 admissions was used for functional outcome analyses (based on FIM gain) while 259,308 admissions was used for the discharge location analyses. Regression models were used to look at both outcomes.

RESULTS

Having private insurance and being young and male was associated with the higher FIM gains while being African American, widowed, and living in the Midwest was associated with the lower FIM gains. Furthermore, having private insurance, being young, male, married and African American or Hispanic was associated with the lower odds of being discharged to a skilled nursing facility while living in the Midwest was associated with the greatest odds of being discharged to a skilled nursing facility. Clinical factors such as days from onset and length of stay also had a significant effect on both outcomes.

CONCLUSION

Our findings suggest that, in the U.S., one of the challenges to successful recovery in the inpatient rehabilitation setting includes insurance status (Medicare/Medicaid), race (African American) but also regional differences (Midwest) and length of stay.

At the Intersection of Race, Socioeconomics, and Chronic Illness: A Case and Frame Analysis of Two Survivor-Caregiver Dyads in the Aftermath of Stroke

Although the overall incidence of stroke in the United States has decreased in recent years, the incidence of stroke among Black Americans has not changed. This has resulted in a widening gap between White and Black stroke survivors and their families. A variety of factors contribute to this inequity including social determinants of health (e.g., adverse life events, discrimination, neighborhood deprivation, lack of access to health care). This article uses a "case and frame" approach, through the lens of ecological systems theory, to illustrate how social determinants of health express themselves in two stroke survivor-caregiver dyads living in a large Midwestern city. We draw out implications for practice and policy in social work and related disciplines that focus on recognizing the impact of social determinants of health, developing culturally-specific interventions that mitigate unique stressors but that also leverage unique strengths, and building capacity for cultural competence and cross-cultural health communication within organizations.

Cognitive decline before and after a first-ever stroke in Africans

OBJECTIVES

There is a knowledge gap on the impact of pre-existing cognitive decline on poststroke decline in indigenous Africans. We describe the trajectories of domain-specific cognitive and activities of daily life (ADL) functioning across the first year of stroke in Nigerians with pre-existing cognitive decline.

MATERIALS AND METHODS

Prospective observational study. Prestroke cognitive decline was ascertained retrospectively using the 16-item Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). Assessments for global cognition, learning, memory, executive and ADL functioning were conducted at 3 time points using the Mini-Mental state examination (MMSE), 10-words list learning and delayed recall test (10 WDRT), Animal naming test and Barthel index, respectively.

RESULTS

Among 150 stroke survivors, prestroke cognitive decline was found in 25 (16.7%, 95% C.I = 11.5%-23.6%). In linear regression analyses adjusting for the effect of age, education, stroke severity and comorbid diabetes mellitus, prestroke cognitive decline predicted poor memory scores at one year [Adjusted standardized mean difference (SMD) = -0.6, 95% C.I = -1.1, -0.1, p = 0.016)]. The association of prestroke cognitive decline with poststroke poor memory was substantially mediated by age (SMD = -0.9, 95% C.I = -1.4, -0.4, p < 0.001).

CONCLUSION

Pre-existing cognitive decline in this sample was associated with an age-mediated poor memory function at one-year poststroke. Early institution of targeted cognitive rehabilitation in stroke survivors with pre-existing cognitive decline may reduce the neurocognitive burden of stroke in Black Africans.

The outcomes of mechanical thrombectomy in nonagenarians and octogenarians in a majority hispanic population

BACKGROUND/OBJECTIVE

Elderly patients (≥ 80 years) were underrepresented in randomized trials that proved the efficacy and safety of mechanical thrombectomy (MT) in acute ischemic strokes (AIS) due to large vessel occlusion (LVO). Additionally, the impact of race and socioeconomics on AIS outcomes is well-reported. We sought to compare the MT clinical outcomes between octogenarians and nonagenarians, the majority of whom are Hispanic, in underserved border communities.

METHODS

This is a retrospective cohort study that was conducted in a comprehensive stroke center between 2012 and 2020. The baseline characteristics and outcomes were compared between the two groups. The primary measured outcome included a favorable outcome on the modified Rankin Scale (mRS) after three months (mRS ≤ 2). Secondary outcomes included mortality, symptomatic intracerebral hemorrhage (sICH), and an improvement in NIH Stroke Scale (NIHSS) score (≤4).

RESULTS

Of 215 included patients, 184 (85.6%) were octogenarians and 31 (14.4%) were nonagenarians. There were no significant differences between octogenarians and nonagenarians in terms of rates of favorable outcomes after three months (30.4% vs. 19.4%, p = 0.247), clinical improvement in discharge NIHSS (16.3% vs. 19.4%, p = 0.753), mortality (24.5% vs. 29.0%; p = 0.710) and sICH (6.5% vs. 3.2%, p = 0.780). Furthermore, Hispanic and non-Hispanic patients had similar outcomes.

CONCLUSION

There were no significant differences in the outcomes of MT between octogenarians and nonagenarians and between Hispanic and non-Hispanic patients. The similar clinical outcomes between both age groups in our study and the lower rates of sICH support the use of this treatment among people who are aged 80 or older.

Neural and Genetic Bases for Human Ability Traits

The judgement of human ability is ubiquitous, from school admissions to job performance reviews. The exact make-up of ability traits, however, is often narrowly defined and lacks a comprehensive basis. We attempt to simplify the spectrum of human ability, similar to how five personality traits are widely believed to describe most personalities. Finding such a basis for human ability would be invaluable since neuropsychiatric disease diagnoses and symptom severity are commonly related to such differences in performance. Here, we identified four underlying ability traits within the National Institutes of Health Toolbox normative data (n = 1, 369): (1) Motor-endurance, (2) Emotional processing, (3) Executive and cognitive function, and (4) Social interaction. We used the Human Connectome Project young adult dataset (n = 778) to show that Motor-endurance and Executive and cognitive function were reliably associated with specific brain functional networks (r ² = 0.305 ± 0.021), and the biological nature of these ability traits was also shown by calculating their heritability (31 and 49%, respectively) from twin data.

Disability in Community-Dwelling Older Adults: Exploring the Role of Stroke and Dementia

Objectives: We sought to determine the relative contributions of stroke, dementia, and their combination to disability and racial differences in disability among community-dwelling older adults. Methods: We performed a cross-sectional study of 6848 community-dwelling older adults. We evaluated the associations of stroke, dementia, and their combination with activities of daily living (ADL) limitations (range 0-7). We then explored the impact of stroke and dementia on race differences in ADL limitations using Poisson regression after accounting for sociodemographics and comorbidities. Results: After full adjustment, ADL limitations differed among older adults with stroke and dementia. Older adults without stroke or dementia had 0.32 (95% CI 0.29-0.35) ADL limitations compared to 0.64 (95% CI 0.54-0.73) with stroke, 1.36 (95% CI 1.20-1.53) with dementia and 1.84 (95% CI 1.54-2.15) with stroke and dementia. Overall, blacks had 0.27 (95%CI 0.19-0.36) more ADL limitations than whites. Models accounting for stroke led to a 3.7% (95%CI 2.98%-4.43%) reduction in race differences, while those for dementia led to a 29.26% (95%CI 28.53%-29.99%) reduction and the stroke-dementia combination -1.48% (95%CI -2.21% to -0.76) had little impact. Discussion: Older adults with stroke and dementia have greater disability than older adults with either of these conditions alone. However, the amount of disability experienced by older adults with stroke and dementia is less than the sum of the contributions from stroke and dementia. Dementia is likely a key contributor to race differences in disability.

Vascular-brain Injury Progression after Stroke (VIPS) study: concept for understanding racial and geographic determinants of cognitive decline after stroke

Cognitive impairment and dementia (CID) are major public health problems with substantial personal, social, and financial burdens. African Americans are at a heightened risk for Vascular Cognitive Impairment (VCI) compared to European Americans. Recent lines of evidence also suggest a high burden of Post-stroke VCI among indigenous Africans. A better understanding of the cause(s) of the racial disparity in CID, specifically VCI, is needed in order to develop strategies to reduce it. We propose and discuss the conceptual framework for a unique tri-population, trans-continental study titled The Vascular brain Injury Progression after Stroke (VIPS) study. The overarching objective of the VIPS Study will be to explore the interplay of multiple factors (racial, geographical, vascular, lifestyle, nutritional, psychosocial and inflammatory) influencing the level and trajectory of post-stroke cognitive outcomes and examine whether differences between indigenous Africans, African Americans and European Americans exist. We hypothesize that differences which might be due to racial factors will be observed in African Americans versus European Americans as well as Indigenous Africans versus European Americans but not in African Americans versus Indigenous Americans; differences due to geographical factors will be observed in Indigenous Americans versus African Americans and Indigenous Africans versus European Americans but not in African Americans versus European Americans. This overarching objective could be accomplished by building upon existing National Institutes of Health investments in the REasons for Geographical And Racial Differences in Stroke (REGARDS) study (based in the United States of America) and the Stroke Investigative Research and educational Network (SIREN) study (based in Sub-Saharan Africa).

Lived experiences of chronic cognitive and mood symptoms among community-dwelling adults following stroke: a mixed-methods analysis

Objectives: Few studies have explored the lived experiences of chronic cognitive and mood symptoms following stroke using a racially/ethnically diverse sample. Therefore, we aimed to explore the perceptions of chronic post-stroke cognition and mood symptoms and goals among a racially/ethnically diverse sample of community-dwelling adults aging with stroke. Method: This qualitative study using mixed-methods analysis included semi-structured interviews regarding perceived post-stroke cognitive and mood symptoms among community-dwelling stroke survivors at least one-year post stroke. Transcripts were subjected to thematic content analysis, and differences in theme usage patterns by age, gender, race/ethnicity, and post-acute rehabilitation setting were assessed using an inferential clustering technique. Results: The majority of participants (93%) reported cognition-related themes, including language and communication, memory, thinking abilities, comprehension, visual-spatial processing, and cognitive assessments and training. Nearly half of participants mentioned mood-related themes, including depression, aggression and anger, mood fluctuations, anxiety, and psychological services and medication. Nearly half reported an unmet need for cognition or mood-related treatment. Inferential clustering analysis revealed that older participants reported a different pattern of cognitive and mood symptoms than those aged younger than 65 (p = 0.02). Older adults were more likely to describe post-stroke language/communication changes, while younger adults described post-stroke mood changes. Conclusion: Stroke survivors experienced cognitive and mood-related symptoms beyond one-year post stroke, which has implications for long-term assessment and management. Incorporation of continued symptom monitoring into existing community-based services is needed to address chronic cognitive and mood symptoms affecting the quality of life of persons with stroke.

Association of sickle cell trait with measures of cognitive function and dementia in African Americans

OBJECTIVE

The incidence and prevalence of cognitive decline and dementia are significantly higher among African Americans compared with non-Hispanic Whites. The aim of this study was to determine whether inheritance of the sickle cell trait (SCT) i.e. heterozygosity for the sickle cell mutation increases the risk of cognitive decline or dementia Among African Americans.

METHODS

We studied African American participants enrolled in the Atherosclerosis Risk in Communities study. SCT genotype at baseline and outcome data from cognitive assessments at visits 2, 4 and 5, and an MRI performed at visit 5 were analyzed for the association between SCT and risk of cognitive impairment and/or dementia.

RESULTS

There was no significant difference in risk factors profile between participants with SCT (N = 176) and those without SCT (N = 2532). SCT was not independently associated with a higher prevalence of global or domain-specific cognitive impairment at baseline or with more rapid cognitive decline. Participants with SCT had slightly lower incidence of dementia (HR = 0.63 [0.38, 1.05]). On the other hand, SCT seems to interact with the apolipoprotein E ε4 risk allele resulting in poor performance on digit symbol substitution test at baseline (z-score = -0.08, Pinteraction = 0.05) and over time (z-score = -0.12, Pinteraction = 0.04); and with diabetes mellitus leading to a moderately increased risk of dementia (HR = 2.06 [0.89, 4.78], Pinteraction = 0.01).

CONCLUSIONS

SCT was not an independent risk factor for prevalence or incidence of cognitive decline or dementia, although it may interact with and modify other putative risk factors for cognitive decline and dementia.

Racial and ethnic disparities in stroke outcomes: a scoping review of post-stroke disability assessment tools

Purpose: To identify how post-stroke disability outcomes are assessed in studies that examine racial/ethnic disparities and to map the identified assessment content to the International Classification of Functioning, Disability, and Health (ICF) across the time course of stroke recovery. Methods: We conducted a scoping review of the literature. Articles published between January 2001 and July 2017 were identified through Scopus, PubMed, CINAHL, and PsycINFO according to predefined inclusion and exclusion criteria. Results: We identified 1791 articles through database and hand-searching strategies. Of the articles, 194 met inclusion criteria for full-text review, and 41 met inclusion criteria for study inclusion. The included studies used a variety of outcome measures encompassing domains within the ICF: body functions, activities, participation, and contextual factors across the time course of stroke recovery. We discovered disproportionate representation among racial/ethnic groups in the post-stroke disability disparities literature. Conclusions: A wide variety of assessments are used to examine disparities in post-stroke disability across the time course of stroke recovery. Several studies have identified disparities through a variety of assessments; however, substantial problems abound from the assessments used including inconsistent use of assessments, lacking evidence on the validity of assessments among racial/ethnic groups, and inadequate representation among all racial/ethnic populations comprising the US. Implications for Rehabilitation An enhanced understanding of racial/ethnic disparities in post-stroke disability outcomes is inherently important among rehabilitation practitioners who frequently engage with racial/ethnic minority populations across the time course of stroke recovery. Clinicians should carefully consider the psychometric properties of assessment tools to counter potential racial bias. Clinicians should be aware that many assessments used in stroke rehabilitation lack cultural sensitivity and could result in inaccurate assessment findings.