Cognitive and physical impairment and the risk of stroke - A prospective cohort study

Cognitive Impairment Is Associated with New-Onset Stroke: Evidence from a Nationwide Prospective Cohort Study

INTRODUCTION

Stroke is closely related to cognitive function, and many patients experience cognitive impairment after stroke; however, whether cognitive impairment is associated with an increased risk of stroke remains inconclusive. This study aims to investigate whether cognitive impairment is associated with new-onset stroke (first ever nonfatal stroke) using a national prospective study.

METHODS

Data from the China Health and Retirement Longitudinal Study (CHARLS) from 2011 to 2018 were used. A total of 11,961 Chinese participants aged ≥45 years without a history of stroke were included in the present study and divided into a cognitive impairment group and a normal group according to the baseline cognitive score. Logistic regression analysis was used to analyse the association between baseline cognitive function and new-onset stroke.

RESULTS

During the 6.96-year follow-up period, 875 participants experienced new-onset stroke. Compared with the cognitively normal group, the odds ratio (95% confidence intervals) for new-onset stroke in the cognitively impaired group was 1.21 (1.04, 1.40) when not adjusted for confounders and 1.22 (1.01, 1.48) after adjusting for established confounding factors, including demographic data, medical history, physical examination, and laboratory indicators.

CONCLUSION

Cognitive impairment was associated with new-onset stroke among middle-aged and elderly Chinese individuals. Further studies should be carried out to confirm the causal relationship between cognitive impairment and stroke.

Does Incident Cardiovascular Disease Lead to Greater Odds of Functional and Cognitive Impairment? Insights From the Health and Retirement Study

BACKGROUND

Although studies to date have broadly shown that cardiovascular disease (CVD) increases cognitive and physical impairment risk, there is still limited understanding of the magnitude of this risk among relevant CVD subtypes or age cohorts.

METHODS

We analyzed longitudinal data from 16 679 U.S. Health and Retirement Study participants who were aged ≥65 years at study entry. Primary endpoints were physical impairment (activities of daily living impairment) or cognitive impairment (Langa-Weir Classification of dementia). We compared these endpoints among participants who developed incident CVD versus those who were CVD free, both in the short term (<2-year postdiagnosis) and long term (>5 years), controlling for sociodemographic and health characteristics. We then analyzed the effects by CVD subtype (atrial fibrillation, congestive heart failure, ischemic heart disease, and stroke) and age-at-diagnosis (65-74, 75-84, and ≥85).

RESULTS

Over a median follow-up of 10 years, 8 750 participants (52%) developed incident CVD. Incident CVD was associated with significantly higher adjusted odds (aOR) of short-term and long-term physical and cognitive impairment. The oldest (≥85) age-at-diagnosis subgroup had the highest risk of short-term physical (aOR 3.01, 95% confidence interval [CI]: 2.40-3.77) and cognitive impairment (aOR 1.96, 95% CI: 1.55-2.48), as well as long-term impairment. All CVD subtypes were associated with higher odds of physical and cognitive impairment, with the highest risk for patients with incident stroke.

CONCLUSIONS

Incident CVD was associated with an increased risk of physical and cognitive impairment across CVD subtypes. Impairment risk after CVD was highest among the oldest patients (≥85 years) who should therefore remain a target for prevention efforts.

Bidirectional associations of intellectual and social activities with cognitive function among middle-aged and elderly adults in China

BACKGROUND

Previous studies evaluating the association between leisure activities and cognitive function produced conflicting results. Different types of leisure activities may have different effects on cognition, and very few studies have explored their bidirectional associations. Our study aimed to explore whether intellectual and social activities had bidirectional associations with cognitive function among the middle-aged and elderly adults in China.

METHODS

Data was derived from the China Health and Retirement Longitudinal Study. The data in this study were based on 11,549 participants aged 45 or older whose intellectual and social activities and cognitive function were assessed at baseline. Cross-lagged panel model was used to examine the temporal relationship of intellectual and social activities with cognitive function.

RESULTS

Totally, 5624 participants completed the third follow-up in 2018. The results showed that the better the cognitive function they had at baseline, the more intellectual activities they were engage in (β = 0.044, P < 0.001) and vice versa (β = 0.042, P = 0.001). Additionally, better cognitive function at baseline was significantly associated with more engagement in social activities (β = 0.028, P = 0.030); in contrast, higher engagement in social activities at baseline was not related to better cognitive function (β = -0.008, P = 0.523).

LIMITATIONS

Engagement in social and intellectual activities was assessed via questionnaire.

CONCLUSIONS

Our findings indicated that there was a bidirectional relationship between intellectual activities and cognitive function. However, participation in social activities did not slow down the decline in cognitive function. Participating in intellectual activities, compared to social activities, is especially beneficial for cognitive function.

Short-term exposure to PM10 and cardiovascular hospitalization in persons with and without disabilities: Invisible population in air pollution epidemiology

Persons with disabilities (PwD), the world's largest minority, can be more susceptible to particulate matter (PM) than persons without disabilities. Although numerous studies have addressed population susceptibility to PM, PwD have not been studied in air pollution epidemiology. This study investigated the association between short-term exposure to PM with an aerodynamic diameter smaller than 10 μm (PM₁₀) and cardiovascular hospital admissions by the existence of a disability, while also considering intersections of disability and other socio-demographic characteristics in South Korea. We used the National Health Insurance Service-National Sample Cohort (NHIS-NSC) to investigate the association between short-term exposure to PM₁₀ and cardiovascular hospital admissions in seven metropolitan cities from 2002 to 2015. We conducted a time-stratified case-crossover analysis using conditional logistic regression and adjusted for daily temperature, relative humidity, air pressure, and national holidays. We conducted stratified analyses according to the existence of a disability, disability type and severity, and socio-demographic characteristics. The results showed that a 10 μg/m³ increase in the 0-3 moving average level of PM₁₀ was associated with 1.9 % (95 % confidence interval [CI]: 0.7 %, 3.2 %) and 0.0 % (95 % CI: -0.5 %, 0.5 %) increase in cardiovascular admissions in persons with and without disabilities, respectively. Among PwD, the associations were pronounced in people with brain lesion disorders (percent change [PC]: 2.7 %, 95 % CI: 0.5 %, 5.0 %), people with visual impairment (PC: 3.0 %, 95 % CI: -1.0 %, 7.1 %), and people with severe disability (PC: 3.0 %, 95 % CI: 0.9 %, 5.0 %). We found that PwD may be more adversely affected by PM₁₀ than their non-disabled counterparts. This suggests that PwD is a social identity reflecting the socially marginalized and disadvantaged population in air pollution epidemiology.

Rehabilitation interventions for cognitive deficits in stroke survivors: A systematic review of randomized controlled trials

Cognitive deficits are one of the most common impairments after stroke. It negatively affects physical and social functioning. Rehabilitation interventions for cognitive deficits post-stroke have taken less consideration. The present study aimed to provide an overview of the effects of various rehabilitation interventions on cognitive functions in patients with stroke. PUBMED, SCOPUS, PEDro, EMBASE, MEDLINE, and REHABDATA were searched for randomized controlled trials (RCTs) investigating the effects of rehabilitation interventions on cognitive domains poststroke until August 2021. The methodological quality of the selected studies was evaluated using the Cochrane Collaboration tool, and the effect sizes were calculated. Forty-four studies met the inclusion criteria. A total of 3561 individuals with stroke, 57.60% of whom were males. The mean age for all participants was 65.48 years. Eighteen RCTs were high, moderate (n = 17), and low methodological quality (n = 9). The results showed evidence for the beneficial effects of many rehabilitation interventions on cognition in individuals with stroke. Rehabilitation plays a crucial role in improving cognitive functions in stroke patients with mild cognitive deficits. Virtual reality (VR), computer-based cognitive rehabilitation (CBCR), and non-aerobic exercises may promote cognitive functions in patients with stroke.

Is robot-assisted gait training intensity a determinant of functional recovery early after stroke? A pragmatic observational study of clinical care

Gait rehabilitation is a critical factor in functional recovery after a stroke. The aim of this pragmatic observational study was to identify the optimal dose and timing of robot-assisted gait training (RAGT) that can lead to a favourable outcome in a sample of subacute stroke survivors. Subacute patients with stroke who underwent a RAGT within a multidisciplinary rehabilitation program were enrolled. A set of clinical (i.e. age, type of stroke and time since stroke) and rehabilitation stay outcomes (length of stay and RAGT number of sessions) were recorded to evaluate their impact on functional outcome measures by functional independence measure (FIM) or functional ambulation category (FAC). We included 236 patients (62.73 ± 11.82 year old); 38.44% were females, and 59.32% were ischaemic stroke patients. Patients that received at least 14 RAGT sessions, had 15.83% more chance to be responders compared to those that receive less sessions (P = 0.006). Similarly, younger patients (≤60 years) were more prone to be responders (+15.1%). Lastly, an early rehabilitation (<6 weeks) was found to be more efficient (+21.09%) in determining responsiveness (P < 0.001). Becoming newly independent for gait, that refers to a FAC score ≥4, was related with age and RAGT sessions (P = 0.001). In conclusion, a younger age (≤60 years), an early rehabilitation (<6 weeks since stroke) and a higher RAGT dose (at least 14 sessions) were related to a favourable outcome in patients with subacute stroke.

Lung function impairment in relation to cognition and vascular brain lesions: the Rotterdam Study

OBJECTIVE

To investigate the association of chronic obstructive pulmonary disease (COPD) and Preserved Ratio Impaired Spirometry (PRISm) with cognitive performance and presence of vascular brain lesions (VBL).

METHODS

We determined both cross-sectional and longitudinal association of lung function impairment with cognition, as well as cross-sectional association of lung function impairment with VBL, in the general population. Between 2009 and 2014 we included 3,941 participants from the Rotterdam Study with spirometry tests, brain MRI scans and cognition tests, of whom 1815 had follow-up data on cognition.

RESULTS

Our finding indicated that cross-sectionally, participants with PRISm or COPD GOLD2-4 had a worse global cognitive performance. We did not find differences in cognition over time between those with normal spirometry versus those with lung function impairment. In addition, PRISm and COPD GOLD2-4 were associated with a higher prevalence of lacunar infarcts compared to normal spirometry.

CONCLUSIONS

This study suggests that persons with COPD GOLD2-4 or restrictive lung function, defined as PRISm, are characterized by poorer global cognitive function and a higher prevalence of lacunar infarcts.

Plasma Amyloid Beta, Total-Tau and Neurofilament Light Chain Levels and the Risk of Stroke: A Prospective Population-Based Study

BACKGROUND AND OBJECTIVES

To unravel whether Alzheimer's disease-related pathology or neurodegeneration play a role in stroke etiology, we determined the effect of plasma levels amyloid β (Aβ), total-tau and neurofilament light chain (NfL) on risk of stroke and its subtypes.

METHODS

Between 2002 and 2005, we measured plasma Aβ40, Aβ42, total-tau, and NfL in 4,661 stroke-free participants from the population-based Rotterdam Study. We used Cox proportional-hazards models to determine the association between these markers with incident stroke for the entire cohort, per stroke subtype, and by median age, sex, Apolipoprotein E (APOE) ε4 carriership, and education.

RESULTS

After a mean follow-up of 10.8 ± 3.3 years, 379 participants suffered a first-ever stroke. Log2 total-tau at baseline showed a non-linear association with risk of any stroke and ischemic stroke: compared to the first (lowest) quartile the adjusted hazard ratio for the highest quartile total-tau was 1.68, 95% CI: 1.18-2.40 for any stroke. Log2 NfL was associated with an increased risk of any stroke (HR per SD increase 1.27, 95% CI: 1.12-1.44), ischemic stroke, and hemorrhagic stroke (HR 1.56, 95% CI: 1.14-2.12). Log2 Aβ40, Aβ42, and Aβ42/40 ratio levels were not associated with stroke risk.Discussion Participants with higher total-tau and NfL at baseline had a higher risk of stroke and several stroke subtypes. These findings support the role of markers of neurodegeneration in the etiology of stroke.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that higher plasma levels of total-tau and NfL are associated with an increased risk of subsequent stroke.

Adverse childhood experiences and cognitive function in adulthood: examining the roles of depressive symptoms and inflammation in a prospective cohort study

PURPOSE

Adverse childhood experiences (ACEs) have been associated with cognitive decline in adulthood. However, the underlying mechanisms implicated remain unclear. This study investigated depressive symptoms and systemic inflammation as potential mediators of the association between ACEs and later cognitive function.

METHODS

Participants were adults aged 50 + from the English Longitudinal Study of Ageing (N = 3029; 54.8% female). Measures included self-reported ACEs at wave 3 (2006-2007), C-reactive protein (CRP) and depressive symptoms at wave 4 (2008-2009), and cognitive function at waves 3 and 7 (2014-2015). Mediation analyses examined the direct associations between ACEs and cognitive function at wave 7 and the indirect associations via depressive symptoms and CRP at wave 4. In a first set of analyses, models were adjusted for sociodemographic factors and baseline cognitive function. In a second set of analyses, models were additionally adjusted for BMI and health behaviours (n = 1915).

RESULTS

Cumulative ACEs exposure positively predicted depressive symptoms (b = 0.184, s.e. = 0.034, p < .001), which in turn predicted poorer cognitive function at wave 7 (b =  - 0.035, s.e. = 0.008, p < .001). ACEs also positively predicted systemic inflammation as measured by CRP (b = 0.031, s.e. = 0.01, p = 0.0016). However, CRP did not mediate the association between ACEs and later cognitive function (b =  - 0.0002, 95% CI: - 0.002, 0.002).

CONCLUSION

These findings suggest that ACEs may be related to cognitive decline partly via depressive symptoms and corroborate prior research linking ACEs with systemic inflammation in adulthood.

Limitations in activities of daily living increase the risk of stroke in older Chinese adults: a population-based longitudinal study

It remains unclear whether limitations in activities of daily living (ADL) increase the risk of stroke in older Chinese adults. This longitudinal study used data from the Chinese Longitudinal Healthy Longevity Survey to investigate the effects of limitations in ADL on the incidence of stroke in older adults. Between 2002 and 2011, 46,728 participants from 22 provinces in China were included in this study. Of participants, 11,241 developed limitations in ADL at baseline. A 3-year follow-up was performed to determine the incidence of stroke. During the 3-year follow-up, 929 participants (8.26%) and 2434 participants (6.86%) experienced stroke in the ADL limitations group and non-ADL limitations group, respectively. Logistic regression was used to analyze the effect of ADL limitations on the risk of stroke. The results showed that after adjusting for the confounding factors gender, age, weight, hypertension, diabetes, heart disease, natural teeth, hearing impairment, visual impairment, smoking, alcohol abuse, exercise, ethnicity, literacy, residential area, and poverty, the ADL limitations group had a 77% higher risk of developing stroke than the non-ADL limitations group. After propensity score matching, the ADL limitations group still had a 33% higher risk of developing stroke than the non-ADL limitations group (OR = 1.326, 95% CI: 1.174–1.497). These findings suggest that limitations in ADL are a stroke risk factor.

Impacts of stroke and cognitive impairment on activities of daily living in the Taiwan longitudinal study on aging

Stroke and cognitive impairment are common in older population. They often occur together and their combined effects significantly increase disability in both basic (BADLs) and instrumental (IADLs) activities of daily living. We investigated the individual and combined impacts of stroke and cognitive impairment on BADLs and IADLs. A total of 3331 community-dwelling older adults were enrolled from the Taiwan longitudinal study on aging in 2011. Both BADLs and IADLs were analyzed. Combination of stroke and cognitive impairment increased severity of ADL disabilities, but similar prevalence, similar numbers of summed BADL and IADL tasks with disability, and similar levels of difficulty for each BADL and IADL task were found between the stroke group and cognitive impairment group. The former had more difficult in dressing while the latter had more difficult in using the telephone, transport, and managing finances. A hierarchy of ADLs was also observed in all groups. ADL skill training supplemented with cognitive and physical interventions should focus on secondary prevention of dementia and improve motor functional capacity to reduce loss of ADLs.

Health-Related Quality of Life in Stroke Survivors in Relation to the Type of Inpatient Rehabilitation in Serbia: A Prospective Cohort Study

Background and objectives: Health-related quality of life after stroke is an important public health issue. The objective of the study was to investigate the relationship between the perceived health-related quality of life in stroke survivors in relation to the type of inpatient rehabilitation. Materials and Methods: Using a random selection method out of a total of 688 patients, every fourth survivor who had a stroke in the period from 1 January 2017 to 31 December 2019 was selected from the admission protocol of the Clinic for Rehabilitation and Physical Medicine of the Clinical Centre Niš, Serbia. A total of 160 first-ever stroke survivors were included (80 underwent additional inpatient rehabilitation and 80 underwent only inpatient rehabilitation in a tertiary health institution) in a twelve-month prospective study. The EuroQuol-5 Dimension (EQ5D) questionnaire and Stroke Impact Scale were used for the assessment. Multivariate linear regression analysis was done. Results: Multivariate linear regression analysis showed that additional inpatient rehabilitation from six up to eight weeks after discharge was significantly associated with better self-reported health condition by 3.9 times (from 1.9 to 8.2), significantly decreased the ranks of EQ5D by 1.78 times (from 1.02 to 3.11), and showed a higher health-related quality of life. We determined a significant increase of strength, emotions, mobility, and participation role in survivors who underwent additional inpatient rehabilitation compared with those who did not. Conclusions: There was a significant difference in health-related quality of life perceived by stroke survivors who underwent additional hospital rehabilitation in relation to those who underwent only inpatient rehabilitation.