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Ashburner JM, Chang Y, Porneala B, Singh SD, Yechoor N, Rosand JM, Singer DE, Anderson CD, Atlas SJ. Predicting post-stroke cognitive impairment using electronic health record data. Int J Stroke 2024:17474930241246156. [PMID: 38546170 DOI: 10.1177/17474930241246156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Secondary prevention interventions to reduce post-stroke cognitive impairment (PSCI) can be aided by the early identification of high-risk individuals who would benefit from risk factor modification. AIMS To develop and evaluate a predictive model to identify patients at increased risk of PSCI over 5 years using data easily accessible from electronic health records. METHODS Cohort study that included primary care patients from two academic medical centers. Patients were aged 45 years or older, without prior stroke or prevalent cognitive impairment, with primary care visits and an incident ischemic stroke between 2003 and 2016 (development/internal validation cohort) or 2010 and 2022 (external validation cohort). Predictors of PSCI were ascertained from the electronic health record. The outcome was incident dementia/cognitive impairment within 5 years and beginning 3 months following stroke, ascertained using International Classification of Diseases, Ninth/Tenth Revision (ICD-9/10) codes. For model variable selection, we considered potential predictors of PSCI and constructed 400 bootstrap samples with two-thirds of the model derivation sample. We ran 10-fold cross-validated Cox proportional hazards models using a least absolute shrinkage and selection operator (LASSO) penalty. Variables selected in >25% of samples were included. RESULTS The analysis included 332 incident diagnoses of PSCI in the development cohort (n = 3741), and 161 and 128 incident diagnoses in the internal (n = 1925) and external (n = 2237) validation cohorts, respectively. The C-statistic for predicting PSCI was 0.731 (95% confidence interval (CI): 0.694-0.768) in the internal validation cohort, and 0.724 (95% CI: 0.681-0.766) in the external validation cohort. A risk score based on the beta coefficients of predictors from the development cohort stratified patients into low (0-7 points), intermediate (8-11 points), and high (12-23 points) risk groups. The hazard ratios (HRs) for incident PSCI were significantly different by risk categories in internal (high, HR: 6.2, 95% CI: 4.1-9.3; Intermediate, HR: 2.7, 95% CI: 1.8-4.1) and external (high, HR: 6.1, 95% CI: 3.9-9.6; Intermediate, HR: 2.8, 95% CI: 1.9-4.3) validation cohorts. CONCLUSION Five-year risk of PSCI can be accurately predicted using routinely collected data. Model output can be used to risk stratify and identify individuals at increased risk for PSCI for preventive efforts. DATA ACCESS STATEMENT Mass General Brigham data contain protected health information and cannot be shared publicly. The data processing scripts used to perform analyses will be made available to interested researchers upon reasonable request to the corresponding author.
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Affiliation(s)
- Jeffrey M Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Bianca Porneala
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sanjula D Singh
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Nirupama Yechoor
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan M Rosand
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel E Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Christopher D Anderson
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Milosevich ET, Moore MJ, Pendlebury ST, Demeyere N. Domain-specific cognitive impairment 6 months after stroke: The value of early cognitive screening. Int J Stroke 2024; 19:331-341. [PMID: 37749759 PMCID: PMC10903146 DOI: 10.1177/17474930231205787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/12/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Cognitive screening following stroke is widely recommended, yet few studies have considered the prognostic value of acute domain-specific function for longer-term cognitive outcome. Identifying which post-stroke cognitive impairments more commonly occur, recover, and persist, and which impairments hold prognostic value, could inform care planning, and resource allocation. AIMS This study aimed to determine the prevalence of domain-specific impairment acutely and at 6 months, assess the proportion of change in cognitive performance, and examine the prognostic value of acute domain-specific cognitive screening. METHODS A prospective stroke cohort completed the Oxford Cognitive Screen acutely (⩽2 weeks) and 6 months post-stroke. We determined the prevalence of acute and 6-month domain-specific impairment and proportion of change in performance from acute to 6 months. Hierarchical multivariable regression was used to predict global and domain-specific cognitive impairment at 6 months adjusted for demographic/vascular factors, stroke severity, and lesion volume. RESULTS A total of 430 stroke survivors (mean/SD age 73.9/12.5 years, 46.5% female, median/interquartile range (IQR) National Institute of Health Stroke Scale (NIHSS) 5/2-10) completed 6-month follow-up. Acutely, domain-specific impairments were highly prevalent ranging from 26.7% (n = 112) in praxis to 46.8% (n = 183) in attention. At 6 months, the proportion of domain-specific recovery was highest in praxis (n = 73, 71%) and lowest in language (n = 89, 46%) and memory (n = 82, 48%). Severity of 6-month cognitive impairment was best predicted by the addition of acute cognitive impairment (adj R2 = 0.298, p < 0.0001) over demographic and clinical factors alone (adj R2 = 0.105, p < 0.0001). Acute cognitive function was the strongest predictor of 6-month cognitive performance (p < 0.0001). Acute domain-specific impairments in memory (p < 0.0001), language (p < 0.0001), and praxis (p < 0.0001) significantly predicted overall severity of cognitive impairment at 6 months. CONCLUSION Post-stroke cognitive impairment is highly prevalent across all domains acutely, while impairments in language, memory, and attention predominate at 6 months. Early domain-specific screening can provide valuable prognostic information for longer-term cognitive outcomes.
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Affiliation(s)
- Elise T Milosevich
- Department of Experimental Psychology, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Margaret J Moore
- Department of Experimental Psychology, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
- Queensland Brain Institute, University of Queensland, St Lucia, QLD, Australia
| | - Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre and Departments of General Medicine and Geratology, John Radcliffe Hospital, Oxford, UK
| | - Nele Demeyere
- Department of Experimental Psychology, Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
- Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Ashburner JM, Chang Y, Porneala B, Singh SD, Yechoor N, Rosand JM, Singer DE, Anderson CD, Atlas SJ. Predicting post-stroke cognitive impairment using electronic health record data. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.02.24302240. [PMID: 38352557 PMCID: PMC10863024 DOI: 10.1101/2024.02.02.24302240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Importance Secondary prevention interventions to reduce post-stroke cognitive impairment (PSCI) can be aided by the early identification of high-risk individuals who would benefit from risk factor modification. Objective To develop and evaluate a predictive model to identify patients at increased risk of PSCI over 5 years using data easily accessible from electronic health records. Design Cohort study with patients enrolled between 2003-2016 with follow-up through 2022. Setting Primary care practices affiliated with two academic medical centers. Participants Individuals 45 years or older, without prior stroke or prevalent cognitive impairment, with primary care visits and an incident ischemic stroke between 2003-2016 (development/internal validation cohort) or 2010-2022 (external validation cohort). Exposures Predictors of PSCI were ascertained from the electronic health record. Main Outcome The outcome was incident dementia/cognitive impairment within 5 years and beginning 3 months following stroke, ascertained using ICD-9/10 codes. For model variable selection, we considered potential predictors of PSCI and constructed 400 bootstrap samples with two-thirds of the model derivation sample. We ran 10-fold cross-validated Cox proportional hazards models using a least absolute shrinkage and selection operator (LASSO) penalty. Variables selected in >25% of samples were included. Results The analysis included 332 incident diagnoses of PSCI in the development cohort (n=3,741), and 161 and 128 incident diagnoses in the internal (n=1,925) and external (n=2,237) validation cohorts. The c-statistic for predicting PSCI was 0.731 (95% CI: 0.694-0.768) in the internal validation cohort, and 0.724 (95% CI: 0.681-0.766) in the external validation cohort. A risk score based on the beta coefficients of predictors from the development cohort stratified patients into low (0-7 points), intermediate (8-11 points), and high (12-35 points) risk groups. The hazard ratios for incident PSCI were significantly different by risk categories in internal (High, HR: 6.2, 95% CI 4.1-9.3; Intermediate, HR 2.7, 95% CI: 1.8-4.1) and external (High, HR: 6.1, 95% CI: 3.9-9.6; Intermediate, HR 2.8, 95% CI: 1.9-4.3) validation cohorts. Conclusions and Relevance Five-year risk of PSCI can be accurately predicted using routinely collected data. Model output can be used to risk stratify and identify individuals at increased risk for PSCI for preventive efforts.
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Affiliation(s)
- Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Bianca Porneala
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sanjula D. Singh
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nirupama Yechoor
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan M. Rosand
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher D. Anderson
- McCance Center for Brain Health and Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Martinez HB, Cisek K, García-Rudolph A, Kelleher JD, Hines A. Understanding and Predicting Cognitive Improvement of Young Adults in Ischemic Stroke Rehabilitation Therapy. Front Neurol 2022; 13:886477. [PMID: 35911882 PMCID: PMC9325998 DOI: 10.3389/fneur.2022.886477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/13/2022] [Indexed: 11/18/2022] Open
Abstract
Accurate early predictions of a patient's likely cognitive improvement as a result of a stroke rehabilitation programme can assist clinicians in assembling more effective therapeutic programs. In addition, sufficient levels of explainability, which can justify these predictions, are a crucial requirement, as reported by clinicians. This article presents a machine learning (ML) prediction model targeting cognitive improvement after therapy for stroke surviving patients. The prediction model relies on electronic health records from 201 ischemic stroke surviving patients containing demographic information, cognitive assessments at admission from 24 different standardized neuropsychology tests (e.g., TMT, WAIS-III, Stroop, RAVLT, etc.), and therapy information collected during rehabilitation (72,002 entries collected between March 2007 and September 2019). The study population covered young-adult patients with a mean age of 49.51 years and only 4.47% above 65 years of age at the stroke event (no age filter applied). Twenty different classification algorithms (from Python's Scikit-learn library) are trained and evaluated, varying their hyper-parameters and the number of features received as input. Best-performing models reported Recall scores around 0.7 and F1 scores of 0.6, showing the model's ability to identify patients with poor cognitive improvement. The study includes a detailed feature importance report that helps interpret the model's inner decision workings and exposes the most influential factors in the cognitive improvement prediction. The study showed that certain therapy variables (e.g., the proportion of memory and orientation executed tasks) had an important influence on the final prediction of the cognitive improvement of patients at individual and population levels. This type of evidence can serve clinicians in adjusting the therapeutic settings (e.g., type and load of therapy activities) and selecting the one that maximizes cognitive improvement.
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Affiliation(s)
- Helard Becerra Martinez
- School of Computer Science, University of College Dublin, Dublin, Ireland
- *Correspondence: Helard Becerra Martinez
| | - Katryna Cisek
- Information, Communication and Entertainment Research Institute, Technological University Dublin, Dublin, Ireland
| | - Alejandro García-Rudolph
- Institut Guttmann Hospital de Neurorehabilitacio, Badalona, Spain
- Universitat Autónoma de Barcelona, Cerdanyola del Vallés, Spain
- Fundació Institut d'Investigació en Ciéncies de la Salut Germans Trias i Pujol, Badalona, Spain
| | - John D. Kelleher
- Information, Communication and Entertainment Research Institute, Technological University Dublin, Dublin, Ireland
| | - Andrew Hines
- School of Computer Science, University of College Dublin, Dublin, Ireland
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Hbid Y, Fahey M, Wolfe CDA, Obaid M, Douiri A. Risk Prediction of Cognitive Decline after Stroke. J Stroke Cerebrovasc Dis 2021; 30:105849. [PMID: 34000605 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/12/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Cognitive decline is one of the major outcomes after stroke. We have developed and evaluated a risk predictive tool of post-stroke cognitive decline and assessed its clinical utility. METHODS In this population-based cohort, 4,783 patients with first-ever stroke from the South London Stroke Register (1995-2010) were included in developing the model. Cognitive impairment was measured using the Mini Mental State Examination (cut off 24/30) and the Abbreviated Mental Test (cut off 8/10) at 3-months and yearly thereafter. A penalised mixed-effects linear model was developed and temporal-validated in a new cohort consisted of 1,718 stroke register participants recruited from (2011-2018). Prediction errors on discrimination and calibration were assessed. The clinical utility of the model was evaluated using prognostic accuracy measurements and decision curve analysis. RESULTS The overall predictive model showed good accuracy, with root mean squared error of 0.12 and R2 of 73%. Good prognostic accuracy for predicting severe cognitive decline was observed AUC: (88%, 95% CI [85-90]), (89.6%, 95% CI [86-92]), (87%, 95% CI [85-91]) at 3 months, one and 5 years respectively. Average predicted recovery patterns were analysed by age, stroke subtype, Glasgow-coma scale, and left-stroke and showed variability. DECISION: curve analysis showed an increased clinical benefit, particularly at threshold probabilities of above 15% for predictive risk of cognitive impairment. CONCLUSIONS The derived prognostic model seems to accurately screen the risk of post-stroke cognitive decline. Such prediction could support the development of more tailored management evaluations and identify groups for further study and future trials.
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Affiliation(s)
- Youssef Hbid
- LMDP, Cadi Ayyad University, Marrakech, Morocco; UMMISCO, IRD, France; Sorbonne University, Laboratoire Jacques-Louis Lions, Paris, France.
| | - Marion Fahey
- King's College London, School of Population Health and Environmental Sciences, London, United Kingdom.
| | - Charles D A Wolfe
- King's College London, School of Population Health and Environmental Sciences, London, United Kingdom; National Institute for Health Research Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Majed Obaid
- King's College London, School of Population Health and Environmental Sciences, London, United Kingdom
| | - Abdel Douiri
- King's College London, School of Population Health and Environmental Sciences, London, United Kingdom; National Institute for Health Research Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
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Donnelly NA, Sexton E, Merriman NA, Bennett KE, Williams DJ, Horgan F, Gillespie P, Hickey A, Wren MA. The Prevalence of Cognitive Impairment on Admission to Nursing Home among Residents with and without Stroke: A Cross-Sectional Survey of Nursing Homes in Ireland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7203. [PMID: 33019730 PMCID: PMC7579486 DOI: 10.3390/ijerph17197203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 12/27/2022]
Abstract
Post-stroke cognitive impairment (PSCI) is a common consequence of stroke. Epidemiological evidence indicates that, with an ageing population, stroke and PSCI are likely to increase in the coming decades. This may have considerable implications for the demand for nursing home placement. As prevalence estimates of both cognitive impairment and dementia on admission to nursing home among residents with and without stroke have not yet been compared, they were estimated and compared in this study. We performed a cross-sectional survey to establish the admission characteristics of 643 residents in 13 randomly selected nursing homes in Ireland. The survey collected data on resident's stroke and cognitive status at the time of nursing home admission. The survey found, among nursing home residents that experienced stroke prior to admission, prevalence estimates for cognitive impairment (83.8%; 95% CI = 76.9-90.6%) and dementia (66.7%; 95% CI = 57.9-75.4%) were significantly higher compared to residents that had not experienced stroke prior to admission (cognitive impairment: 56.6%; 95% CI = 52.4-60.8%; X2 (1) = 28.64; p < 0.001; dementia: 49.8%; 95% CI = 45.6-54.1%; X2 (1) = 10.47; p < 0.01). Since the prevalence of PSCI is likely to increase in the coming decades, the findings highlight an urgent need for health service planning for this increased demand for nursing home care to meet the care needs of these stroke survivors.
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Affiliation(s)
- Nora-Ann Donnelly
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, D02 P796, Ireland; (E.S.); (N.A.M.); (K.E.B.); (A.H.)
- Social Research Division, Economic and Social Research Institute, D02 K138, Ireland;
| | - Eithne Sexton
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, D02 P796, Ireland; (E.S.); (N.A.M.); (K.E.B.); (A.H.)
| | - Niamh A. Merriman
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, D02 P796, Ireland; (E.S.); (N.A.M.); (K.E.B.); (A.H.)
| | - Kathleen E. Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, D02 P796, Ireland; (E.S.); (N.A.M.); (K.E.B.); (A.H.)
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, D02 P796, Ireland;
| | - Frances Horgan
- Department Physiotherapy, Royal College of Surgeons in Ireland, D02 P796, Ireland;
| | - Paddy Gillespie
- Health Economics & Policy Analysis Centre (HEPAC), Department of Economics, NUI Galway, H91 TK33, Ireland;
| | - Anne Hickey
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, D02 P796, Ireland; (E.S.); (N.A.M.); (K.E.B.); (A.H.)
| | - Maev-Ann Wren
- Social Research Division, Economic and Social Research Institute, D02 K138, Ireland;
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Myint PK, Macleod MJ, Clark AB, Smith TO, Bettencourt-Silva JH, Metcalf AK, Potter JF. Anaemia and incidence of post stroke dementia. Clin Neurol Neurosurg 2020; 191:105688. [DOI: 10.1016/j.clineuro.2020.105688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 11/25/2022]
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8
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Tang EY, Amiesimaka O, Harrison SL, Green E, Price C, Robinson L, Siervo M, Stephan BC. Longitudinal Effect of Stroke on Cognition: A Systematic Review. J Am Heart Assoc 2018; 7:e006443. [PMID: 29335318 PMCID: PMC5850140 DOI: 10.1161/jaha.117.006443] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 10/30/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Stroke is associated with an increased risk of dementia; however, the impact of stroke on cognition has been found to be variable, such that stroke survivors can show decline, remain stable, or revert to baseline cognitive functioning. Knowing the natural history of cognitive impairment after stroke is important for intervention. The aim of this systematic review is to investigate the longitudinal course of cognitive function in stroke survivors. METHODS AND RESULTS Three electronic databases (Medline, Embase, PsycINFO) were searched using OvidSP from inception to July 15, 2016. Longitudinal studies with ≥2 time points of cognitive assessment after stroke were included. In total, 5952 articles were retrieved and 14 were included. There was a trend toward significant deterioration in cognitive test scores in stroke survivors (8 studies). Cognitive stability (3 studies) and improvement (3 studies) were also demonstrated, although follow-up time tended to be shorter in these studies. Variables associated with impairment included age, ethnicity, premorbid cognitive performance, depression, stroke location, and history of previous stroke. Associations with APOE*E4 (apolipoprotein E with the E4 allele) allele status and sex were mixed. CONCLUSIONS Stroke is associated with an increased risk of cognitive decline, but cognitive decline is not a consequence. Factors associated with decline, such as sociodemographic status, health-related comorbidity, stroke history, and clinical features could be used in models to predict future risk of dementia after stroke. A risk model approach could identify patients at greatest risk for timely intervention to reduce the frequency or delay the onset of poststroke cognitive impairment and dementia.
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Affiliation(s)
- Eugene Yh Tang
- Institute of Health and Society, Newcastle University Institute of Ageing Newcastle University, Newcastle upon Tyne, UK
- Newcastle University Institute of Ageing, Newcastle University, Newcastle upon Tyne, UK
| | - Obreniokibo Amiesimaka
- Institute of Health and Society, Newcastle University Institute of Ageing Newcastle University, Newcastle upon Tyne, UK
| | - Stephanie L Harrison
- Department of Rehabilitation, Aged and Extended Care, Repatriation General Hospital, Flinders University, Daw Park, South Australia
| | - Emma Green
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Christopher Price
- Institute of Neuroscience, Stroke Research Group, Newcastle University, Newcastle upon Tyne, UK
| | - Louise Robinson
- Institute of Health and Society, Newcastle University Institute of Ageing Newcastle University, Newcastle upon Tyne, UK
- Newcastle University Institute of Ageing, Newcastle University, Newcastle upon Tyne, UK
| | - Mario Siervo
- Institute of Cellular Medicine, Human Nutrition Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Blossom Cm Stephan
- Institute of Health and Society, Newcastle University Institute of Ageing Newcastle University, Newcastle upon Tyne, UK
- Newcastle University Institute of Ageing, Newcastle University, Newcastle upon Tyne, UK
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