Risk Factors for Stroke among Young-Old and Old-Old Community-Dwelling Adults in Japan: The Ohasama Study

Incidence, case fatality, and functional outcome of intracerebral haemorrhage, according to age, sex, and country income level: a systematic review and meta-analysis

Background

Intracerebral haemorrhage (ICH) accounts for approximately 28% of all strokes worldwide. ICH has a high case fatality, and only few survivors recover to independent living. Over the past decades, demographic changes, and changes in prevalence and management of risk factors may have influenced incidence. Widespread implementation of stroke units and improved care in general may have affected case fatality and outcome. We aimed to update the evidence on incidence, case fatality, and functional outcome of ICH, according to age, sex, and country income level.

Methods

We systematically searched PubMed and Embase from 2008 to April 2023 for prospective population-based studies on incidence, case fatality, or functional outcome of first-ever ICH. We excluded studies in which less than 80% of cases was confirmed with imaging or autopsy. Quality of the studies was assessed based on the used case finding methods. We used inverse variance-based random-effects meta-analyses to pool the crude incidence, case fatality at 1 month, and the percentage of patients with good functional outcome after 3, 6, or 12 months, as defined by the authors of the individual studies. Time trends were assessed using weighted linear meta-regression. Funnel plots were constructed to study publication bias. The review was registered on PROSPERO (CRD42023413314).

Findings

We identified 70 eligible studies, describing 19,470 ICH patients from 26 different countries. Of these, 62 studies reported on crude incidence, 41 on case fatality, and 10 on functional outcome. Overall crude incidence was 29.2 per 100,000 person-years (95% CI 23.3-36.4; I2 = 100%). Incidence was lower in women than in men and increased with age. Incidence was highest in lower-middle income countries, followed by high and upper-middle income countries. Case fatality at 1 month was 35.5% (95% CI 32.3-38.9; I2 = 90%). The percentage of patients with good functional outcome (mRS 0-2 in nine studies, mRS 0-3 in one) after 3-12 months was 31.2% (95% CI 24.7-38.6; I2 = 76%). We found no time trends in incidence, case fatality, or functional outcome.

Interpretation

Our results demonstrate the persistently high burden and devastating consequences of ICH, stressing the need for better preventive strategies and acute treatments.

Funding

None.

Sex differences in the association of physical functions with hospitalization and mortality events among community-dwelling older adults with disabilities

This study aimed to investigate the role of sex in the association between physical function and the occurrence of hospitalization and mortality among community-dwelling older adults with impairments in activities of daily living (ADL). Participants included community-dwelling older adults aged ≥65 years with ADL disabilities. Physical functions (hand grip strength [HGS], knee extension muscle strength, and comfortable walking speed [CWS]) were measured at baseline and analyzed for association with hospitalization and mortality by sex using Cox regression analysis, adjusted for potential confounders. In this Cox regression analysis, HGS was significantly associated with the occurrence of hospitalization and mortality in women, whereas CWS was significantly associated with the occurrence of hospitalization and HGS with mortality in men. These findings reveal that the predictive ability of adverse events in community-dwelling older adults with disabilities differs by sex, requiring outcome- and sex-specific prognostication.

Decrease in maximum paced walking speed predicts hospitalization in community-dwelling older people with disabilities

PURPOSE

Walking speed is a useful predictor of hospitalization for community-dwelling older people. However, whether it is an effective predictor for disabled older people has not been clarified. This study aimed to investigate the association of walking speed with unexpected hospitalizations in community-dwelling, disabled, older people.

METHODS

The participants were ambulatory, community-dwelling older adults aged ≥ 65 years with disabilities. Comfortable and maximum walking speeds were measured at two timepoints, baseline and 3 months later. Furthermore, the change over time at 3 months in walking speed was also calculated. If the change in walking speed decreased more than 0.1 m/s, it was defined as walking speed decreased. The primary outcome was unexpected hospitalization during 4-year follow-up. The associations among baseline walking speed, walking speed decline, and hospitalization were analyzed using Cox regression analysis adjusted for potential confounding factors.

RESULTS

A total of 93 people (age 81.8 ± 7.0 years, 64 female) were included, and unexpected hospitalization occurred in 47 people during 4-year follow-up. On Cox regression analysis adjusted for potential confounding factors, only the maximum walking speed decrease was significantly associated with hospitalization (hazard ratio = 2.53, 95% confidence interval: 1.23-5.21), not baseline walking speed and comfortable walking speed decrease.

CONCLUSION

As for the assessment of walking speed for the prediction of unexpected hospitalization in disabled people, measurement at a single timepoint is not useful, whereas change over time is. Monitoring of change over time in maximum walking speed appears to be one of the indicators for the health management of disabled people.

Evidence relating cigarettes, cigars and pipes to cardiovascular disease and stroke: Meta-analysis of recent data from three regions

BACKGROUND

More recent data are required relating to disease risk for use of various smoked products and of other products containing nicotine. Earlier we published meta-analyses of recent results for chronic obstructive pulmonary disease and lung cancer on the relative risk (RR) of current compared to never product use for cigarettes, cigars and pipes based on evidence from North America, Europe and Japan. We now report corresponding up-to-date evidence for acute myocardial infarction (AMI), ischaemic heart disease (IHD) and stroke.

AIM

To estimate, using recent data, AMI, IHD and stroke RRs by region for current smoking of cigarettes, cigars and pipes.

METHODS

Publications in English from 2015 to 2020 were considered that, based on epidemiological studies in the three regions, estimated the current smoking RR of AMI, IHD or stroke for one or more of the three products. The studies should involve at least 100 cases of stroke or cardiovascular disease (CVD), not be restricted to populations with specific medical conditions, and should be of cohort or nested case-control study design or randomized controlled trials. A literature search was conducted on MEDLINE, examining titles and abstracts initially, and then full texts. Additional papers were sought from reference lists of selected papers, reviews and meta-analyses. For each study identified, we entered the most recent available data on current smoking of each product, as well as the characteristics of the study and the RR estimates. Combined RR estimates were derived using random-effects meta-analysis for stroke and, in the case of CVD, separately for IHD and AMI. For cigarette smoking, where far more data were available, heterogeneity was studied by a wide range of factors. For cigar and pipe smoking, a more limited heterogeneity analysis was carried out. A more limited assessment of variation in risk by daily number of cigarettes smoked was also conducted. Results were compared with those from previous meta-analyses published since 2000.

RESULTS

Current cigarette smoking: Ten studies gave a random-effects RR for AMI of 2.72 [95% confidence interval (CI): 2.40-3.08], derived from 13 estimates between 1.47 and 4.72. Twenty-three studies gave an IHD RR of 2.01 (95%CI: 1.84-2.21), using 28 estimates between 0.81 and 4.30. Thirty-one studies gave a stroke RR of 1.62 (95%CI: 1.48-1.77), using 37 estimates from 0.66 to 2.91. Though heterogeneous, only two of the overall 78 RRs were below 1.0, 71 significantly (P < 0.05) exceeding 1.0. The heterogeneity was only partly explicable by the factors studied. Estimates were generally higher for females and for later-starting studies. They were significantly higher for North America than Europe for AMI, but not the other diseases. For stroke, the only endpoint with multiple Japanese studies, RRs were lower there than for Western studies. Adjustment for multiple factors tended to increase RRs. Our RR estimates and the variations by sex and region are consistent with earlier meta-analyses. RRs generally increased with amount smoked. Current cigar and pipe smoking: No AMI data were available. One North American study reported reduced IHD risk for non-exclusive cigar or pipe smoking, but considered few cases. Two North American studies found no increased stroke risk with exclusive cigar smoking, one reporting reduced risk for exclusive pipe smoking (RR 0.24, 95%CI: 0.06-0.91). The cigar results agree with an earlier review showing no clear risk increase for IHD or stroke.

CONCLUSION

Current cigarette smoking increases risk of AMI, IHD and stroke, RRs being 2.72, 2.01 and 1.62. The stroke risk is lower in Japan, no increase was seen for cigars/pipes.

From Admission to Discharge: Predicting National Institutes of Health Stroke Scale Progression in Stroke Patients Using Biomarkers and Explainable Machine Learning

As a result of social progress and improved living conditions, which have contributed to a prolonged life expectancy, the prevalence of strokes has increased and has become a significant phenomenon. Despite the available stroke treatment options, patients frequently suffer from significant disability after a stroke. Initial stroke severity is a significant predictor of functional dependence and mortality following an acute stroke. The current study aims to collect and analyze data from the hyperacute and acute phases of stroke, as well as from the medical history of the patients, in order to develop an explainable machine learning model for predicting stroke-related neurological deficits at discharge, as measured by the National Institutes of Health Stroke Scale (NIHSS). More specifically, we approached the data as a binary task problem: improvement of NIHSS progression vs. worsening of NIHSS progression at discharge, using baseline data within the first 72 h. For feature selection, a genetic algorithm was applied. Using various classifiers, we found that the best scores were achieved from the Random Forest (RF) classifier at the 15 most informative biomarkers and parameters for the binary task of the prediction of NIHSS score progression. RF achieved 91.13% accuracy, 91.13% recall, 90.89% precision, 91.00% f1-score, 8.87% FNrate and 4.59% FPrate. Those biomarkers are: age, gender, NIHSS upon admission, intubation, history of hypertension and smoking, the initial diagnosis of hypertension, diabetes, dyslipidemia and atrial fibrillation, high-density lipoprotein (HDL) levels, stroke localization, systolic blood pressure levels, as well as erythrocyte sedimentation rate (ESR) levels upon admission and the onset of respiratory infection. The SHapley Additive exPlanations (SHAP) model interpreted the impact of the selected features on the model output. Our findings suggest that the aforementioned variables may play a significant role in determining stroke patients' NIHSS progression from the time of admission until their discharge.

Combined Effect of Dynapenia and Abdominal Obesity on the Prevalence of Peripheral Artery Disease in Older Adults Over 75 Years Old in China

The objective is to examine the separate and joint effects of dynapenia and abdominal obesity on the prevalence of peripheral artery disease (PAD) in older adults of different ages (60-74 and over 75 years old). This study comprised 1293 community-dwelling Chinese participants recruited from Shanghai, China, who were aged at least 60 years (753 women; mean age: 72.0 ± 5.9 years). Dynapenia was defined as low-grip strength (<28.0 kg for males and <18.0 kg for females) but normal skeletal muscle index (≥7.0 kg/m² for males and ≥5.7 kg/m² for females). Abdominal obesity was determined according to waist circumference (≥90 cm for males and ≥85 cm for females), and PAD was diagnosed by an ankle-brachial index  ≤ 0.9. Binary logistic regression models were performed to determine associations between dynapenia, abdominal obesity, and the combination of dynapenia and abdominal obesity and PAD. According to dynapenia and abdominal obesity status stratified by age (60-74 or over 75), the patients were divided into 4 groups: normal, dynapenia alone, abdominal obesity alone, and co-occurring groups. A logistic regression showed that the co-occurring groups (odds ratio = 4.63, 95% confidence interval = 1.41-15.21) had a higher prevalence of PAD than the normal group after adjusting for the covariates in older adults over 75 years of age. The combination of dynapenia and abdominal obesity increase the prevalence of PAD in older adults over 75 years. The present findings have important implications for the early identification of older adults with PAD and appropriate interventions should be implemented.

Dynamic physical examination indicators of cardiovascular health: A single-center study in Shanghai, China

Dynamic physical examination data can provide both cross-sectional and time-series characteristics of cardiovascular health. However, most physical examination databases containing health and disease information have not been fully utilized in China. Hence, this study aimed to analyze dynamic physical examination indicators for cardiovascular health to provide evidence for precise prevention and control of cardiovascular diseases in the primary prevention domain among healthy population with different demographic characteristics in Shanghai. Three-year continuous data were collected from the physical examination center of a hospital in Shanghai from 2018 to 2020, which included a total of 14,044 participants with an average age of 46.51±15.57 years. The cardiovascular status of overall healthy individuals may have a decreasing trend, which is manifested as a significant year-on-year decrease in high-density lipoprotein cholesterol; a significant year-on-year increase in total cholesterol, low-density lipoprotein cholesterol, and blood glucose levels; and a possible increasing trend of diastolic blood pressure, body mass index, and triglycerides. Healthy population with different sex and age groups have various sensitives to cardiovascular physical examination indicators. To conduct more accurate cardiovascular health management and health promotion for key populations in primary prevention, focusing on the dynamic trends of blood pressure, blood lipids, blood glucose, and body mass index in men and changes in total cholesterol in women over time is especially important. The age group of 50–69 years is key for better prevention and control of cardiovascular health.

Stroke risk factors, subtypes and outcome in elderly Thai patients

Background

Nowadays, the number of elderly has steadily increased annually.

Elderly patients with ischemic stroke often have worse outcomes than younger patients. However, there has not been a study of ischemic stroke in the elderly in Thailand. A better knowledge of the risk factors, subtypes, and outcomes of strokes in the elderly may have significant practical implications for the aged society in the future. The objective of the study was to assess the risk factor, stroke subtypes, and outcome of stroke in the elderly compared to the younger patients.

Method

All patients presented with acute ischemic stroke and transient ischemic attack (TIA) aged over 45 years who were admitted in the Stroke unit between November 1st, 2016 and December 31st, 2017 were retrospectively studied.

Result

Five hundred forty-two patients were included. The average age was 68.78 ± 12.03, 44.8% of them were male. 186 (34.3%) patients were 75 or older. Cardioembolism was found to be the most common cause of ischemic stroke in 156 patients (28.8%) and was associated with poor outcome. Patients who were 75 or older had significantly worse outcomes in all categories including NIHSS at discharge, modified Rankin scale, length of stay and the number of deaths compared to the younger group. Atrial fibrillation was the risk factors associated with older age with OR 3.861 (p value< 0.001). Aged 75 years or older, atrial fibrillation, more NIHSS score on admission and history of the previous stroke were the risk factors associated with a patient’s death.

Conclusion

The elderly who are 75 years or older accounts for more than one-third of ischemic stroke in our study. Stroke in the elderly correlates with higher mortality and poorer outcome. Cardioembolism related to atrial fibrillation is the major cause of stroke in this population.

Effects of different rehabilitation provision systems on functional recovery in patients with subacute stroke

INTRODUCTION

The extent of rehabilitation is a key element in promoting functional recovery in patients with stroke. However, the type of rehabilitation therapy that should be provided to improve functional outcomes remains unclear.

OBJECTIVE

This study aimed to compare the effects of three different rehabilitation provision systems, namely conventional rehabilitation therapy, conventional rehabilitation therapy plus physical therapy (PT) on weekends, and conventional rehabilitation therapy plus PT and occupational therapy (OT) on weekends, on functional recovery in patients with subacute stroke.

DESIGN

Retrospective observational cohort study.

SETTING

Convalescence Rehabilitation Hospital.

PATIENTS

Three hundred and one patients with subacute stroke (mean age, 69.7 ± 12.8 years).

INTERVENTIONS

Patients were classified into three groups according to rehabilitation therapy they received: a conventional group (only weekdays PT and OT; n = 70), an additional PT group (additional PT on weekends; n = 119), and an additional PT + OT group (additional PT and OT on weekends; n = 112).

MAIN OUTCOME MEASURE

Functional Independence Measure (FIM) effectiveness was calculated as (discharge FIM - admission FIM/maximum FIM - admission FIM) × 100. A multivariate general linear model was used to assess the difference in FIM effectiveness among the groups.

RESULTS

The mean FIM effectiveness in the conventional, additional PT, and additional PT + OT groups were 39.3 ± 30.1, 43.4 ± 33.2, and 54.3 ± 29.1, respectively. The multivariate analysis revealed a significant difference in FIM effectiveness among the three groups (P = 0.036), and the η_p ² was 0.02, indicating a small effect. The additional PT + OT group showed significantly greater improvements in FIM effectiveness than the conventional group (mean difference = 8.78, SE = 3.58, 95% confidence interval: 0.17-17.39).

CONCLUSIONS

This study showed that the additional PT + OT group had better functional recovery than did the conventional group. This indicates that increasing the amount of both PT and OT can promote post-stroke functional recovery. This article is protected by copyright. All rights reserved.

Treatment Outcome and Its Determinants among Patients Admitted to Stroke Unit of Jimma University Medical Center, Southwest Ethiopia

Background

Stroke is a public health problem in Ethiopia. Despite the high prevalence of stroke in Ethiopia, there is a paucity of data with regard to drug treatment, treatment outcome, and risk factors of poor treatment outcome of stroke. Hence, this study is aimed at assessing treatment outcome and its determinants among patients admitted to stroke unit of Jimma University Medical Center (JUMC).

Methods

A two-year hospital-based retrospective cross-sectional study was employed to analyze the medical records of patients admitted with stroke to stroke unit of Jimma University Medical Centre from February 1^st, 2016 to March 30^th, 2018. Data was entered by Epidata manager version 4.0.2 and analyzed by SPSS version 24. Multivariable logistic regression analysis with the backward stepwise approach was done to identify independent predictors of poor treatment outcome of stroke. Variables with P value less than 0.05 were considered as statically significant determinants of poor treatment outcome.

Results

Of 220 patients with stroke admitted to the Jimma University, 67.30% were male. Nearly two thirds (63.18%) of them had poor treatment outcomes. Dyslipidimics were administered to 60% of the patients, and the most popular antiplatelet used was aspirin, which was prescribed to 67.3% the patients. Age ≥ 65 adjusted odd ratio ((AOR): 2.56; 95% CI: 1.95-9.86, P = 0.001), presence of comorbidity (AOR: 5.25; 95% CI: 1.08-17.69, P < 0.001), admission with hemorrhagic stroke (AOR: 18.99; 95% CI: 7.05-42.07, P < 0.001), and admission to the hospital after 24 hour of stroke onset (AOR: 4.98; 95% CI: 1.09-21.91, P = 0.03) were independent predictors of poor treatment outcomes.

Conclusion

Substantial numbers of stroke patients had poor treatment outcomes. Elderly patients, patients diagnosed with hemorrhagic stroke, patients with comorbidity, and those with delayed hospital admission were more likely to have poor treatment outcome. Hence, frequent monitoring and care should be given for the aforementioned patients. Awareness creation on the importance of early admission should be delivered particularly for patients who have risk factors of stroke (cardiovascular diseases).

The impact of wheelchair propulsion based physical activity on functional recovery in stroke rehabilitation: a multicenter observational study

PURPOSE

We aimed to evaluate the relationship between the daily wheelchair self-propulsion distance and functional recovery in subacute stroke survivors.

METHODS

Seventy-four patients with stroke were prospectively recruited from four convalescent rehabilitation hospitals. All participants were unable to walk independently and required manual wheelchairs for locomotion on admission. The daily wheelchair self-propulsion distance was measured using a cycle computer that was connected to a touch switch to exclude the assistance-propulsion distance. The outcome measures were represented as the relative gain of the Functional Independence Measure (FIM) effectiveness during hospitalization. Moreover, a better functional recovery was defined as a FIM effectiveness > 50%. Participants were categorized into three groups according to tertiles of the average daily wheelchair self-propulsion distance: lowest tertile (T1, ≤0.59 km/day); middle tertile (T2, 0.60-1.23 km/day); and highest tertile (T3, ≥1.24 km/day).

RESULTS

Multivariate logistic regression analysis adjusted for baseline characteristics showed that the T2 and T3 groups had a significant association with better FIM effectiveness, and their odds ratios (95% confidence interval, p) were 7.26 (1.13-45.85, p = .038), and 10.19 (1.15-91.75, p = .035), respectively.

CONCLUSIONS

The daily wheelchair self-propulsion distance was significantly associated with functional recovery in subacute stroke survivors.IMPLICATIONS FOR REHABILITATIONNon-ambulatory stroke survivors can obtain extra independent physical activity by using wheelchair self-propulsion, when they do not have someone to assist them with walking.This multicenter observational study revealed that the self-propulsion distance of a manual-wheelchair was significantly associated with functional recovery in subacute stroke survivors.

Cardiovascular Health and Stroke in Older British Men: Prospective Findings From the British Regional Heart Study

BACKGROUND AND PURPOSE

Research exploring the utility of cardiovascular health (CVH) and its Life's Simple 7 (LS7) components (body mass index, blood pressure [BP], glucose, cholesterol, physical activity, smoking, and diet) for prevention of stroke in older adults is limited. In the British Regional Heart Study, we explored (1) prospective associations of LS7 metrics and composite CVH scores with, and their impact on, stroke in middle and older age; and (2) if change in CVH was associated with subsequent stroke.

METHODS

Men without cardiovascular disease were followed from baseline recruitment (1978-1980), and again from re-examination 20 years later, for stroke over a median period of 20 years and 16 years, respectively. LS7 were measured at each time point except baseline diet. Cox models estimated hazard ratios (95% CI) of stroke for (1) ideal and intermediate versus poor levels of LS7; (2) composite CVH scores; and (3) 4 CVH trajectory groups (low-low, low-high, high-low, high-high) derived by dichotomising CVH scores from each time point across the median value. Population attributable fractions measured impact of LS7.

RESULTS

At baseline (n=7274, mean age 50 years), healthier levels of BP, physical activity, and smoking were associated with reduced stroke risk. At 20-year follow-up (n=3798, mean age 69 years) only BP displayed an association. Hazard ratios for intermediate and ideal (versus poor) levels of BP 0.65 (0.52-0.81) and 0.40 (0.24-0.65) at baseline; and 0.84 (0.67-1.05) and 0.57 (0.36-0.90) at 20-year follow-up. With reference to low-low trajectory, the low-high trajectory was associated with 40% reduced risk, hazard ratio 0.60 (0.44-0.83). Associations of CVH scores weakened, and population attributable fractions of LS7 reduced, from middle to old age; population attributable fraction of nonideal BP from 53% to 39%.

CONCLUSIONS

Except for BP, CVH is weakly associated with stroke at older ages. Prevention strategies for older adults should prioritize BP control but also enhance focus beyond traditional risk factors.

Effects of Age on Long-Term Functional Recovery in Patients with Stroke

Background and objectives: Age might be a determinant that limits functional recovery in patients with stroke. Here, we investigated the effect of age on functional recovery within 30 months after stroke onset. Materials and Methods: This retrospective longitudinal study enrolled 111 patients with first-ever stroke. Functional recovery was assessed at 2 weeks and at 1, 6, and 30 months after stroke onset using the modified Barthel Index (MBI), modified Rankin Score (mRS), functional ambulation category (FAC), muscle strength, and Mini-Mental State Examination (MMSE). A generalized estimating equation analysis was performed. Results: With the MBI, function improved until 6 months after stroke onset in patients aged <70 years and until 1 month after stroke onset in patients ≥70 years. At 30 months after stroke, there was no significant change of MBI in patients aged <70 years, whereas there was a significant decline in older patients. With the mRS and FAC, function improved until 30 months after stroke onset in patients aged <70 years and until 1 month after stroke onset in older patients. Motor deficit, assessed using the Medical Research Council (MRC), improved significantly until 6 months after stroke onset in patients aged <70 years. There was a significant improvement in cognition (assessed using the MMSE) until 6 months after stroke onset in patients aged <70 years and until 1 month after stroke onset in older patients. Conclusions: Long-term functional recovery occurred for up to 30 months after stroke. Patients aged ≥70 years showed functional decline between 6 and 30 months after onset. These findings could be useful when measuring functional recovery after stroke.

Comparison and Analysis of Epidemiologic Characteristics of Stroke in Sichuan Province, China

Previous studies have shown that there is a geographic variation in the prevalence of stroke, with a lower prevalence of stroke in Sichuan province. And a stroke transition was found during the period of economic development as well. However, as the center of Southwest China, with a greatly developed economy, whether the geographic variation remained with lower burden of stroke in Sichuan province is unknown. Therefore, in this study, we analyzed the secular stroke status in Sichuan province to help explore the potential reasons for geographic disparity. From a cross-sectional study conducted based on eight national disease surveillance points (DSPs) in Sichuan province in 2013, the epidemiologic data of stroke were collected. Data of risk factors were obtained from a cross-sectional study based on 12 national DSPs in Sichuan province in 2013. The results showed that the age-standardized prevalence, incidence, and mortality of stroke in Sichuan province were 338.6/100,000 people [95% confidence interval (CI), 267.8–409.4], 147.1/100,000 person-years (95% CI = 100.6–193.6), and 72.4/100,000 person-years (95% CI = 40.0–104.8), respectively, which were significantly lower than those determined from the contemporary data of China in 2013. The analysis of the risk factors showed that the weights of contribution of the potential risk factors to stroke were in consistency with those published reports from other areas. In conclusion, the disparity of lower stroke burden in Sichuan than the average China remained, although with the great developments in Sichuan province over all those decades. In addition to traditional modifiable factors, we suggest that unknown or intrinsic differences such as genetic factors might play an important role in geographic disparity, which should be investigated in future studies.

Age-Related Risk Factors at the First Stroke Event

(1) Background: Stroke is a multifactorial disease, which can affect individuals at any age. Risk factors (RFs) associated with the first stroke event have been well identified; however, the influence of these RFs on the patient’s age needs to be studied. (2) Objective: This study aimed to examine the effect of modifiable RFs on the age at which a stroke occurs. (3) Methods: A cross-sectional study was conducted on patients admitted consecutively with a first-ever acute stroke at the Burgos University Hospital (Spain). Data on sociodemographic and clinical parameters were collected (high blood pressure (HBP), smoking habit, diabetes mellitus (DM), dyslipemia, abdominal obesity, sedentary lifestyle, alcohol consumption, and cardiovascular diseases). The possible associations between RFs and age were studied using univariate and multivariate regression analyses and a decision tree. (4) Results: A total of 436 patients with a mean age of 75.39 years (standard deviation (SD) ± 12.67) were included. HBP and overweight/obesity were the most prevalent stroke RFs. Being an active smoker (OR 21.48; 95% confidence interval (CI) 8.80–52.41), having a sedentary lifestyle (OR 3.24; 95% CI 1.97–5.31), being an excessive alcohol drinker (OR 2.36; 95% CI 1.45–3.84), or being overweight or obese (OR 1.95; 95% CI 1.14–3.34) increased the risk of having an acute cerebrovascular event in individuals aged 75 years or below. However, a personal history of HBP (OR 0.40; 95% CI 0.24–0.67) was significantly associated with a greater likelihood of having an acute stroke in individuals aged more than 75 years. (5) Conclusions: This study showed that the modifiable RFs strongly influence the first stroke event in patients aged below 75 years, which will be useful in guiding different prevention strategies.

Non-participation in health checkup and Kihon Checklist predicts loss of certification-free survival in community-dwelling older adults

AIM

Despite efforts toward health promotion and preventive care for older adults, including health checkups and postal Kihon Checklist survey, one fifth of community-dwelling older adults do not participate in them. The aim of the present study was to examine the relationship between this non-participation and the end of certification-free survival in older adults.

METHODS

In a cohort of 4120 older adults with no prior history of Long-Term Care Insurance certification, the associations of non-participation with risk of later death without certification and support/care-need certification for 72 months were evaluated using Cox proportional hazards analysis.

RESULTS

Of them, 4022 (mean age 72.7 years, 54.7% women) were followed up (97.6%). At baseline, 1072 received health checkups, 2085 replied to the Kihon Checklist alone and 865 did not participate. During 72 months, 310 deaths without certification and 701 certifications occurred. After adjustment, non-participating individuals had significantly higher hazard ratios for death up to 72 months and for certification up to 36 months, compared with the other two groups. The Kruskal-Wallis test showed associations of increasing incidence of certification due to stroke in pre-old (aged 65-74 years) men for 72 months, and due to arthralgia/fracture and dementia in old (aged ≥75 years) women for 24 months, with non-participation in health promotions. Certified non-participating individuals incurred higher estimated Long-Term Care Insurance expenditure per person for 72 months, especially in pre-old men and old women.

CONCLUSIONS

Health promotion by health checkup and even Kihon Checklist survey increases certification-free survival in older residents, and decreases Long-Term Care Insurance expenditure. Geriatr Gerontol Int 2019; 19: 1206-1214.

Predictive clinical features of cardioembolic infarction in patients aged 85 years and older

OBJECTIVE

To assess predictive clinical factors of cardioembolic infarction in very old patients (85 years of age and older).

METHODS

Prospective hospital-based stroke registry ("The Sagrat Cor Hospital of Barcelona Stroke Registry") is an acute-care teaching hospital in Barcelona, Catalonia, Spain. From 956 first-ever cardioembolic stroke patients included in the stroke registry over a 24-year period, 639 were younger than 85 years of age and 317 were 85 years or older (mean age: 88.9 years). Demographics, clinical characteristics, risk factors and early outcome were compared. Predictors of cardioembolic infarction in the oldest age group were assessed by multivariate analyses.

RESULTS

In a logistic regression model based on demographics, risk factors, clinical features and complications, female gender (odds ratio [OR] = 1.74, 95% confidence interval [CI]: 1.27-2.39), heart failure (OR = 2.27, 95% CI: 1.46-3.56), altered consciousness (OR = 1.76, 95% CI: 1.28-2.42), and infectious complications (OR = 2.01, 95% CI: 1.39-2.91) were predictors of cardioembolic stroke in the oldest age group. By contrast, heavy smoking, heart valve disease, hypertension, headache, early seizures, sensory deficit, and involvement of the posterior cerebral artery were independently associated with cardioembolic stroke in the younger group.

CONCLUSIONS

Identification of a differential clinical profile of cardioembolic stroke between patients aged 85 years or more and those younger than 85 years helps clinicians to the optimal management of ischemic infarction in the oldest segment of the population.

Five-year incidence of common comorbidities, such as hypertension, dyslipidemia, diabetes mellitus, cardiovascular disease, cerebrovascular disease and cancer, in older Japanese patients with rheumatoid arthritis

AIM

To estimate the 5-year incidence of common comorbidities, including lifestyle-associated diseases, in older Japanese patients with rheumatoid arthritis (RA).

METHODS

We enrolled 129 consecutive patients with RA aged ≥65 years in this study. We examined all patients for the presence of hypertension, dyslipidemia, diabetes mellitus, cardiovascular disease, cerebrovascular disease and cancer at baseline (in 2013) and 5 years later (in 2018) using clinical records, self-reported questionnaires, interviews and medication records.

RESULTS

At baseline, hypertension was prevalent in 37.2% of the patients, dyslipidemia in 18.6%, diabetes mellitus in 9.3%, cardiovascular disease in 14.7%, cerebrovascular disease in 10.1% and cancer in 10.1%. Furthermore, the change of prevalence after 5 years from baseline of hypertension, dyslipidemia, diabetes mellitus, cardiovascular disease, cerebrovascular disease and cancer was 4.6%, 3.9%, 0.8%, 4.7%, 2.3% and 1.5%, respectively. The factors associated at baseline and/or after 5 years of hypertension, dyslipidemia, diabetes mellitus, cardiovascular disease and cancer included disease duration and body mass index, body mass index and anti-cyclic citrullinated peptide antibody, corticosteroid use, body mass index, and male and disease duration, respectively.

CONCLUSIONS

The Japanese population is aging and so is the population of patients with RA. In older patients with RA, hypertension and cardiovascular disease should be particularly considered. Therefore, although the therapeutic agents for RA have improved, a better understanding of the comorbidities in older patients with RA should impact the treatment of RA. Geriatr Gerontol Int 2019; 19: 577-581.

Evaluation of Lenticulostriate Arteries Changes by 7 T Magnetic Resonance Angiography in Type 2 Diabetes

AIM

Progress in neuroimaging techniques allows us to investigate the microvasculature characteristics including lenticulostriate arteries (LSA), which are closely associated with lacunar infarction. Because ischemic stroke is a more critical health problem in East Asian than in other populations, in order to clarify pathological changes underlying cerebral small vessel disease (SVD), we projected an imaging analysis of LSA using high-resolution brain magnetic resonance imaging (MRI) in middle-aged Japanese subjects with type 2 diabetes.

METHODS

Twenty-five subjects with type 2 diabetes and 25 non-diabetic control subjects underwent 7 Tesla (7 T) brain MRI. The prevalences of SVD and LSA structural changes were determined in each group.

RESULTS

SVD prevalence did not differ significantly between the type 2 diabetes and control groups. The average numbers of stems, as well as numbers of branches, of LSA were significantly smaller in diabetic subjects than non-diabetic control subjects. The signal intensity of LSA was markedly decreased, indicating reduced blood flow in type 2 diabetes.

CONCLUSION

In spite of the prevalence of SVD being similar, structural changes and decreased signal intensity of LSA were highly detected in diabetic subjects compared with non-diabetic controls, suggesting that 7 T MRA enables us to determine LSA impairment prior to the development of SVD. Early detection of LSA impairment allows us earlier interventions aimed at the prevention of atherosclerotic events.

Carotid Plaque Score and Risk of Cardiovascular Mortality in the Oldest Old: Results from the TOOTH Study

Aim: Accumulating evidence suggests that predictability of traditional cardiovascular risk factors declines with advancing age. We investigated whether carotid plaque scores (CPSs) were associated with cardiovascular disease (CVD) death in the oldest old, and whether asymmetrical dimethylarginine (ADMA), a marker of endothelial dysfunction, moderated the association between the CPS and CVD death.

Methods: We conducted a prospective cohort study of Japanese subjects aged ≥ 85 years without CVD at baseline. We followed this cohort for 6 years to investigate the association of CPS with CVD death via multivariable Cox proportional hazard analysis. We divided participants into three groups according to CPS (no, 0 points; low, 1.2–4.9 points; high, ≥5.0 points). The predictive value of CPS for estimating CVD death risk over CVD risk factors, including ADMA, was examined using C-statistics.

Results: We analyzed 347 participants (151 men, 196 women; mean age, 87.6 years), of which 135 (38.9%) had no carotid plaque at baseline, and 48 (13.8%) had high CPS. Of the total, 29 (8.4%) participants experienced CVD-related death during the study period. Multivariable analysis revealed a significant association of high CPS with CVD-related mortality relative to no CPS (hazard ratio, 3.90; 95% confidence interval: 1.47–10.39). ADMA was not associated with CVD death, but the significant association between CPS and CVD death was observed only in lower ADMA level. The addition of CPS to other risk factors improved the predictability of CVD death (p = 0.032).

Conclusions: High CPS correlated significantly with a higher CVD death risk in the oldest old with low cardiovascular risk. Ultrasound carotid plaque evaluation might facilitate risk evaluations of CVD death in the very old.