Prevalence of stroke and its sequelae

Stroke in Nottingham: provision of nursing care and possible implications for the future

Although the care of stroke patients accounts for a considerable proportion of Health Service resources, there have been few attempts to measure this burden directly. A survey was therefore performed in Nottingham (approximate population 700 000) during a two-week period to find out the total number and dependency levels of stroke patients receiving professional nursing care, whether in hospital, nursing homes or at home from the Community Nursing Service. Altogether 822 patients were surveyed, of whom 232 were in hospital (46 in general medical, 171 in geriatric wards and 15 on the stroke unit), 221 were in nursing homes and 369 at home with district nurse support. Of this total, 61 % were aged over 75 and 18% over 85; nearly half of the latter group being in nursing homes. Overall levels of dependency were greatest in nursing homes and the prevalence of severe disability was highest amongst the oldest patients. Two-thirds of all patients had had their strokes over six months before and 39% over two years before and 31 % had suffered more than one stroke. Thus, the main demand for nursing services is amongst the old and those with longstanding stroke disease. The rapid increase in the number of old people and changes in medical practice which reduce fatality in the early stages of stroke are both likely to increase the numbers of disabled elderly stroke survivors, and a large proportion of these may be cared for in private nursing homes. Simple cross-sectional studies of this kind should be repeated every few years so that these trends can be accurately plotted.

Seasonal variation in stroke in the Hunter Region, Australia: a 5-year hospital-based study, 1995-2000

BACKGROUND AND PURPOSE

Seasonal variation in stroke has long been recognized. To date, there are minimal published data on seasonal variations in rates of stroke and subsequent case fatality in the Southern Hemisphere. The aim of this study was to examine stroke seasonality through the use of data from a hospital-based stroke register in the Hunter Region of New South Wales, Australia.

METHODS

From July 1, 1995, to June 30, 2000, 3803 stroke events were registered in residents of the Hunter Region, New South Wales, Australia. We analyzed the trend of seasonal and monthly stroke attack rates and case-fatality rates using Poisson regressions with age and sex as covariates.

RESULTS

Stroke attack rates were highest in the winter and lowest in the summer. From February (summer) to July (winter), there was a significant trend in increasing stroke attack rates (rate ratio, 1.07; 95% confidence interval, 1.05 to 1.10; P<0.001). This increase was seen mainly in those >or=65 years of age. Case-fatality rates showed similar trends with a 1- to 2-month lag compared with attack rates.

CONCLUSIONS

There is an increase in stroke attack rates and case-fatality rate from summer to winter in the Hunter Region, Australia. These trends are similar to those found in the Northern Hemisphere.

Age specific prevalence of impairment and disability relating to hemiplegic stroke in the Hai District of northern Tanzania. Adult Morbidity and Mortality Project

OBJECTIVES

To determine the age specific prevalence of impairment and disability relating to hemiplegic stroke in one rural area of Tanzania.

METHODS

During the yearly house to house census of the study population of 148 135 (85 152 aged 15 and over) in August 1994, specific questions were asked to identify those who might be disabled from stroke. People thus identified were subsequently interviewed and examined by one investigator. In those in whom the clinical diagnosis of stroke was confirmed a more detailed interview and examination relating to risk factors and recovery was carried out.

RESULTS

One hundred and eight patients, 61 men and 47 women, were identified with a median age of 70 (range 18-100). Median age at first stroke was 65 years. The age specific rates in this study were lower than previous studies in developed countries. All were cared for at home although 23 (21%) were bedbound.

CONCLUSIONS

Although prevalence of impairment and disability related to stroke in this population as a whole was low this is mainly explained by the age structure, with less than 6% being aged 65 and over. Age standardised rates for stroke with residual disability were about half those found in previous studies in developed countries. Death from stroke in Africa may be higher but data are limited. With the demographic transition stroke is likely to become a more important cause of disability in sub-Saharan Africa.

Prevalence of stroke and stroke-related disability. Estimates from the Auckland stroke studies

BACKGROUND AND PURPOSE

To provide estimates of the prevalence of stroke and stroke-related disability for international comparisons and for planning purposes.

METHODS

Estimates of prevalence were derived from two population-based studies conducted 10 years apart in Auckland, New Zealand. The first, carried out in 1981, included information on survival and stroke-related disability to 14 years after stroke, and the second, undertaken in 1991 to 1992, included this information up to 3 years after stroke. An actuarial model was developed that took into account changes in incidence, long-term survival, and population structure.

RESULTS

Overall, it was estimated that 7491 people (3793 men and 3698 women) living in Auckland (total population 945,000) in 1991 had experienced a stroke at some stage in the past. This represents an age-standardized rate of 833 per 100,000 (991 per 100,000 in men and 706 per 100,000 in women) in the population aged 15 years and older. When only those who have made an incomplete recovery are considered, prevalence falls to 461 per 100,000. Of this group, one third (173 per 100,000 population 15 years and older) required assistance in at least one self-care activity.

CONCLUSIONS

Usual estimates of stroke prevalence, which include all people who have ever experienced a stroke, may overestimate by almost twofold the prevalence of stroke-related disability, since many have either recovered or have no continuing dependency related to stroke. Overall prevalence does not provide information with sufficient precision for planning and purchasing ongoing services for stroke patients.

Therapeutic strategies for atrial fibrillation. The value of decision analysis

In the absence of randomized, controlled trials of low-dose amiodarone in atrial fibrillation or a randomized, controlled trial of ventricular rate control versus antifibrillatory therapy, a Markov decision analysis is useful in comparing different therapeutic strategies for atrial fibrillation. The decision analysis described compared warfarin, quinidine, and low-dose amiodarone in patients with asymptomatic or minimally symptomatic chronic, persistent atrial fibrillation. This model suggests that electrical cardioversion followed by low-dose amiodarone is a relatively safe, effective alternative to long-term warfarin therapy.

[Prevalence and distribution of stroke and transient ischemic insults: secondary data analysis of a representative sample of insured members of the General Local Insurance Dortmund]

Apoplexia is not only one of the leading causes of death, but also a major contributor to disability in the aged. Population based prevalence rates, though being of basic importance for describing and planning health care structures, are sparse in the Federal Republic of Germany. We estimated the prevalence of apoplexia and transient ischemic attack (TIA). Data were gathered from a 5% representative random sample of insured of the local statuatory health insurance (AOK) in Dortmund, Germany (n = 7447). Cases were identified by the diagnosis on medical certificates, being further validated internally by other patient data. The rough prevalence rate was 0.86% (m 0.79%, f 0.93%) for apoplexia and 0.6% (m 0.4%, f 0.78%) for TIA. Adjusted for age and sex to the whole population of the FRG (excluding the former German Democratic Republic) the prevalence rate was 0.75% (m 0.8%, f 0.7%) for apoplexia and 0.52% (m 0.41%, f 0.63%) for TIA. 65% of the insured with apoplexia were 70 years and older; their average age was 71.7 years. The average age of the insured with TIA was 65.4 years. Prevalence rates for apoplexia increased continuously by age and were higher for men than for women in all age groups. Prevalence rates for TIA also increased with age, but under men only to the age of 70; after that-simultaneous to a steep rise of apoplexia prevalence-no more TIAs were noticed.

Validation of a population screening questionnaire to assess prevalence of stroke

BACKGROUND AND PURPOSE

A cross-sectional survey is the best method for determining the prevalence of a chronic condition such as stroke. Before embarking on a large population study, a valid screening instrument is necessary. This study aimed to validate a self-completion postal screening questionnaire for assessing lifetime history of stroke.

METHODS

A random sample of 2000 people aged 45 years and over was selected from the Family Health Services Authority register. A brief self-completion questionnaire requesting self-reported history of stroke was mailed to each individual. Responders reporting a history of stroke received a request for a standardized home assessment visit. Confirmation of the diagnosis of stroke was made based on information from the home visit together with multiple sources of case ascertainment. False-negative responses and assessment of nonresponse bias were documented.

RESULTS

The response rate for the questionnaire was 88%. Of the sample, 120 (6%) who were wrongly registered were excluded; 173 (10%) of the 1663 responders reported a history of stroke. The question "Have you ever had a stroke?" had a sensitivity of 95% and a specificity of 96%.

CONCLUSIONS

This simple self-completion questionnaire is a valid means of screening for cases of stroke in the community and could form the basis for subsequent studies of prevalence and health needs.

Stroke rehabilitation: Australian patient profile and functional outcome

A prospective, multi-institutional, population based study identified 1274 non-surgical stroke admissions to all hospitals in a major Australian city during 1984. The demographic and diagnostic profile and the nature of functional recovery of all 258 first stroke survivors who were referred for inpatient rehabilitation are presented. The median duration of rehabilitation stay was 49 days. The mean functional independence score, as measured on a modified Barthel Index at admission was 44, compared with 78 on discharge, a mean improvement of 34. Stair climbing had the lowest mean value on admission (12), while bowel control had the lowest residual deficit on discharge (95). The stroke study group was representative of the unimpaired aged population in all respects except ethnicity, where differences are attributed to age. The variables identified as significant are; side and severity of paralysis, age and sex, marital status and ethnicity. Stroke rehabilitation outcome was not influenced by etiology, site of lesion, arterial distribution, occupation or education.

Incidence and outcome of cerebrovascular disease in Perth, Western Australia

We estimated the event rates for stroke and transient cerebral ischemic attacks in a prospective community-based epidemiologic study in a representative segment of the city of Perth, Western Australia, during a 10-month period in 1986. Of 349 persons with an initial diagnosis of stroke or transient ischemic attack, 154 had suffered a first stroke, 75 a recurrent stroke, and 47 a transient ischemic attack; the remaining 73 persons were thought not to have had an episode of acute cerebrovascular disease. Annual event rates for first stroke (age-standardized to the "world" population) were 120 per 100,000 for males and 56 per 100,000 for females. The crude case-fatality ratio at 28 days after the index event for first stroke was 23% and varied from 0% for lacunar infarction to 57% for subarachnoid hemorrhage.

Prevalence of stroke in Finland

The prevalence of stroke was investigated in a Finnish population study. The results were based on cross-sectional data from a follow-up examination of a prospective study conducted in 1973-1976. The study population drawn from four regions of the country comprised 11,103 men and 11,096 women aged 20 years and over. The age-adjusted prevalence of stroke was 10.3/1000 in men and 5.8/1000 in women. The prevalence was significantly higher in non-attendants at the examination than in attendants. In 15 per cent of the prevalence cases the stroke was caused by subarachnoid hemorrhage, in six per cent by cerebral hemorrhage and in the remainder by cerebral infarction or the type could not be specified. Over half (57 per cent) of the survivors of stroke had no or only slight disability; eight per cent were totally disabled. Some form of organic heart disease and hypertension was significantly more common in the prevalence cases than in the others.

Epidemiology of some neurological diseases with special reference to work load on the NHS

This paper reviews evidence relating to the incidence, prevalence, and likely workload upon the NHS in relation to neurological diseases, particularly those causing long-term disability. Three studies suggest that a population of 250,000 people will contain about 5000 people with disabling neurological disease, of whom 1500 will be sufficiently disabled to require daily assistance. The review highlights the scarcity of reliable information concerning the epidemiology of neurological diseases and their disabilities, and emphasizes the need to plan neurological services at the level of the district general hospital serving a population of 250,000 people.

Patterns of stroke. An analysis of the first 700 consecutive admissions to the Austin Hospital Stroke Unit

An analysis is presented of the first 700 admissions to the Austin Hospital Stroke Unit with special emphasis on the incidence of the various patterns of stroke and the underlying mechanisms involved. There were 616 admissions for confirmed stroke events--the remainder were for events simulating stroke. Three hundred and fifty-three (57.3% of stroke events) were for cortical (including retinal) ischaemic events. Of these, arterial lesions were demonstrated in 55% and suspected in 20% whilst embolism from the heart probably accounted for 14% of events. No cause was determined in 11% despite complete investigation. Where arterial lesions were found, they were extracranial in 85%. There were 140 cases of internal capsular ischaemia (22.7% of stroke events) and 16 cases (2.6%) for which the exact site of ischaemia was not determined, although it was presumed to have occurred within the carotid territory. Vertebrobasilar ischaemic events were responsible for 71 admissions (11.5%). There were 36 cases of primary intracerebral haemorrhage (5.8%). This survey has highlighted some aspects of stroke requiring further research. These include the elucidation of cortical and retinal ischaemic events of unknown aetiology, the possible role of large vessel lesions in the pathogenesis of capsular ischaemic events and pathologic mechanisms involved in ischaemic events of the vertebrobasilar territory.