Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis

doi:10.1016/S1474-4422(09)70236-4

The Lancet Neurology

Volume 8, Issue 11, November 2009, Pages 1006-1018

https://doi.org/10.1016/S1474-4422(09)70236-4 Get rights and content

Summary

Background

Reliable data on the prevalence and predictors of post-stroke dementia are needed to inform patients and carers, plan services and clinical trials, ascertain the overall burden of stroke, and understand its causes. However, published data on the prevalence and risk factors for pre-stroke and post-stroke dementia are conflicting. We undertook this systematic review to assess the heterogeneity in the reported rates and to identify risk factors for pre-stroke and post-stroke dementia.

Methods

Studies published between 1950 and May 1, 2009, were identified from bibliographic databases, reference lists, and journal contents pages. Studies were included if they were on patients with symptomatic stroke, were published in English, reported on a series of consecutive eligible patients or volunteers in prospective cohort studies, included all stroke or all ischaemic stroke, measured dementia by standard criteria, and followed up patients for at least 3 months after stroke. Pooled rates of dementia were stratified by study setting, inclusion or exclusion of pre-stroke dementia, and by first, any, or recurrent stroke. Pooled odds ratios were calculated for factors associated with pre-stroke and post-stroke dementia.

Findings

We identified 22 hospital-based and eight population-based eligible cohorts (7511 patients) described in 73 papers. The pooled prevalence of pre-stroke dementia was higher (14·4%, 95% CI 12·0–16·8) in hospital-based studies than in population-based studies (9·1%, 6·9–11·3). Although post-stroke (≤1 year) dementia rates were heterogeneous overall, 93% of the variance was explained by study methods and case mix; the rates ranged from 7·4% (4·8–10·0) in population-based studies of first-ever stroke in which pre-stroke dementia was excluded to 41·3% (29·6–53·1) in hospital-based studies of recurrent stroke in which pre-stroke dementia was included. The cumulative incidence of dementia after the first year was little greater (3·0%, 1·3–4·7) per year in hospital-based studies than expected on the basis of recurrent stroke alone. Medial temporal lobe atrophy, female sex, and a family history of dementia were strongly associated with pre-stroke dementia, whereas the characteristics and complications of the stroke and the presence of multiple lesions in time and place were more strongly associated with post-stroke dementia.

Interpretation

After study methods and case mix are taken into account, reported estimates of the prevalence of dementia are consistent: 10% of patients had dementia before first stroke, 10% developed new dementia soon after first stroke, and more than a third had dementia after recurrent stroke. The strong association of post-stroke dementia with multiple strokes and the prognostic value of other stroke characteristics highlight the central causal role of stroke itself as opposed to the underlying vascular risk factors and, thus, the likely effect of optimum acute stroke care and secondary prevention in reducing the burden of dementia.

Funding

None.

Introduction

Although there is broad consensus that stroke is associated with an increased risk of subsequent dementia, the results of previous studies on the prevalence of post-stroke dementia are conflicting: the 3-month post-stroke rates of dementia vary from 6%¹ to more than 30%,² and the findings in relation to risk factors are inconsistent. Reported rates of pre-stroke dementia are similarly discordant. Therefore, more reliable estimates of the risks of post-stroke dementia and its predictors are needed to inform patients and carers, plan clinical services, design clinical trials, and ascertain the overall burden of stroke.

We did a quantitative systematic review of the prevalence of pre-stroke dementia and the prevalence and incidence of post-stroke dementia and their associated risk factors. Although it has been suggested that much of the variation in the reported rates of pre-stroke and post-stroke dementia is caused by differences in the method of diagnosis,3, 4 we hypothesised that the heterogeneity might be better explained by differences in the study design, with lower rates expected in population-based studies (which would include patients with minor strokes), in studies of post-stroke dementia that excluded pre-stroke dementia, and in studies restricted to first-ever stroke. Also, to better understand the probable causes of post-stroke dementia, we aimed to identify the risk factors for dementia and whether there were any differences in the risk factors associated with pre-stroke and post-stroke dementia. Specifically, we aimed to ascertain the importance of the characteristics of the stroke itself (eg, lesion volume, multiple lesions, and acute complications) versus the underlying vascular risk factors in the causes of post-stroke dementia.

Section snippets

Procedures

This systematic review was done according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) criteria.⁵ Ovid Medline (1950 to April, 2009) and Embase (1980 to April, 2009) were searched (last on May 1, 2009) by one researcher (STP) with the exploded medical subject headings (MESH) “dementia” or “vascular dementia” or “multi-infarct dementia” and “stroke”. The bibliographies of relevant review articles on post-stroke dementia and the contents pages of the four journals that

Results

The search of the electronic published work produced 6197 references (including 326 duplicates), of which 64 articles were eligible for inclusion (figure 1). A further 24 original research articles were identified by hand-searching the four journals that contained the highest number of relevant publications from the electronic search (Stroke; Journal of Neurology, Neurosurgery and Psychiatry; Neurology; and Dementia and Geriatric Cognitive Disorders) and reference lists. Nine of these 24

Discussion

We have shown that more than 90% of the heterogeneity among the reported rates of post-stroke dementia can be explained by study setting (hospital based vs population based), the inclusion or exclusion of patients with pre-stroke dementia, and whether first ever, any (first ever or recurrent), or recurrent strokes were included. The prevalence of post-stroke dementia in the first year after stroke ranged from around 7% in population-based studies in which pre-stroke dementia was excluded to

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The increased risk of dementia after delirium and infection might be influenced by cerebral white matter disease (WMD). In patients with transient ischaemic attack (TIA) and minor stroke, we assessed associations between hospital admissions with delirium and 5-year dementia risk and between admissions with infection and dementia risk, stratified by WMD severity (moderate or severe vs absent or mild) on baseline brain imaging.
We included patients with TIA and minor stroke (National Institutes of Health Stroke Score <3) from the Oxford Vascular Study (OXVASC), a longitudinal population-based study of the incidence and outcomes of acute vascular events in a population of 94 567 individuals, with no age restrictions, attending eight general practices in Oxfordshire, UK. Hospitalisation data were obtained through linkage to the Oxford Cognitive Comorbidity, Frailty, and Ageing Research Database–Electronic Patient Records (ORCHARD-EPR). Brain imaging was done using CT and MRI, and WMD was prospectively graded according to the age-related white matter changes (ARWMC) scale and categorised into absent, mild, moderate, or severe WMD. Delirium and infection were defined by ICD-10 coding supplemented by hand-searching of hospital records. Dementia was diagnosed using clinical or cognitive assessment, medical records, and death certificates. Associations between hospitalisation with delirium and hospitalisation with infection, and post-event dementia were assessed using time-varying Cox analysis with multivariable adjustment, and all models were stratified by WMD severity.
From April 1, 2002, to March 31, 2012, 1369 individuals were prospectively recruited into the study. Of 1369 patients (655 with TIA and 714 with minor stroke, mean age 72 [SD 13] years, 674 female and 695 male, and 364 with moderate or severe WMD), 209 (15%) developed dementia. Hospitalisation during follow-up occurred in 891 (65%) patients of whom 103 (12%) had at least one delirium episode and 236 (26%) had at least one infection episode. Hospitalisation without delirium or infection did not predict subsequent dementia (HR 1·01, 95% CI 0·86–1·20). In contrast, hospitalisation with delirium predicted subsequent dementia independently of infection in patients with and without WMD (2·64, 1·47–4·74; p=0·0013 vs 3·41, 1·91–6·09; p<0·0001) especially in those with unimpaired baseline cognition (cognitive test score above cutoff; 4·01, 2·23–7·19 vs 3·94, 1·95–7·93; both p≤0·0001). However, hospitalisation with infection only predicted dementia in those with moderate or severe WMD (1·75, 1·04–2·94 vs 0·68, 0·39–1·20; p_diff=0·023).
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Fast track — ArticlesPrevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Procedures

Results

Discussion

J Neurological Sci

Arch Clin Neuropsychol

J Neurol Sci

J Neurol Sci

J Neurol Sci

J Neurol Sci

Alzheimers Dement

Arch Clin Neuropsychol

Dementia and cognitive impairment three months after stroke

Euro J Neurol

Poststroke dementia: incidence and relationship to prestroke cognitive decline

Neurology

Dementia three months after stroke: baseline frequency and effect of different definitions of dementia in the Helsinki Stroke Aging Memory Study (SAM) cohort

Stroke

The effect of different diagnostic criteria on the prevalence and incidence of post-stroke dementia

Neuroepidemiology

Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group

JAMA

Dementia after stroke: baseline frequency, risks, and clinical features in a hospitalized cohort

Neurology

Frequency and clinical determinants of dementia after ischemic stroke

Neurology

Generalised linear models

Cognitive decline in prospectively studied group of stroke survivors, with a particular emphasis on the >75s

Age Ageing

Clinical factors associated with dementia in ischaemic stroke

J Neurol Neurosurg Psychiatry

Effect of a clinical stroke on the risk of dementia in a prospective cohort

Neurology

Dementia after stroke

Eur Neurol

Cognitive impairment and functional outcome after stroke associated with small vessel disease

J Neurol Neurosurg Psychiatry

Dementia associated with lacunar infarction

Stroke

Incidence of stroke in relation to cognitive function and dementia in the Kungsholmen Project

Neurology

Dementia in Thai stroke survivors: analysis of 212 patients

J Med Assoc Thai

Cognitive changes in patients with multiple cerebral infarcts

Stroke

Intellectual impairment and cerebral lesions in multiple cerebral infarcts. A clinical-computed tomography study

Stroke

Cognitive impairment after acute supratentorial stroke: a 6-month follow-up clinical and computed tomographic study

Eur Arch Psychiatry Clin Neurosci

Cognition in stroke

Acta Neurologica Scand

Dementia in stroke survivors in the stroke data bank cohort

Stroke

Cognitive impairment and quality of life among stroke survivors in Nigeria

Psychol Rep

Education and the cognitive decline associated with MRI-defined brain infarct

Neurology

Early detection of mild cognitive impairment in patients with cerebrovascular disease

Acta Clinica Croatica

Longitudinal assessment of depression and cognitive impairment following stroke

J Nerv Ment Dis

Leukoaraiosis as a predictor for mortality and morbidity after an acute ischaemic stroke

Singapore Med J

Prestroke dementia in patients with atrial fibrillation. Frequency and associated factors

J Neurol

Prediction of poststroke dementia

Neurology

Clinical determinants of dementia and mild cognitive impairment following ischaemic stroke: the Sydney Stroke Study

Dement Geriatr Cogn Disord

Cognitive impairment and dementia 20 months after stroke

Neuroepidemiology

Cognitive functioning after stroke: a one-year follow-up study

Fast track — Articles
Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis