1029
Journal of Alzheimer’s Disease 40 (2014) 1029–1038 DOI 10.3233/JAD-131580 IOS Press
Post-Stroke Cognitive Impairment: High Prevalence and Determining Factors in a Cohort of Mild Stroke Agn`es Jacquina,∗ , Christine Binquetb , Olivier Rouauda , Anny Graule-Petota , Benoit Daubaila , Guy-Victor Ossebya , Claire Bonithon-Koppb , Maurice Girouda and Yannick B´ejota a Memory
Centre, Department of Neurology, University Hospital, University of Burgundy, Stroke Registry, Dijon, France b Clinical Investigation Center, Clinical Epidemiology/Clinical Trials, University Hospital, Dijon, France
Accepted 5 January 2014
Abstract. Background: Because of the aging population and a rise in the number of stroke survivors, the prevalence of post-stroke cognitive impairment (PSCI) is increasing. Objective: To identify the factors associated with 3-month PSCI. Methods: All consecutive stroke patients without pre-stroke dementia, mild cognitive disorders, or severe aphasia hospitalized in the Neurology Department of Dijon, University Hospital, France (November 2010 – February 2012) were included in this prospective cohort study. Demographics, vascular risk factors, and stroke data were collected. A first cognitive evaluation was performed during the hospitalization using the Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MOCA). Patients assessable at 3 months were categorized as cognitively impaired if the MMSE score was ≤26/30 and MOCA 6.5% had been reported in the medical record or if the patient was under insulin or oral hypoglycemic agents) and hypercholesterolemia (defined by a history of known hypercholesterolemia or if the patient had lipidlowering therapy). We also recorded atrial fibrillation, smoking status (current, former, or non-smoker), body mass index, obstructive apnoea syndrome (declarative information according to a pre-existing treatment or diagnosis), and alcohol abuse. The following clinical data were recorded at stroke onset: demographic variables, educational and socioprofessional status (belonging to a partnership was defined as associative work), pre-morbid cognitive status using IQCODE for the patients without prior known dementia [12] and the short version of the Neuropsychiatric Inventory (NPI-R [15]), pre-morbid functional status using the modified Rankin Scale (mRS), and the Instrumental Activities of Daily Living (IADL)–4 items. Stroke severity was assessed at the first examination using the NIHSS score. A brain CT scan was used to evaluate the location of stroke, the degree of leukoaraiosis using the Blennow score [16], and the presence of silent infarcts. Handicap at discharge
Study design and case ascertainment This observational prospective cohort study screened all of the consecutive first-ever ischemic or hemorrhagic stroke patients older than 18 years hospitalized in the Neurology Department (either the conventional ward or the Stroke Unit) of Dijon, University Hospital, France (reference center for stroke care in the region of Burgundy), between November 2010 and February 2012, and alive at the fifth day after their stroke. Patients with subarachnoid hemorrhage or who suffered from severe aphasia (score ≥2 in the Neurological Institute of Health Stroke Scale (NIHSS) “aphasia” sub-test) or from loss of consciousness or severe hemiparesis or hemiplegia or vision or hearing loss that could limit the participation in the writing or drawing cognitive tests were excluded. The exclusion criteria also included illiteracy, mental retardation, not fluent French, psychiatric disorders, and pre-stroke dementia (diagnosis based on the DSM-IV criteria linked to their pre-morbid own history [11] or based on treatment with anti-cholinesterase or antiNMDA drug). Patients with a severe cognitive disorder before stroke (diagnosed by the Informant Questionnaire on Cognitive decline in the Elderly (IQCODE)
Stroke definition Stroke was defined according to World Health Organization (WHO) recommendations, and the International Classification of Diseases [14]. All of the patients underwent a cerebral imaging (CT-scan completed with an encephalic MRI in some cases). Patients were classified into two groups: ischemic versus hemorrhagic stroke. Baseline assessment
A. Jacquin et al. / Post-stroke Cognitive Impairment
was evaluated using the mRS. A favorable outcome at the initial hospital discharge was defined by an mRS ≤2. For all of the patients, baseline cognitive status was assessed using the standardized French translation of the MMSE and MOCA, described elsewhere [17, 18], between the fourth and the eighth day after stroke onset, when the neurological condition was considered stabilized. One point was added to the MOCA for patients with fewer than 12 years of formal education, as mentioned in the guidelines of Nasreddine et al. [18]. Each test took around 10 minutes to complete. Three-month follow-up All of the patients assessable at 3 months were screened for PSCI according to an MMSE ≤26/30 [19] and an MOCA
Journal of Alzheimer’s Disease 40 (2014) 1029–1038 DOI 10.3233/JAD-131580 IOS Press
Post-Stroke Cognitive Impairment: High Prevalence and Determining Factors in a Cohort of Mild Stroke Agn`es Jacquina,∗ , Christine Binquetb , Olivier Rouauda , Anny Graule-Petota , Benoit Daubaila , Guy-Victor Ossebya , Claire Bonithon-Koppb , Maurice Girouda and Yannick B´ejota a Memory
Centre, Department of Neurology, University Hospital, University of Burgundy, Stroke Registry, Dijon, France b Clinical Investigation Center, Clinical Epidemiology/Clinical Trials, University Hospital, Dijon, France
Accepted 5 January 2014
Abstract. Background: Because of the aging population and a rise in the number of stroke survivors, the prevalence of post-stroke cognitive impairment (PSCI) is increasing. Objective: To identify the factors associated with 3-month PSCI. Methods: All consecutive stroke patients without pre-stroke dementia, mild cognitive disorders, or severe aphasia hospitalized in the Neurology Department of Dijon, University Hospital, France (November 2010 – February 2012) were included in this prospective cohort study. Demographics, vascular risk factors, and stroke data were collected. A first cognitive evaluation was performed during the hospitalization using the Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MOCA). Patients assessable at 3 months were categorized as cognitively impaired if the MMSE score was ≤26/30 and MOCA 6.5% had been reported in the medical record or if the patient was under insulin or oral hypoglycemic agents) and hypercholesterolemia (defined by a history of known hypercholesterolemia or if the patient had lipidlowering therapy). We also recorded atrial fibrillation, smoking status (current, former, or non-smoker), body mass index, obstructive apnoea syndrome (declarative information according to a pre-existing treatment or diagnosis), and alcohol abuse. The following clinical data were recorded at stroke onset: demographic variables, educational and socioprofessional status (belonging to a partnership was defined as associative work), pre-morbid cognitive status using IQCODE for the patients without prior known dementia [12] and the short version of the Neuropsychiatric Inventory (NPI-R [15]), pre-morbid functional status using the modified Rankin Scale (mRS), and the Instrumental Activities of Daily Living (IADL)–4 items. Stroke severity was assessed at the first examination using the NIHSS score. A brain CT scan was used to evaluate the location of stroke, the degree of leukoaraiosis using the Blennow score [16], and the presence of silent infarcts. Handicap at discharge
Study design and case ascertainment This observational prospective cohort study screened all of the consecutive first-ever ischemic or hemorrhagic stroke patients older than 18 years hospitalized in the Neurology Department (either the conventional ward or the Stroke Unit) of Dijon, University Hospital, France (reference center for stroke care in the region of Burgundy), between November 2010 and February 2012, and alive at the fifth day after their stroke. Patients with subarachnoid hemorrhage or who suffered from severe aphasia (score ≥2 in the Neurological Institute of Health Stroke Scale (NIHSS) “aphasia” sub-test) or from loss of consciousness or severe hemiparesis or hemiplegia or vision or hearing loss that could limit the participation in the writing or drawing cognitive tests were excluded. The exclusion criteria also included illiteracy, mental retardation, not fluent French, psychiatric disorders, and pre-stroke dementia (diagnosis based on the DSM-IV criteria linked to their pre-morbid own history [11] or based on treatment with anti-cholinesterase or antiNMDA drug). Patients with a severe cognitive disorder before stroke (diagnosed by the Informant Questionnaire on Cognitive decline in the Elderly (IQCODE)
Stroke definition Stroke was defined according to World Health Organization (WHO) recommendations, and the International Classification of Diseases [14]. All of the patients underwent a cerebral imaging (CT-scan completed with an encephalic MRI in some cases). Patients were classified into two groups: ischemic versus hemorrhagic stroke. Baseline assessment
A. Jacquin et al. / Post-stroke Cognitive Impairment
was evaluated using the mRS. A favorable outcome at the initial hospital discharge was defined by an mRS ≤2. For all of the patients, baseline cognitive status was assessed using the standardized French translation of the MMSE and MOCA, described elsewhere [17, 18], between the fourth and the eighth day after stroke onset, when the neurological condition was considered stabilized. One point was added to the MOCA for patients with fewer than 12 years of formal education, as mentioned in the guidelines of Nasreddine et al. [18]. Each test took around 10 minutes to complete. Three-month follow-up All of the patients assessable at 3 months were screened for PSCI according to an MMSE ≤26/30 [19] and an MOCA
