Social engagement after stroke – is it relevant to cognitive function? A cross-sectional analysis of UK Biobank data

Background: Findings from studies in older adult populations suggest that measures of social engagement may be associated with health outcomes, including cognitive function. Plausibly the magnitude and direction of this association may differ in stroke. The disabling nature of stroke increases the likelihood of social isolation and stroke survivors are at high risk of cognitive decline. We assessed the association between social engagement and cognitive function in a sample of stroke survivors. Methods: We included available data from stroke survivors in the UK Biobank (N=8776; age range: 40-72; 57.4% male). In a series of regression models, we assessed cross-sectional associations between proxies of social engagement (frequency of family/friend visits, satisfaction with relationships, loneliness, opportunities to confide in someone, participation in social activities) and performance on domain specific cognitive tasks: reaction time, verbal-numerical reasoning, visual memory and prospective memory. We adjusted for demographics, health-, lifestyle-, and stroke-related factors. Accounting for multiple testing, we set our significance threshold at p<0.003. Results: After adjusting for covariates, we found independent associations between faster reaction times and monthly family visits as compared to no visit (standardised beta=-0.32, 99.7% CI: -0.61 to -0.03, N=4,930); slower reaction times and religious group participation (standardised beta=0.25, 99.7% CI 0.07 to 0.44, N=4,938); and poorer performance on both verbal-numerical reasoning and prospective memory tasks with loneliness (standardised beta=-0.19, 99.7% CI: -0.34 to -0.03, N=2,074; odds ratio=0.66, 99.7% CI: 0.46 to 0.94, N=2,188; respectively). In models where all proxies of social engagement were combined, no associations remained significant. Conclusions: We found limited task-specific associations between cognitive performance and proxies of social engagement, with only loneliness related to two tasks. Further studies are necessary to confirm and improve our understanding of these relationships and investigate the potential to target psychosocial factors to support cognitive function in stroke survivors

Who is classified as untestable on brief cognitive screens in an acute stroke setting?

Full completion of cognitive screening tests can be problematic in the context of a stroke. Our aim was to examine the completion of various brief cognitive screens and explore reasons for untestability. Data were collected from consecutive stroke admissions (May 2016–August 2018). The cognitive assessment was attempted during the first week of admission. Patients were classified as partially untestable (≥1 test item was incomplete) and fully untestable (where assessment was not attempted, and/or no questions answered). We assessed univariate and multivariate associations of test completion with: age (years), sex, stroke severity (National Institutes of Health Stroke Scale (NIHSS)), stroke classification, pre-morbid disability (modified Rankin Scale (mRS)), previous stroke and previous dementia diagnosis. Of 703 patients admitted (mean age: 69.4), 119 (17%) were classified as fully untestable and 58 (8%) were partially untestable. The 4A-test had 100% completion and the clock-draw task had the lowest completion (533/703, 76%). Independent associations with fully untestable status had a higher NIHSS score (odds ratio (OR): 1.18, 95% CI: 1.11–1.26), higher pre-morbid mRS (OR: 1.28, 95% CI: 1.02–1.60) and pre-stroke dementia (OR: 3.35, 95% CI: 1.53–7.32). Overall, a quarter of patients were classified as untestable on the cognitive assessment, with test incompletion related to stroke and non-stroke factors. Clinicians and researchers would benefit from guidance on how to make the best use of incomplete test data

Cardiovascular risk factors indirectly affect acute post-stroke cognition through stroke severity and prior cognitive impairment: A moderated mediation analysis

Abstract: Background: Cognitive impairment is an important consequence of stroke and transient ischaemic attack, but its determinants are not fully understood. Simple univariable or multivariable models have not shown clinical utility for predicting cognitive impairment. Cardiovascular risk factors may influence cognition through multiple, direct, and indirect pathways, including effects on prior cognition and stroke severity. Understanding these complex relationships may help clinical teams plan intervention and follow-up strategies. Methods: We analysed clinical and demographic data from consecutive patients admitted to an acute stroke ward. Cognitive assessment comprised Abbreviated Mental Test and mini-Montreal Cognitive Assessment. We constructed bias-corrected confidence intervals to test indirect effects of cardiovascular risk factors (hypertension, vascular disease, atrial fibrillation, diabetes mellitus, previous stroke) on cognitive function, mediated through stroke severity and history of dementia, and we assessed moderation effects due to comorbidity. Results: From 594 eligible patients, we included 587 in the final analysis (age range 26–100; 45% female). Our model explained R2 = 62.10% of variance in cognitive test scores. We found evidence for an indirect effect of previous stroke that was associated with increased risk of prevalent dementia and in turn predicted poorer cognitive score (estimate = − 0.39; 95% bias-corrected CI, − 0.75 to − 0.13; p = 0.02). Atrial fibrillation was associated with greater stroke severity and in turn with a poorer cognitive score (estimate = − 0.27; 95% bias-corrected CI, − 0.49 to − 0.05; p = 0.02). Conversely, previous TIA predicted decreased stroke severity and, through that, lesser cognitive impairment (estimate = 0.38; 95% bias-corrected CI, 0.08 to 0.75; p = 0.02). Through an association with reduced stroke severity, vascular disease was associated with lesser cognitive impairment, conditional on presence of hypertension and absence of diabetes mellitus (estimate = 0.36; 95% bias-corrected CI, 0.03 to 0.68; p = 0.02), although the modelled interaction effects did not reach statistical significance. Conclusions: We have shown that relationships between cardiovascular risk factors and cognition are complex and simple multivariable models may be overly reductionist. Including direct and indirect effects of risk factors, we constructed a model that explained a substantial proportion of variation in cognitive test scores. Models that include multiple paths of influence and interactions could be used to create dementia prognostic tools for use in other healthcare settings

The prevalence of frailty amongst acute stroke patients, and evaluation of method of assessment

Objective: We aimed to determine prevalence of pre-stroke frailty in acute stroke and describe validity of a Frailty Index–based assessment. Design: Cross-sectional. Setting: Single UK urban teaching hospital. Subjects: Consecutive acute stroke unit admissions, recruited in four waves (May 2016–August 2018). We performed the assessments within first week and attempted to include all admissions. Main measures: Our primary measure was a Frailty Index, based on cumulative disorders. A proportion of participants were also assessed with the ‘Frail non-disabled’ questionnaire. We evaluated concurrent validity of Frailty Index against variables associated with frailty in non-stroke populations. We described predictive validity of Frailty Index for stroke severity and delirium. We described convergent validity, quantifying agreement between frailty assessments and a measure of pre-stroke disability (modified Rankin Scale) using kappa statistics and correlations. Results: We included 546 patients. A Frailty Index–defined frailty syndrome was observed in 427 of 545 patients (78%), of whom, 151 (28%) had frank frailty and 276 (51%) were pre-frail. Phenotypic frailty was observed in 72 of 258 patients (28%). We demonstrated concurrent validity via significant associations with all variables (all p < 0.01). We demonstrated predictive validity for stroke severity and delirium (p < 0.01). Agreement between the frailty measures was poor (kappa = –0.06) and convergent validity was moderate (Frail non-disabled ‘Cramer’s V’ = 0.25; modified Rankin Scale ‘Cramer’s V’ = 0.47). Conclusion: Frailty is present in around one in four patients with acute stroke; if pre-frailty is included, then a frailty syndrome is seen in three out of four patients. The Frailty Index is a valid measure of frailty in stroke; however, there is little agreement between this scale and other measurements of frailty

Thinking About the Future: A Review of Prognostic Scales Used in Acute Stroke

Background: There are many prognostic scales that aim to predict functional outcome following acute stroke. Despite considerable research interest, these scales have had limited impact in routine clinical practice. This may be due to perceived problems with internal validity (quality of research), as well as external validity (generalizability of results). We set out to collate information on exemplar stroke prognosis scales, giving particular attention to the scale content, derivation, and validation.Methods: We performed a focused literature search, designed to return high profile scales that use baseline clinical data to predict mortality or disability. We described prognostic utility and collated information on the content, development and validation of the tools. We critically appraised chosen scales based on the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies (CHARMS).Results: We chose 10 primary scales that met our inclusion criteria, six of which had revised/modified versions. Most primary scales used 5 input variables (range: 4–13), with substantial overlap in the variables included. All scales included age, eight included a measure of stroke severity, while five scales incorporated pre-stroke level of function (often using modified Rankin Scale), comorbidities and classification of stroke type. Through our critical appraisal, we found issues relating to excluding patients with missing data from derivation studies, and basing the selection of model variable on significance in univariable analysis (in both cases noted for six studies). We identified separate external validation studies for all primary scales but one, with a total of 60 validation studies.Conclusions: Most acute stroke prognosis scales use similar variables to predict long-term outcomes and most have reasonable prognostic accuracy. While not all published scales followed best practice in development, most have been subsequently validated. Lack of clinical uptake may relate more to practical application of scales rather than validity. Impact studies are now necessary to investigate clinical usefulness of existing scales

Pre-stroke frailty is independently associated with post-stroke cognition: A cross-sectional study

Objective: Post-stroke cognitive impairment is common, but mechanisms and risk factors are poorly understood. Frailty may be an important risk factor for cognitive impairment after stroke. We investigated the association between pre-stroke frailty and acute post-stoke cognition. Methods: We studied consecutively admitted acute stroke patients in a single urban teaching hospital during three recruitment waves between May 2016 and December 2017. Cognition was assessed using the Mini-Montreal Cognitive Assessment (min=0; max=12). A Frailty Index was used to generate frailty scores for each patient (min=0; max=100). Clinical and demographic information were collected, including pre-stroke cognition, delirium, and stroke-severity. We conducted univariate and multiple-linear regression analyses with covariates forced in (covariates included were: age, sex, stroke severity, stroke-type, pre-stroke cognitive impairment, delirium, previous stroke/transient ischemic attack) to investigate the association between pre-stroke frailty and post-stroke cognition. Results: Complete data were available for 154 stroke patients. Mean age was 68 years (SD=11; range=32–97); 93 (60%) were male. Median mini-Montreal Cognitive Assessment score was 8 (IQR=4–12). Mean Frailty Index score was 18 (SD=11). Pre-stroke cognitive impairment was apparent in 13/154 (8%) patients. Pre-stroke frailty was significantly associated with lower post-stroke cognition (Standardized-Beta=−0.40; p<0.001) and this association was independent of covariates (Unstandardized-Beta=−0.05; p=0.005). Additional significant variables in the multiple regression model were age (Unstandardized-Beta=−0.05; p=0.002), delirium (Unstandardized-Beta=−2.81; p<0.001), pre-stroke cognitive impairment (Unstandardized-Beta=−2.28; p=0.001), and stroke-severity (Unstandardized-Beta=−0.20; p<0.001). Conclusions: Pre-stroke frailty may be a moderator of post-stroke cognition, independent of other well-established post-stroke cognitive impairment risk factors. (JINS, 2019, 00, 1–6

30 Leczenie skojarzone (brachyterapia HDR oraz teleterapia) zaawansowanego raka oskrzela

WstępW paliatywnym leczeniu raka oskrzela jedną z metod skutecznych w zwalczaniu duszności wywołanej obturacją jest brachyterapia. Ze względu na umiejscowienie zmiany, u niektórych chorych brachyterapia jest z leczeniem z wyboru. Leczenie skojarzone łączące teleterapię z brachyterapią jest stosowane jako radykalne (brachyterapia jako podwyższenie miejscowe dawki) lub paliatywne (teleterapia skierowana przeciw pakietom węzłów chłonnych uciskających oskrzele z zewnątrz). W pracy omówiono wyniki leczenia skojarzonego chorych na zaawansowanego raka oskrzeli.Materiał i metodyW okresie od maja 1999 do marca 2000 r. leczono w Wielkopolskim Centrum Onkologii 15 chorych na raka oskrzeli łącząc brachyterapię HDR z paliatywną teleterapią metodą hypofrakcjonacji. Wiek chorych sięgał od 39 do 80 lat, średnio 54,3 lata. U 3 chorych leczenie rozpoczęto od teleterapii (20–30 Gy) a u 12 – od brachyterapii HDR. Stosowano dawkę 3 × 7,5 Gy (9 chorych) lub 3 ×10 Gy (6 chorych) liczoną w odległości 1 cm od osi aplikatora. Chorych poddano obserwacji klinicznej oraz bronchoskopowej, oceniając remisję miejscową oraz ustępowanie duszności, kaszlu oraz krwioplucia w 1, 3 i 6 miesiącu obserwacji.WynikiPo zakończeniu leczenia subiektywną poprawę (ustępowanie duszności, kaszlu, krwawienia, bólu) stwierdzono u wszystkich chorych. W jednym przypadku uzyskano całkowitą remisję zmian utrzymującą się ponad 6 miesięcy, u 12 chorych – remisję częściową, u 2 chorych nie stwierdzono remisji w kolejnych badaniach.WnioskiLeczenie skojarzone (brachyterapia HDR i teleterapia) zaawansowanego raka oskrzela jest metodą skuteczna., powoduje u wielu chorych ustępowanie duszności oraz poprawę komfortu życia. Wysoka miejscowa dawka łączna nie wpłynęła na wzrost częstości powikłań

Prognostic rules for predicting cognitive syndromes following stroke: a systematic review

Purpose: Stroke survivors are at high risk of developing cognitive syndromes, such as delirium and dementia. Accurate prediction of future cognitive outcomes may aid timely diagnosis, intervention planning, and stratification in clinical trials. We aimed to identify, describe and appraise existing multivariable prognostic rules for prediction of post-stroke cognitive status. Method: We systematically searched four electronic databases from inception to November 2019 for publications describing a method to estimate individual probability of developing a cognitive syndrome following stroke. We extracted data from selected studies using a pre-specified proforma and applied the Prediction model Risk Of Bias Assessment Tool (PROBAST) for critical appraisal. Findings: Of 17,390 titles, we included 10 studies (3143 participants), presenting the development of 11 prognostic rules – 7 for post-stroke cognitive impairment and 4 for delirium. Most commonly incorporated predictors were: demographics, imaging findings, stroke type and symptom severity. Among studies assessing predictive discrimination, the area under the receiver operating characteristic (AUROC) in apparent validation ranged from 0.80 to 0.91. The overall risk of bias for each study was high. Only one prognostic rule had been externally validated. Discussion/conclusion: Research into the prognosis of cognitive outcomes following stroke is an expanding field, still at its early stages. Recommending use of specific prognostic rules is limited by the high risk of bias in all identified studies, and lack of supporting evidence from external validation. To ensure the quality of future research, investigators should adhere to current, endorsed best practice guidelines for conduct of prediction model studies

Physical and brain frailty in ischaemic stroke or TIA: shared occurrence and outcomes. A cohort study

Background: There is increasing interest in the concept of frailty in stroke, including both physical frailty and imaging-evidence of brain frailty. We aimed to establish the prevalence of brain frailty in stroke survivors as well as the concurrent and predictive validity of various frailty measures against long-term cognitive outcomes. Methods: We included consecutively admitted stroke or transient ischaemic attack (TIA) survivors from participating stroke centres. Baseline CT scans were used to generate an overall brain frailty score for each participant. We measured frailty via the Rockwood frailty index, and a Fried frailty screening tool. Presence of major or minor neurocognitive disorder at 18-months following stroke or TIA was established via a multicomponent assessment. Prevalence of brain frailty was established based upon observed percentages within groups defined by frailty status (robust, pre-frail, frail). We assessed the concurrent validity of brain frailty and frailty scales via Spearman’s rank correlation. We conducted multivariable logistic regression analyses, controlling for age, sex, baseline education and stroke severity, to evaluate association between each frailty measure and 18-month cognitive impairment. Results: Three-hundred-forty-one stroke survivors participated. Three-quarters of people who were frail had moderate-severe brain frailty and prevalence increased according to frailty status. Brain frailty was weakly correlated with Rockwood frailty (Rho: 0.336; p < 0.001) and with Fried frailty (Rho: 0.230; p < 0.001). Brain frailty (OR: 1.64, 95% CI = 1.17–2.32), Rockwood frailty (OR: 1.05, 95% CI = 1.02–1.08) and Fried frailty (OR: 1.93, 95% CI = 1.39–2.67) were each independently associated with cognitive impairment at 18 months following stroke. Conclusions: There appears to be value in the assessment of both physical and brain frailty in patients with ischaemic stroke and TIA. Both are associated with adverse cognitive outcomes and physical frailty remains important when assessing cognitive outcomes