Abstract
Background:Stroke and dementia are interrelated diseases and risk for both increases with age. Even though stroke incidence and age-standardized death rates have decreased due to prevention of stroke risk factors, increased utilization of reperfusion therapies, and other changes in healthcare, the absolute numbers are increasing due to population growth and aging.Objective:To analyze predictors of death after stroke in patients with dementia and investigate possible time and treatment trends.Methods:A national longitudinal cohort study 2007–2017 using Swedish national registries. We compared 12,629 ischemic stroke events in patients with dementia with matched 57,954 stroke events in non-dementia controls in different aspects of patient care and mortality. Relationship between dementia status and dementia type (Alzheimer’s disease and mixed dementia, vascular dementia, other dementias) and death was analyzed using Cox regressions.Results:Differences in receiving intravenous thrombolysis between patients with and without dementia disappeared after the year 2015 (administered to 11.1% dementia versus 12.3% non-dementia patients, p = 0.117). One year after stroke, nearly 50% dementia and 30% non-dementia patients had died. After adjustment for demographics, mobility, nursing home placement, and comorbidity index, dementia was an independent predictor of death compared with non-dementia patients (HR 1.26 [1.23–1.29]).Conclusion:Dementia before ischemic stroke is an independent predictor of death. Over time, early and delayed mortality in patients with dementia remained increased, regardless of dementia type. Patients with≤80 years with prior Alzheimer’s disease or mixed dementia had higher mortality rates after stroke compared to patients with prior vascular dementia.
Highlights
In the past years, stroke incidence and age-standardized death rates have decreased [1] due to prevention of stroke risk factors, of stroke recurrence, complications after stroke, other changes in healthcare [2], and increased utilization of reperfusion therapies [3]
Even though intravenous thrombolysis and mechanical thrombectomy have lower population benefits than, e.g., hospitalization in a stroke unit or pharmacological prevention [18], lower utilization of these in patients with dementia [19] could lead to worse outcomes and worse survival
Information on dementia type was available only for 3,756 stroke events in patients registered in SveDem; there were 754 (20.1%) with Alzheimer’s disease dementia (AD), 809 (21.5%) with mixed, 1,100 (29.3%) with vascular dementia and 1,093 (29.1%) with other dementias
Summary
Stroke incidence and age-standardized death rates have decreased [1] due to prevention of stroke risk factors, of stroke recurrence, complications after stroke, other changes in healthcare [2], and increased utilization of reperfusion therapies [3]. In our prior study, performed in a similar population, pre-stroke dementia was associated with excess mortality risk 3 months after stroke; this was partially mediated by poorer pre-stroke mobility [13]. Another possible explanation for increased mortality could be the higher occurrence of cardioembolic strokes in patients with dementia due to underutilization of anticoagulation in patients with dementia and atrial fibrillation (AF), as these strokes are more severe [14,15,16,17]. Patients with ≤ 80 years with prior Alzheimer’s disease or mixed dementia had higher mortality rates after stroke compared to patients with prior vascular dementia
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