African American Stroke Survivors Research Articles

African American patients have a higher probability of cognitive impairment after incident stroke: An analysis of national electronic health record data

BackgroundCognitive impairment (CI) and stroke are diseases with significant disparities in race and geography. Post stroke cognitive impairment (PSCI) can be as high as 15–70 % but few studies have utilized large administrative or electronic health records (EHR) to evaluate trends in PSCI. We utilized an EHR database to evaluate for disparities in PSCI in a large sample of patients after first recorded stroke to evaluate for disparities in race. MethodsThis is a retrospective cohort analysis of Cerner Health Facts® EHR database, which is comprised of EHR data from hundreds of hospitals/clinics in the US from 2009–2018. We evaluated patients ≥40 years of age with a first time ischemic stroke (IS) diagnosis for PSCI using ICD9/10 codes for both conditions. Patients with first stroke in the Cerner database and no pre-existing cognitive impairment were included, we compared hazard ratios for developing PSCI for patient characteristics ResultsA total of 150,142 IS patients with follow-up data and no pre-existing evidence of CI were evaluated. Traditional risk factors of age, female sex, kidney injury, hypertension, and hyperlipidemia were associated with PSCI. Only African American stroke survivors had a higher probability of developing PSCI compared to White survivors (HR 1.347, 95 % CI (1.270, 1.428)) and this difference was most prominent in the South. Among those to develop PSCI, median time to documentation was 1.8 years in African American survivors. ConclusionIn a large national database, African American stroke survivors had a higher probability of PSCI five years after stroke than White survivors.

SOCIAL CHARACTERISTICS OF RACIAL MINORITY STROKE SURVIVORS AND PERCEIVED DISCRIMINATION: A SECONDARY ANALYSIS

Abstract African American and Black persons experience significant disability after stroke. They also experience high external stressors, including discrimination, which may attenuate stroke recovery. Further understanding of the associations among external stressors, disability severity, and attenuated recovery are important to reduce healthcare disparities and improve patient outcomes. However, persons of the same race may not have the same lived experiences due to variations in social characteristics such as age or education. Associations between these social characteristics and perceived discrimination may offer insights into the recovery of older adult African American and Black stroke survivors. We conducted a secondary analysis of 11 poststroke patients who were recruited to participate in the Black Lived Experiences of Stroke Study (female=10, age=67±11, ≥2 years post-secondary education=63%) to assess the frequency of perceived discrimination. Perceived discrimination was measured with the Everyday Discrimination Scale survey. We examined correlations between age and education and perceived discrimination using Cramer’s V tests. Semi-structured participant interviews were also examined for examples of perceived discrimination during poststroke healthcare. Nine participants reported perceived discrimination post-stroke. Analyses revealed a clinically meaningful but not statistically significant relationship between chronological age and perceived discrimination (Cramer’s V=0.62, p=0.12). There was no meaningful relationship between educational level and perceived discrimination. All participants reported challenges with communication, missed diagnoses and poor delivery of care poststroke. Findings support the need for additional research to examine the relationships between participants’ social characteristics and perceived discrimination among Black and African American stroke survivors, and the impact on stroke recovery.

High tech and high touch: Recruitment strategies for enrolling African American stroke survivors in Community Based Intervention under Nurse Guidance after stroke (CINGS) trial

BackgroundSubstantial effort has been undertaken to improve the recruitment and retention of participants in stroke trials. African Americans are disproportionately under-represented in stroke clinical trials as well as clinical trials for other chronic disease conditions. To circumvent barriers to recruitment, clinical trial recruitment strategies used to recruit African Americans have focused on different aspects of community engagement. PurposeThis study examined a community-engaged, multi-phased tailored approach to recruiting African Americans with stroke. The recruitment approach described was designed to support the Community Based Intervention under Nurse Guidance after Stroke (CINGS) trial, part of the Wide Spectrum Investigation of Stroke Outcome Disparities on Multiple Levels (WISSDOM) Center established to explore stroke disparities. MethodsA multiple-phased recruitment approach was undertaken and involved a recruitment planning phase and a recruitment phase. The recruitment planning phase involved the use of focus groups designed to explore barriers and facilitators of stroke recovery. The active recruitment phase included multiple strategies with ongoing evaluation. ResultsInformation gained from focus groups offered insights into strategies critical to recruiting African Americans with stroke for behavioral research during the early recovery period. Strategies to enhance the identification of and recruitment of potential participants included use of: a) a hospital system stroke database, b) system-wide friendly visits/warm handoff approaches, c) electronic health record, d) associated external sites and e) protocol adjustments. ConclusionsDeveloping tailored approaches to curtail barriers to research participation is critical for increasing the probability of reaching African American study participant recruitment and retention goals. Research teams may require training in community-engagement research strategies essential for obtaining achieving target recruitment goals.

Health-related quality of life, social support, and social networks in African-American stroke survivors with and without aphasia.

Background Health-related quality of life (HRQL) provides insight into the impact of a health condition on an individual's ability to lead a fulfilling life. Previous research has identified determinants of HRQL in stroke survivors to include communication, mobility, mental/emotional health, role, and social functioning. However, health disparities among minority populations may influence HRQL in stroke survivors with and without aphasia. The aim of this study was to explore the HRQL and social functioning in a homogenous sample of African-Americans with chronic stroke. Methods A cross-sectional case control descriptive research design was adopted. A total of 39 African-American men (53.8%) and women (46.2%) participated in the study aged from 33 to 79 (M = 62.4 ±11.10). Three groups of 13 were developed based on behavioral performance and neurological report: stroke survivors with aphasia (SWA), stroke survivors without aphasia (SSA) and successfully aging/healthy adults with no history of neurological injury (SAH). The majority of stroke survivors (84.6%) reported a left hemisphere stroke. Patient-reported outcomes were administered face to face without the use of a proxy to measure HRQL and social functioning–the Stroke and Aphasia Quality of Life Scale-39g, the EuroQol-5D, the Medical Outcome Study Social Support Survey and the Lubben Social Network Scale. An ANOVA test and Scheffe post hoc analysis was used to compare means of the three groups. Results Chronic stroke survivors reported a lower HRQL than SAH adults. No differences were noted between the groups in specific areas of social functioning related to social support and social network. However, condition-specific HRQL differences in communication and social domains were identified between SWA to SSA and SAH adults. Physical domain differences were noted between SSA and SAH groups. Level of education was significantly different among the sample with individuals with higher education reporting a better HRQL. No significant differences were noted between the groups for presence of co-morbid conditions. Conclusion This study provides a preliminary examination of HRQL and social functioning in African American stroke survivors with and without aphasia compared to age and ethnicity-matched peers. Larger studies will be needed to examine determinants of HRQL in this understudied population.

Return to Work Among Stroke Survivors.

Despite improvements in the treatment of stroke, many individuals still face cognitive, emotional, and physical impairments. Stroke is a leading cause of serious long-term disability and subsequent failure to return to work (RTW). The purpose of this literature review was to synthesize and discuss the literature relevant to factors affecting RTW for stroke survivors, summarize the identified gaps, and discuss steps occupational health nurses can take to facilitate RTW among stroke survivors. A literature search was conducted using the keywords: "stroke," "cerebrovascular disease," "return to work," and "employment." After excluding articles based on inclusion/exclusion criteria, 19 quantitative research articles were reviewed. Consistent themes found in the literature affecting RTW following stroke included physical, social, and cognitive factors. One of the most consistent predictors of RTW found was stroke severity. Individuals who experienced a mild to moderate stroke, those of Caucasian ethnicity, and higher socioeconomic levels were more likely to RTW. Findings suggest the importance of future studies to examine factors among African American stroke survivors that predict RTW and the role of occupational health nurses.

Reducing Stroke Risk Among Young Adult African Americans: A Feasibility Study.

African Americans are disproportionately affected by stroke and its modifiable risk factors, and strategies are needed to help African Americans adopt healthy lifestyles early in life. The purpose of this study was to assess the feasibility of the Stroke Counseling for Risk Reduction (SCORRE) intervention, a tailored, theory-based intervention consisting of a motivational video of young African American stroke survivors, the American Heart Association's Life's Simple 7® (LS7) risk assessment and education tool, and a 6-week behavioral risk reduction diary. Feasibility and changes in theoretical variables were evaluated over 6 weeks. In four months, 30 participants were enrolled and randomized and 29 (97%) completed the study. Participants averaged 23 years old, most were female university students, and they had an average of 2.1 out of 7 risk factors for stroke. Only 7% had missing items on questionnaires, and 17% had missing daily diary entries. Although statistical significance of differences was not assessed, both intervention and control groups had improvements in knowledge scores following the initial session, and larger improvements in accuracy of perceived stroke risk and in health behaviors (physical activity and diet quality) were observed among participants receiving SCORRE. An exit survey indicated the majority of participants receiving SCORRE were motivated to achieve better health; enjoyed the video, LS7 and diary; and felt the program length was appropriate. Results suggest that SCORRE is feasible and acceptable, and with additional refinement and further testing has potential for reducing stroke risk among African Americans. © 2016 Wiley Periodicals, Inc.

Depression and Functional Status Among African American Stroke Survivors in Inpatient Rehabilitation

To examine the prevalence of poststroke depression (PSD) among African American stroke survivors and the association of depression with functional status at inpatient rehabilitation facility (IRF) discharge. Secondary data analysis was conducted of a patient cohort who received care at 3 IRFs in the United States from 2009 to 2011. Functional status was measured by the Functional Independence Measure (FIM). Multiple linear regression models were used to examine associations of PSD and FIM motor and cognitive scores. Of 458 African American stroke survivors, 48.5% were female, 84% had an ischemic stroke, and the mean age was 60.8 ± 13.6 years. Only 15.4% (n = 71) had documentation of PSD. Bivariate analyses to identify factors associated with depression identified a higher percentage of patients with depression than without who were retired due to disability (17.1% versus 11.6%) or employed (31.4% versus 19.6%) prestroke (P = .041). Dysphagia, cognitive deficits, and a lower admission motor FIM score were also significantly more common among those with depression. There was no significant relationship between depression and functional status after adjusting for patient characteristics. In this study, 15% of the African Americans who received rehabilitation after a stroke had documentation of PSD but this was not associated with functional status at discharge.

Abstract WP318: Racial Differences in the Prevalence of Falls among Stroke Survivors

Background: National data shows that African Americans (AA) are less likely to fall than whites. However, the reasons for this difference and whether it is true amongst stroke survivors are unknown. We hypothesized that AA stroke survivors fall less than white stroke survivors, and sought to understand which risk factors drive racial differences. Methods: Data from the 2011 wave of National Health and Aging Trends Study (NHATs), a nationally representative population of community-dwelling adults over 65, were used. We compared the prevalence of self-reported falling in the past year between AA and white stroke survivors using Poisson regression models. Models were adjusted for groups of variables that may predict race-based differences in falls: sociodemographic, comorbidity, capacity, fall risk factor, fall access, and environment. Race-specific predictive margins and prevalence ratios (PR) were calculated. Results: The sample included 806 stroke survivors; 581 white and 228 AA. AAs had lower income, physical and cognitive capacity, were less likely to be married, to go outside, to have osteoporosis, and lived in worse neighborhood environments compared to white stroke survivors. Unadjusted, prevalence of falling in the past year was similar comparing AA to whites (PR: 0.89, p=0.2). Adjustment for sociodemographic variables produced a marginal racial difference, which became statistically significant after adding physical and cognitive capacity measures (Table). After full adjustment, AA were 30% less likely to have reported a fall compared to whites (p=0.004). Conclusions: African American stroke survivors are significantly less likely to report falling in the previous year compared to whites. Differences in sociodemographics and capacity may be most influential, yet other factors did not account for differences in fall prevalence. Further study of falls among AA stroke survivors may provide insight to decrease falls among other racial/ethnic groups.

Abstract T P116: Impact of Serum Nutritional Status on Physical Function in African American and Caucasian Stroke Survivors

Difficulties with speech and cognition may interfere with obtaining accurate dietary records to assess dietary quality in those chronically disabled by stroke. Several serum biomarkers commonly found on general comprehensive chemistry panels (e.g. albumin, hemoglobin, uric acid, and lipids) may provide a surrogate clinical indication of nutritional risk when dietary recall is not valid. Thus, the purpose of this study was to determine whether serum nutritional markers differ by race and relate to physical function in stroke. Further, we sought to compare serum profiles in chronic stroke survivors with a representative sample of U.S. Adults (NHANESIII). Fasting serum samples were collected for analysis of lipids, hemoglobin, uric acid, and albumin in 145 African American (AA) and 111 Caucasian (C) stroke survivors (age: 60±1 years [mean±SEM]; BMI: 28 kg/m2). VO2max (N=159), six-minute walk (N=134), 30 foot timed walk (N=161), and isokinetic hamstring strength (N=91) tests were performed in subsets of stroke survivors. VO2max was “very poor” in 96% of stroke survivors and mean walking speed was 40% below recommendations for maintenance of functional independence. Lipids were less favorable in C than AA women stroke survivors (40% higher triglycerides (TG) and 11% lower HDL cholesterol; Ps<0.05). In contrast, serum albumin was 6% lower in AA than C women (P<0.05). Uric acid was ~10% lower in C than AA stroke survivors (P<0.05). These racial differences were similar to that observed in the reference sample, but HDL cholesterol, albumin, and hemoglobin generally were lower (Ps<0.05) in stroke. Lipids were more favorable (~20% lower total cholesterol and ~25% lower TG; Ps<0.01) in stroke, likely due to a high prevalence of lipid lowering medication usage (64%). Uric acid was related to six-minute walk time (r=0.16) and hamstring strength (r=0.20) in stroke survivors (Ps<0.05), suggesting that low uric acid qualifies as a marker worth monitoring in the context of predicting stroke-related functional decline. Although nutritional risk varies according to race in stroke, the racial differences appear similar to a representative U.S. non-stroke sample. Regardless of race, serum nutritional risk does appear elevated in stroke compared to the general population.

Impact of serum nutritional status on physical function in african american and caucasian stroke survivors.

Background. The purpose of this study is to compare serum nutritional profiles in chronic stroke survivors to a representative sample of US Adults (NHANESIII) and determine whether these serum markers differed by race and impact physical function in stroke. Methods. Fasting serum samples were collected for analysis of lipids, uric acid, and albumin in 145 African American (AA) and 111 Caucasian (C) stroke survivors (age: 60 ± 1 years [mean ± SEM]). A six-minute walk was performed in a subset of stroke survivors (N = 134). Results. Triglycerides were higher and HDL-cholesterol and albumin lower in C than AA women stroke survivors (Ps < 0.05). Uric acid was lower in C than AA stroke survivors (P < 0.05). Compared to NHANESIII, HDL-cholesterol, albumin, and hemoglobin generally were lower (Ps < 0.05) and lipids were more favorable in stroke (Ps < 0.01). Uric acid was related to six-minute walk performance among a subset of stroke survivors (P < 0.05). Conclusion. In stroke, racial differences exist with regard to serum nutritional risk, but these differences are similar to that observed in the general population. Regardless of race, nutritional risk appears elevated above that of the general population with regard to many of the serum markers. As a modifiable biomarker, uric acid should be monitored closely as it may provide insight into the functional risk of stroke survivors.

Race and Gender Differences in 1-Year Outcomes for Community-Dwelling Stroke Survivors With Family Caregivers

Previous research has reported worse outcomes after stroke for women and for African Americans, but few prospective population-based studies have systematically examined demographic differences on long-term stroke outcomes. Race and gender differences in 1-year stroke outcomes were examined using an epidemiologically derived sample of first-time stroke survivors from the national REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Participants of REGARDS who reported a first-time stroke event during regular surveillance calls were interviewed by telephone and then completed an in-home evaluation approximately 1 year after the verified first-time stroke event (N=112). A primary family caregiver was also enrolled and interviewed for each stroke survivor. Measures from the in-home evaluation included previously validated stroke outcomes assessments of neurological deficits, functional impairments, and patient-reported effects of stroke in multiple domains. Results- African American stroke survivors were less likely to be living with their primary family caregivers than white participants. Analyses that controlled for age, education, and whether the stroke survivors lived with their primary family caregivers indicated that African Americans and women showed significantly greater deficits on multiple 1-year outcome measures compared to whites and men, respectively. Among community-dwelling stroke survivors with family caregivers, women and African Americans are at heightened risk for poor long-term outcomes 1 year after first-time stroke events. Rehabilitation services and public health policies aimed at enhancing stroke recovery rates should address these disparities in poststroke outcomes.

Using a Classification Process to Optimize Outcome of Stroke Rehabilitation

ABSTRACTBackground: Although it is generally presumed that experienced clinicians are capable of making reasonable decisions concerning rehabilitation potential, inexperienced clinicians may expend efforts and resources somewhat unproductively in managing patients with nonprogressive neurological conditions such as stroke. Clinicians with varied experience may also be influenced by extraneous factors least likely to contribute to an effective admission and treatment planning. Purpose: We report a process for efficient utilization of resources to maximize outcome following stroke rehabilitation. Description: A care planning process with distinctive features of patient profiling, treatment tracking, and outcome staircasing was developed and utilized in the subacute stroke management of African American stroke survivors in an inpatient facility in New York. Outcome of stroke rehabilitation care were compared before and after the implementation of the process using Functional Independence Measures (FIM) scores in activities of daily living, Length of Stay (LOS), FIM change at discharge, and LOS efficiency. A priori comparison of outcome before and after program implementation was also made with those of similar facilities in the region and in the nation. Results: The results show significant decrease in LOS and consistent improvement in LOS efficiency following program implementation. While averages in LOS and LOS efficiency approach those of similar facilities in the region and nation, a trend of FIM change that exceeded regional and national averages observed before program continued postprogram implementation. Conclusion: A structured process involving patient profiling and treatment tracking could result in improved outcome in stroke rehabilitation.

Coherence in the Urban Family Caregiver Role with African American Stroke Survivors

Expressions of coherence by urban caregivers in African American family systems are the focus of this ethnographic study. The profound changes that can accompany stroke may create considerable stress for families caring for the affected person. Coherence, a sense of mutuality, and differences in functioning among family members were discovered in this study to be important for maintaining stability within the family. Through coherence, family caregivers felt connected and this helped them survive in stressful times related to caring situations. The findings aid in defining coherence as an interpersonal process and place it in a family system context.

Effects of a short-term health promotion intervention for a predominantly African-American group of stroke survivors

Background: The study examined the effects of a 12-week health promotion intervention for a predominantly urban African-American population of stroke survivors. Design: A pre-test/post-test lag control group design was employed. Participants/Setting: Participants were 35 stroke survivors (9 male, 26 female) recruited from local area hospitals and clinics. Main Outcome Measures: Biomedical, fitness, nutritional, and psychosocial measures were employed to assess program outcomes. Results: Treatment group made significant gains over lag controls in the following areas: (1) reduced total cholesterol, (2) reduced weight, (3) increased cardiovascular fitness, (4) increased strength, (5) increased flexibility, (6) increased life satisfaction and ability to manage self-care needs, and (7) decreased social isolation. Conclusion: A short-term health promotion intervention for predominantly African-American stroke survivors was effective in improving several physiological and psychological health outcomes.