Elderly Post-stroke Patients Research Articles

Study of the Possibility of Using Virtual Reality Application in Rehabilitation among Elderly Post-Stroke Patients.

Thanks to medical advances, life expectancy is increasing. With it comes an increased incidence of diseases, of which age is a risk factor. Stroke is among these diseases, and is one of the causes of long-term disability. The opportunity to treat these patients is via rehabilitation. A promising new technology that can enhance rehabilitation is virtual reality (VR). However, this technology is not widely used by elderly patients, and, moreover, the elderly often do not use modern technology at all. It therefore becomes a legitimate question whether elderly people will be able to use virtual reality in rehabilitation. This article presents a rehabilitation application dedicated to patients with upper limb paresis and unilateral spatial neglect (USN). The application was tested on a group of 60 individuals including 30 post-stroke patients with an average age of 72.83 years. The results of the conducted study include a self-assessment by the patients, the physiotherapist's evaluation, as well as the patients' performance of the exercise in VR. The study showed that elderly post-stroke patients are able to use virtual reality applications, but the ability to correctly and fully perform an exercise in VR depends on several factors. One of them is the ability to make logical contact (p = 0.0001 < 0.05). However, the study presented here shows that the ability to use VR applications does not depend on age but on mental and physical condition, which gives hope that virtual reality applications can be used in post-stroke rehabilitation among patients of all ages.

SOME FACTORS RELATED TO FATIGUE STATUS IN ELDERLY POST-STROKE PATIENTS

Objectives: To identify factors related to fatigue status in elderly post-stroke patients. Methods: A cross-sectional study on 157 patients those ages ≥ 60, diagnosed with stroke (according to the World Health Organization - WHO) and examined or treated as inpatients and outpatients at the National Geriatric Hospital, from July to November 2021. Data were collected using designed tools including characteristics of these patients. Entered data on Redcap and used SPSS version 22.0 for analysis. Results: Relevant factors affecting fatigue in elderly patients after stroke were physical activity daily living, cognitive impairment by Mini-Mental State Examination (MMSE), sleep disturbance by Pittsburgh Sleep Quality Index (PSQI), depression, and malnutrition. Factors that increased the risk of fatigue were age ≥ 60, using medication total, and cognitive decline. Conclusion: Early detection by performing the Fatigue Severity Scale (FSS) test to screen for fatigue in elderly post-stroke patients can provide appropriate treatment that helps improve treatment effectiveness as well as patients' quality of life.

(In)visibilité dans la clinique de l’AVC du sujet âgé : effets intrapsychiques et intersubjectifs de l’utilisation de l’IRM

ContextThis paper illustrates a psychodynamic analysis of the intrapsychic and intersubjective effects of the use of MRI in a Neurovascular Unit (NVU) for elderly post-stroke patients, in mainland France. The sudden onset of the stroke and the shift from independence to dependence are juxtaposed with the reality of normal and pathological aging in the elderly, making the boundaries around these two issues difficult to determine. ObjectivesThe aim of this paper is to propose a reflection about the intrapsychic and intersubjective effects of the almost automatic use of the MRI results during the hospitalization of elderly post-stroke patients. MethodThis is a theoretical-clinical elaboration based on clinical cases derived from clinical psychotherapeutic sessions with post-stroke hospitalized patients, institutional observations during staff meetings, and transdisciplinary interviews with the patients and their families. ResultsWe can conclude, through the cases studied and the theoretical analysis that a more personalized use of MRI is essential, because it may help the patient to visualize his or her stroke, to organize what has been psychologically and physically disorganized, and to create a link with the healthcare professional. However, an automated and mechanized way of showing these results may lead the patient into a psychological impasse, accentuate the psycho-corporal disorganization, and complexify the relationship with others. InterpretationsMRI is nowadays the main tool for diagnosing strokes, allowing in vivo exploration of the human brain. Despite its relatively recent appearance, MRI seems to be essential in the treatment and monitoring of stroke patients. However, the use of showing the MRI results to the elderly patients in a stroke unit, their families, and the healthcare professionals does not seem to have been thought through, or at the very least, reflected upon consciously.

Prevalence of Dementia and its Correlation with Cognitive Function in Elderly Post-Stroke Patients

BACKGROUND: Post-stroke dementia (PSD) is a clinical entity that encompasses all types of dementia following an index stroke, which may affect up to one third of stroke survivors. Unlike physical disability after stroke, cognitive function usually worsens over time and are often overlooked with detrimental impacts on the quality of life of survivors. MATERIALS AND METHOD: This work is a cross-sectional questionnaire-based study. Elderly post-stroke patients participated in this study. We adopted Dementia Severity Rating Scale (DSRS) and The Mini Mental State Examination (MMSE) we recorded the prevalence of dementia and its correlation with cognitive function in elderly post stroke patients. RESULT: Data of 46 participants was analysed. The mean age group was above 60years, as this study was conducted in elderly post-stroke patients. In this study 41% females and 59% males participated based on the inclusion and exclusion criteria. Two components were collected using Dementia Severity Rating Scale (DSRS) and The Mini Mental State Examination (MMSE). CONCLUSION: The study concluded that in present scenario of post stroke patient. the sub items of questionnaire (MMSE) and (DSRS) have increased values indicating towards risk factor of dementia and cognitive functions in post-stroke elderly patients in Pravara Rural Hospital is mostly when the age increases as shown significant correlation in Group B with age group of 60-70 years. whereas in Group A with age group of 71-80 years shows that there is no significant correlation. Hence, our study concluded that there is a co-relation of dementia and cognitive function in elderly post stroke patients. So, it determines that the correlation between dementia and cognitive function is more significant at age 71-80 hence, statistically proved.

Effect of functional electrical stimulation of interscapular muscles on trunk performance and balance in post-stroke elderly patients

BackgroundDisability in the upper limb in post-stroke survivors may have a variety of effects, particularly in the elderly, that require planning therapeutic actions to restore function. Thirty-four patients were randomly assigned to the control group (CON) and the Functional Electrical Stimulation (FES) group. For 12 weeks, the CON group received core stabilization exercises (CSEs). The FES group received (FES) for the interscapular muscles with CSEs for the first six weeks and completed the following six weeks with only CSEs. Patients were assessed at baseline, 6 and 12 weeks post-intervention. The trunk impairment scale (TIS) and the Postural Assessment Scale for Stroke (PASS) were used to assess trunk performance. A palpation meter was used to measure the scapular horizontal position (SP). Balance was assessed by the Berg Balance Scale (BBS), and the Timed Up-and-Go test (TUG). Function was assessed with Barthel Index (BI).ResultsBoth groups improved significantly (P < 0.001 for both groups, d = 1.1–3.7 for control group and d = 1.9–6.1 for FES group) post-treatment (at 6 and 12 weeks) in all outcomes except SP in the control group (P < 0.05 at both times, d = 0.6 at 6 weeks and 0.8 at 12 weeks).ConclusionFES for interscapular muscles may have positive effects on trunk performance, scapular position, balance, and function in stroke patients. Also, additional improvements were observed post-intervention compared to baseline. FES is recommended to be part of the rehabilitation program of elderly post-stroke patients.

The effectiveness of virtual reality games in improving cognition, mobility, and emotion in elderly post-stroke patients: a systematic review and meta-analysis.

This review is aimed to assess the effectiveness of virtual reality (VR) games on cognition, mobility, and emotion in elderly stroke patients. We selected relevant articles from eight databases from 2011 to 2022 and extracted articles on cognitive ability (general cognition, mini-mental state examination (MMSE), Montreal cognitive assessment (MoCA) et al.), mobility (modified Barthel index (MBI), Fugl-Meyer assessment (FMA), Berg balance scale (BBS), functional independence measure motor (FIM MOT)), and emotion (depression/anxiety). Twenty-nine studies including 1311 participants were included in the analysis. In the results, virtual reality games were more effective in improving overall cognitive function in stroke patients compared to conventional therapies. In addition, the intervention group in the MMSE (SMD = 0.6, 95%CI = 0.26-0.95, P = 0.0007), MoCA (MD = 1.97, 95%CI = 1.3-2.64, P < 0.00001), and attention test (MD = 0.25, 95% CI = 0.01-0.49, P < 0.00001) scores were also higher. In terms of physical function, MBI (SMD = 0.61, 95%CI = 0.14-1.08, P = 0.01), FMA (SMD = 0.47, 95%CI = 0.02-0.93, P = 0.04), BBS (SMD = 0.78, 95%CI = 0.42-1.15, P < 0.0001), and FIM MOT (MD = 5.87, 95%CI = 2.57-9.17, P = 0.0005) indicators showed better results. It is also observed that virtual reality games can effectively relieve depression and improve mental health in stroke patients. Sports game training, especially with VR equipment, had a positive impact on improving the cognitive performance, mobility, and emotional state of stroke patients compared to a control group. Although the improvement in cognitive ability is relatively low, the effect of improving physical activity and depression is obvious.

Application of Immersive Virtual-Reality-Based Puzzle Games in Elderly Patients with Post-Stroke Cognitive Impairment: A Pilot Study.

The society is aging in China, and the cognitive level of elderly post-stroke patients gradually declines. Face-to-face cognitive functional training is no longer sufficient. Immersive virtual reality (IVR) is a promising rehabilitation training device. In this study, we developed an IVR-based puzzle game to explore its effectiveness, feasibility, and safety in elderly stroke patients with cognitive dysfunction. A total of 30 patients with mild post-stroke cognitive impairment after stroke were randomly assigned to a control or IVR group. Patients in both groups received routine rehabilitation therapy. Patients in the control group received traditional cognitive training, and those in the IVR group received IVR-based puzzle game therapy. Before and after treatment, Montreal cognitive assessment (MOCA), trail-making test-A (TMT-A), digit symbol substitution test (DSST), digital span test (DST), verbal fluency test (VFT), and modified Barthel index (MBI) were evaluated in both groups. In addition, the IVR group was administered a self-report questionnaire to obtain feedback on user experience. There was no significant difference in the baseline data between the two groups. After six weeks of treatment, the cognitive assessment scores were improved in both groups. Moreover, the IVR group showed more improvements than the control group in the DSST (Z = 2.203, p = 0.028 &lt; 0.05, η2 = 0.16); MOCA (T = 1.186, p = 0.246 &gt; 0.05, d = 0.44), TMT-A (T = 1.791, p = 0.084 &gt; 0.05, d = 0.65), MBI (T = 0.783, p = 0.44 &gt; 0.05, d = 0.28), FDST (Z = 0.78, p = 0.435 &gt; 0.05, η2 = 0.02), BDST (Z = 0.347, p = 0.728 &gt; 0.05, η2 = 0.004), and VFT(Z = 1.087, p = 0.277 &gt; 0.05, η2 = 0.039) did not significantly improve. The significant difference in DSST represents an improvement in executive function and visual-spatial cognitive characteristics. The other assessment scores did not show such features. Therefore, we did not observe significant differences through this measure. According to the results of the self-report questionnaire, most of the patients were satisfied with the equipment stability and training content. Several individuals reported mild adverse reactions. This pilot study suggests that IVR-based puzzle games are a promising approach to improve post-stroke cognitive function, especially executive cognitive function, and visual-spatial attention in older adults.

Electrocardiogram analysis of post-stroke elderly people using one-dimensional convolutional neural network model with gradient-weighted class activation mapping

Stroke is the second leading cause of death globally after ischemic heart disease, also a risk factor of cardioembolic stroke. Thus, we postulate that heartbeats encapsulate vital signals related to stroke. With the rapid advancement of deep neural networks (DNNs), it emerges as a powerful tool to decipher intriguing heartbeat patterns associated with post-stroke patients. In this study, we propose the use of a one-dimensional convolutional network (1D-CNN) architecture to build a binary classifier that distinguishes electrocardiograms (ECGs) between the post-stroke and the stroke-free. We have built two 1D-CNNs that were used to identify distinct patterns from an openly accessible ECG dataset collected from elderly post-stroke patients. In addition to prediction accuracy, which is the primary focus of existing ECG deep neural network methods, we have utilized Gradient-weighted Class Activation Mapping (GRAD-CAM) to facilitate model interpretation by uncovering subtle ECG patterns captured by our model. Our stroke model has achieved ~90 % accuracy and 0.95 area under the Receiver Operating Characteristic curve. Findings suggest that the core PQRST complex alone is important but not sufficient to differentiate the post-stroke and the stroke-free. In conclusion, we have developed an accurate stroke model using the latest DNN method. Importantly, our work has illustrated an approach to enhance model interpretation, overcoming the black-box issue confronting DNNs, fostering higher user confidence and adoption of DNNs in medicine.

The Impact of Nasogastric Feeding Tube on Physiologic Swallow in Head and Neck Cancer Patients: A Multidisciplinary Clinical Trial

<h3>Purpose/Objective(s)</h3> Nasogastric feeding tubes (NGT) are ubiquitous within the head and neck (H&N) cancer patient population. NGT are often placed in post-surgical H&N cancer patients to allow for healing of suture lines in oral cavity and oropharyngeal free flap patients and are also used in transoral robotic surgery (TORS) patients. Despite their widespread use, the impact of NGT on the physiologic swallow of H&N cancer patients remains unknown. In the neurology literature, there is data demonstrating alterations in the functional swallow of elderly post-stroke patients with NGTs. This showed significant differences in pharyngeal transit time of an ingested barium bolus, with increased barium residue in the vallecula and pyriform sinus with the NGT in place, suggesting the NGT itself plays a role in altering physiologic swallow. The goals of the present study are twofold: 1: Determine the effects of an indwelling NGT on swallowing function in head and neck surgery patients. We hypothesize that the NGT will impair the physiologic swallow function resulting in a higher likelihood of laryngeal penetration and aspiration. 2: Determine the effect of an NGT on head and neck surgery patients perceived ability to swallow. We hypothesize that the presence of the NGT will negatively affect participants perception of their own ability to swallow. <h3>Materials/Methods</h3> This study was approved by our institutional review board (clinical trial VICC HN 2102). A multidisciplinary team involving H&N surgeons, speech language pathologists, and radiologists were critical in the development of this project. This is a crossover trial in which participants serve as their own control. Inclusion criteria include adult patients who underwent oral cavity or oropharyngeal cancer surgery including TORS and received an NGT as part of their standard of care. Exclusion criteria included altered mental status, need for long-term enteral feeding (i.e. NGT could not be safely removed to allow the patient to receive all nutrition via oral intake) and total or partial laryngectomy. Participants will complete two surveys about their subjective swallow, the Sydney Swallow Questionnaire and a 5-question supplemental survey utilizing a visual analog scale. They will undergo a video fluoroscopic swallow study (VFSS) with the NGT in place with thin and thick barium consistencies. The NGT is then removed and the two surveys and VFSS are repeated without the NGT in place. Objective measurements collected during the VFSS include oral, pharyngeal, and esophageal transit times and the penetration-aspiration scale scores. Ten of planned forty participants have been enrolled in the study. <h3>Results</h3> TBD <h3>Conclusion</h3> TBD

Characteristics of cognitive impairment in elderly post-stroke patients at the National Geriatric Hospital

Objective: To identify prevalence and characteristics of cognitive impairment in eldery post-stroke patients at the National Geriatrics Hospital. Subject and method: A cross-sectional descriptive study on 267 post-stroke patients aged ≥ 60 years old treated at the National Geriatrics Hospital. Patients were interviewed according to uniform questionnaire, cognitive function was assessed by using the Mini-Mental State Examination (MMSE): Total MMSE point &lt; 24: Cognitive impairment. Result: The mean age of the patients was 70.5 ± 8.7 years, male patients accounted for 60.3%. The prevalence of cognitive impairment was 66.3%. The rate of severe, moderate and mild cognitive impairment were 32.2%; 18.4% and 15.7%, respectively. The registration, the language and the copying ability of hemorrhagic stroke patients were significantly lower than those in the group of ischemic stroke (p&lt;0.05). Conclusion: This study confirms the high prevalence of cognitive impairment after stroke (66.3%) in which severe cognitive impairment (32.2%) was in majority. Cognitive impairment screening and early diagnosis will help to take remedial measures.

Association of affected lower limb flexor muscle strength with swing phase duration and gait speed in elderly post-stroke patients.

Although several studies have shown an association of muscle weakness with gait speed (GS), no study has explored the relationship of muscle strength with swing phase duration and GS after stroke among the elderly in Saudi Arabia. To examine the association of affected ankle dorsiflexor and hip flexor muscle strength with swing phase duration and GS in the elderly with different stroke chronicity. In this cross-sectional study, we included a total of 60 post-stroke patients aged ≥55 years who were admitted in neurorehabilitation units between May 2017 and August 2018. Linear regression was employed to examine the association of muscle strength (measured using a handheld dynamometer) with swing phase duration and GS (both measured using the computerized Zebris-Mat). The chronicity of the stroke was negatively associated (p < 0.05) with swing phase duration. The ankle dorsiflexor muscle strength was significantly associated with GS (β= 0.656, p = 0.041). In contrast, hip flexor muscle strength was significantly associated with GS (β= 0.574, p < 0.0001) even after adjusting for stroke chronicity (β= 0.561, p < 0.0001). Stroke chronicity was the predictor that reduced swing phase duration. The ankle dorsiflexor muscle strength was associated with GS. However, the hip flexor muscle strength was associated with GS even after adjusting for stroke chronicity.

Kinematic on Ankle and Knee Joint of Post-Stroke Elderly Patients by Wearing Newly Elastic Band-Type Ankle-Foot Orthosis in Gait.

PurposeThe post-stroke elderly was increased caused by increasing stroke and advanced medical. However, ankle–foot orthoses (AFOs) can be uncomfortable for hemiplegic patients; therefore, the usability is not good. In this study, we analyzed ankle and knee joint angles in post-stroke elderly patients to assess the functional effectiveness (specifically prevention of back knee and drop-foot) of a new elastic band-type AFO (New Product: NP) during gait.Patients and methodsNine elderly post-stroke patients (eight males, one female; 55.7±8.4 years; 165.8±9.2 cm; 68.8±11.5 kg; five with right hemiplegia, four with left hemiplegia; onset period: 6.6 years) were selected for participation in this study. We captured gait motion using 12 cameras (MX-T20, Vicon, Inc., Oxford, UK) under three different conditions [wearing nothing (WI), using existing ordinary AFOs made from hard plastic material (EP), and using NP]. The angle variation and maximum–minimum angle of the lower body joints were analyzed during dorsi-plantar flexion of the ankle joint and flexion–extension of knee joint. A one-way ANOVA test for multiple comparisons was performed, followed by a Tukey’s b test to identify statistical significance, which was set at 0.005.ResultsRegarding the ankle joint, the maximum plantar flexion (drop-foot) value decreased with the NP, and the maximum dorsiflexion value increased. Regarding the knee joint, the maximum extension (back knee) value decreased, and the maximum flexion value increased (p < 0.005).ConclusionUsing analysis of the kinematics of the ankles and knees during walking, this research confirmed the effectiveness of the NP, an elastic band-type AFO, for use in ordinary post-stroke elderly patients.

Effect of an indwelling nasogastric tube on swallowing function in elderly post-stroke dysphagia patients with long-term nasal feeding

BackgroundIn clinical practice, a large number of post-stroke survivors require nasogastric tube (NGT) placement and nasal feeding for a relatively long period. However, its impact on the swallowing function remains largely unknown. This study examines the impact of prolonged placement of an NGT on the swallowing function of elderly post-stroke patients.MethodsThe participants of this study were 30 elderly post-stroke patients who had been using an NGT for more than 2 months. A videofluoroscopic swallowing study (VFSS) was performed before and 5 h after removal of the NGT. The following parameters were analyzed and compared, the functional dysphagia scale (FDS), residue in the valleculae, residue in the pyriform sinuses, and the penetration-aspiration scale (PAS). In addition, prior to the VFSS, the pharynx and larynx were examined using a fiberoptic laryngoscope.ResultsSignificant differences were observed between the total scores of the FDS, pharyngeal transit times (PTTs), the residue in the valleculae, and the residue in the pyriform sinuses before and after the NGT removal, suggesting an improved swallowing function following the removal of the NGT. A significantly lower penetration-aspiration degree was found after removing the NGT compared with that before its removal. In addition, examinations using the fiberoptic laryngoscope showed that laryngopharyngeal edema was present in three quarters of the patients.ConclusionsOur results demonstrate that prolonged placement of the NGT had a negative impact on the swallowing function of elderly post-stroke dysphagia patients, mainly on the pharyngeal phase.

Learning of a postural control task by elderly post-stroke patients

&lt;p class="ResumoAbstract"&gt;The aim of this study was to compare the learning process of a postural control task between post-stroke patients and healthy subjects. The sample was composed of 20 post-stroke individuals (Experimental Group) and 20 aged matched healthy individuals (Control Group). Participants practiced a postural control task in a virtual environment with increasing of complexity. The study design involved four phases: pre-test (five trials), acquisition phase (four blocks of thirty minutes), post-test (five trials), and retention test (five trials after a week without practice). The statistical analysis was run by a 2 x 3 ANOVA (groups x learning tests). Results: There was no difference in motor learning between Experimental Group and Control Group (F= 41.22; p=0.88). In addition, it was founded that the Control Group could learn the task in a higher-level complexity than Experimental Group (F = 4.77; p = 0.01), and both groups increased the error during the trials of practice (F = 0.53; p = 0.00) because of task complexity. Conclusion: Therefore has been found that post-stroke individuals have the ability to learn a postural control task similar to healthy subjects, and the task complexity seems to be a key-factor in order to differentiate stroke from healthy subject's motor learning process.&lt;/p&gt;

Study of the Recovery Patterns of Elderly Subacute Stroke Patients in an Interdisciplinary Neurorehabilitation Unit

This study seeks to establish the facts of the improvement over time in elderly poststroke patients. A retrospective study was performed with regard to 106 subacute stroke patients aged older than 65 years, who were treated in an interdisciplinary neurorehabilitation unit. Three assessment points were established (on admission, 6 months post-onset, and 12 months post-onset), with the scores relative to 10 assessment scales having been collected at each point. By means of a principal component analysis, a first component was obtained, which is taken to represent a combined index of the 10 scales and to express the overall health status of the patient. An analysis of variance of this first component enabled a clear improvement trend to be identified, with this being more marked during the first 6-month period (72.7%) than the second 6-month period (27.3%). The elderly stroke patients underwent an interdisciplinary rehabilitation program lasting 1 year, experimented an initial period of rapid recovery during the first 6 months followed by a less marked period of improvement. However, no stabilization period in the patients' progress was found.

Abstract TP323: Does Serum Level Of Sex Hormones Before Rehabilitation Predict Functional Recovery In Elderly Post-stroke Patients?

Background: Sex hormone is recognized as a critical factor affecting physical function in the elderly. However, the influence of these hormones on functional recovery after stroke has not been studied in elderly patients. The objective of the study was to examine whether serum level of sex hormones before rehabilitation can predict clinical outcome in elderly post-stroke patients. Subjects and Methods: Seventy-on post-stroke hemiparetic patients who were hospitalized to our rehabilitation ward in their subacute-chronic phase, were subjected (age: 78 ± 6 years, period between onset and admission: 47 ± 31 days). On their admission, serum levels of dehydroepiandrosterone sulfate (DHEA-S) and free testosterone (only in male patients) were measured after an overnight fast. As functional measures, NIHSS and functional Independence Measure (FIM) were evaluated at their admission and discharge. We assessed the correlation between changes in serum levels of measured hormones and functional changes during hospitalization. Results: Neither DHEA-S nor free testosterone levels at admission correlated with the severity of stroke at admission. In male patients, significant positive correlation was found between free testosterone level at admission and FIM at discharge (r=0.31, p&lt;0.05), although there was not significant correlation between DHEA-S level at admission and FIM change. Furthermore, the results of multivariate analysis showed that free testosterone level at admission significantly predicted the rate of FIM change during hospitalization in male patients. Conclusions: Serum level of free testosterone at the admission to rehabilitation ward can be a predictor of functional recovery in elderly male patients after stroke.

Letter by Tsuda Regarding Article, “Vitamin D Deficiency Is Associated With Subclinical Carotid Atherosclerosis: The Northern Manhattan Study”

HomeStrokeVol. 42, No. 12Letter by Tsuda Regarding Article, “Vitamin D Deficiency Is Associated With Subclinical Carotid Atherosclerosis: The Northern Manhattan Study” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Tsuda Regarding Article, “Vitamin D Deficiency Is Associated With Subclinical Carotid Atherosclerosis: The Northern Manhattan Study” Kazushi Tsuda, MD, FAHA Kazushi TsudaKazushi Tsuda Cardiovascular and Metabolic Research Center Kansai University of Health Sciences Osaka, Japan (Tsuda) Search for more papers by this author Originally published27 Oct 2011https://doi.org/10.1161/STROKEAHA.111.634154Stroke. 2011;42:e639Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2011: Previous Version 1 To the Editor:We read with great interest the article by Carrelli et al1 dealing with the relationship between serum vitamin D levels and carotid atherosclerosis in a free-living, stroke-free, multiethnic, urban cohort. The results of their study demonstrated that serum phosphorus and calcium–phosphorus product were associated with a greater burden of subclinical carotid atherosclerosis. Among those with carotid plaque, the authors found that lower 25-hydroxyvitamin D levels were associated with thicker plaque and higher intima-media thickness of the carotid artery. The authors proposed the strong relationship between vitamin D deficiency and carotid vascular abnormalities that predicts the development of myocardial infarction and stroke.Evidence indicates that there were significant associations between low bone mineral density (BMD) and stroke. Jörgensen et al2 proposed that low BMD might predict first stroke in women. In a study we presented previously, a relationship between BMD and hypertension was investigated in women. Using the dual-energy X-ray absorptiometric method, we demonstrated that BMD in lumbar spine was significantly decreased in elderly hypertensive women compared with elderly normotensive women.3 In addition, BMD was inversely correlated with systolic blood pressure, suggesting that high blood pressure might be associated with the decrease in BMD in elderly women. Several studies have shown that hypertension is related to abnormalities of the calcium metabolism, such as increased calcium losses from the kidney, secondary activation of parathyroid glands, and vitamin D deficiency. It was demonstrated that the greater the 24-hour calcium excretion was, the lower the BMD was in women.3 It was also shown that BMD correlated negatively with serum vitamin D levels in elderly poststroke patients.4 Recently, Pilz et al5 demonstrated that low levels of 25-hydroxyvitamin D and 1, 25-hydroxyvitamin D were independent determinants of fatal stroke and were reduced in patients with a history of previous cerebrovascular diseases. Furthermore, they proposed that vitamin D supplementation might be a promising approach in the prevention of stroke.In this context, it can be speculated that in subjects with hypertension and lowered BMD, the disturbances in the calcium metabolism might be more pronounced. Therefore, we would like to know whether serum vitamin D levels might be related to the magnitudes of blood pressure or BMD in the populations in the study of Carrelli et al. It would be important to assess more precisely the relationships among vitamin D deficiency, BMD losses, and hypertension, and their contribution to stroke incidence.Kazushi Tsuda, MD, FAHA Cardiovascular and Metabolic Research Center Kansai University of Health Sciences Osaka, JapanDisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. Include a completed copyright transfer agreement form (available online at http://stroke.ahajournals.org and http://submit-stroke.ahajournals.org).

Correlations Between Folate, B12, Homocysteine Levels, and Radiological Markers of Neuropathology in Elderly Post-Stroke Patients

Objective: To investigate serum levels of folate, B12, and total homocysteine (tHcy) in elderly post-stroke patients, and the possible correlations with radiological markers of neuropathology.Design: Cross-sectional study.Setting: Department of Neurology, Cardinal Tien Hospital.Subjects: Eighty-nine elderly post-stroke patients were enrolled for dietary assessment and blood tests. Neuroradiological assessment was done in 62 of these patients.Main Outcome Measures: Dietary folate and vitamin B12 intakes were evaluated by a 24-h recall system using a semi-quantitative questionnaire. Circulating levels of folate, B12, and tHcy were measured. Magnetic resonance imaging (MRI) or computed tomography (CT) was used for evaluation of brain lesions including infarction and atrophy.Results: Mean folate and B12 intakes of these post-stroke patients were 69% and 261% of the recommended dietary allowances (RDA), respectively. Inadequate folate levels, defined as serum folate < 6 ng/mL, was noted in 68% of these patients. Hyperhomocysteinemia levels (tHcy ≥15 μmol/L) were observed in 48%. According to tertiles of serum tHcy and folate levels, the rate of brain atrophy, but not brain infarctions, are significantly associated with elevated tHcy (P = 0.0126) and decreased folate levels (P = 0.0273). After adjustments for age, sex, disease status, brain infarctions and carotid stenosis, the odds ratio of brain atrophy was 9.8 (95% CI: 1.7–56.4, P = 0.0101) in the hyperhomocysteinemia group and 9.6 (95% CI: 1.1–81.3, P = 0.0377) in the low folate group (serum folate < 3.0 ng/mL) compared with the group with normal tHcy and folate levels. No significant association was noted between vitamin B12 levels and brain lesions.Conclusions: Our data shows that folate deficiency and hyperhomocysteinemia are prevalent in elderly post-stroke patients. These two conditions are strongly and independently associated with the development of brain atrophy.

RETRACTED: Abnormal calcium homeostasis in disabled stroke patients with low 25-hydroxyvitamin D

Disabled elderly stroke patients occasionally have very low serum 25-hydroxyvitamin D (25-OHD), which may be due to sunlight deprivation and malnutrition. Many of such patients have very low level of serum 1, 25-dihydroxyvitamin D (1, 25-[OH]2D; calcitriol), and immobilization-induced hypercalcemia may be responsible for inhibition of renal synthesis of calcitriol. To elucidate determinants of serum 1, 25-[OH]2D levels in elderly poststroke patients, we measured serum indices of bone and calcium metabolism and metacarpal bone mineral density (BMD). Patients whose serum 1, 25-[OH]2D concentration was below the mean-3 SD of normal control subjects were defined as the low 1, 25-[OH]2D group and the rest of the patients were designated as the normal group. Mean illness duration was 59 months in the normal group and 20 months in the low group. The Barthel index (BI), which predicts the degree of immobilization, was significantly lower in the low group than in the normal group. Mean serum 1, 25-[OH]2D and 25-OHD concentrations in the normal group were 36.7 pg/ml and 4.4 ng/ml, respectively; and those in the low group were 14.2 pg/ml and 1.8 ng/ml, respectively. Multiple regression analysis identified illness duration and calcium level as independent determinants of 1, 25-[OH]2D in both groups, and PTH in the normal group and 25-OHD in the low group were additional independent determinants. BMD in stroke patients was significantly lower than that in controls, and BMD in the normal group was lower as compared to the low group. BMD correlated negatively with 1, 25-[OH]2D and PTH in the normal group, and hyperparathyroidism may contribute to reduced BMD. These results suggest that treatment of decreased bone mass in stroke patients has to be individualized according to vitamin D status and calcium homeostasis.