Functional, cognitive and psychological outcomes, and recurrent vascular events in Pakistani stroke survivors: a cross sectional study

Abstract

BackgroundThere is little direct data describing the outcomes and recurrent vascular morbidity and mortality of stroke survivors from low and middle income countries like Pakistan. This study describes functional, cognitive and vascular morbidity and mortality of Pakistani stroke survivors discharged from a dedicated stroke center within a nonprofit tertiary care hospital based in a multiethnic city with a population of more than 20 million.MethodsPatients with stroke, aged > 18 years, discharged alive from a tertiary care centre were contacted via telephone and a cross sectional study was conducted. All the discharges were contacted. Patients or their legal surrogate were interviewed regarding functional, cognitive and psychological outcomes and recurrent vascular events using standardized, pretested and translated scales. A verbal autopsy was carried out for patients who had died after discharge. Stroke subtype and risk factors data was collected from the medical records. Subdural hemorrhages, traumatic ICH, subarachnoid hemorrhage, iatrogenic stroke within hospital and all other diagnoses that presented like stroke but were subsequently found not to have stroke were also excluded. Composites were created for functional outcome variable and depression. Data were analyzed using logistic regression.Results309 subjects were interviewed at a median of 5.5 months post discharge. 12.3% of the patients had died, mostly from recurrent vascular events or stroke complications. Poor functional outcome defined as Modified Rankin Score (mRS) of > 2 and a Barthel Index (BI) score of < 90 was seen in 51%. Older age (Adj-OR-2.1, p = 0.01), moderate to severe dementia (Adj-OR-19.1, p < 0.001), Diabetes (Adj-OR-2.1, p = 0.02) and multiple post stroke complications (Adj-OR-3.6, p = 0.02) were independent predictors of poor functional outcome. Cognitive outcomes were poor in 42% and predictors of moderate to severe dementia were depression (Adj-OR-6.86, p < 0.001), multiple post stroke complications (Adj-OR-4.58, p = 0.01), presence of bed sores (Adj-OR-17.13, p = 0.01) and history of atrial fibrillation (Adj-OR-5.12, p < 0.001).ConclusionsPakistani stroke survivors have poor outcomes in the community, mostly from preventable complications. Despite advanced disability, the principal caretakers were family rarely supported by health care personnel, highlighting the need to develop robust home care support for caregivers in these challenging resource poor settings.

The Epidemiology of Stroke in a Developing Country (Pakistan)

“…In addition, an improvement in acute stroke care may have led to an overall reduction in the percentage of stroke hospitalizations resulting in death in the United States. While there have been reports of reduction in stroke incidence and mortality in developed countries, the opposite has been observed in low-to-middle income countries [71]. However, the overall early stroke case fatality in low-to-middle income countries is found to be 25% higher than that seen in high-income countries in the past decade.…”

“…People ≥80 years old with stroke had a longer length of stay in contrast to younger patients (24.7 ± 27.6 vs. 22.3 ± 24.2 days; p = 0.013) [70]. Furthermore, case fatality rate for the same age group can be as high as 21% [71]. Although age seems to influence activities of daily living recovery, it has not been found to have an outcome on neurological recovery [72].…”

First-Year Outcomes after Stroke Rehabilitation: A Multicenter Study in Thailand

“…Those significant predictors are age and baseline disability [15][16][17][18]. The study of Khan et al reported that older age was one of the independent predictors of poor functional outcome with adjusted OR of 2.1 [19]. In our study, the independent factors associated with the improvement in functional score included LOS, onset to admission interval, and depression score.…”

“…The BI represents severity of disability and is categorized into 5 scales according to the scores. Those were very severely disabled (score 0-4), severely disabled (score 5-9), moderately disabled (score [10][11][12][13][14], mildly disabled (score [15][16][17][18][19], and independent (score 20) [12].…”

Major Depression as a Predictor of Poor Long-Term Survival in a Brazilian Stroke Cohort (Study of Stroke Mortality and Morbidity in Adults) EMMA study

“…[2][3][4] Besides that, among all chronic debilitating burdens associated with stroke, [5][6][7][8] depression is one of most common conditions that arise among stroke survivors [7][8][9][10][11][12][13][14][15][16] in higher levels compared to other clinical and nonclinical populations. 17,18 Previous prospective studies, mostly from high-income countries including population-and hospitalbased samples mainly based on ischemic stroke cases, suggest a wide variation in depressive symptoms (15.4%-54%) [7][8][9][10][11]15,[19][20][21][22][23] and major depressive disorder (9%-31%) during different periods of follow-up. [10][11][12][13][14] A systematic review, which included 51 prospective studies, that evaluated poststroke depression (PSD) (minor and major depressions), mainly based on the Diagnostic and Statistical Manual of Mental Disorders, Third and Fourth Editions, estimated that about 33% of all stroke survivors experienced depressive symptoms from 1 to 6 months after an acute event.…”