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ARTICLES: V. K. Srikanth, J. F.I. Anderson, G. A. Donnan, M. M. Saling, E. Didus, R. Alpitsis, H. M. Dewey, R. A.L. Macdonell, and A. G. Thrift Progressive dementia after first-ever stroke: A community-based follow-up study Neurology 2004; 63: 785-792 [Abstract] [Full text] [PDF]

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Reply to Rabadi

Velandai K Srikanth, Jacqueline Anderson, Geoffrey Donnan, Michael Saling, Elissa Didus, Rubina Alpitsis, Helen Dewey, Richard Macdonell, Amanda Thrift   (18 November 2004)

Progressive dementia after first-ever stroke: A community-based follow-up study

Meheroz Hoshang Rabadi   (18 November 2004)

Reply to Rabadi 18 November 2004
Velandai K Srikanth, National Stroke Research Institute, Melbourne, and Menzies Research Institute, Hobart Menzies Research Institute, Hobart, Tasmania, 7001, Jacqueline Anderson, Geoffrey Donnan, Michael Saling, Elissa Didus, Rubina Alpitsis, Helen Dewey, Richard Macdonell, Amanda Thrift Send Correspondence to journal: Re: Reply to Rabadi velandai.srikanth{at}utas.edu.au Velandai K Srikanth, et al.	We thank Dr. Rabadi for his interest and comments on our manuscript. Our responses to the questions are as follows: 1. Our finding of persistent cognitive impairment not dementia (CIND) at 12 months after stroke does not support the commonly held clinical notion of cognitive improvement in most post-stroke survivors. In our cohort of first-ever stroke patients, we found that 52/99 (52.5%) were cognitively impaired three months after stroke. [1] Of these, 11 (21%) progressed to dementia, four (8%) recovered completely and 6 (11%) were lost to follow-up leaving 31 (60%) with persistent impairment at 12 months. These figures are similar to those quoted by Ballard et al [2] where 87/115 (76%) had persistent or stable impairment between 3 and 15 months. These results confirm that the majority of stroke patients with early cognitive impairment after stroke will have persistent CIND at 12 or more months after stroke. Furthermore, in our study, CIND was diagnosed using a comprehensive neuropsychological battery. Subjects without dementia scoring more than one standard deviation below age and education derived normative means on at least two cognitive domains were classified as having CIND. This method more sensitive for detecting cognitive impairment than the mini-mental state exam (MMSE) alone; a measure commonly adopted in clinical practice. Thus, the persistence of CIND at 1 year may not have been detected had we used this less sensitive method. 2. We agree that the post-stroke cognitive state would be influenced by the prior cognitive state of the population. We have presented the data on pre-stroke cognitive decline using the Informant Questionnaire for Cognitive Decline in Elderly (IQCODE) among unimpaired, CIND and demented stroke patients in our supplemental data table E2 (www.neurology.org), with mean scores of 3.1 (0.5), 3.0 (0.7) and 3.8 (1.1), respectively. This suggests that those who had dementia were more likely to have pre-stroke cognitive decline, and that CIND patients were more likely to have been unimpaired pre-stroke. This was borne out in our logistic regression models. 3. In any multivariable analysis it is important to account for the possibility of confounding. The logistic regression model for risk of CIND was unchanged with the addition of vascular risk history, alcohol use and psychotropic medication usage (results, page 790, paragraph 1). These variables consequently did not account for the persistence of CIND at 12 months.
Progressive dementia after first-ever stroke: A community-based follow-up study 18 November 2004
Meheroz Hoshang Rabadi, Burke Rehabilitation Hospital 785 Mamaroneck Ave, White Plains NY 10605 Send Correspondence to journal: Re: Progressive dementia after first-ever stroke: A community-based follow-up study mrabadi{at}burke.org Meheroz Hoshang Rabadi	The authors Srikanth et al should be congratulated on their article which is a timely reminder on the presence of cognitive impairment not dementia (CIND) post stroke. [1] What is not clear is the persistence of CIND 1 year later: 1. Both practice-based observation and current literature [2] support the findings that cognitive impairment (based on Mini Mental State Examination) improves with time in most post-stroke patients. The authors do not give a reason for the persistence of this finding. 2. No information is provided as to the prior cognitive state of the study population, and in particular the stroke patients as this would influences post-stroke cognitive state. 3. The CIND stroke patients at baseline had more diabetics (42%), higher use of psychotropic medications (27%), and heavy alcohol use (15%) compared to non-stroke CIND group. All of these affect cognition. [3,4] We would like to know if the authors corrected for these confounding variables while analyzing CIND progression in stroke patients. Could these confounding variables have accounted for persistence of CIND 1 year later? References 1. Srikanth VK, Anderson JF, Donnan GA, et al. Progressive dementia after first- ever stroke: A community-based follow-up study. Neurology. 2004 Sep 14;63:785-92. 2. Ballard C, Rowan E, Stephens S, Kalaria R, Kenny RA. Prospective follow-up study between 3 and 15 months after stroke: improvements and decline in cognitive function among dementia-free stroke survivors >75 years of age. Stroke. 2003 Oct;34:2440-4. 3. Knopman D, Boland LL, Mosley T, et al. Atherosclerosis Risk in Communities (ARIC) Study Investigators. Cardiovascular risk factors and cognitive decline in middle-aged adults. Neurology. 2001 Jan 9;56:42-8. 4. Kivipelto M, Helkala EL, Hanninen T, et al. Midlife vascular risk factors and late-life mild cognitive impairment: A population-based study. Neurology. 2001 Jun 26;56:1683-9.