Dynamic aspect of functional recovery after stroke using a multistate model.

OBJECTIVE: To estimate time to functional recovery and quantify the effects of significant prognostic factors affecting the dynamic change of 3-state functional outcome after stroke. DESIGN: Modeling of clinical predictions. SETTING: Referral center. PARTICIPANTS: One hundred eleven patients with first-time ischemic stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Serial Barthel Index scores at onset, 2 weeks, and 1, 2, 4, and 6 months poststroke. The severity of disability was classified into 3 functional states: poor functional state (PFS) for Barthel Index scores from 0 to 40, moderate functional state (MFS) for scores from 45 to 80, and good functional state (GFS) for scores greater than 80. A 3-state Markov regression model together with Bayesian acyclic graphic underpinning was used to estimate transition parameters and mean time to functional recovery between states and to predict the probability of functional recovery by using Gibbs sampling technique. RESULTS: The mean total recovery time was 3.1 months for patients with PFS at baseline and 1.3 months for patients with MFS at baseline. The mean recovery times to different functional states were also estimated. Age predominantly affected the probabilities of MFS to GFS transitions, younger patients had faster transition rates (rate ratio, 4.51; 95% confidence interval [CI], 2.72-7.40); but age had only borderline effects on PFS to MFS transitions. In contrast, infarct size exerted substantial effects on PFS to MFS transitions: small-size infarct correlated with a higher transition rate (rate ratio, 10.17; 95% CI, 5.25-20.13), whereas only a borderline effect on MFS to GFS transitions was found. The baseline functional state significantly affected the MFS to GFS transitions. CONCLUSIONS: By using a multistate model, overall and patient-specific mean time to functional recovery to different functional states can be estimated and the effect of clinical predictors on functional transitions can be precisely quantified to predict patient-specific probability of functional recovery.

A prospective cohort study on the effect of sexual activity, libido and widowhood on mortality among the elderly people: 14-year follow-up of 2,453 elderly Taiwanese.

BACKGROUND: Sexual activity in elderly people is a topic of growing interest but the relationships of sexual activity, libido and widowhood to mortality have been barely investigated. METHODS: A total of 2,453 subjects enrolled from a nationwide survey on health status of residents aged 65 years or older in Taiwan between 1989 and 1991 were followed up until 31 December 2003 for ascertaining cause of death. Information on the frequency of sexual activity, libido (sexual desire), widowhood, disease status and relevant risk factors for risk of death at baseline were collected. RESULTS: After controlling for age and relevant confounding factors, sexual activity was found to be inversely related to mortality {adjusted hazard ratio (aHR) = 0.67 [95% confidence interval (CI):0.56-0.80] for males, aHR = 0.84 (95% CI:0.65-1.09) for females and aHR = 0.72 (95% CI: 0.62-0.84) for both sexes combined}. Men having libido had lower mortality [aHR = 0.81 (95% CI:0.68-0.97)]. Widowhood status was positively correlated with mortality [aHR = 1.66 (95% CI: 1.25-2.19) for males, aHR = 1.33 (95% CI: 1.09 to -1.62) for females and aHR = 1.43 (95% CI: 1.21-1.68) for both sexes combined]. Sexual activity was also inversely related to mortality from stroke [aHR = 0.64 (95% CI: 0.41-1.00)]. CONCLUSIONS: Sexual activity was associated with all-cause and cause-specific mortality independently of other risk factors. This finding was consistent with the elevated risk of death associated with widowhood for both men and women, and by the decreased mortality risk in men having libido.

Reduction of disability after stroke is a more informative predictor of long-time survival than initial disability status.

PURPOSE: Few studies have evaluated the roles of reducing disability after stroke in predicting survival. This study aimed to investigate the effects of improvement in the Barthel Index (BI) and other prognostic factors on survival in patients with first-time noncardioembolic ischemic stroke. METHOD: BI effectiveness was defined as the improvement of BI between initial stroke (within 3 days) and 2 months after stroke. Cox regression analysis and Kaplan-Meier methods were used to evaluate the predictive roles of various prognostic factors. RESULTS: A total of 111 patients were enrolled. Mean age at the time of stroke was 68 (+ or - 11.2) years. Median follow-up time was 77.4 months. Mean initial BI was 36.1 (+ or - 28.5) and mean BI effectiveness was 46.9 + or - 29.0. Overall, 55 deaths (49.5%) of the cohort were ascertained. The BI effectiveness had significant effects on long-time survival while initial BI was not a significant predictor. Higher BI effectiveness led to lower risk of mortality (hazard ratio = 0.44, 95% CI 0.24 - 0.80, p = 0.007). Elder age was correlated with poor survival (overall p = 0.006). Subjects in the eldest age group (> or = 70 years) showed a significant elevated risk for death (hazard ratio = 3.42, 95% CI 1.18 - 9.92). There was a trend indicating that the smaller the lesion size, the more favourable the prognosis (overall p = 0.057). CONCLUSIONS: BI effectiveness in the first 2 months after first-time noncardioembolic stroke was more informative than initial disability status for predicting long-time mortality. It highlights the potential benefit in maximizing functional performance in patients with stroke.

Location and size of infarct on functional outcome of noncardioembolic ischemic stroke.

PURPOSE: Studies regarding the effects of location and size of infarct on the functional outcome after stroke have yielded inconsistent results. This study aimed to investigate the relationships of neuroimage findings and longitudinal Barthel index (BI) scores in patients with first-ever ischemic stroke. METHOD: The neuroimage findings of enrolled subjects were grouped by anatomical location. The size of infarct was determined by the largest diameter of the lesion. Patients were followed up prospectively at onset, 2 weeks, 1, 2, 4, and 6 months after stroke. Linear mixed model was employed for the repeated measurement analysis of BI at these six time points in each patient. RESULTS: A total of 111 patients were enrolled. The BI increased rapidly during the first two months, and reached plateau after four months. The location and size of the lesion had significant effects on serial measurements of BI. After adjustment for age, sex, treatment mode, and baseline BI score, the posterior cerebral artery infarct group showed the largest improvement in BI. There was a trend that the smaller the lesion size, the more favourable the functional outcome. CONCLUSIONS: Both location and size of lesion in noncardioembolic stroke were significant prognostic factors for functional outcome.

Risk factors for cardiovascular disease in the elderly in Taiwan.

The major objective of the present study was to identify biologic and behavioral risk factors of cardiovascular disease (CVD) in the elderly population in Taiwan. It is hypothesized that the selected risk factors are significantly associated with the prevalence of CVD. Data came from a nationwide geriatric survey in 1991. Stratified proportional sampling was used to recruit 2,600 subjects. These were evaluated by family physicians working for the Departments of Family Medicine at four medical centers in four major cities in Taiwan. Univariate and multivariate logistic regression analyses were used to examine the associations between risk factors and the prevalence of CVD. The prevalence of CVD was 38.31%. Patients with CVD consistently had higher values for each selected risk factor except high-density lipoprotein-cholesterol (HDL-C) and glucose concentrations. The findings also indicated that hypertension, hypertriglyceridemia, low HDL-C concentration, ex-drinking status, and overweight were significantly associated with the prevalence of CVD among the elderly in Taiwan. The findings not only confirm the risk factors for CVD, but also invite more attention to be given to the importance of biologic and behavioral risk factors in CVD.

Prevalence of cardiovascular risk factors of elderly persons in Taiwan.

Cardiovascular disease has been one of the top-ten causes of death continuously for older persons in Taiwan. However, There is still a lack of sufficient information on prevalence rates of cardiovascular risk factors. The present study was intended to provide prevalence rates of biological and behavioral risk factors for cardiovascular disease by gender, age group, and dwelling area. Data were extracted from a nationwide, cross-sectional, geriatric survey (1989-1991) by four medical centers in Taiwan. A total of 2,600 community senior residents were successfully interviewed for analysis. For the whole sample, hypertension was found to be the most prevalent biological risk factor (36.9%), while being overweight was the first behavioral risk factor (34.38%). By gender, higher prevalence rates of biological risk factors were found in older women except for the low value of high density lipoprotein cholesterol (HDL-C); higher prevalence rates of behavioral risk factors were found in men except for being overweight. No statistically significant difference in prevalence rates was found between the 65-74 and 75+ years age groups. By dwelling area, significant differences in the prevalence rates of risk factors existed across the four study areas. In conclusion, hypertension and excessive weight are critical cardiovascular risk factors that can be early identified or prevented by screening programs and health education. Cardiovascular prevention programs for elderly people should be designed in their gender and dwelling area.

Long-term mortality assessment using biological measures among elderly people. Ten-year follow-up of 597 healthy elderly subjects in Taiwan.

BACKGROUND: Identifying biological measures that are predictive of mortality for elderly people aged over 65 years has not been fully elucidated in oriental studies. OBJECTIVE: The associations between these biological measures and long-term mortality were therefore investigated, and classifications for risk of death were developed among Taiwanese elderly people METHODS: Data used in this study were derived from a total of 597 apparently healthy subjects aged over 65 years identified from a nationwide survey that was conducted between 1989 and 1991 in Taiwan. Each participant received a physical examination and a wide range of biological measures. These 597 apparently healthy subjects were followed to 31 December 1999 to determine the cause of death. The grouping technique using factor analysis was first used to aggregate similar characteristics of biological measures into reduced components. Risk of death for each subject was classified into four groups: good (A), fair (B), modest (C) and poor (D). Hazard ratios for groups B, C, D against A were calculated. RESULTS: The overall 10-year survival rate was 72% [95% confidence interval (CI) 68-76%]. The adjusted hazard ratios for all-cause death in high and mid-level categories of haematological components versus the lowest group were 0.51 (95% CI 0.33-0.80) and 0.56 (95% CI 0.37-0.85), respectively. Group D had a 6-fold risk of death as compared with group A (relative risk = 6.34, 95% CI 3.85-10.52). The corresponding figures were 2.48 (95% CI 1.43-4.29) and 1.60 (95% CI 2.88-6.89) for groups B and C, respectively. CONCLUSIONS: The relationships of biological measures to long-term mortality were elucidated. Information on classification for risk of death may be helpful for elderly people to pay attention to their health status after receiving a health check-up.