A community-based study of reporting demographic and clinical information concordance between informants and cognitively impaired participants.

BACKGROUND: Understanding concordance between informants' and cognitively impaired participants' information reporting is crucial for Alzheimer's and Alzheimer's-related dementia studies. METHODS: The Brain Attack Surveillance in Corpus Christi-Cognitive is a community-based cohort study. Households in Nueces County, Texas, USA, were randomly identified. 330 dyads of participants and their named informants answered questions. Models were generated to examine which predictors, including age, gender, ethnicity, cognitive function, and relationship to informant, influenced answer discordance. RESULTS: For demographic items, female participants and participants with spouses/partners as informants had significantly less discordance, with incidence rate rations (IRRs) of 0.65 (CI = 0.44, 0.96) and 0.41 (CI = 0.23, 0.75), respectively. For health items, better cognitive function of the participant was associated with less discordance, with an IRR of 0.85 (CI = 0.76, 0.94). CONCLUSIONS: Demographic information concordance is most associated with gender and informant-participant relationship. Level of cognitive function is most associated with concordance for health information. CLINICALTRIALS: gov identifier NCT03403257.

Differential Impact of Stroke on Cognitive Impairment in Mexican Americans and Non-Hispanic White Americans.

BACKGROUND: The association between stroke and dementia is well established. Less is known about this association in underrepresented ethnic groups. In a large ethnically diverse cohort, we examined whether history of stroke was associated with cognitive impairment, and whether this relationship differed by ethnicity (Mexican American [MA] versus non-Hispanic White). METHODS: This was a population-based cohort study conducted in Nueces County, TX, a biethnic community with a large and primarily nonimmigrant MA population. Residents aged ≥65 were recruited door-to-door or by telephone between May 2018 and December 2021. The primary exposure was history of stroke, obtained by self-report. Demographic, medical, and educational histories were also obtained. The primary outcome was the Montreal Cognitive Assessment (MoCA), a scale that evaluates multiple domains of cognitive performance. Scores were divided into 3 ordinal categories, roughly corresponding to normal cognition (MoCA 26-30), mild cognitive impairment (MoCA 20-25), or probable dementia (MoCA 0-19). RESULTS: One thousand eight hundred one participants completed MoCA screening (55% female; 50% MA, 44% Non-Hispanic White, 6% other), of whom 12.4% reported history of stroke. Stroke prevalence was similar across ethnicities (X2 2.1; P=0.34). In a multivariable cumulative logit regression model for the ordinal cognition outcome, a stroke by ethnicity interaction was observed (P=0.01). Models stratified by ethnicity revealed that stroke was associated with cognitive impairment across ethnicities, but had greater impact on cognition in non-Hispanic Whites (cumulative odds ratio=3.81 [95% CI, 2.37-6.12]) than in MAs (cumulative odds ratio=1.58 [95% CI, 1.04-2.41]). Increased age and lower educational attainment were also associated with cognitive impairment, regardless of ethnicity. CONCLUSIONS: History of stroke was associated with increased odds of cognitive impairment after controlling for other factors in both MA and Non-Hispanic White participants. The magnitude of the impact of stroke on cognition was less in MA than in Non-Hispanic White participants.

Differential Relationships Between the Montreal Cognitive Assessment and Informant-Rated Cognitive Decline Among Mexican Americans and Non-Hispanic Whites.

OBJECTIVES: We compared the concurrent validity of the Montreal Cognitive Assessment (MoCA) with other cognitive screening instruments among Mexican Americans (MA) and non-Hispanic whites (NHW). METHODS: In a community-based study in Nueces county, Texas (5/2/18-2/26/20), participants 65+ with MoCA ≤25 completed the Harmonized Cognitive Assessment Protocol. Regressions examined associations between MoCA and: 1) Mini Mental State Examination (MMSE); 2) abbreviated Community Screening Interview for Dementia (CSI-D); 3) Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). RESULTS: MA (n = 229) and NHW (n = 81) differed by education but not age or sex. MoCA and cognitive performance associations (MMSE, CSI-D-Respondent) did not differ between MA and NHW (p's > .16). MoCA and informant rating associations (IQCODE, CSI-D-Informant) were stronger in NHW than MA (NHW R2 = 0.39 and 0.38, respectively; MA R2 = 0.30 and 0.28, respectively). DISCUSSION: Our findings suggest non-equivalence across cognitive screening instruments among MAs and NHWs.

Dementia care needs for individuals and caregivers among Mexican Americans and non-Hispanic Whites.

Mexican Americans (MA) are more likely to have cognitive impairment and dementia (CID), be diagnosed at an earlier age and live with CID longer, compared to non-Hispanic Whites (NHW). While studies have examined unmet needs of individuals with CID and their caregivers, few have focused on MA populations in the U.S. This paper examines the needs of community-residing individuals with CID and their caregivers in Nueces County, Texas, a county with one of the largest MA populations in the U.S., while exploring ethnic differences in needs identified.Using concept mapping, a mixed-method approach, qualitative input on perceived needs by informal caregivers and health professionals was collected. Participants then sorted and rated perceived needs. Using this information, multidimensional scaling and cluster analyses were conducted to map the relationship between perceived needs and determine their importance and priority.Five clusters were derived for caregivers and four for the health professionals. Themes across both caregivers and health professionals highlighted the need for specialized and team-based medical care, caregiver support and training, along with socio-economic and physical needs that help with day-to-day care of individuals with CID. Among caregivers, MA rated financial resources as more important and of higher priority compared to NHW. The health professionals' perspectives were aligned with those of all caregivers.By understanding the needs of caregivers and individuals with CID, we can help families deal with this disease and let caregivers thrive. This is especially important for minority populations like MAs.

Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke.

Background and Purpose- Do-not-resuscitate (DNR) orders are common after stroke, though there are limited data on trends over time. We investigated time trends in DNR orders in a community with a large minority population. Methods- Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the BASIC study (Brain Attack Surveillance in Corpus Christi) from June 2007 through October 2016. Cox proportional hazards models were used to assess time to DNR orders, with an interaction term added to allow separate hazard ratios for early (≤24 hours) and late (>24 hours) DNR. Stroke type-specific calendar trends were assessed with an interaction term between calendar year (linear) and stroke type. Results- Two thousand six hundred seventy-two cases were included (ICH, 14%). Mean age was 69, 50% were female, and race-ethnicity was Mexican American (58%), non-Hispanic white (37%), and African American (5%). Overall, 16% had a DNR order during the hospitalization. For ICH, DNR orders (early and late) were stable over the study period. However, early DNR orders became more common over time after ischemic stroke (hazard ratio for 2016 versus 2007: 1.89; 95% CI, 1.06-3.39), with no change over time for late DNR orders after ischemic stroke. Mexican Americans (hazard ratio, 0.65; 95% CI, 0.50-0.86) and African Americans (hazard ratio, 0.17; 95% CI, 0.04-0.71) were less likely than non-Hispanic whites to have early DNR orders, though there were no race-ethnic differences in late DNR orders. There was no change in race-ethnic difference in DNR orders over the time of the study (interaction P>0.60). Conclusions- Despite revised national guidelines cautioning against early DNR orders in ICH, presence of DNR orders after ICH was stable between 2007 and 2016, with only slight increases in early DNR orders after ischemic stroke. Mexican Americans and African Americans remain less likely than non-Hispanic whites to have early DNR orders after stroke.

A Population-Based Study of Intracerebral Hemorrhage Survivors' Outcomes.

BACKGROUND: We evaluated 3-month neurologic, functional, cognitive, and quality of life (QOL) outcomes in intracerebral hemorrhage (ICH) overall, and by sex and ethnicity in a population-based study. METHODS: Spontaneous ICH patients were identified from the Brain Attack Surveillance in Corpus Christi project (November 2008 to December 2013). Outcomes included neurologic (National Institutes of Health Stroke Scale: range 0-42), functional (activities of daily living/instrumental activities of daily living score: range 1-4, higher worse), cognitive (Modified Mini-Mental State Examination [3MSE]: range 0-100), and QOL (short-form stroke-specific QOL scale: range 0-5, higher better). Ethnic and sex differences were assessed with Tobit regression adjusted for age, sex, or ethnicity, and presenting Glasgow coma scale. RESULTS: A total of 245 patients completed baseline interviews, with 103 (42%) dying prior to follow-up, leaving 142 eligible for outcome assessment. Three-month follow-up was completed in 100 (neurologic), 107 (functional), 79 (cognitive), and 83 (QOL) participants. Median age was 66 years (interquartile range 58.0-77.0). Cognitive outcomes were worse in Mexican Americans (MA) compared to non-Hispanic whites (NHW) after multivariable adjustment (MA scoring 13.3 3MSE points lower than NHW [95% confidence interval: 5.8, 20.7; P = .0005]). There was no difference by sex or ethnicity in neurological, functional, or QOL outcomes, and no sex differences in cognitive outcomes. CONCLUSIONS: In this population-based study, worse cognitive outcomes were found in MAs compared with NHW. There were no differences between neurologic, functional, and QOL outcomes in ICH survivors based on sex or ethnicity.

Sex Disparity in Stroke Quality of Care in a Community-Based Study.

BACKGROUND: Studies have suggested that women may receive lower stroke quality of care (QOC) than men, although population-based studies at nonacademic centers are limited. We investigated sex disparities in stroke QOC in the Brain Attack Surveillance in Corpus Christi Project. METHODS: All ischemic stroke patients admitted to 1 of 6 Nueces County nonacademic hospitals between February 2009 and June 2012 were prospectively identified. Data regarding compliance with 7 performance measures (PMs) were extracted from the medical records. Two overall quality metrics were calculated: a composite score of QOC representing the number of achieved PMs over all patient-appropriate PMs, and a binary measure of defect-free care. Multivariable models with generalized estimating equations assessed the association between sex and individual PMs and between sex and overall quality metrics. RESULTS: A total of 757 patients (51.6% female) were included in our analysis. After adjustment, women were less likely to receive deep vein thrombosis prophylaxis at 48 hours (relative risk [RR] = .945; 95% CI, .896-.996), an antithrombotic by 48 hours (RR = .952; 95% CI, .939-.965), and to be discharged on an antithrombotic (RR = .953; 95% CI, .925-.982). Women had a lower composite score (mean difference -.030, 95% CI -.057 to -.003) and were less likely to receive defect-free care than men (RR = .914; 95% CI, .843-.991). CONCLUSIONS: Women had lower overall stroke QOC than men, although absolute differences in most individual PMs were small. Further investigation into the factors contributing to the sex disparity in guideline-concordant stroke care should be pursued.

The Impact of Pre-Stroke Depressive Symptoms, Fatalism, and Social Support on Disability after Stroke.

BACKGROUND: Psychological and social factors have been linked to stroke mortality; however, their impact on stroke disability is unclear. The purpose of this study was to evaluate the impact of pre-stroke fatalism, depressive symptoms, and social support on 90-day neurologic, functional, and cognitive outcomes. METHODS: Ischemic strokes (2008-2011) were identified from the Brain Attack Surveillance in Corpus Christi Project. Validated scales were used to assess fatalism, depressive symptoms, and social support during baseline interviews. The National Institutes of Health Stroke Scale, activities of daily living/instrumental activities of daily living (ADL/IADL) scale, and Modified Mini-Mental State Exam (3MSE) were used to assess 90-day outcomes. The associations between the pre-stroke variables and 90-day outcomes were estimated from regression models adjusting for demographics, risk factors, tissue-type plasminogen activator treatment, and comorbidities. RESULTS: Among 364 stroke survivors, higher pre-stroke fatalism was associated with worse functional (.17 point higher ADL/IADL per interquartile range [IQR] higher fatalism; 95% confidence interval [CI]: .05, .30) and cognitive (2.81 point lower 3MSE per IQR higher fatalism; 95% CI: .95, 4.67) outcomes. Higher pre-stroke depressive symptoms were associated with worse functional (.16 point higher ADL/IADL per IQR higher Patient Health Questionnaire-9; 95% CI: .04, .28) and cognitive (2.28 point lower 3MSE per IQR higher Patient Health Questionnaire-9; 95% CI: .46, 4.10) outcomes. Participants in the middle tertile of social support had better cognitive outcomes (3.75 points higher 3MSE; 95% CI: .93, 6.56) compared with the highest tertile. CONCLUSIONS: The associations between pre-stroke fatalism, depressive symptoms, and social support and 90-day outcomes suggest that psychosocial factors play an important role in stroke recovery.

Ischemic stroke subtype and presence of sleep-disordered breathing: the BASIC sleep apnea study.

BACKGROUND: Little is known about the prevalence of sleep-disordered breathing (SDB) across ischemic stroke subtypes. Given the important implications for SDB screening, we tested the association between SDB and ischemic stroke subtype in a population-based study. METHODS: Within the Brain Attack Surveillance in Corpus Christi Project, ischemic stroke patients were offered SDB screening with the ApneaLink Plus (n = 355). A neurologist assigned Trial of the ORG 10172 in Acute Stroke Treatment subtype (with an additional category for nonlacunar infarctions of unknown etiology) using hospital records. Unadjusted and adjusted (demographics, body mass index, National Institutes of Health Stroke Scale, diabetes, history of stroke/transient ischemic attack) logistic and linear regression models were used to test the association between subtype and SDB or apnea-hypopnea index (AHI). RESULTS: Median age was 65%, and 55% were men; 59% were Mexican American. Median time from stroke onset to SDB screen was 13 days (interquartile range [IQR] 6, 21). Overall, 215 (61%) had SDB (AHI ≥ 10). Median AHI was 13 (IQR 6, 27). Prevalence of SDB by subtype was cardioembolism, 66%; large-artery atherosclerosis, 57%; small-vessel occlusion, 68%; other determined, 50%; undetermined etiology, 58%; and nonlacunar stroke of unknown etiology, 63%. Ischemic stroke subtype was not associated with SDB in unadjusted (P = .72) or adjusted models (P = .91) models. Ischemic stroke subtype was not associated with AHI in unadjusted (P = .41) or adjusted models (P = .62). CONCLUSIONS: In this population-based stroke surveillance study, ischemic stroke subtype was not associated with the presence or severity of SDB. Sleep-disordered breathing is likely to be present after ischemic stroke, and the subtype should not influence decisions about SDB screening.

Neurological, functional, and cognitive stroke outcomes in Mexican Americans.

BACKGROUND AND PURPOSE: Our objective was to compare neurological, functional, and cognitive stroke outcomes in Mexican Americans (MAs) and non-Hispanic whites using data from a population-based study. METHODS: Ischemic strokes (2008-2012) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project. Data were collected from patient or proxy interviews (conducted at baseline and 90 days poststroke) and medical records. Ethnic differences in neurological (National Institutes of Health Stroke Scale: range, 0-44; higher scores worse), functional (activities of daily living/instrumental activities of daily living score: range, 1-4; higher scores worse), and cognitive (Modified Mini-Mental State Examination: range, 0-100; lower scores worse) outcomes were assessed with Tobit or linear regression adjusted for demographics and clinical factors. RESULTS: A total of 513, 510, and 415 subjects had complete data for neurological, functional, and cognitive outcomes and covariates, respectively. Median age was 66 (interquartile range, 57-78); 64% were MAs. In MAs, median National Institutes of Health Stroke Scale, activities of daily living/instrumental activities of daily living, and Modified Mini-Mental State Examination score were 3 (interquartile range, 1-6), 2.5 (interquartile range, 1.6-3.5), and 88 (interquartile range, 76-94), respectively. MAs scored 48% worse (95% CI, 23%-78%) on National Institutes of Health Stroke Scale, 0.36 points worse (95% CI, 0.16-0.57) on activities of daily living/instrumental activities of daily living score, and 3.39 points worse (95% CI, 0.35-6.43) on Modified Mini-Mental State Examination than non-Hispanic whites after multivariable adjustment. CONCLUSIONS: MAs scored worse than non-Hispanic whites on all outcomes after adjustment for confounding factors; differences were only partially explained by ethnic differences in survival. These findings in combination with the increased stroke risk in MAs suggest that the public health burden of stroke in this growing population is substantial.

Loss of the Mexican American survival advantage after ischemic stroke.

BACKGROUND AND PURPOSE: Mexican Americans (MAs) were previously found to have lower mortality after ischemic stroke than non-Hispanic whites. We studied mortality trends in a population-based design. METHODS: Active and passive surveillance were used to find all ischemic stroke cases from January 2000 to December 2011 in Nueces County, TX. Deaths were ascertained from the Texas Department of Health through December 31, 2012. Cumulative 30-day and 1-year mortality adjusted for covariates was estimated using log-binomial models with a linear term for year of stroke onset used to model time trends. Models used data from the entire study period to estimate adjusted mortality among stroke cases in 2000 and 2011 and to calculate projected ethnic differences. RESULTS: There were 1974 ischemic strokes among non-Hispanic whites and 2439 among MAs. Between 2000 and 2011, model estimated mortality declined among non-Hispanic whites at 30 days (7.6% to 5.6%; P=0.24) and 1 year (20.8% to 15.5%; P=0.02). Among MAs, 30-day model estimated mortality remained stagnant at 5.1% to 5.2% (P=0.92), and a slight decline from 17.4% to 15.3% was observed for 1-year mortality (P=0.26). Although ethnic differences in 30-day (P=0.01) and 1-year (P=0.06) mortality were apparent in 2000, they were not so in 2011 (30-day mortality, P=0.63; 1-year mortality, P=0.92). CONCLUSIONS: Overall, mortality after ischemic stroke has declined in the past decade, although significant declines were only observed for non-Hispanic whites and not MAs at 1 year. The survival advantage previously documented among MAs vanished by 2011. Renewed stroke prevention and treatment efforts for MAs are needed.

Persistent ischemic stroke disparities despite declining incidence in Mexican Americans.

OBJECTIVE: To determine trends in ischemic stroke incidence among Mexican Americans and non-Hispanic whites. METHODS: We performed population-based stroke surveillance from January 1, 2000 to December 31, 2010 in Corpus Christi, Texas. Ischemic stroke patients 45 years and older were ascertained from potential sources, and charts were abstracted. Neurologists validated cases based on source documentation blinded to ethnicity and age. Crude and age-, sex-, and ethnicity-adjusted annual incidence was calculated for first ever completed ischemic stroke. Poisson regression models were used to calculate adjusted ischemic stroke rates, rate ratios, and trends. RESULTS: There were 2,604 ischemic strokes in Mexican Americans and 2,042 in non-Hispanic whites. The rate ratios (Mexican American:non-Hispanic white) were 1.94 (95% confidence interval [CI] = 1.67-2.25), 1.50 (95% CI = 1.35-1.67), and 1.00 (95% CI = 0.90-1.11) among those aged 45 to 59, 60 to 74, and 75 years and older, respectively, and 1.34 (95% CI = 1.23-1.46) when adjusted for age. Ischemic stroke incidence declined during the study period by 35.9% (95% CI = 25.9-44.5). The decline was limited to those aged ≥60 years, and happened in both ethnic groups similarly (p > 0.10), implying that the disparities seen in the 45- to 74-year age group persist unabated. INTERPRETATION: Ischemic stroke incidence rates have declined dramatically in the past decade in both ethnic groups for those aged ≥60 years. However, the disparity between Mexican American and non-Hispanic white stroke rates persists in those <75 years of age. Although the decline in stroke is encouraging, additional prevention efforts targeting young Mexican Americans are warranted.

A Community-Based Study of Dementia in Mexican American and Non-Hispanic White Individuals.

BACKGROUND: Little information is available on the prevalence of cognitive impairment in Mexican American persons. OBJECTIVE: To determine the prevalence of mild cognitive impairment (MCI) and dementia in those 65 years and older among Mexican American and non-Hispanic white individuals in a community. METHODS: This was a population-based cohort study in Nueces County, Texas, USA. Participants were recruited using a random housing sample. The Harmonized Cognitive Assessment (HCAP) participant and informant protocol was performed after Montreal Cognitive Assessment (MoCA) screening. An algorithm was used to sort participants into diagnostic categories: no cognitive impairment, MCI, or dementia. Logistic regression determined the association of ethnicity with MCI and dementia controlling for age, gender, and education. RESULTS: 1,901 participants completed the MoCA and 547 the HCAP. Mexican Americans were younger and had less educational attainment than non-Hispanic whites. Overall, dementia prevalence was 11.6% (95% CI 9.2-14.0) and MCI prevalence was 21.2% (95% CI 17.5-24.8). After adjusting for age, gender, and education level, there was no significant ethnic difference in the odds of dementia or MCI. Those with ≤11 compared with ≥16 years of education had much higher dementia [OR = 4.9 (95% CI 2.2-11.1)] and MCI risk [OR = 3.5 (95% CI 1.6-7.5)]. CONCLUSIONS: Dementia and MCI prevalence were high in both Mexican American and non-Hispanic white populations. Mexican American persons had double the odds of mild cognitive impairment and this was attenuated when age and educational attainment were considered. Educational attainment was a potent predictor of cognitive impairment.

Exploring Pathways to Caregiver Health: The Roles of Caregiver Burden, Familism, and Ethnicity.

OBJECTIVES: This study examines the associations of ethnicity, caregiver burden, familism, and physical and mental health among Mexican Americans (MAs) and non-Hispanic Whites (NHWs). METHODS: We recruited adults 65+ years with possible cognitive impairment (using the Montreal Cognitive Assessment score<26), and their caregivers living in Nueces County, Texas. We used weighted path analysis to test effects of ethnicity, familism, and caregiver burden on caregiver's mental and physical health. RESULTS: 516 caregivers and care-receivers participated. MA caregivers were younger, more likely female, and less educated compared to NHWs. Increased caregiver burden was associated with worse mental (B = -0.53; p < .001) and physical health (B = -0.15; p = .002). Familism was associated with lower burden (B = -0.14; p = .001). MA caregivers had stronger familism scores (B = 0.49; p < .001). DISCUSSION: Increased burden is associated with worse caregiver mental and physical health. MA caregivers had stronger familism resulting in better health. Findings can contribute to early identification, intervention, and coordination of services to help reduce caregiver burden.

Validation of the 12-item stroke-specific quality of life scale in a biethnic stroke population.

The 12-item Stroke-Specific Quality of Life Scale (SSQOL), a shortened version of the original SSQOL, was developed to be an efficient and valid outcome in stroke research. We aimed to assess the validity of this scale in a biethnic ischemic stroke population. Patients with validated ischemic stroke who completed the original 49-item SSQOL at 90 days poststroke were identified from a population-based study, the Brain Attack Surveillance in Corpus Christi Project. Cronbach's α was used to assess the internal consistency of the scales. Intraclass correlation coefficients and linear regression were used to assess agreement between the 2 scales. The study cohort comprised 45 patients with ischemic stroke, 56% female and 51% Mexican American, with a mean age of 66.0±11.3 years. The mean score for the 49-item scale was 3.33±0.84, compared with 3.31±0.95 for the 12-item scale. Internal consistency was 0.96 for the 49-item scale and 0.88 for the 12-item scale. The 2 scales were highly correlated (intraclass correlation coefficient, 0.98; R2=0.97). This study in patients with ischemic stroke from diverse racial/ethnic backgrounds found that the more efficient 12-item SSQOL is a valid alternative to the full 49-item SSQOL for the assessment of health-related quality of life.

A Community-Based Study of Cognitive Impairment Caregiving Outcomes Pre- and During the COVID-19 Pandemic.

The impact of the COVID-19 pandemic on informal caregiving was examined in a Mexican American (MA) and Non-Hispanic White (NHW) population-based cohort. 395 participants age > 65 years were recruited via door-to-door and phone recruitment as part of the Brain Attack Surveillance in Corpus Christi-Cognitive (BASIC-C) project. Both recipients and caregivers answered questions regarding the recipient's health and the COVID-19 pandemic. 15% of caregivers saw their caregiving recipient less than before the pandemic and 18% saw their recipient more than before. 55% of caregivers reported a slight to severe impact of the pandemic on their caregiving, and 45% reported no impact. For most caregivers, their caregiving role did not change markedly during the pandemic. MA and NHW caregivers had similar survey responses.

Driving predictors in a cohort of cognitively impaired Mexican American and non-Hispanic White individuals.

BACKGROUND: Individuals with Alzheimer's disease and Alzheimer's disease-related dementias may lose the ability to drive safely as their disease progresses. Little is known about driving prevalence in older Latinx and non-Hispanic White (NHW) individuals. We investigated the prevalence of driving status among individuals with cognitive impairment in a population-based cohort. METHODS: This was a cross-sectional analysis of the cohort BASIC-Cognitive study in a community of Mexican American (MA) and NHW individuals in South Texas. Participants scored ≤25 on the Montreal Cognitive Assessment (MoCA), indicating a likelihood of cognitive impairment. Current driving status was assessed by the Harmonized Cognitive Assessment Protocol informant interview. Logistic regression was used to assess driving versus non-driving adjusted for pre-specified covariates. Chi-square and Mann-Whitney U tests were used to compare NHW and MA differences in driving outcomes from the American Academy of Neurology (AAN) questions for evaluating driving risk in dementia. RESULTS: There were 635 participants, 77.0 mean age, 62.4% women, and 17.3 mean MoCA. Of these, 360 (61.4%) were current drivers with 250 of 411 (60.8%) MA participants driving, and 121 of 190 (63.70%) NHW participants driving (p = 0.50). In fully adjusted models age, sex, cognitive impairment, language preference, and Activities of Daily Living scores were significant predictors for the likelihood of driving (p < 0.0001). Severity of cognitive impairment was inversely associated with odds of driving, but this relationship was not found in those preferring Spanish language for interviews. Around one-third of all caregivers had concerns about their care-recipient driving. There were no significant differences in MA and NHW driving habits and outcomes from the AAN questionnaire. CONCLUSIONS: The majority of participants with cognitive impairment were currently driving. This is a cause for concern for many caregivers. There were no significant ethnic driving differences. Associations with current driving in cognitively impaired persons require further research.

Computed tomography findings for intracerebral hemorrhage have little incremental impact on post-stroke mortality prediction model performance.

BACKGROUND: Stroke outcome studies often combine cases of intracerebral hemorrhage (ICH) and ischemic stroke (IS). These studies of mixed stroke typically ignore computed tomography (CT) findings for ICH cases, though the impact of omitting these traditional predictors of ICH mortality is unknown. We investigated the incremental impact of ICH CT findings on mortality prediction model performance. METHODS: Cases of ICH and IS (2000-2003) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project. Base models predicting 30-day mortality included demographics, stroke type, and clinical findings (National Institutes of Health Stroke Scale (NIHSS) +/- Glasgow Coma Scale (GCS)). The impact of adding CT data (volume, intraventricular hemorrhage, infratentorial location) was assessed with the area under the curve (AUC), unweighted sum of squared residuals (S), and integrated discrimination improvement (IDI). The model assessment was performed first for the mixed case of IS and ICH, and then repeated for ICH cases alone to determine whether any lack of improvement in model performance with CT data for mixed stroke type was due to IS cases naturally forming a larger proportion of the total sample than ICH. RESULTS: A total of 1,256 cases were included (86% IS, 14% ICH). Thirty-day mortality was 16% overall (11% for IS; 43% for ICH). When both clinical scales (NIHSS and GCS) were included, none of the model performance measures showed improvement with the addition of CT findings whether considering IS and ICH together (ΔAUC: 0.002, 95% CI -0.01, 0.02; ΔS: -3.0, 95% CI -9.1, 2.6; IDI: 0.017, 95% CI -0.004, 0.05) or considering ICH cases alone (ΔAUC: 0.02, 95% CI -0.02, 0.08; ΔS: -2.0, 95% CI -9.7, 3.4; IDI 0.065, 95% CI -0.03, 0.21). If NIHSS was the only clinical scale included, there was still no improvement in AUC or S when CT findings were added for the sample with IS/ICH combined (ΔAUC: 0.005, 95% CI -0.01, 0.02; ΔS: -5.0, 95% CI -11.6, 1.0) or for ICH cases alone (ΔAUC: 0.05, 95% CI -0.002, 0.11; ΔS: -4.2, 95% CI -11.5, 2.3). However, IDI was improved when NIHSS was the only clinical scale for IS/ICH combined (IDI: 0.029, 95% CI 0.002, 0.065) and ICH alone (IDI: 0.12, 95% CI 0.005, 0.26). CONCLUSIONS: Excluding ICH CT findings had only minimal impact on mortality prediction model performance whether examining ICH and IS together or ICH alone. These findings have important implications for the design of clinical studies involving ICH patients.

A population-based analysis of ethnic differences in admission to the intensive care unit after stroke.

BACKGROUND: Mexican-Americans (MAs) have shown lower post-stroke mortality compared to non-hispanic whites (NHWs). Limited evidence suggests race/ethnic differences exist in intensive care unit (ICU) admissions following stroke. Our objective was to investigate the association of ethnicity with admission to the ICU following stroke. METHODS: Cases of intracerebral hemorrhage and acute ischemic stroke were prospectively ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project for the period of January 2000 through December 2009. Logistic regression models fitted within the generalized additive model framework were used to test associations between ethnicity and ICU admission and potential confounders. An interaction term between age and ethnicity was investigated in the final model. RESULTS: A total 1,464 cases were included in analysis. MAs were younger, more likely to have diabetes, and less likely to have atrial fibrillation, health insurance, or high school diploma than NHWs. On unadjusted analysis, there was a trend toward MAs being more likely to be admitted to ICU than NHWs (34.6 vs 30.3 %; OR = 1.22; 95 % CI 0.98-1.52; p = 0.08). However, on adjusted analysis, no overall association between MA ethnicity and ICU admission (OR = 1.13; 95 % CI 0.85-1.50) was found. When an interaction term for age and ethnicity was added to this model, there was only borderline evidence for effect modification by age of the ethnicity/ICU relationship (p = 0.16). CONCLUSIONS: No overall association between ethnicity and ICU admission was observed in this community. ICU utilization alone does not likely explain ethnic differences in survival following stroke between MAs and NHWs.

The prevalence of spirituality, optimism, depression, and fatalism in a bi-ethnic stroke population.

To provide insight into the reduced post-stroke all-cause mortality among Mexican Americans, we explored ethnic differences in the pre-stroke prevalence of (1) spirituality, (2) optimism, (3) depression, and (4) fatalism in a Mexican American and non-Hispanic white stroke population. The Brain Attack Surveillance in Corpus Christi (BASIC) project is a population-based stroke surveillance study in Nueces County, Texas. Seven hundred ten stroke patients were queried. For fatalism, optimism, and depression scales, unadjusted ethnic comparisons were made using linear regression models. Regression models were also used to explore how age and gender modify the ethnic associations after adjustment for education. For the categorical spirituality variables, ethnic comparisons were made using Fisher's exact tests. Mexican Americans reported significantly more spirituality than non-Hispanic whites. Among women, age modified the ethnic associations with pre-stroke depression and fatalism but not optimism. Mexican American women had more optimism than non-Hispanic white women. With age, Mexican American women had less depression and fatalism, while non-Hispanic white women had more fatalism and similar depression. Among men, after adjustment for education and age, there was no ethnic association with fatalism, depression, and optimism. Spirituality requires further study as a potential mediator of increased survival following stroke among Mexican Americans. Among women, evaluation of the role of optimism, depression, and fatalism as they relate to ethnic differences in post-stroke mortality should be explored.