Featured Article
Abstract Introduction: Longitudinal studies are needed to understand the long-term associations between
stroke and dementia.
Methods: A population sample of 1460 women without stroke or dementia at baseline was followed
over 44 years, from 1968 to 2012. Information on stroke and dementia was obtained from neuropsy-
chiatric examinations, key-informant interviews, hospital registry, and medical records.
Results: During 44 years follow-up, 362 women developed stroke and 325, dementia. The age-
specific incidence of the two disorders was similar. The incidence of dementia was higher in those
with stroke than among those without (33.7% vs. 18.5%; age-adjusted hazard ratio 1.44, 95% confi-
dence interval 1.15–1.81). The increased risk of dementia started already 5 years before stroke, was
highest 1 year after stroke, and continued more than 11 years after stroke.
Discussion: There is an increased risk for dementia both before and after stroke. This has implications
for understanding the relation between the two disorders and for prevention of dementia and stroke.
Ó 2018 The Authors. Published by Elsevier Inc. on behalf of the Alzheimer’s Association. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).
Keywords: Stroke; Dementia; Longitudinal study; Population-based study; Women
https://doi.org/10.1016/j.jalz.2018.05.009
1552-5260/ Ó 2018 The Authors. Published by Elsevier Inc. on behalf of the Alzheimer’s Association. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1254 X. Guo et al. / Alzheimer’s & Dementia 14 (2018) 1253-1260
already several years before stroke and that the decline nurses in 2000–2001, 2005–2006, and 2009–2011. All exam-
accelerated after the index stroke [17]. Stroke survivors inations were semi-structured, allowing for clarifying ques-
had faster memory decline both before and after stroke tions, and included a comprehensive psychiatric interview
compared with stroke-free adults [17]. and observations of mental symptoms during the interview,
Ideally, studies on the relation between stroke and demen- as described previously [19,20]. The examinations included
tia should be performed in large population samples fol- ratings of common signs and symptoms of dementia, for
lowed over a long time, allowing enough dementia cases example, assessments of memory, orientation, general
to occur at different time periods in relation to the index knowledge, apraxia, visuospatial function, understanding
stroke, that is, short and long time before stroke as well as proverbs, following commands, naming ability, and
short and long time after stroke. We examined the risk of de- language. These examinations used identical instruments,
mentia before and after stroke in a large population of including the Comprehensive Psychopathological Rating
women followed over 44 years. Scale, Gottfries-Br ane-Steen Scale, the Mini–Mental State
Examination, the Alzheimer’s Disease Assessment Scale,
and the Clinical Dementia Rating, for more than 4 decades
2. Methods of follow-up. The last author (I.S.) came into the studies in
1983 and trained the examiners from 1992 to 2012. Inter-
2.1. Study population rater agreements between psychiatrists and psychiatric
The study is part of the Prospective Population Study of research nurses for the signs and symptoms of dementia
Women in Gothenburg [18], which was initiated in 1968. were between 89.4% and 100.0% (kappa values between
Women born in 1908, 1914, 1918, 1922, and 1930 were sys- 0.74 and 1.00).
tematically sampled from the Swedish Population Register. Close informant interviews were performed by psychiat-
Follow-ups were performed in 1974–1975, 1980–1981, ric nurses since 1992. The interviews were semi-structured
1992–1993, 2000–2001, 2005–2006, and 2009–2011 and comprised questions about changes in behavior and in-
(Fig. 1). Seven women with stroke or transient ischemic tellectual function, psychiatric symptoms, activities of daily
attack (TIA) before examination in 1968 were excluded, living, and, when relevant, age at onset for stroke and de-
leaving 1460 women for the present study (age 38, mentia, and disease course.
n 5 371; age 46, n 5 433; age 50, n 5 397; age 54, Medical records on all women were collected from all
n 5 180; age 60, n 5 79). None of the women had dementia inpatient and outpatient departments and general practi-
in 1968. The examinations included neuropsychiatric and tioners’ offices in Gothenburg. The Swedish Hospital
physical examinations, psychometric testing, key informant Discharge Register provided information on diagnoses of
interviews, electrocardiography, and blood sampling. all individuals discharged from hospitals on a nationwide ba-
The study was approved by the Regional Ethical Review sis since 1978. Diagnoses are classified according to the In-
Board at the University of Gothenburg. All participants gave ternational Statistical Classification of Diseases and Related
informed consent to participate, in accordance with the pro- Health Problems (ICD).
visions of the Helsinki Declaration.
Neuropsychiatric examinations were performed by experi- 2.2. Diagnoses of dementia
enced neuropsychiatrists in 1968–1969, 1974–1975, 1980–
1981, and 1992–1993 and by experienced psychiatric research Dementia was diagnosed according to the Diagnostic and
Statistical Manual of Mental Disorders-III-R criteria, as
described previously [19,20]. For participants in the
neuropsychiatric examinations, dementia diagnoses were
made by neuropsychiatrists after reviewing information
from both neuropsychiatric examinations and the close
informant interview. The diagnosis was made if the
participant had dementia according to both sources of
information, or if there was clear evidence of dementia
from one source and subthreshold symptoms from the
other. For individuals lost to follow-up, dementia diagnoses
were based on information from medical records evaluated
in consensus conferences and from the Hospital Discharge
Register. In total, 325 cases of dementia were diagnosed
(95 from hospital register and/or medical records only;
119 from clinical examination and/or close informant inter-
view only; and 111 according to both sources). Among those
with dementia, 161 had Alzheimer’s disease, 46 vascular de-
Fig. 1. The Prospective Population Study of Women in Gothenburg. mentia, 84 mixed dementia, and 34 other types of dementia.
X. Guo et al. / Alzheimer’s & Dementia 14 (2018) 1253-1260 1255
Age of dementia onset was based on the combined informa- Poisson regressions were used to test the risk of dementia
tion sources of neuropsychiatric examination, close infor- at different time periods before and after stroke. The models
mants, and register. were adjusted first for age and later for multiple con-
founders. Selection of confounders was made by Poisson
2.3. Diagnoses of stroke regression with dementia incidence as dependent variable
and with age and each potential confounder as independent
The diagnosis of stroke was based on information from variables. The potential confounders included both variables
participants and key informants, the hospital register, and at the baseline examination (education, marital status,
medical records, as described previously [21]. Information social-economic status, alcohol consumption, smoking,
on stroke from participants was obtained using identical physical activities, hypertension, cholesterol, diabetes melli-
questionnaires at all examinations and with identical instru- tus, and myocardial infarct) and time-varying variables
ments for the close informant interviews since 1992. The in- (smoking, hypertension, cholesterol, diabetes mellitus, and
terviews included questions about sudden onset of focal myocardial infarct from 1968 to 2012). Variables were
neurological symptoms or acute aphasia, symptom duration, included in the final models if they met the criteria of
age at stroke, and admission to hospital due to stroke. All in- P .05 in the analyses.
formation was evaluated, and diagnoses were made by two As age of stroke onset may influence relationship be-
of the authors (X.G. and I.S.). For a diagnosis of stroke, tween stroke and dementia, this relation was examined
the symptoms had to be present for more than 24 hours. In among women with first stroke before age 80 and among
those with less duration, a diagnosis of TIA was made. women with first stroke after age 80 by Cox regression.
Totally, 362 strokes were diagnosed (236 from hospital reg- Cox regressions were also used to examine the relationship
ister and/or medical records only; 14 from examinations and/ between TIA and dementia as well as between recurrent
or close informants only; 112 from both sources). stroke and dementia. SAS, version 9.4, and Stata, version
14, were used for the analyses.
2.4. Assessments of confounders
Education was dichotomized as mandatory (6–7 years)
3. Results
and more than mandatory. Social-economic status was clas-
sified as high, medium, and low based on husband’s occupa- 3.1. Incidence of stroke and dementia in the population
tion and income for married women and own occupation and
income for unmarried. Marital status was classified as mar- Characteristics of the population at baseline are presented
ried or unmarried. Smoking was classified as never smoker, in Table 1. Among 1460 women at baseline, 362 developed
ex-smoker (ceased smoking more than 1 year before the ex-
amination), or current smoker (ceased smoking within 1 year Table 1
before the examination or those smoking at the year of exam- Baseline characteristics of study population (n 5 1460)
ination). Alcohol consumption was classified as never/less Age (mean 6 SD) 46.8 6 6.2
than once a week and once or more than once a week. Levels Education, %
of physical activity in leisure time were rated as less than Mandatory 72.7
4 hours/week and more than 4 hours/week. Hypertension More than mandatory 27.3
was defined as systolic blood pressure 140 mm Hg and/ Marital status, %
Married 77.8
or diastolic blood pressure 90 mm Hg and/or taking antihy- Unmarried 22.2
pertensive medication. History of myocardial infarct was Social-economic status, %
based on self-report or hospital register. Diabetes mellitus Low 12.6
was defined as a diagnosis told by a doctor, being on antidi- Medium 45.2
abetic therapy, having two fasting venous or capillary whole High 42.2
Smoking, %
blood glucose values 7.0 mmol/L, or hospital register. Ex-smoker 6.7
Current smoker 41.6
2.5. Statistical methods Alcohol consumption, %
Never or less than once/week 24.4
Incidence rates of stroke and dementia by age intervals Once or more than once/week 75.6
are presented as cases per 1000 person-years and 95% con- Physical activity, %
fidence interval (CI). Both stroke and dementia are associ- Less than 4 hours/week 18.1
More than 4 hours/week 81.9
ated with increased mortality. Thus, mortality is a BMI (mean 6 SD) 24.1 6 3.8
competing risk for development of dementia. This may Cholesterol (mean 6 SD) 6.9 6 1.2
lead to biased comparisons between stroke and nonstroke Hypertension, % 38.5
groups due to different mortality. The association between Diabetes mellitus, % 0.8
stroke and dementia was thus tested by Cox regressions Myocardial infarct, % 0.1
both with and without competing risk of death analyses. Abbreviation: BMI, body mass index; SD, standard deviation.
1256 X. Guo et al. / Alzheimer’s & Dementia 14 (2018) 1253-1260
the year around stroke, it could be discussed whether these than 6 years. Selective survival might therefore
cases should be diagnosed with vascular or mixed dementia. underestimate the risk of prestroke dementia. It may
Strengths of this study include the large population- also affect the long-term risk of dementia after stroke.
based sample, the long follow-up and the use of several Finally, only women were included in the study. World-
information sources to diagnose stroke and dementia. wide, the stroke prevalence and incidence rate were
Several methodological issues need to be considered. higher in men than in women [49]. Previous studies re-
First, cumulative attrition is a problem in long-term ported that women have higher risks of both prestroke
follow-up studies. While this problem was, to some and poststroke dementia [8]. However, men with stroke
extent, alleviated by using medical records and hospital still have a higher risk for dementia than men without
registry in those lost to follow-up. Almost all people in stroke [1]. Future studies need to examine if the impact
Sweden receive their hospital treatment within the public of stroke on the development of dementia in men is as
health system, and the Hospital Discharge Register covers strong and long-lasting as in women.
the entire country. Second, the validity of stroke case Our findings may have important implications for under-
ascertainment could be questioned. A previous study re- standing the relationship between stroke and dementia, for
ported that 94% of strokes in the hospital discharge reg- the prevention and treatment of dementia and stroke, and
ister are correctly classified [45], and this register for the classification of subtypes of dementia disorders.
misses less than 10% of stroke patients in Sweden [46]. Our study shows that prestroke dementia is common. It is
In the present study, 88% of strokes were detected by reg- thus important to check patients with dementia for cardio-
isters. The detection of stroke was somewhat improved by vascular risk factors to prevent incidence stroke, and to eval-
using self-reports and key informants [21]. All informa- uate preexisting dementia and cognitive symptoms in
tion from self-reports and key informants was evaluated patients with stroke. Our finding that dementia risk is
by neuropsychiatrists, and the criteria were rather strict, increased more than 11 years after stroke highlights the
allowing only cases with a clear history of focal symp- importance to regularly test cognitive function among indi-
toms. These methods may thus underestimate stroke inci- viduals with stroke, both in the short and long term, as this
dence in the population. Actually, only 35% of total may lead to early diagnosis and treatment of dementia.
stroke was detected by self-reports and/or key informants. Furthermore, our study underscores the importance to pre-
However, among those cases detected by self-reports and/ vent and treat stroke, as stroke lesions have significant con-
or key informants, 89% were confirmed in the hospital tributions on poststroke dementia. Early intervention and
register. Third, there might have been misclassification treatment of vascular risk factors such as hypertension,
of prestroke and poststroke dementia as dementia onset hyperlipidemia, diabetes, and smoking may have great im-
is often gradual and insidious. It is thus difficult to judge plications on prevention of stroke, small vessel diseases,
the exact time sequence between stroke and dementia, and cognitive impairment. Our findings need to be confirmed
especially when two events occurred close to each other. by other studies. More studies are needed to investigate un-
However, there is no systematic bias in this misclassifica- derlying mechanisms of the association between dementia
tion, as dementia onset was estimated blindly to informa- and stroke. More research is needed to study predictors of
tion on stroke onset. Furthermore, we required that stroke prestroke and poststroke dementia.
and dementia should not occur at the same year for the
classification of prestroke and poststroke dementia.
Acknowledgments
Fourth, the study was conducted over 44 years during
which time large changes occurred in treatment of stroke This study was supported by grants from the Swedish
and its risk factors. In addition, recognition of dementia Research Council for Health, Working Life and Welfare
and stroke has improved. Studies showed that the risk (no 2013-2496, AGECAP 2013-2300), Swedish Council
of dementia in relation to stroke has also decreased dur- for Working Life and Social Research (no 2001-2835,
ing the last decades [47,48]. Birth cohort was thus 2001-2646, 2003-0234, 2004-0150, 2004-0145, 2006-
controlled in our analyses. Fifth, our findings are 0596, 2006-0020, 2008-1111, 2008-1229, 2010-0870), the
influenced by selective survival as each of dementia and Alzheimer’s Association Stephanie B. Overstreet Scholars
stroke is related to mortality. This may be one reason (IIRG-00-2159), the Swedish Research Council (no.
why risk of dementia was decreased more than 6 years 11267, 2005-8460, 825-2007-7462, 2013-8717, 2015-
before stroke, as the index stroke group comprises only 02830), Sahlgrenska University Hospital (ALF), the Swed-
individuals who survived 6 years or more, while the ish Stroke Association, Alzheimerfonden, the Bank of
nonstroke control group comprises also individuals who Sweden Tercentenary Foundation, Eivind och Elsa K:son
survive less than 6 years. Individuals with dementia, Sylvans stiftelse, Stiftelsen f€or Gamla Tj€anarinnor, and
especially those with risk factors for stroke, have Handlanden Hjalmar Svenssons Foundation, Swedish Brain
higher mortality and thus less chance to live more Power, Swedish Alzheimer Foundation, Hj€arnfonden and
X. Guo et al. / Alzheimer’s & Dementia 14 (2018) 1253-1260 1259
Konung Gustaf V:s och Drottning Victorias Frimurarestif- of incident dementia in a population-based first-ever stroke cohort.
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