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Association of Dementia in Ischemic Stroke: A Case Control Study

Objectives: To evaluate the association of dementia in ischemic stroke. Methodology: This case control study was carried out in the department of Neurology at BSMMU, Dhaka from 1st January 2010 to 31st December 2011 for duration of two years to evaluate the association of dementia in ischemic stroke. The target population for this study include all patients presented with ischemic stroke at the range of 3 to 6 months after stroke with the age group of 40 to 70 years are included in this study and patients of dementia other than ischemic stroke like Alzhiemer’s disease, vit-B12 deficiency, thyroid dysfunction were excluded from this study. A total number of 120 respondents were included in this study. Age & sex matched 60 patients of ischemic stroke were selected as cases and rest 60 people were taken as control group. Informed written consent was taken from each patient or his/ her attendant. All information regarding history and physical findings; and other risk factors for dementia were collected to fill up the preformed questionnaire. Relevant physical examinations like nervous system examination, selected general and systemic examination were recorded. Result & Observation: Dementia was present in case and control group 18(30.0%) and 2(3.3%) respectively. The difference was statistically significant (p=0.001). Present smoking habit was more in case (45.0%) than in control group (16.7%) which was statistically significant (p=0.001) with a OR of 4.07 with a 95% CI of 1.89-8.75. Past smoking habit was more in case (16.7%) than control group (11.7%). Non-smoker was more in control (71.7%) than case group (38.3%). Diabetes mellitus was more common in case group (38.3%) than control group 5(8.3%) which was statistically significant (p=0.001) with a 6.84 OR and 95% CI of 2.39-19.6. Conclusion: The study permit to conclude that dementia is directly associated with ischemic stroke. We found a correlation between age, family history of dementia, hypertension, diabetes mellitus and dyslipidemia with dementia.

and reversible, these distinctions are more relative than absolute 2 .
Dementia is a syndrome consisting of a loss of several separable but overlapping intellectual abilities and present in a number of different combinations 3 . Memory is the most common cognitive ability lost with dementia; 10% of persons >70 and 20-40% of individuals >85 years of age have clinically identifiable memory loss. In addition to memory, other mental faculties are also affected in dementia; these include language, visuospatial ability, calculation, judgment, and problem solving. Neuropsychiatric and social deficits also develop in many dementia syndromes, resulting in depression, withdrawal, hallucinations, delusions, agitation, insomnia, and disinhibition. The most common forms of dementia are progressive, but some are static and unchanging or fluctuate dramatically from day to day. Most diagnoses of dementia require some sort of memory deficit, although there are many dementias, such as frontotemporal dementia, where memory loss is not a presenting feature 4 .
Dementia affects more than 4 million Americans and results in a total health care cost of >$100 billion annually. The reported frequency of dementia due to potentially reversible causes varies from 0 to 23% 5,6,7 . Historically, patients with dementia due to recurrent strokes were diagnosed with multiinfarct dementia termed as vascular dementia, since the disease can occur after a single vascular incident 8 . Vascular dementia is widely accepted as the second most common cause of cognitive impairment.
Stroke is clearly related to vascular dementia, the second-most-common type of dementia 9 . There has been a recent upsurge of interest in poststroke dementia (PSD), which is a subtype of vascular dementia. PSD is operationally defined as the presence of dementia identified at 3 months after an acute, either recurrent or first-ever, stroke 10 . The prevalence of PSD among recurrent or first-ever stroke patients varies from 6% to 31.8% 10-12 . Stroke is the major cause of physical disability in adults 13 . It is the second most common cause of dementia, and the third leading cause of death in developed countries 14 . In a population of 1 million inhabitants, 2400 patients will have a stroke every year, of whom fewer than 50% will be independent 1 year later 15 . Leys et al (2005) 13 reported that dementia is one of the major causes of dependency after stroke.
Poststroke dementia (PSD) is one of the main causes of dependency in survivors and includes any dementia after a stroke, irrespective of its cause like vascular, degenerative, or mixed 13 . A huge increase in prevalence and burden of PSD is likely to happen because of the decline in mortality after stroke and ageing of populations 16 . PSD includes all types of dementias that happen after stroke, irrespective of their cause 13 . In prevalence studies, PSD included both pre-existing dementia and newonset dementia after stroke 3 . In community-based studies with adjustment for age, the prevalence of dementia in people with a history of stroke is about 30% 17 . In hospital-based studies, the prevalence of PSD ranges from 5·9 to 32% 13 . Stroke increases the risk of dementia up to 12 times 18,19 . The overall prevalence of dementia is estimated in India was 3.36% 20 .
In Bangladesh there is no research and data about prevalence or incidence of post stroke dementia. Post stroke dementia is the most disabling of all the neurological diseases and in the context of our country it poses a huge burden both socially and economically. The treatment cost benefit is frustrating and rehabilitation is not expectedly available. So, we should concentrate more on prevention. As there is no local data on this topic, this study is therefore planned to identify the association of dementia with ischemic stroke and to find out the determinants of dementia in ischemic stroke.

Methods:
This study was a case control study, which was carried out in the department of Neurology at BSMMU, Dhaka, from 1st January 2010 to 31st December 2011 for a duration of two years. The target population for this study included all patients presented with ischemic stroke of 40-70 years of age in both sexes. Age and sex matched volunteer/ patients other than ischemic stroke were selected as the control group. Data collection was conducted by researcher himself. All data were compiled and edited meticulously by thorough checking and rechecking. All omissions and inconsistencies were corrected and were removed methodically. All data were recorded systematically in preformed data collection form (questionnaire) and quantitative data was expressed as mean and standard deviation and qualitative data was expressed as frequency distribution and percentage. Statistical analysis was performed by using SPSS for windows version 15.0. 95% confidence limit was taken. Probability value <0.05 was considered as level of significance.

Results and Observations:
A total number of 120 respondents were included in this study of which 60 patients of ischemic stroke were selected as case and the rest 60 volunteer were selected as control.
The mean age of case and control group were 57.13 ± 7.39 and 57.37 ± 7.94 respectively (p=0.868). In both case and control groups male and female were equal in number which were 42(70.0%) and 18(30.0%) respectively. Smokers/ ex-smokers were more in case than control group which was 39(65.0%) and 15 (25.0%) respectively (p=0.001) with as OR of 5.57 with a 95% CI of 2.53-12.27.
Non-smokers were more in case than control group which was 21 (35.0%) and 45(75.0%) respectively. Diabetes mellitus was more common in case group than control which was 30 (50.0%) and 5(8.3%) respectively. The difference was statistically significant (p=0.001) with 11.00 as OR and 95% CI of 3.87-31.31. Hypertension was more common in case group than control which was 45(75.0%) and 20(33.3%) respectively. The difference was statistically significant (p=0.001) with 6.84 as OR and 95% CI of 2.71-13.27. Dyslipidaemia was more common in case group than control which was 39(65.0%) and 26(43.3%) respectively. The difference was statistically significant (p=0.017) with 2.43 as OR and 95% CI of 1. 16-5.07. Cardiac diseases were more common in control group than case which was 5(8.3%) and 4(6.7%) respectively. The difference was statistically not significant (p=0.729) with 0.79 as OR and 95% CI of 0.20-3.08. Family history of dementia was more common in case group than control which was 6 (10.0%) and 1 (1.7%) respectively. The difference was statistically not significant (p=0.051) with 6.56 as OR and 95% CI of 0.76-56. 22. These are shown in Table I.     respectively. In control group no smoker was found and only 2 (100.0%) cases were non-smokers. The difference is statistically significant (p=0.023).                         Table XV shows the distribution of the respondents by dementia and hypertension. Out of all patients of dementia 70% were hypertensive. On the contrary among all respondents of non-dementia 51% were hypertensive. This variation is statistically not significant at p value less than 0.012 level.  Table XVI shows the distribution of the respondents by dementia and diabetes mellitus. Out of all patients of dementia 65% were diabetic. On the contrary among all respondents of non-dementia 35% were non diabetic. This variation is statistically significant at p value less than 0.001 level. Diabetic patients had 6.58 times more chance to develop dementia than that of non-diabetic patients.    A total number of 120 respondents were included in this study of which 60 patients of ischemic stroke were selected as case and the rest 60 volunteers were selected as control.
The distribution of the patients by age was recorded in this study. In 40 -49 years age group among cases dementia was present in 2 (11.1%) cases and absent in control group. In 50 -59 years age group dementia was present in 5(27.8%) cases and absent in control group. In 60 years and above age group dementia was present in 11(61.1%) cases and 2 (100.0%) in control group. The mean age± SD is 60.50±7.44 and 70.00 ± 0.0 in case and control groups respectively (p=0.021). Similar result was recorded by Lis and Gaviria 21 .  23 and mentioned that smoking increased the risk of dementia significantly.
The distribution of the patients by MMSE is recorded in this study. In case group dementia was present The distribution of the patients with dementia by dyslipidaemia was recorded in this study. In case group dyslipidaemia was present in 13 (72.2%) cases and absent in 5 (27.8%) cases. In control group dyslipidaemia was absent in all 2 (100.0%) cases. The difference is statistically significant (p=0.042).
The distribution of the patients with dementia by cardiac disease was recorded in this study. In case group cardiac disease was present in 1 (5.6%) case and absent in 17 (94.4%) cases. In control group cardiac disease was present 1 (50.0%) case and absent in 1 (50.0%) case. The difference is statistically significant (p=0.047). Similar result was reported by Posner et al(2000) 23 and mentioned that a history of hypertension may be an antecedent to VaD, particularly in the presence of heart disease.
The distribution of the patients by family history of dementia was recorded. In case group family history of dementia was present in 4 (22.2%) cases and absent in 14 (77.8%) cases. In control group no family history of dementia was found i.e. absent in all 2 (100.0%) cases. The difference is not statistically significant (p=0.456). But Huang et al (2004) 27 mentioned that a family history of dementia continue to influence the occurrence of dementia. Launer et al (1999) 22 also reported a result correlating between family history of dementia and occurrence of dementia and found a result which is consistent with the present study.