Zdravljenje in bolnišnična obravnava ishemične možganske kapi pri bolnikih z demenco

Županič, Eva (author), Gregorič Kramberger, Milica (mentor), Winbald, Bengt (comentor)

Uvod: Demenca in možganska kap se pogosto pojavljata skupaj; kar 10% možganski kapi se pojavi pri bolnikih z predobstoječo demenco. Predpostavlja se, da predobstoječa demenca vpliva na zdravljenje možganske kapi in funkcijski izhod, vendar večjih raziskav, ki bi to potrdile, ni. Cilji: Preučiti bolnike z demenco, ki utrpijo ishemično možgansko kap (IMK), in jih primerjati z bolniki z IMK, a brez demence v: (1) dostopu, zapletih in izhodih zdravljenja z intravensko trombolizo (IVT), (2) bolnišnični obravnavi s poudarkom na hospitalizaciji v enotah za možgansko kap, izvajanju specifičnih diagnostičnih preiskav, rehabilitaciji in trajanju hospitalizacije, in (3) pričetku zdravljenja s sekundarno farmakološko preventivo tekom hospitalizacije in vzdrževanju takega zdravljenja v letih po IMK. Hipoteze: Pričakovali smo, da bodo imeli bolniki z demenco, ki utrpijo IMK, v primerjavi z bolniki brez demence: (1) slabši dostop do zdravljenja z IVT, (2) več zapletov in slabši izid zdravljenja z IVT, (3) slabši dostop do zdravljenja v enotah za možgansko kap, diagnostičnih preiskav in obravnav s strani rehabilitacijskega tima, (4) krajšo hospitalizacijo in (5) manjšo verjetnost predpisa sekundarne farmakološke preventive možganske kapi. Metode: Nacionalna longitudinalna raziskava je temeljila na podatkih iz švedskih nacionalnih registrov za demenco in možgansko kap (SveDem in Riksstroke). Podatke o pridruženih boleznih, zdravilih in smrti smo pridobili s pomočjo dodatnih nacionalnih registrov (the Swedish National Patient Registry, the Swedish Prescribed Drug Registry, the Swedish Population Register). V prvih dveh raziskavah smo vključili 1356 bolnikov s predobstoječo demenco ter kontrolno skupino 6755 bolnikov brez demence, ki so v obdobju 2010–2014 utrpeli prvo IMK. Kontrolna skupina bolnikov se je ujemala po starosti (+/- 3 leta), spolu, letu nastopa IMK ter geografski regiji. Primerjali smo dostop, zaplete in izide zdravljenja z IVT, bolnišnično obravnavo s poudarkom na hospitalizaciji v enotah za možgansko kap, uporabo diagnostičnih preiskav, rehabilitacije in trajanje hospitalizacije. V tretji raziskavi smo vključili 1410 bolnikov s predobstoječo demenco ter kontrolno skupino 7150 bolnikov brez demence, ki so utrpeli IMK v obdobju 2007–2014. Zanimalo nas je predpisovanje statinov, antiagregacijskega, antikoagulacijskega in antihipertenzivnega zdravljenja ob odpustu iz bolnice in po 1., 2. in 3. letu po IMK. Za preučevanje odnosa med demenco in dostopom ter izidi zdravljenja smo uporabili multivariatno logistično regresijo. Predstavljena so prilagojena razmerja obetov (»odds ratio«–OR) s 95% intervalom zaupanja (»confidence intervals«–CI). Rezultati: Bolniki z demenco so imeli manjšo verjetnost zdravljenja z IVT; IVT je prejelo 94 (7,0 %) bolnikov z in 639 (9,5 %) bolnikov brez demence. Modele v analizi smo prilagodili za spremenljivke, ki bi lahko vplivale na izhode zdravljenja. Tudi po prilagoditvi za možne moteče dejavnike so bila razmerja obetov za prejetje IVT pri bolnikih z demenco nižja (0,68 [95% CI 0,54-0,86]). Ko je bila analiza izvedena le med bolniki, ki so bili pred IMK samostojni v vsakodnevnih aktivnostih, je razlika med bolniki z in brez demence vztrajala le pri bolnikih ? 80 let (OR 0,58; 95% CI 0,36-0,94). Med bolniki z in brez demence, ki so prejeli IVT, nismo našli razlik v incidenci simptomatskih intrakranialnih krvavitev (7,4% v primerjavi z 7,3%, p = 0,960) in smrti 3 mesece po nastopu IMK (22,0% v primerjavi z 18,8%, p = 0,494). Bolniki z demenco so imeli slabši funkcionalni izhod z višjo stopnjo prizadetosti po Modificirani Rankinovi lestvici (mRS, angl. modified Rankin Scale) in večjo verjetnost nove namestitve v domovih starejših občanov (obe p < 0,001). Razlik v neposredni nastanitvi v enotah za možgansko kap nismo našli (72,8% v primerjavi z 72,9%, p = 0.931). Dolžina celotne hospitalizacije v enotah za možgansko kap je bila pri bolnikih z demenco krajša (11,6 v primerjavi z 13,5 dnevi in 10,5 v primerjavi z 11,2 dnevoma, p < 0.001). Bolniki z demenco so prejeli manj obravnav interdisciplinarnega tima za obravnavo možganskih kapi (fizioterapevti, delovni terapevti, logopedi; p < 0.05 za vse prilagojene modele analize). Razlik v testu požiranja med bolniki z in brez demence nismo našli (90,7 % v primerjavi z 91,8 %, p = 0,218). Ob odpustu iz bolnišnice so imeli bolniki z demenco manj možnosti predpisa antihipertenzivov (0,57 [0,49-0,67]), statinov (0,57 [0,50-0,66]) in antikoagulantov (bolniki z atrijsko fibrilacijo – AF; 0,41 [0,32-0,53]). Bolniki z demenco so imeli večjo možnost prejema antiagregacijskega zdravljenja le v primeru AF (1,56 [1,21-2,01]), ob odsotnosti AF razlika v predpisu antiagregacijske terapije ni bila statistično značilna (0,99 [0,75-1,33]). Podobni trendi so bili prisotni v 1., 2. in 3. letu po IMK. Zaključki: Bolniki z demenco, ki utrpijo IMK, imajo manj možnosti, da prejmejo IVT, vendar na to vpliva starost in predhodno funkcionalno stanje. Bolniki z demenco in IMK niso imeli več zapletov zdravljenja z IVT (simptomatskih znotrajmožganskih krvavitev, smrti), vendar je bil njihov funkcionalni izhod slabši in z večjo verjetnostjo so bili na novo nastanjeni v domovih starejših občanov. Torej smo potrdili prvo hipotezo, da imajo bolniki z demenco slabši dostop do zdravljenja z IVT, drugo hipotezo pa smo le delno potrdili, saj imajo bolniki z demenco resda slabši funkcionalni izhod po IVT, vendar podobno verjetnost zapletov zdravljenja. V nasprotju z našo hipotezo so imeli bolniki z demenco enak dostop do zdravljenja v enotah za možgansko kap, a so imeli v povprečju 2 dni krajšo celotno hospitalizacijo. Potrdili smo, da bolniki z demenco prejmejo manj diagnostičnih preiskav in obravnav s strani rehabilitacijskega tima. Bolniki z demenco so imeli manj možnosti, da prejmejo zdravila za sekundarno preventivo IMK, s čimer smo potrdili zadnjo hipotezo.

• Language: Slovenian
• Keywords: demenca, ishemična možganska kap, intravenska tromboliza, bolnišnična obravnava, sekundarna preventiva
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2021
• PID: 20.500.12556/RUL-125894
• COBISS.SI-ID: 61586691
• Publication date in RUL: 09.04.2021

Secondary language

• Language: English
• Title: Treatment and hospital management of ischemic stroke in patients with dementia

Abstract

Background: Dementia and stroke are frequent comorbidities; 10% of strokes occur in patients with pre-existing dementia. Pre-stroke dementia is postulated to influence stroke treatment and to cause worse functional outcome, however, there is a lack of larger-scale studies to support these assumptions. Objective: To compare dementia patients who suffer an ischemic stroke (IS) with non-dementia IS patients in: (1) access, complications and outcomes in treatment with intravenous thrombolysis (IVT), (2) hospital management with focus on hospitalization in specialized stroke units, performance of specific diagnostic tests, rehabilitation and hospitalization length, and (3) institution of pharmacological secondary stroke prevention during hospitalization and its maintenance over the years after IS. Hypotheses: In comparison to non-dementia IS patients, patients with dementia and IS: (1) have worse access to IVT, (2) have more complications and worse outcomes after IVT, (3) have worse access to specialized stroke units, receive less diagnostic tests and rehabilitation assessments, (4) have shorter hospitalization, and (5) are less likely to receive secondary stroke prevention therapy. Methods: National longitudinal studies based on collected data of Swedish national dementia and stroke registries (SveDem in Riksstroke). Data on comorbidities, medication and death was obtained using additional Swedish national registries (the Swedish National Patient Registry, the Swedish Prescribed Drug Registry, the Swedish Population Registry). In the first two studies we included 1356 patients with pre-existing dementia and first IS and 6755 patients with first IS and no dementia, matched in age (+/- 3 years), sex, year of stroke, and geographic region, who suffered first IS between 2010 and 2014. We compared access, complications and outcomes in treatment with IVT, hospital management with focus on hospitalization in specialized stroke units, performance of specific diagnostic tests, rehabilitation and hospitalization length between dementia and non-dementia IS patients. In the third study we used years 2007–2014 and included 1410 patients with dementia and IS and compared them to 7150 non-dementia IS patients. We analysed antiplatelet, anticoagulant, blood pressure lowering, and statin treatment as planned medication initiation at discharge and actual dispensation of medications at first, second, and third year post-stroke. To assess the relationship between dementia status and outcomes, multivariate logistic regression analyses were used. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were presented. Results: Patients with dementia were less likely to receive IVT; IVT was administered to 94 (7.0%) dementia and 639 (9.5%) non-dementia patients. Even when adjusting for possible covariates, OR of receiving IVT was lower for patients with dementia (0.68 [95% CI 0.54-0.86]). When the analysis was repeated exclusively among patients independent in everyday activities, the difference persisted only in patients aged 䁤80 years (OR 0.58; 95% CI 0.36-0.94). We found no differences in the incidence of symptomatic intracerebral hemorrhage (sICH, 7.4% vs. 7.3%, p = 0.960) and death at 3 months (22.0% vs. 18.8%, p = 0.494) after IVT between the two groups, however, functional outcomes (reflected in new nursing home placements and modified Rankin scale–mRS) were worse in patients with dementia (both p<0.001). There were no differences in direct stroke unit admittance (72.8% vs. 72.9%, p = 0.931). In patients with dementia, stroke unit and total hospitalization length were shorter (10.5 vs. 11.2 days and 11.6 vs. 13.5 respectively, p<0.001). Dementia patients were less likely to undergo assessments by the interdisciplinary team members (physiotherapists, speech therapists, occupational therapists; p<0.05 for all adjusted models). A similar proportion of patients received swallowing assessment (90.7% vs. 91.8%, p=0.218). At discharge from hospital, planned initiation of medication was lower in patients with dementia compared to non-dementia patients for blood pressure lowering medication (BPLM; 0.57 [0.49-0.67]), statins (0.57 [0.50-0.66]), and anticoagulants (patients with atrial fibrillation – AF; 0.41 [0.32-0.53]). Patients with dementia were more likely to receive antiplatelets only in the presence of AF (1.56 [1.21-2.01]), in the absence of AF the differences were not significant (0.99 [0.75-1.33]). Similar trends were observed in 1st, 2nd, and 3rd year post-stroke. Conclusions: Patients with dementia and consequent IS are less likely to receive thrombolysis, however, this association is influenced by age and prior functional status. There were no differences in IVT complications (symptomatic intracranial hemorrhage, death), however, dementia was associated with greater disability and new nursing home placement. The hypothesis that patients with dementia have worse access to IVT was confirmed, while we partly disproved the second hypothesis, since patients with dementia had worse functional outcomes after IVT, but similar complications rate. In contrast with our hypothesis there were no differences in access to stroke unit care between patients with and without dementia, however, patients with dementia had on average 2 days shorter hospitalization. We confirmed patients with dementia receive less diagnostic and rehabilitation assessments. Finally, we also confirmed our last hypothesis that patients with dementia are less likely to receive secondary stroke prevention therapy.

• Keywords: dementia, ischemic stroke, intravenous thrombolysis, hospital management, secondary prevention