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Slow Decline Often Follows Stroke Recovery

People with less access to health care may deteriorate most, study finds,,

THURSDAY, June 25 (HealthDay News) -- Within five years of a stroke, even people who initially recover often slip into a gradual decline -- especially those with limited access to health care, a new study finds.

Stroke is the third leading cause of death in the United States, and some 795,000 people in the country have a stroke each year, according to the American Heart Association.

"Usually, stroke is seen as an episodic condition that occurs in discrete events," said the study's lead researcher, Dr. Mandip S. Dhamoon, a neurology resident at Columbia University College of Physicians and Surgeons in New York City.

However, "our data suggest that, in terms of function, stroke could be considered a chronic condition showing a steady decline over time, even in the absence of discrete events such as recurrent strokes or heart attacks," he said.

The report is published in the June 25 online edition of Stroke.

For the study, Dhamoon's team collected data on 525 participants from what's known as the Northern Manhattan Study. All had been 40 or older when they had a stroke for the first time.

The researchers rated people's function over time, assessing their ability to carry out 10 activities with and without assistance. They were evaluated every year for five years.

The team found that, "even when patients recover most functional ability in the first months after an ischemic stroke, they gradually become more dependent over the next five years," Dhamoon said. An ischemic stroke is caused by a clot that blocks a blood vessel in the brain.

"The odds of having a full recovery -- living independently or needing very little assistance -- fell as much as 9 percent per year over five years," he said. "At the same time, the odds of patients being rated as severely disabled compared to the first six months rose as much as 13 percent per year."

Insurance status also had a significant effect on whether function deteriorated over time, Dhamoon said. "Uninsured patients and those covered by Medicaid had a significant decline in function over five years, while those covered by Medicare or private insurance did not," he said.

Access to health care is not just important at the time of a stroke, but in the years after, Dhamoon said. "Those with poorer access to health care may be less likely to get ongoing rehabilitation and may be less able to manage their blood pressure and other risk factors," he said.

In addition, people who were older, had diabetes, were unmarried, had a more severe stroke, had a stroke on their right side or had urinary incontinence within a week of the stroke were more likely to be disabled within five years, Dhamoon noted.

Dhamoon's group is currently studying a group of about 3,000 people who had not had a stroke when they enrolled in the Northern Manhattan Study. The researchers plan to use data gathered over eight or nine years to compare the rate of decline in function between people who have a stroke during the follow-up period and those who don't.

But Dr. Majaz Moonis, director of Stroke Services and the Stroke Prevention Program at the University of Massachusetts Memorial Medical Center, said the study failed to take into account several key factors.

Stroke prevention is a comprehensive management strategy, and the authors did not account for the medication used to prevent a second stroke, Moonis said. "Also, they have not looked at the impact of acute rehabilitation on this delayed decline," he said.

"Personally, in our own stroke prevention clinic over the last eight years of close follow-up, I have not seen such a uniform decline," Moonis said. "The difference may be related to a very close follow-up and intervention as needed. In our stroke prevention service, we follow patients every six months with the best medical management paradigms."

More information

The U.S. National Institute of Neurological Disorders and Stroke has more on stroke.

SOURCES: Mandip S. Dhamoon, M.D., M.P.H., neurology resident, Columbia University College of Physicians and Surgeons, New York City; Majaz Moonis, M.D., director, Stroke Services and Stroke Prevention Program, University of Massachusetts Memorial Medical Center, Worcester, Mass.; June 25, 2009, Stroke, online

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