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Background: Mild cognitive impairment (MCI)—measurable cognitive impairment that doesn't severely affect daily functioning—is common, affecting 1 in 5 adults 65 or older. Little is known about the quality of stroke care for patients with pre-existing MCI despite evidence in other diseases that these patients may be under-treated. Methods: Prospective study of 708 patients aged ≥65 hospitalized with acute ischemic stroke between 2000 and 2014 from the Health and Retirement Study with linked Medicare and American Hospital Association data. We compared receipt of process measures after acute ischemic stroke between patients with pre-existing MCI (based on modified Telephone Interview for Cognitive Status [TICS-m] score, 7-11, a valid measure of MCI) and normal cognition (TICS-m score, 12-27). We used Cox regression to estimate the effect of pre-existing MCI on receipt of process measures after adjusting for patient and hospital factors (Table 1). Results: Patients with pre-existing MCI, compared to those with normal cognition, were less likely to receive IV t-PA, carotid revascularization, cardiac monitoring, and rehabilitation assessment, but not carotid imaging (Table 1). Pre-existing MCI was not independently associated with stroke process measures after adjusting for patient and hospital factors such as sex, educational and marriage status, and facility size. Conclusion: Modest differences in use of IV t-PA, carotid revascularization, rehabilitation assessment, cardiac monitoring, and carotid imaging exist in patients with pre-existing MCI and normal cognition after acute ischemic stroke. These differences were largely explained by patients with MCI being more likely to be women, less educated, unmarried, and using smaller hospitals.

Background: High blood pressure (BP), particularly in mid-life, increases the risk for late-life cognitive impairment and dementia (CID). The extent to which Blacks’ and Hispanics’ worse BP control starting in young adulthood contributes to their greater risk of CID compared to Whites is uncertain. Objective: To describe a pooled, multi-ethnic cohort created to determine the associations between BP levels over the life course and CID risk in Blacks, Hispanics, and Whites. Methods: We pooled individual-level data from 35,473 adults (22.6% Blacks, 8.1% Hispanics, 67.3% Whites, 2% Other) with baseline age ≥18 and cognitive assessments across 6 longitudinal cohorts in the United States from 1971 to 2016: Atherosclerosis Risk in Communities Study (ARIC), Coronary Artery Risk Development in Young Adults Study (CARDIA), Cardiovascular Health Study (CHS), Framingham Offspring Study (FOS), Multi-Ethnic Study of Atherosclerosis (MESA), and Northern Manhattan Study (NOMAS). We harmonized cognitive tests across studies into 3 factors representing global cognitive performance, executive function, and memory using statistically appropriate confirmatory factor analysis. Mean (SD) follow up was 17.1 (10.9) years. Results: The mean (SD) baseline age was 54.3 (16.4) years and 19554 (55.1%) participants were female (Table). There were 3193 (9.0%) first incident strokes (2651 ischemic, 348 hemorrhagic, and 117 other or undetermined type) and 15147 (42.7%) deaths. The Table presents mean BPs at the first and last visits by cohort and the pooled sample. From the initial to the last assessment, mean global cognition decreased over time (p Conclusion: This will be the first comprehensive, large investigation of the association of BP levels from young adulthood to late-life and CID risk in Blacks, Hispanics, and Whites.

Background: It is unclear whether blood pressure is associated with cognitive function after stroke. Methods: Cross-sectional analysis of prospectively obtained data of 432 subjects (mean age, 66; 46% female) with stroke (92% ischemic; median NIH stroke score, 3 [IQR, 2-6]) aged 45 or older without dementia from the population-based Brain Attack Surveillance in Corpus Christi project in 2011-2013. We examined associations between systolic and diastolic blood pressure (BP) and cognitive performance each measured 90 days after stroke. BP measured 3 times using standard protocol and averaged. Cognition was assessed using 4 tests: Modified Mini-Mental Status Examination (3MSE), animal fluency test, Trails A and B. Linear or tobit regression adjusted associations for age, education, and race/ethnicity as well as variables that were significantly associated with both BP and cognition. Results: Systolic BP was not significantly associated with cognitive performance (Model 1) unless diastolic BP was included in the model (Model 3)(Table). Both higher systolic BP and lower diastolic BP each were significantly associated with worse cognitive performance for all 4 tests (Model 3). Diastolic BP remained significantly associated with cognitive performance after adjusting for age, education, and race/ethnicity but systolic BP did not (Model 4). With further adjustment for clinical factors, diastolic BP did not remain independently associated with cognition (Model 5). Lower cognitive performance was significantly associated with older age, less education, Mexican American ethnicity, diabetes, higher stroke severity, more depressive symptoms, and lower BMI. Conclusion: Patients with higher systolic BP and lower diastolic BP are more likely to have worse cognitive performance after stroke but sociodemographic and clinical factors may explain these associations.

Objective: We aimed to explore factors associated with clinical evaluations for cognitive impairment among older residents of the United States. Methods: Two hundred ninety-seven of 845 subjects in the Aging, Demographics, and Memory Study (ADAMS), a nationally representative community-based cohort study, met criteria for dementia after a detailed in-person study examination. Informants for these subjects reported whether or not they had ever received a clinical cognitive evaluation outside of the context of ADAMS. Among subjects with dementia, we evaluated demographic, socioeconomic, and clinical factors associated with an informant-reported clinical cognitive evaluation using bivariate analyses and multivariable logistic regression. Results: Of the 297 participants with dementia in ADAMS, 55.2% (representing about 1.8 million elderly Americans in 2002) reported no history of a clinical cognitive evaluation by a physician. In a multivariable logistic regression model (n = 297) controlling for demographics, physical function measures, and dementia severity, marital status (odds ratio for currently married: 2.63 [95% confidence interval: 1.10–6.35]) was the only significant independent predictor of receiving a clinical cognitive evaluation among subjects with study-confirmed dementia. Conclusions: Many elderly individuals with dementia do not receive clinical cognitive evaluations. The likelihood of receiving a clinical cognitive evaluation in elderly individuals with dementia associates with certain patient-specific factors, particularly severity of cognitive impairment and current marital status.

Background and Objectives: Cardiovascular disease (CVD) is the leading cause of death and serious morbidity in older adults with mild cognitive impairment (MCI), many of whom will not progress to dementia. It is unclear whether patients with pre-existing MCI (without dementia) get evidence-based treatments for CVD less often than patients without MCI. We compared treatment for acute ischemic stroke and acute myocardial infarction (AMI) between MCI patients and cognitively normal patients in a nationally representative sample. Methods: Prospective study of patients aged ≥65 years hospitalized with ischemic stroke (n=517) or AMI (n=509) from the Health and Retirement Study and Medicare data from 2000-2011. We compared receipt of CVD process measures (Table) within 12 months of the stroke or AMI hospitalization from Medicare claims between subjects with pre-existing MCI (modified Telephone Interview for Cognitive Status [TICS-m] score, 7-11, a valid measure of MCI) and those with normal cognition (TICS-m score, 12-27), and used logistic regression to adjust associations for age, sex, race, education, number of preexisting functional limitations, and comorbidity. Results: Compared with cognitively normal patients, patients with pre-existing MCI were significantly less likely to receive all 3 AMI process measures, and they got stroke process measures less frequently but results were not statistically significant (Table). MCI patients were less likely than cognitively normal patients to receive any post-MI revascularization (adjusted odds ratio, 0.54; 95% CI, 0.33-0.88), but not the other CVD process measures, after adjustment (Table). Conclusion: Older MCI patients less frequently got process measures for AMI and ischemic stroke compared with cognitively normal patients. Patient factors explain some but not all of this reduced use. We need to better understand decision making for CVD treatment in older MCI patients and reasons for treatment differences.

High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known.We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995-1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression.In adjusted analyses, 32.1% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27-2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9% vs. 8.2%; AOR, 1.50; CI, 1.09-2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8% vs. 5.3%; AOR, 1.51; CI, 1.02-2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort.Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

The number of older individuals with dementia will likely increase significantly in the next decades, but there is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by cognitively impaired individuals and their families. We used data from the 1993 and 1995 Asset and Health Dynamics Study, a nationally representative longitudinal survey of older Americans, to determine the OOPE for individuals with and without dementia. Dementia was identified in 1993 using a modified version of the Telephone Interview for Cognitive Status for self-respondents, and proxy assessment of memory and judgment for proxy respondents. In 1995, respondents reported OOPE over the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. The adjusted mean annual OOPE was 1,350 US dollars for those without dementia, 2,150 US dollars for those with mild/moderate dementia, and 3,010 US dollars for those with severe dementia (p < 0.01). Expenditures for hospital/nursing home care (1,770 per year US dollars) and prescription medications (800 per year US dollars) were the largest OOPE components for those with severe dementia. We conclude that dementia is independently associated with significantly higher OOPE for medical care compared with those with normal cognitive function. Severe dementia is associated with a doubling of OOPE, mainly due to higher payments for long-term care. Given that the number of older Americans with dementia will likely increase significantly in the coming decades, changes in public funding aimed at reducing OOPE for both long-term care and prescription medications would have considerable impact on individuals with dementia and their families.

Background: As the US population ages, increased stroke incidence will result in higher stroke-associated costs. Although estimates of direct costs exist, little information is available regarding informal caregiving costs for stroke patients.Objective: To determine a nationally representative estimate of the quantity and cost of informal caregiving for stroke.Methods: The authors used data from the first wave of the Asset and Health Dynamics (AHEAD) Study, a longitudinal study of people over 70, to determine average weekly hours of informal caregiving. Two-part multivariable regression analyses were used to determine the likelihood of receiving informal care and the quantity of caregiving hours for those with stroke, after adjusting for important covariates. Average annual cost for informal caregiving was calculated.Results: Of 7,443 respondents, 656 (8.8%) reported a history of stroke. Of those, 375 (57%) reported stroke-related health problems (SRHP). After adjusting for cormorbid conditions, potential caregiver networks, and sociodemographics, the proportion of persons receiving informal care increased with stroke severity, and there was an association of weekly caregiving hours with stroke ± SRHP (p < 0.01). Using the median 1999 home health aide wage ($8.20/hour) as the value for family caregiver time, the expected yearly caregiving cost per stroke ranged from $3,500 to $8,200. Using conservative prevalence estimates from the AHEAD sample (750,000 US elderly patients with stroke but no SRHP and 1 million with stroke and SRHP), this would result in an annual cost of up to $6.1 billion for stroke-related informal caregiving in the United States.Conclusions: Informal caregiving-associated costs are substantial and should be considered when estimating the cost of stroke treatment.

Objective: Although dementia prevalence is higher in blacks than whites, it is unknown whether blacks’ elevated risk of dementia is due to racial differences in acute stroke, the impact of stroke on cognitive health, or other factors. We determined whether racial differences in cognitive function are explained by differences in the frequency or impact of incident stroke between blacks and whites, controlling for baseline cognition. Methods: The study population was a prospective cohort of 5,126 white or black adults aged ≥65 years responding to the Health and Retirement Study in 1998 and followed through 2006. Cognitive function was assessed at 2-year intervals with a modified version of the Telephone Interview for Cognitive Status (TICS-m). Acute strokes were identified using linked Medicare claims. Adults with cognitive impairment (TICS-m Results: There were 5,126 adults with ≥1 follow-up TICS-m measure, of whom 490 had acute stroke (466 whites and 24 blacks; P=0.39). Blacks had lower adjusted TICS-m scores than whites (mean difference, -1.41 points; 95% CI, -1.67 to -1.16 points; P Conclusions: In this nationally representative cohort of older adults, acute stroke did not explain black-white differences in cognition or impact cognition differently by race.

Objective: Although stroke’s short-term cognitive effects are known, less is known about long-term cognitive changes after stroke. We determined changes in cognitive function among survivors of incident stroke, controlling for prestroke cognition. Methods: REasons for Geographic And Racial Differences in Stroke participants aged 45-84 years were recruited from 2003-2007 and followed through March 2013. Cognitive function was assessed every 18-24 months with the Consortium to Establish a Registry for Alzheimer’s Disease Word List Delayed Recall (WLD), a verbal memory test, and the Animal Fluency Test (AFT) of executive function. Adults with cognitive impairment (Six Item Screener Results: There were 10,665 adults with ≥1 follow-up WLD measure, of whom 190 had incident stroke, and 11,909 with ≥1 follow-up AFT measure, of whom 213 had incident stroke. Participants with incident stroke had acute decreases in WLD scores (adjusted decrease for incident stroke vs. no stroke, 1.58 points; 95% CI, 0.90-2.27 points) and AFT scores (adjusted decrease, 0.78 points; 95% CI, 0.23-1.33 points)(Figure). Following stroke, WLD scores improved over time (adjusted improvement, 0.24 points per year; 95% CI, 0.07-0.40; P for stroke*time interaction=0.005) but AFT scores did not change significantly (P for stroke*time interaction=0.91) compared with pre-stroke slopes. Conclusion: In this prospective population-based cohort, incident stroke was associated with significant new deficits in verbal memory and executive function and a new slope for verbal memory. These findings suggest that verbal memory recovers years after stroke, but executive function deficits persist.

OBJECTIVE Public expenditures for home health care grew rapidly in the 1990s, but it remains unclear to whom the additional services were targeted. This study tests whether the rapidly increasing expenditures were targeted to the elderly with high levels of disability and low levels of social support, 2 groups that have historically been higher users of paid home health and nursing home services. METHODS The Asset and Health Dynamics Study, a nationally representative, longitudinal survey of people > or = 70 years of age (n = 7,443), was used to determine the association of level of disability and level of social support with the use of paid home care services in both 1993 and 1995. Multivariable regression models were used to adjust for sociodemographics, recent hospital or nursing home admissions, chronic medical conditions, and receipt of informal care from family members. RESULTS Those with higher levels of disability received more adjusted weekly hours of paid home care in both 1993 and 1995. In 1993, users of paid home care with the least social support (unmarried living alone) received more adjusted weekly hours of care than the unmarried elderly living with others (24 versus 13 hours, P < 0.01) and the married (24 versus 18 hours, P = 0.06). However, by 1995, those who were unmarried and living with others were receiving the most paid home care: 40 versus 26 hours for the unmarried living alone (P < 0.05) and 24 hours for the married (P < 0.05). CONCLUSIONS The recent large increase in formal home care services went disproportionately to those with greater social support. Home care policy changes in the early 1990s resulted in a shift in the distribution of home care services toward the elderly living with their children.