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Background: The association between stroke and dementia is well established. Less is known about this association in underrepresented ethnic groups. In a large ethnically diverse cohort, we examined whether history of stroke was associated with cognitive impairment, and whether this relationship differed by ethnicity (Mexican American [MA] versus non-Hispanic White). Methods: This was a population-based cohort study conducted in Nueces County, TX, a biethnic community with a large and primarily nonimmigrant MA population. Residents aged ≥65 were recruited door-to-door or by telephone between May 2018 and December 2021. The primary exposure was history of stroke, obtained by self-report. Demographic, medical, and educational histories were also obtained. The primary outcome was the Montreal Cognitive Assessment (MoCA), a scale that evaluates multiple domains of cognitive performance. Scores were divided into 3 ordinal categories, roughly corresponding to normal cognition (MoCA 26–30), mild cognitive impairment (MoCA 20–25), or probable dementia (MoCA 0–19). Results: One thousand eight hundred one participants completed MoCA screening (55% female; 50% MA, 44% Non-Hispanic White, 6% other), of whom 12.4% reported history of stroke. Stroke prevalence was similar across ethnicities (X 2 2.1; P =0.34). In a multivariable cumulative logit regression model for the ordinal cognition outcome, a stroke by ethnicity interaction was observed ( P =0.01). Models stratified by ethnicity revealed that stroke was associated with cognitive impairment across ethnicities, but had greater impact on cognition in non-Hispanic Whites (cumulative odds ratio=3.81 [95% CI, 2.37–6.12]) than in MAs (cumulative odds ratio=1.58 [95% CI, 1.04–2.41]). Increased age and lower educational attainment were also associated with cognitive impairment, regardless of ethnicity. Conclusions: History of stroke was associated with increased odds of cognitive impairment after controlling for other factors in both MA and Non-Hispanic White participants. The magnitude of the impact of stroke on cognition was less in MA than in Non-Hispanic White participants.

To investigate stroke outcomes at 3, 6, and 12 months post-stroke overall and by ethnicity in a population-based, longitudinal study.First-ever ischemic strokes (2014-2019, n = 1,332) among Mexican American persons (n = 807) and non-Hispanic white persons (n = 525) were identified from the Brain Attack Surveillance in Corpus Christi Project. Data were collected from patient or proxy interviews (baseline, 3, 6, and 12 months post-stroke) and medical records, including functional (activities of daily living/instrumental activities of daily living score), neurological (National Institutes of Health Stroke Scale), cognitive (Modified Mini-Mental State Examination), and quality of life (QOL) outcomes (12-domain Stroke-specific Quality of Life scale). Outcome trajectories were analyzed using multivariable adjusted linear models, with generalized estimating equations to account for within-subject correlations; interactions between ethnicity and time were included to investigate ethnic differences in outcomes.The median age was 67 years (interquartile range 58,78), 48.5% were women, and 60.6% were Mexican American persons. For all outcomes, significant improvement was seen between 3 and 6 months (p 0.05 for all), with stability between 6 and 12 months. Mexican American persons had significantly worse outcomes compared with non-Hispanic white persons at all time points (3, 6, and 12 months), with the exception of the National Institutes of Health Stroke Scale, which did not differ by ethnicity at 6 and 12 months, and the average change in outcomes did not vary significantly by ethnicity.Outcomes were at their worst at 3 months post-stroke, and ethnic disparities were already present, suggesting the need for early assessment and strategies to improve outcomes and possibly reduce disparities. ANN NEUROL 2022.

OBJECTIVE. To identify Hispanic/Latinx and non Hispanic white participation rates in a community-based project using door-to-door recruitment. METHODS. We conducted a two-stage area probability sample of housing units in Nueces County, Texas, using Census data including Mexican Americans (MAs) and non-Hispanic Whites (NHWs). From May 2018-February 2020 residents over 64 were asked to take a cognitive screen. We compared expected and observed ethnic-specific participation. RESULTS. 996 participants enrolled. Accounting for sampling error, the observed count of MAs (n=609) significantly exceeded expectations ([Formula: see text] =532, [95% CI: 521,542]). The observed count of NHWs (n=387) was less than expected ([Formula: see text] =464, [95% CI: 455, 473]. The sub-group with the largest difference in observed vs. expected participants was MA women, n=376 observed, 306 (95% CI: 300, 312) expected. CONCLUSIONS. Mexican Americans were significantly more likely to participate than expected, challenging the notion that ethnic minority populations are less likely to agree to research.

Older adults with significant cognitive impairment require help with activities of daily living. The BASIC-Cognitive Project, set in Nueces County, Texas, is a community-based study examining trends in cognition among Mexican Americans and non-Hispanic Whites. Using cross-sectional data from a cohort study, we found that at least 7% of individuals aged 65 and older with a Montreal Cognitive Assessment (MoCA) score of

Objectives:We examined whether language preference was associated with 90-day post stroke outcomes among Mexican Americans (MAs).Methods:Ischemic stroke and intracerebral hemorrhage (ICH) patients from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project (2009-2018) were compared by language preference in 90-day neurological, functional and cognitive outcomes using weighted Tobit regression. Models were adjusted for demographics, initial NIHSS, medical history, stroke characteristics, and insurance status.Results:Of 1,096 stroke patients, 926 were English-speaking and 170 were Spanish only speaking. Spanish speakers were older (p < 0.01), received less education (p < 0.01), had higher initial NIHSS values (p = 0.02), had higher prevalence of atrial fibrillation (p < 0.01), and had lower prevalence of smoking (p = 0.01) than English speakers. In fully adjusted models, Spanish only speakers had worse neurological outcome (NIHSS, range 0–44 [higher worse], mean difference: 1.93, p < 0.01), but no difference in functional outcome measured by activities of daily living/instrumental activities of daily living or cognitive outcome compared with English speakers.Conclusions:This population-based study found worse neurologic but similar functional and cognitive stroke outcomes among Spanish only speaking MAs compared with English speaking MAs.

Background and Purpose: Mexican Americans (MAs) have worse stroke outcomes and a different profile of multiple chronic conditions (MCC) compared with non-Hispanic White people. MCC has implications for stroke treatment, complications, and poststroke care, which impact poststroke functional outcome (FO). We sought to assess the contribution of MCC to the ethnic difference in FO at 90 days between MAs and non-Hispanic White people. Methods: In a prospective cohort of ischemic stroke patients (2008–2016) from Nueces County, Texas, data were collected from patient interviews, medical records, and hospital discharge data. MCC was assessed using a stroke-specific and function-relevant index (range, 0–35; higher scores greater MCC burden). Poststroke FO was measured by an average score of 22 activities of daily living (ADLs) and instrumental ADLs at 90 days (range, 1–4; higher scores worse FO). The contribution of MCC to the ethnic difference in FO was assessed using Tobit regression. Effect modification by ethnicity was examined. Results: Among the 896 patients, 70% were MA and 51% were women. Mean age was 68±12.2 years; 33% of patients were dependent in ADL/instrumental ADLs (FO score >3, representing a lot of difficulty with ADL/instrumental ADLs) at 90 days. MAs had significantly higher age-adjusted MCC burden compared with non-Hispanic White people. Patients with high MCC score (at the 75th percentile) on average scored 0.70 points higher in the FO score (indicating worse FO) compared with those with low MCC score (at the 25th percentile) after adjusting for age, initial National Institutes of Health Stroke Scale, and sociodemographic factors. MCC explained 19% of the ethnic difference in FO, while effect modification by ethnicity was not statistically significant. Conclusions: MAs had a higher age-adjusted MCC burden, which partially explained the ethnic difference in FO. The prevention and treatment of MCC could potentially mitigate poststroke functional impairment and lessen ethnic disparities in stroke outcomes.

Background and AimsWhether and how much stroke survivors’ blood pressure (BP) control changed over the 2010s decade is unclear. We assessed whether 90-day BP control changed from 2011 to 2019, and whether temporal changes varied by ethnicity and sex.MethodsWe conducted a prospective cohort study of 1,755 first expert-adjudicated stroke cases ≥45 years in the Brain Attack Surveillance in Corpus Christi (BASIC) project with BP measurements from 2011-2019. We measured BP in patients’ residences at ∼90 days post-stroke using standardized procedures and validated oscillometric devices. The average of three BP measurements was used. Outcomes were BP control ResultsMedian age was 66 years (interquartile range, 58-76 years), 59% were Mexican American, 49% were women. From 2011 to 2019, BP control ConclusionsFrom 2011 to 2019, BP control AHA Journals Subject TermsCerebrovascular Disease/Stroke, Blood Pressure, Quality and Outcomes, Health Services

Introduction: Mexican Americans (MAs) have worse stroke outcomes than non-Hispanic whites (NHWs). One possible explanation is that MAs receive less intense rehabilitation than NHWs. Our objective was to examine ethnic differences in use and type of rehabilitation in the first 90-days following stroke. Methods: Stroke cases were identified from the population-based Brain Attack Surveillance in Corpus Christi Project from Oct 2019-Oct 2021 and followed for 90 days for self-reported use of post-acute rehabilitation care. Sociodemographics, risk factors, stroke severity and treatment were ascertained from interviews and medical records. Functional outcome and depression were assessed at 90 days. Propensity score (PS) methods were used to balance characteristics by ethnicity and PS scores and other covariates were included in a logistic regression model of the association between ethnicity and the primary outcome of use of any rehabilitation. Results: Five hundred fifty-four stroke patients were included, with 66% MA and 49% women. MAs were younger, had lower education and income, worse pre-stroke function, more comorbidities, greater average BMI and worse functional outcome and depression at 90-days than NHWs. One-third of participants did not receive any rehabilitation. MAs (66.9%) were more likely to use any rehabilitation following stroke than NHWs (55.9%; p-value=0.01). After adjustment, MAs were 1.9 times (95% CI: 1.2-2.9) more likely to use any rehabilitation than NHWs. MAs were more likely to use outpatient (11.3% vs 4.8%) and home health rehabilitation (38.0% vs 29.8%) than NHWs, while no differences were noted in use of rehabilitation in inpatient or skilled nursing facilities. Conclusion: A high proportion of stroke survivors report no rehabilitation in the first 90 days following stroke. MAs report greater use of less intense forms of rehabilitation than NHWs despite worse outcomes. Future research should investigate barriers to use of more intense rehabilitation care, particularly in MAs, with the goal of maximizing recovery and reducing ethnic disparities.

Introduction: Neighborhood socioeconomic status is associated with stroke recovery and mortality. Researchers suggest increased recreation, civic, and social sites (referred to as sites) may support physical, social, and cognitive activity resulting in more favorable outcomes. Hypothesis: Stroke survivors in neighborhoods with lower versus higher number of sites will have a higher rate of mortality and stroke recurrence; these associations will be modified by stroke severity, ethnicity, and sex. Methods: We included non-Hispanic white and Mexican American first-ever stroke survivors enrolled in the Brain Attack Surveillance in Corpus Christi project (2009-19), a population-based cohort in Nueces County, Texas. From a national database, we linked sites per square mile by census tract. We censored at second stroke (stroke recurrence model), death, or 1/1/2020, whichever occurred first. We fit cox regression models using a shared frailty model, adjusting for individual, interpersonal, and neighborhood factors. We considered interactions with stroke severity, sex, and ethnicity. We applied inverse probability weighting and multiple imputation to account for missing data. Results: There were 1,688 survivors; 408 deaths, 189 stroke recurrences, over median follow-up of 1372 days. Median age was 64 years, 74% with mild stroke, 54% male and 60% Mexican American. There was no association between site density and mortality (HR comparing 75 th to 25 th percentile=1.01, 95% CI=0.83-1.23) or stroke recurrence (HR=0.98, 95% CI=0.74-1.30). Stroke severity, sex, and ethnicity did not modify the effect of site density on post-stroke mortality (p=0.33, p=0.17, p=0.58, respectively) or stroke recurrence (p=0.43, p=0.91, p=0.99, respectively). Conclusions: We did not observe associations between neighborhood density of sites and post-stroke recurrence or mortality. Future research is needed to determine if other neighborhood features may support secondary stroke prevention or post-stroke survival.

Introduction: We investigated long-term psychological distress among stroke family surrogate decision makers in Mexican Americans (MAs) and non-Hispanic Whites (NHWs). Methods: Ischemic and hemorrhagic stroke patients from the Brain Attack Surveillance in Corpus Christi (BASIC) project and their family surrogate decision makers from the Outcomes Among Surrogate Decision Makers in Stroke (OASIS) were enrolled. Family surrogates completed validated measures of post-traumatic stress (NSESSS), anxiety (GAD-7), and depression (PHQ-8) at discharge, 3, 6, and 12 months. Ethnic differences were assessed with multilevel linear mixed models, sequentially adjusted for pre-specified covariates as shown in the table. Results: There were 301 family surrogates for 241 stroke patients. MA patients were younger and less likely than NHWs to have died before the initial outcome interview (43% vs 56%, p=0.05), with no difference in baseline severity. MA family surrogates had lower educational attainment, income, and less use of advance care plans than NHWs. High scores on measures of psychological distress were common at all time points (Table). All psychological outcomes were worse among MAs on unadjusted analyses (Table). Symptoms of post-traumatic stress remained worse among MAs in the fully-adjusted model. Ethnic differences in anxiety were attenuated after adjustment for family demographics. Ethnic differences in depression were attenuated after adjustment for socioeconomic factors. Advance care plans were not associated with outcomes after accounting for other covariates and did not seem to confound any ethnic differences. Conclusions: Psychological distress is prevalent among family surrogate decision makers in the year after stroke and may be worse among MAs. Efforts are needed to support family members of all ethnic groups after severe strokes.

The growing number of stroke survivors in the US, especially among women, makes understanding sex-specific trends in recurrent strokes crucial. Yet, such data are rare. We estimated 20-year sex-specific trends in recurrence in a population-based stroke study. Methods: We included first-ever ischemic strokes (IS) ascertained between January 1, 2000 and December 31, 2019 from the Brain Attack Surveillance in Corpus Christi (BASIC) Project in South Texas. Time to recurrence was calculated from first-ever IS to recurrence, death, or December 31, 2019, whichever came first. We estimated the cumulative incidence function (CIF) of recurrence by a multivariable Fine-Gray subdistribution hazard model, which accounted for the competing risk of death. An interaction term between calendar year and sex was used to generate 1-year and 5-year sex-specific trends in risks of recurrence between 2000-2019 from the fitted CIF. Results: Among the 5,752 IS (median age 69, 49.9% women), 786 (13.7%) had recurrences over a median of 7.6 years of follow-up and 2,653 (46.1%) died over a median of 3.7 years of follow-up. Women had significantly higher adjusted 1-year and 5-year risks of recurrence than men in 2000 (Figure). One-year and 5-year risk of recurrence declined in both sexes over time but women experienced larger declines such that the risks were similar between both sexes around 2009 but higher among men after that. The largest sex difference in recurrence was in the 5-year risk in 2000 with women having 5.0% (1.5%-8.4%) higher risk. Conclusions: The welcoming trends in recurrent strokes suggest successful secondary stroke prevention, especially in women, where greater declines were noted.

Introduction: Stroke is the leading cause of adult disability in the U.S. Mexican Americans (MAs) have worse 90-day neurologic, functional, cognitive and quality of life outcomes and a higher prevalence of post-stroke depression compared to non-Hispanic whites (NHWs). MAs receive more help through informal, unpaid caregiving than NHWs. Little is known about caregivers’ needs and whether they differ by ethnicity. We examine ethnic differences in the number and type of needs identified by MA and NHW caregivers. Methods: Caregivers were identified from the population-based Basic Attack Surveillance in Corpus Christi Project from October 2019 to November 2021 in Nueces County, Texas. Responses to the 32-item Caregiver Needs and Concerns Checklist (CNCC) were collected at 90-days post stroke and were used to assess needs and concerns of stroke caregivers within 5 domains: information, emotions and behaviors, physical care, instrumental care, and personal responses to caregiving. Bivariate analyses were used to examine differences between CNCC items by ethnicity. Linear regressions were used to examine adjusted associations of ethnicity with the total average of needs for each domain. Results: 187 caregivers were included; 74.3% MAs and 25.7% NHWs. MA caregivers had lower education and income, and more had other jobs while providing care. Significant ethnic differences were only observed in the average frequency of the “finding information on stroke” domain (B=0.17; 99.17%CI: 0.02-0.32) after adjusting for various caregiver and patient characteristics. Within the information domain, MAs reported an overall greater need and some individual needs differed by ethnicity (Table 1). Discussion: There exists differences in the needs of MA caregivers compared to NHWs. Understanding these differences can help develop or improve resources needed to help with post-stroke recovery, improve caregiver well-being in this population and strengthen health equity.

ObjectiveTo compare 18-year (2000–2017) temporal trends in ischemic stroke rates by ethnicity, sex, and age.MethodsData are from a population-based stroke surveillance study conducted in Nueces County, Texas, a geographically isolated, biethnic, urban community. Active (screening hospital admission logs, hospital wards, intensive care units) and passive (screening inpatient/emergency department discharge diagnosis codes) surveillance were used to identify cases aged ≥45 (n = 4,875) validated by stroke physicians using a consistent stroke definition over time. Ischemic stroke rates were derived from Poisson regression using annual population counts from the US Census to estimate the at-risk population.ResultsIn those aged 45–59 years, rates increased in non-Hispanic Whites (104.3% relative increase; p < 0.001) but decreased in Mexican Americans (−21.9%; p = 0.03) such that rates were significantly higher in non-Hispanic Whites in 2016–2017 (p for ethnicity–time interaction < 0.001). In those age 60–74, rates declined in both groups but more so in Mexican Americans (non-Hispanic Whites −18.2%, p = 0.05; Mexican Americans −40.1%, p = 0.002), resulting in similar rates for the 2 groups in 2016–2017 (p for ethnicity–time interaction = 0.06). In those aged ≥75, trends did not vary by ethnicity, with declines noted in both groups (non-Hispanic Whites −33.7%, p = 0.002; Mexican Americans −26.9%, p = 0.02). Decreases in rates were observed in men (age 60–74, −25.7%, p = 0.009; age ≥75, −39.2%, p = 0.002) and women (age 60–74, −34.3%, p = 0.007; age ≥75, −24.0%, p = 0.02) in the 2 older age groups, while rates did not change in either sex in those age 45–59.ConclusionPreviously documented ethnic stroke incidence disparities have ended as a result of declining rates in Mexican Americans and increasing rates in non-Hispanic Whites, most notably in midlife.

Objectives: We compared the concurrent validity of the Montreal Cognitive Assessment (MoCA) with other cognitive screening instruments among Mexican Americans (MA) and non-Hispanic whites (NHW). Methods: In a community-based study in Nueces county, Texas (5/2/18-2/26/20), participants 65+ with MoCA ≤25 completed the Harmonized Cognitive Assessment Protocol. Regressions examined associations between MoCA and: 1) Mini Mental State Examination (MMSE); 2) abbreviated Community Screening Interview for Dementia (CSI-D); 3) Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Results: MA (n = 229) and NHW (n = 81) differed by education but not age or sex. MoCA and cognitive performance associations (MMSE, CSI-D-Respondent) did not differ between MA and NHW (p’s > .16). MoCA and informant rating associations (IQCODE, CSI-D-Informant) were stronger in NHW than MA (NHW R2 = 0.39 and 0.38, respectively; MA R2 = 0.30 and 0.28, respectively). Discussion: Our findings suggest non-equivalence across cognitive screening instruments among MAs and NHWs.

Mexican Americans (MA) are more likely to have cognitive impairment and dementia (CID), be diagnosed at an earlier age and live with CID longer, compared to non-Hispanic Whites (NHW). While studies have examined unmet needs of individuals with CID and their caregivers, few have focused on MA populations in the U.S. This paper examines the needs of community-residing individuals with CID and their caregivers in Nueces County, Texas, a county with one of the largest MA populations in the U.S., while exploring ethnic differences in needs identified.Using concept mapping, a mixed-method approach, qualitative input on perceived needs by informal caregivers and health professionals was collected. Participants then sorted and rated perceived needs. Using this information, multidimensional scaling and cluster analyses were conducted to map the relationship between perceived needs and determine their importance and priority.Five clusters were derived for caregivers and four for the health professionals. Themes across both caregivers and health professionals highlighted the need for specialized and team-based medical care, caregiver support and training, along with socio-economic and physical needs that help with day-to-day care of individuals with CID. Among caregivers, MA rated financial resources as more important and of higher priority compared to NHW. The health professionals' perspectives were aligned with those of all caregivers.By understanding the needs of caregivers and individuals with CID, we can help families deal with this disease and let caregivers thrive. This is especially important for minority populations like MAs.

We examined whether cognitive trajectories from 0-3 months after stroke differ between Mexican Americans (MAs) and non-Hispanic white (NHW) adults.The sample included 701 participants with ischemic stroke (62% MA; 38% NHW) from the population-based stroke surveillance study, the Brain Attack Surveillance in Corpus Christi (BASIC) Project, between 2008-2013. The outcome was the modified Mini Mental State Examination (3MSE, range 0-100 lower scores worse). Linear mixed effects models were utilized to examine the association between ethnicity and cognitive trajectories from 0-3 months following stroke, adjusting for confounders.MAs were younger, had lower educational attainment, and fewer had health insurance than NHWs (all p0.01). A smaller proportion of MAs were rated by informants as exhibiting pre-stroke cognitive decline than NHW (p.0.05). After accounting for confounders, MAs demonstrated lower cognitive performance at post-stroke baseline and at 3-months following stroke (-2.00; 95% CI =-3.92, -0.07). Cognitive trajectories from 0-3 months following stroke were indicative of modest cognitive recovery (increase of 0.034/day, 95% CI =0.030-0.036) and did not differ between MAs and NHWs (p = 0.68).We found no evidence that cognitive trajectories in the first three months following stroke differed between MAs and NHWs. MAs demonstrated lower cognitive performance shortly after stroke and at three months following stroke compared to NHWs. Further research is needed to identify factors contributing to ethnic disparities in cognitive outcomes after stroke.

Compared with non-Hispanic whites (NHWs), Mexican Americans (MAs) have worse stroke outcomes. We report here the methods, background literature, and initial recruitment of the Brain Attack Surveillance in Corpus Christi-Post Acute Care (BASIC-PAC) Project which aims to explore PAC in MAs and NHWs from multiple perspectives: patients, caregivers, and community.Rigorous active and passive stroke surveillance captures all strokes in Nueces County, Texas. Stroke patients are followed for 90 days to determine their care transitions and factors influencing their rehabilitation setting. Informal caregivers of the stroke patients are identified and interviewed at 90 days to determine aspects of their caregiving and caregiver outcomes. Available community resources are compared with stated needs among stroke patient and caregivers to determine unmet needs.Between October, 2019 and October, 2021, among the 629 stroke patients eligible, 413 were MA, 227 were NHW. Of the 629, all of the six follow-up calls were completed by 355 of the MAs (87%) and 191 of the NHWs (87%). During this same time period, we attempted to approach 621 potential caregivers. Of these, 458 (73.8%) potential caregivers participated in interviews to determine caregiver eligibility, and 373 (81.4%) of these participating potential caregivers met the eligibility criteria.BASIC-PAC has strong initial recruitment and is poised to provide valuable data on multiple aspects of PAC and how PAC differs by ethnicity and contributes to worse stroke outcomes in MAs. Based on the study findings, interventions can be developed that will improve stroke health equity.

ObjectiveTo determine whether a new index for multiple chronic conditions (MCCs) predicts poststroke functional outcome (FO), we developed and internally validated the new MCC index in patients with ischemic stroke.MethodsA prospective cohort of patients with ischemic stroke (2008–2017) was interviewed at baseline and 90 days in the Brain Attack Surveillance in Corpus Christi Project. An average of 22 activities of daily living (ADL)/instrumental ADL (IADL) items measured the FO score (range 1–4) at 90 days. A FO score >3 (representing a lot of difficulty with ADL/IADLs) was considered unfavorable FO. A new index was developed using machine learning techniques to select and weight conditions and prestroke impairments.ResultsPrestroke modified Rankin Scale (mRS) score, age, congestive heart failure (CHF), weight loss, diabetes, other neurologic disorders, and synergistic effects (dementia × age, CHF × renal failure, and prestroke mRS × prior stroke/TIA) were identified as important predictors in the MCC index. In the validation dataset, the index alone explained 31% of the variability in the FO score, was well-calibrated (p = 0.41), predicted unfavorable FO well (area under the receiver operating characteristic curve 0.81), and outperformed the modified Charlson Comorbidity Index in predicting the FO score and poststroke mRS.ConclusionsA new MCC index was developed and internally validated to improve the prediction of poststroke FO. Novel predictors and synergistic interactions were identified.Classification of EvidenceThis study provides Class II evidence that in patients with ischemic stroke, an index for MCC predicts FO at 90 days.

BACKGROUND/OBJECTIVE: Surrogate decision makers for patients with intracerebral hemorrhage (ICH) are frequently asked to make difficult decisions on use of life-sustaining treatments. We explored ICH surrogate satisfaction with decision making and experience of decision regret using validated measures in a prospective multicenter study. METHODS: Cases of non-traumatic ICH were enrolled from 3 hospitals (September 2015 to December 2016) and surrogate decision makers were invited to complete a self-administered survey. The primary outcome was the 10-item decision making subscale of the Family Satisfaction in the Intensive Care Unit scale (FSICU-DM, range 0–100, higher is greater satisfaction), and the secondary outcome was the decision regret scale (range 0–100, higher is greater regret). Linear regression models were used to assess the association between satisfaction with decision making and pre-specified covariates using manual backwards selection. RESULTS: A total of 73 surrogates were approached for participation (in person or mail), with 48 surrogates returning a completed survey (Median surrogate age 60.5 years, 63% female, 77% White). Patients had a median age of 72.5, 54% were female, with a median admission Glasgow coma scale of 10, in-hospital mortality of 31%, and 56% with an in-hospital DNR order. Physicians commonly made treatment recommendation (>50%) regarding brain surgery or transitions to comfort measures, but rarely made recommendations (0.25). Decision regret scores were generally low (median 12.5, IQR 0–31.3). CONCLUSIONS: Considering the severity and abruptness of ICH, it is reassuring that surrogate satisfaction with decision making was generally high and regret was generally low. However, more work is needed to define the appropriate outcome measures and optimal methods of recruitment for studies of surrogate decision makers of ICH patients.

ObjectiveThis study investigated the sex difference in prevalence of depression at 90 days after first-ever stroke.MethodsPatients with first-ever stroke (n = 786) were identified from the population-based Brain Attack Surveillance in Corpus Christi project (2011–2016). Poststroke depressive symptoms were assessed by the 8-item Patient Health Questionnaire, and prestroke depression status (history and medication use) was self-reported. Logistic regression was used to examine the association between sex and depression after stroke, and effect modification by prestroke depression status, accounting for missing data.ResultsWomen were more likely to have a history of and be on medication for depression at the time of stroke than men (p< 0.001). Prevalence of depression at 90 days was 28.2% for men (95% confidence interval [CI], 23.7%–32.8%) and 32.7% for women (95% CI, 27.8%–37.5%). The age-adjusted odds ratio (OR) of depression after stroke comparing women and men was 1.34 (95% CI, 0.97–1.85), and fully attenuated after adjustment for sociodemographic, stroke, and prestroke characteristics. Effect modification by prestroke depression status was present (p= 0.038). Among participants on medication for depression at the time of stroke, women were significantly less likely to have depression at 90 days compared with men (OR, 0.39; 95% CI, 0.16–0.96), whereas significant sex differences were not noted among those with and without a depression history.ConclusionThe sex difference in prevalence of depression at 90 days after first-ever stroke was not significant overall, but varied by prestroke depression status. Interventions to address and prevent poststroke depression are needed, particularly among those with prestroke depression but not undergoing treatment for depression at stroke onset.

We examine relations between housing status, mortgage, financial burden, and healthy aging among older U.S. adults. We combine cross-sectional data from 2012 to 2014 Health and Retirement Study cohorts. Using regression models, we examined associations between owners and renters, mortgage and non-mortgage holders, financial strain, and difficulty paying bills, and poor self-rated health (SRH), heart condition (HC) and hospitalization (past two years). We find that compared to owners, renters had greater likelihood of poor SRH and hospitalization. Regardless of tenure, financial strain was associated with greater likelihood of poor SRH, HC and hospitalization, while difficulty paying bills was associated with poor SRH and HC. Mortgage holders had lower likelihood of poor SRH. Accounting for mortgage status, financial strain was associated with greater likelihood of poor SRH, HC and hospitalization, while difficulty paying bills was associated with poor SRH and HC. Associations between tenure or mortgage status and health were not modified by either financial burden factors. We conclude that there need to be more robust and inclusive programs that assist older populations with housing could improve self-rated health, with particular attention to renters, mortgage holders and those experiencing financial burden.

Objective: To explore ethnic differences in stroke patient surrogate decision makers’ (e.g. family) impressions of physician quality of communication (QOC) and shared decision making (SDM) in Mexican Americans (MAs) and non-Hispanic Whites (NHWs). Methods: Surrogate decision makers who discussed life-sustaining treatments for severe stroke patients (ischemic or intracerebral hemorrhage) from the Brain Attack Surveillance in Corpus Christi (BASIC) project completed validated measures of physician QOC (QOC-overall, QOC-general, and QOC-end-of-life) and SDM (collaboRATE). Regression models with Generalized Estimating Equations were used to investigate ethnic differences in outcome adjusted for pre-specified demographics, severity, mortality, and identified confounders. Results: From 4/2016 to 9/2020, 320 surrogates for 257 stroke cases were enrolled. Patient characteristics: median age 75 (IQR 64-87), female 52%, Race-ethnicity (MA 61%, NHW 33%, Other 5%), ICH 25%, median NIHSS 12 (IQR 5-20), deceased 45%. Surrogates had a median age of 57 (IQR 46-66) and were mostly female (77%). Compared to NHW surrogates, MA surrogates were more often women, had lower education, and less use of advance directives, but had more trust in physicians and were more likely to pray daily. Regression results for QOC are shown in the table. MA surrogates reported higher unadjusted scores for QOC-overall and QOC-end-of-life. These associations were stronger after adjustment for demographics, severity, and patient survival, though were no longer significant in the final fully adjusted models. A generally similar pattern was seen for SDM. Conclusions: MA surrogates tended to report better physician communication and more SDM than NHWs, though no difference was seen after adjustment for factors such as trust, daily prayer, or advance care planning. Further study of contributions to positive outcomes among diverse populations of stroke surrogates are warranted.

Introduction: We examined if language preference was associated with differences in neurological, functional, and cognitive stroke outcomes among Mexican Americans (MAs). Methods: Ischemic or hemorrhagic stroke patients identified from the Brain Attack Surveillance in Corpus Christi (BASIC) Project (2009-2018). Poststroke outcomes at 90 days included neurological [National Institutes of Health Stroke Scale (NIHSS) range 0-44, higher worse], functional [activities of daily living/instrumental activities of daily living (ADL/iADL) range 1-4, higher worse], and cognitive [modified Mini-Mental State Examination (3MSE) range 0-100, lower worse]. Language was determined by which language participant preferred to complete outcome interview in. Differences in stroke outcomes by language were analyzed by weighted Tobit regression. Weights (baseline and outcome interview participation) were created by logistic regression to account for attrition. Age, education, initial NIHSS score, smoking status, BMI, insurance status, sex, and comorbidities were included in weighted Tobit regression models. Results: Of 1,096 patients, 1,001 preferred English and 95 Spanish. Spanish speakers were older (72 versus 66 years; p < 0.01), received less education (p < 0.01), and had higher prevalence of atrial fibrillation (p = 0.02) than English speakers. No other significant differences in baseline demographics or clinical factors were found. In fully adjusted models (Table 1) Spanish speakers had significantly better neurological and functional but worse cognitive outcomes compared with English speakers. Conclusion: This population-based study found better neurologic and functional stroke outcomes among Spanish speaking versus English speaking MAs. The difference in the cognitive outcome may be explained, at least in part, to lack of cultural equivalence of the test instrument. These data suggest further research into the resilience observed among Spanish speakers.

Introduction: Mexican Americans (MAs) are less likely to receive post-stroke intensive rehabilitation, more likely to suffer from depression, and have worse functional, neurologic and cognitive outcomes compared with non-Hispanic whites (NHWs). The aim of this study was to determine if there is a difference between readmission rates post-stroke among NHWs and MAs. Methods: This was a population-based study of all validated strokes among MAs and NHWs in Nueces County, Texas, October 2019 - March 2021. Baseline demographic and clinical information was recorded from the chart including comorbidity index, age, sex, and NIHSS. Follow up calls were made to the patient or their proxy at 2 week intervals post-discharge up to 12 weeks. Readmission was assessed by asking the patient or proxy if the patient had been readmitted for any reason. P-values were obtained using Fisher exact tests of equivalence between NHWs vs MAs. Additionally, Poisson regression with robust standard errors was used to investigate the association between readmission and race-ethnicity adjusting for age, sex, log of NIHSS, and comorbidity index, with an offset to account for differences in length of observation. Results: 403 patients (256 MAs and 147 NHWs) were followed. Of these, there were 65 total (16.1%) including 42 MAs (16.4%) and 23 NHWs (15.6%) who reported readmission within a 12 week follow up period. Table 1 provides the regression results. There was no ethnic difference in readmission rate. Median comorbidity index was higher for MAs when compared to NHWs (3 vs 2, p=.00345) but was not associated with readmission. Only stroke severity was associated with readmission. Conclusion: In our study of patients followed up after discharge post-stroke, a similar proportion of MAs reported readmission compared to NHWs. Overall, the readmission rate was high, with approximately 1 in 6 patients requiring readmission within 90 days. Renewed efforts to promote health post-stroke are needed.

This Viewpoint discusses the need to improve the quality of care in neuromuscular disease for all individuals, no matter their race and ethnicity.

Introduction: Estimating trends in long-term outcomes after stroke is important for long-term planning of health resources. Data on trends in long-term post-stroke outcomes are not available among Hispanics. Whether race-ethnic disparities exist and how trends in these outcomes have changed over time comparing non-Hispanic Whites (NHWs) with Mexican Americans (MAs) are also unknown. Thus, we aimed to estimate ethnic-specific trends in risk of 5-year all-cause mortality and recurrence after initial stroke in MAs and NHWs. Methods: We included 3308 patients who had first-ever ischemic stroke ascertained between January 1, 2000 and December 31, 2012 from the Brain Attack Surveillance in Corpus Christi (BASIC) project in Texas. Data on recurrent stroke and death were available through December 31, 2017. Fine-Gray subdistribution hazard models including covariates and an interaction term between calendar year and ethnicity were used to calculate 5-year cumulative incidence of recurrence and death in both ethnic groups in each year. Results: Among the 3308 index stroke patients, 402 (12.15%) recurrences and 1420 (37.61%) deaths were observed during the 5-year follow-up. Adjusted 5-year cumulative incidence of recurrence among MAs declined from 15.76% to 11.28%. Among NHWs, a slight decline from 12.49% to 10.46% was observed. An ethnic disparity in 5-year recurrence was not apparent in 2000 (risk difference 3.27%, [95% CI, -10.41, 9.10]) or during the study duration (Figure). The greatest ethnic disparity in 5-year mortality risk was observed in 2000 but disappeared in 2012, which was driven by the increasing trend in MAs from 23.11% in 2000 to 24.28% in 2012 and the decreasing trend in NHWs from 31.09% to 27.19% accordingly. Conclusions: No apparent ethnic disparity in long-term stroke recurrence was found and long-term survival advantage in MAs presented early in the study gradually disappeared over the 13 years.

Few studies have examined the impacts of neighborhood SES and individual ethnicity and SES characteristics on cognitive function in aging populations. Hispanics/Latinx are more likely to have cognitive impairment and be community dwellers than non-Hispanic Whites. Neighborhood factors can have greater impacts on the relationship between Hispanics/Latinx and cognitive function. This study examines these relationships in Nueces County, Texas.A mixed-effects regression analysis of data from 1,140 older adults participating in the Brain Attack Surveillance in Corpus Christi - Cognitive project from 2018 to 2020 was completed. Cognitive function was measured with the Montreal Cognitive Assessment, a cognitive screening measure. Participant addresses were geocoded to obtain census tracts, which were proxies for neighborhoods. Neighborhood SES was measured by household median income, percentage of Hispanic/Latinx residents, and percentage of residents aged ≥65 years with Medicaid, all from the American Community Survey. Interactions were used to examine the impact of neighborhood SES on ethnicity and cognitive function.The sample consisted of 62.5% Hispanic/Latinx and 37.5% non-Hispanic White participants. Results from the F-statistics, test of effects, indicate that being older (FFindings suggest that neighborhood SES could further impact cognitive function independent of individual characteristics. This could be attributed to minimal resources in communities with lower SES, impacting policies and programs for older individuals, particularly those with worse cognitive function.

Objective To examine the association between sleep-disordered breathing and stroke outcomes, and determine the contribution of sleep-disordered breathing to outcome disparities in Mexican Americans. Methods Ischemic stroke patients (n = 995), identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2010-2015), were offered participation in a sleep-disordered breathing study including a home sleep apnea test (ApneaLink Plus). Sleep-disordered breathing (respiratory event index ≥10) was determined soon after stroke. Neurologic, functional, cognitive, and quality of life outcomes were assessed at 90 days poststroke. Regression models were used to assess associations between sleep-disordered breathing and outcomes, adjusted for sociodemographics, prestroke function and cognition, health-risk behaviors, stroke severity, and vascular risk factors. Results Median age was 67 years (interquartile range [IQR] = 59-78); 62.1% were Mexican American. Median respiratory event index was 14 (IQR = 6-25); 62.8% had sleep-disordered breathing. Sleep-disordered breathing was associated with worse functional outcome (mean difference in activities of daily living/instrumental activities of daily living score = 0.15, 95% confidence interval [CI] = 0.01-0.28) and cognitive outcome (mean difference in modified Mini-Mental State Examination = -2.66, 95% CI = -4.85 to -0.47) but not neurologic or quality of life outcomes. Sleep-disordered breathing accounted for 9 to 10% of ethnic differences in functional and cognitive outcome and was associated with cognitive outcome more strongly for Mexican Americans (β = -3.97, 95% CI = -6.63 to -1.31) than non-Hispanic whites (β = -0.40, 95% CI = -4.18 to 3.39, p-interaction = 0.15). Interpretation Sleep-disordered breathing is associated with worse functional and cognitive function at 90 days poststroke. These outcomes are reasonable endpoints for future trials of sleep-disordered breathing treatment in stroke. If effective, sleep-disordered breathing treatment may somewhat lessen ethnic stroke outcome disparities. ANN NEUROL 2019;86:241-250.

Background and Purpose— We assessed ethnic differences in medication adherence 3 months poststroke in a population-based study as an initial step in investigating the increased stroke recurrence risk in Mexican Americans compared with non-Hispanic whites. Methods— Ischemic stroke cases from 2008 to 2015 from the Brain Attack Surveillance in Corpus Christi project in Texas were followed prospectively for 3 months poststroke to assess medication adherence. Medications in 5 drug classes were analyzed: statins, antiplatelets, anticoagulants, antihypertensives, and antidepressants. For each drug class, patients were considered adherent if they reported never missing a dose in a typical week. The χ 2 tests or Kruskal-Wallis nonparametric tests were used for ethnic comparisons of demographics, risk factors, and medication adherence. A multivariable logistic regression model was constructed for the association of ethnicity and medication nonadherence. Results— Mexican Americans (n=692) were younger (median 65 years versus 68 years, P P P P =0.003), smoking ( P =0.003), and education ( P Conclusions— This study did not find ethnic differences in medication adherence, thus challenging this patient-level factor as an explanation for stroke recurrence disparities. Other reasons for the excessive stroke recurrence burden in Mexican Americans, including provider and health system factors, should be explored.