Long-term trajectories of decline in cognition and daily functioning before and after stroke

J Neurol Neurosurg Psychiatry. 2021 Nov;92(11):1158-1163. doi: 10.1136/jnnp-2021-326043. Epub 2021 Jul 6.


Objective: Although knowledge on poststroke cognitive and functional decline is increasing, little is known about the possible decline of these functions before stroke. We determined the long-term trajectories of cognition and daily functioning before and after stroke.

Methods: Between 1990 and 2016, we repeatedly assessed cognition (Mini-Mental State Examination (MMSE), 15-Word Learning, Letter-Digit Substitution, Stroop, Verbal Fluency, Purdue Pegboard) and basic and instrumental activities of daily living (BADL and IADL) in 14 712 participants within the population-based Rotterdam Study. Incident stroke was assessed through continuous monitoring of medical records until 2018. We matched participants with incident stroke to stroke-free participants (1:3) based on sex and birth year. Trajectories of cognition and daily functioning of patients who had a stroke 10 years before and 10 years after stroke and the corresponding trajectories of stroke-free individuals were constructed using adjusted linear mixed effects models.

Results: During a mean follow-up of 12.5±6.8 years, a total of 1662 participants suffered a first-ever stroke. Patients who had a stroke deviated from stroke-free controls up to 10 years before stroke diagnosis in cognition and daily functioning. Significant deviations before stroke were seen in scores of MMSE (6.4 years), Stroop (5.7 years), Purdue Pegboard (3.8 years) and BADL and IADL (2.2 and 3.0 years, respectively).

Conclusion: Patients who had a stroke have steeper declines in cognition and daily functioning up to 10 years before their first-ever stroke compared with stroke-free individuals. Our findings suggest that accumulating intracerebral pathology already has a clinical impact before stroke.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Activities of Daily Living / psychology*
  • Aged
  • Aged, 80 and over
  • Cognition / physiology*
  • Cognitive Dysfunction / psychology*
  • Disease Progression
  • Female
  • Humans
  • Incidence
  • Male
  • Neuropsychological Tests
  • Stroke / epidemiology*
  • Stroke / psychology