Validity of Self-Reported Stroke in Elderly African Americans, Caribbean Hispanics, and Whites
Total Page：16
File Type：pdf, Size：1020Kb
ORIGINAL CONTRIBUTION Validity of Self-reported Stroke in Elderly African Americans, Caribbean Hispanics, and Whites Christiane Reitz, MD, PhD; Nicole Schupf, PhD; Jose´ A. Luchsinger, MD, MPH; Adam M. Brickman, PhD; Jennifer J. Manly, PhD; Howard Andrews, PhD; Ming X. Tang, PhD; Charles DeCarli, PhD; Truman R. Brown, PhD; Richard Mayeux, MD, MSc Background: The validity of a self-reported stroke re- Results: In analyses of the whole sample, sensitivity of mains inconclusive. stroke self-report for a diagnosis of stroke on MRI was 32.4%, and specificity was 78.9%. In analyses stratified Objective: To validate the diagnosis of self-reported by median age (80.1 years), the validity between re- stroke using stroke identified by magnetic resonance ported stroke and detection of stroke on MRI was sig- imaging (MRI) as the standard. nificantly better in the younger than the older age group (for all vascular territories: sensitivity and specificity, Design, Setting, and Participants: Community- 36.7% and 81.3% vs 27.6% and 26.2%; P=.02). Im- based cohort study of nondemented, ethnically diverse paired memory, cognitive skills, or language ability and elderly persons in northern Manhattan. the presence of hypertension or myocardial infarction were associated with higher rates of false-negative results. Methods: High-resolution quantitative MRIs were ac- quired for 717 participants without dementia. Sensitiv- Conclusions: Using brain MRI as the standard, speci- ity and specificity of stroke by self-report were exam- ficity and sensitivity of stroke self-report are low. Accu- ined using cross-sectional analyses and the 2 test. Putative relationships between factors potentially influencing the racy of self-report is influenced by age, presence of vas- reporting of stroke, including memory performance, cog- cular disease, and cognitive function. In stroke research, nitive function, and vascular risk factors, were assessed sensitive neuroimaging techniques rather than stroke self- using logistic regression models. Subsequently, all analy- report should be used to determine stroke history. ses were repeated, stratified by age, sex, ethnic group, and level of education. Arch Neurol. 2009;66(7):834-840 ELF-ADMINISTERED QUESTION- elderly, has been emphasized,2 most pre- naires are frequently used to vious studies assessing validity of stroke self- obtain information about a report either used neurological examina- previous history of stroke, but tion or medical record review as the the validity of self-reported standard or performed brain imaging only Sstroke remains inconclusive. In general, self- for persons reporting to have had a stroke.3-9 reports on medical conditions that are well This likely produces underreporting of pa- defined and relatively easy to diagnose of- ten have a high positive predictive value, CME available online at in contrast to conditions characterized by www.jamaarchivescme.com and questions on page 816 For editorial comment see page 819 tients with ambiguous symptoms or silent strokes and, consequently, increases the rate 1 of false-negative results and diminishes sen- complex symptoms. Stroke is associated sitivity estimates. with motor impairment but can also be ac- The Washington/Hamilton Heights– companied by impairments in memory, Inwood Columbia Aging Project sensation, and speech or language, dimin- (WHICAP) is an ongoing, community- ishing the ability of an individual to accu- based study of aging and dementia that rately report a history of stroke. Although comprises elderly participants from an ur- Author Affiliations are listed at the importance of being aware of these dif- ban community. A unique aspect of the co- the end of this article. ficulties, particularly in studies among the hort is its multiethnic composition; white, (REPRINTED) ARCH NEUROL / VOL 66 (NO. 7), JULY 2009 WWW.ARCHNEUROL.COM 834 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Caribbean Hispanic, and African American participants are included in the sample, which allows for the exami- 2776 at Baseline nation of diverse cultural, educational, medical, and ge- netic factors as possible modifiers in aging diseases. We Reasons for discontinuation previously observed a higher prevalence and incidence 209 Refused of cerebrovascular disease and white matter hyperinten- 205 Died 204 Unavailable for follow-up sities (WMHs), as well as a larger relative brain volume 105 Moved in African Americans and Hispanics than in whites.10,11 These observations strongly suggest that it is important 2053 Completed first to take ethnic differences in vascular disease and brain follow-up form and structure into account when assessing the va- lidity of self-reported vascular events. 60 “Picked up” from The objective of the present study was to examine the baseline validity of the self-reported history of stroke across ethnic 2113 Considered for groups in the large, multiethnic WHICAP cohort by calcu- magnetic resonance lating sensitivity and specificity of self-reported stroke using imaging (MRI) eligibility magnetic resonance imaging (MRI) as the standard. We also explored whether the validity of stroke self-report differed by age and whether it is influenced by cognitive function, 1841 Not demented at last 272 Demented at last educational level, or specific concomitant diseases. visit available visit and not considered further for MRI study METHODS PARTICIPANTS 769 Scanned 1072 Not scanned Participants were part of the original cohort for a prospective Reasons not scanned study of aging and dementia among Medicare recipients 65 years 407 Refused 11 166 Died and older and residing in northern Manhattan. These partici- 191 Unavailable for follow-up pants were recruited at 2 time points (1992-1994 and 1999- 283 Had an MRI 2000) and followed up at regular 18-month intervals. The sam- contraindication pling strategies and recruitment outcomes have been described 25 Could not be scheduled in detail.10 Recruitment, informed consent, and study proce- dures were approved by the institutional review boards of Co- Figure 1. Description of study sample. lumbia Presbyterian Medical Center and Columbia University Health Sciences and the New York State Psychiatric Institute. The WHICAP MRI imaging project was concurrent with the 1. Have you ever had a stroke of the brain, ministroke, CVA (cerebrovascular second follow-up visit of the cohort recruited in 1999 and the accident), or TIA (transient ischemic attack)? sixth follow-up visit of the cohort recruited in 1992. Partici- 2. Did a doctor tell you that you had a stroke of the brain, ministroke, CVA pants were deemed eligible for MRI if they did not meet crite- (cerebrovascular accident), or TIA (transient ischemic attack)? 3. Did you have a stroke of the brain, ministroke, CVA (cerebrovascular accident), or ria for dementia at their last research assessment (Figure 1). TIA (transient ischemic attack) within the past year? At the conclusion of the first follow-up period, 2113 partici- 4. Have you ever had a sudden paralysis (weakness) or numbness (loss of sensation) pants were considered for MRI eligibility; 2053 of these indi- on one side of the body but not the other? 5. Have you ever suddenly lost the use of speech (not being able to talk at all) or viduals (97.2%) had been seen at the first follow-up visit, and, suddenly had slurred speech (not being able to say words clearly)? for 60 of these participants (2.8%), their most recent visit was 6. Have you ever had sudden loss of consciousness with severe headache, nausea, at baseline (ie, they were not seen during the first follow-up and vomiting? 7. Did the stroke or symptoms last more than 24 hours? period). Dementia was diagnosed in 272 of these 2113 partici- 8. Have the stroke symptoms continued without ever going away? pants (12.9%). Of the remaining 1841 participants, 769 (41.8%) received MRI scans. Of the 1072 participants who did not re- Figure 2. Survey questions assessing stroke. Stroke on self-report was ceive MRI scans, 407 (38.0%) refused to participate, 166 (15.4%) defined as an affirmative answer to 1 of these questions. died before they were able to be scheduled for imaging, 191 (17.8%) were unavailable for follow-up, 283 (26.3%) had MRI psychological test battery and its validity in the diagnosis of contraindications, and 25 (2.3%) were unable to be sched- dementia has been described previously.12 The diagnosis of de- uled. Compared with persons who received MRI scans, those mentia was based on standard research criteria13 and was estab- who refused to participate in the MRI study but otherwise met lished at a consensus conference of physicians, neurologists, neu- inclusion criteria were a year older, more likely to be women, ropsychologists, and psychiatrists using all available information and less likely to be African American. There were no differ- (except the MRI results) gathered from the initial and fol- ences in educational level between the 2 groups. low-up assessments and the participants’ medical records. CLINICAL ASSESSMENT SELF-REPORT OF STROKE At each evaluation, participants underwent an in-person inter- Stroke was defined according to World Health Organization cri- view about general health and functioning, medical history, a teria.14 The presence of stroke was ascertained from an inter- physical and neurological examination, and a neuropsychologi- view with participants and/or their informants (caregivers or cal battery that included measures of memory, orientation, lan- family members). A positive response to any 1 of the 8 ques- guage, abstract reasoning, and visuospatial ability.12 The neuro- tions shown in Figure 2 was considered to suggest a history (REPRINTED) ARCH NEUROL / VOL 66 (NO. 7), JULY 2009 WWW.ARCHNEUROL.COM 835 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 of stroke. Persons who answered yes to at least 1 of the 8 ques- baseline, all participants were asked whether they had a his- tions were referred to see a board-certified neurologist.