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Incident Cognitive Impairment Is Elevated in the Stroke Belt: the REGARDS Study

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Incident Cognitive Impairment Is Elevated in the Stroke Belt: the REGARDS Study ORIGINAL ARTICLE Incident Cognitive Impairment is Elevated in the Stroke Belt: The REGARDS Study Virginia G. Wadley, PhD,1 Frederick W. Unverzagt, PhD,2 Lisa C. McGuire, PhD,3 Claudia S. Moy, PhD,4 Rodney Go, PhD,5 Brett Kissela, MD,6 Leslie A. McClure, PhD,7 Michael Crowe, PhD,8 Virginia J. Howard, PhD,5 and George Howard, DrPH7 Objective: To determine whether incidence of impaired cognitive screening status is higher in the southern Stroke Belt region of the United States than in the remaining United States. Methods: A national cohort of adults age 45 years was recruited by the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study from 2003 to 2007. Participants’ global cognitive status was assessed annually by telephone with the Six-Item Screener (SIS) and every 2 years with fluency and recall tasks. Participants who reported no stroke history and who were cognitively intact at enrollment (SIS >4 of 6) were included (N ¼ 23,913, including 56% women; 38% African Americans and 62% European Americans; 56% Stroke Belt residents and 44% from the remaining contiguous United States and the District of Columbia). Regional differences in incident cognitive impairment (SIS score 4) were adjusted for age, sex, race, education, and time between first and last assessments. Results: A total of 1,937 participants (8.1%) declined to an SIS score 4 at their most recent assessment, over a mean of 4.1 (61.6) years. Residents of the Stroke Belt had greater adjusted odds of incident cognitive impairment than non-Belt residents (odds ratio, 1.18; 95% confidence interval, 1.07–1.30). All demographic factors and time independently predicted impairment. Interpretation: Regional disparities in cognitive decline mirror regional disparities in stroke mortality, suggesting shared risk factors for these adverse outcomes. Efforts to promote cerebrovascular and cognitive health should be directed to the Stroke Belt. ANN NEUROL 2011;00:000–000 he Reasons for Geographic and Racial Differences in however, whether incidence of cognitive impairment is TStroke (REGARDS) study is an epidemiological elevated in the Stroke Belt region of the United States, a study following a cohort of US adults for stroke and cog- region of the southeastern United States first described in nitive decline. In reports from REGARDS, self-reported 1965 as having 50% higher stroke mortality rates than stroke symptoms in the absence of diagnosed stroke were the remaining United States.8 Centers for Disease Con- considered as potential markers of ischemic changes. trol and Prevention state statistics from 2000 to 2006 Such symptoms, reported by 18% of REGARDS partici- reveal that among adults aged 35 years and older, age- pants,1 were associated with a 24% increased risk of adjusted annual rates of stroke mortality in the 8 Stroke prevalent cognitive impairment after controlling for age, Belt states were, on average, 125 per 100,000, compared sex, race, education, and region of residence.2 Decre- to an average rate of 96 per 100,000 in the remaining ments in cognitive function may serve in some cases as a 40 contiguous states and the District of Columbia.9 Dur- proxy for unrecognized small strokes,2 a notion that is ing the same period, age-adjusted stroke hospitalization supported by demonstrated associations between mag- rates among Medicare beneficiaries aged 65 years and netic resonance imaging-defined silent brain infarcts, cog- older followed a similar pattern of higher concentration nitive deficits, and incident dementia.3–7 It is not known, in the Stroke Belt.9 View this article online at wileyonlinelibrary.com. DOI: 10.1002/ana.22432 Received Feb 13, 2011, and in revised form Mar 16, 2011. Accepted for publication Mar 18, 2011. Address correspondence to Dr. Wadley, University of Alabama at Birmingham, CH19 218T, Birmingham, AL 35294-2041. E-mail: [email protected] From the 1Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; 2Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN; 3Healthy Aging Program, Centers for Disease Control and Prevention, Atlanta, GA; 4National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD; 5Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL; 6Department of Neurology, University of Cincinnati, Cincinnati, OH; 7Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL; and 8Department of Psychology, University of Alabama at Birmingham, Birmingham, AL. VC 2011 American Neurological Association 1 ANNALS of Neurology It is plausible that incidence of cognitive impair- ments, blood and urine, and an electrocardiogram were ment might be elevated in the Stroke Belt due to sub- obtained. Participants were followed by telephone twice per clinical strokes and cerebrovascular disease as well as to year to gather information on hospitalized events. When sus- precursor or concomitant risk factors for both stroke and pected incident stroke events were reported during follow-up cognitive impairment, such as hypertension, diabetes, calls, medical records were obtained and adjudicated by study physicians. kidney disease, and metabolic syndrome.10–16 The pur- A baseline telephone cognitive screener was first adminis- pose of the present analysis from the REGARDS study tered to REGARDS participants in December 2003, 11 months was to examine incident impairment in cognitive screen- after study enrollment began. Subsequently, it was administered ing status in the southern Stroke Belt region relative to to all participants annually. An expanded cognitive battery the remaining 40 contiguous states. Among participants including list learning and recall and verbal fluency assessment who had intact cognitive screening status at baseline and was implemented in 2006 and conducted during follow-up calls no history of stroke, we predicted regional differences in at 2-year intervals. incident cognitive impairment that reflect well-docu- The REGARDS study was approved by the institutional mented regional differences in stroke incidence and mor- review boards of all participating institutions. Written informed tality. Specifically, we hypothesized that there would be consent was obtained from all participants. greater occurrence of incident impairment in cognitive screening performance in the Stroke Belt relative to the Participants For the present analyses, participants were excluded if they rest of the United States. reported a history of stroke at baseline, if they had impaired cognitive status at first assessment, or if they lacked at least 2 Subjects and Methods cognitive screening assessments. Any cognitive data obtained Design and Procedures after the date of a confirmed incident stroke were censored. Designed to determine the causes of higher stroke mortality among African Americans (AAs) and residents of the Stroke Measures Belt, the REGARDS study included only AAs and European Age, sex, race, educational attainment, and state of residence Americans (EAs). Using mail and telephone contact methods, were assessed by self report. Age was a continuous variable cal- participants were recruited from January 2003 to October 2007 culated from birth date. Race was categorized as AA or EA. from lists of US residents purchased from Genesys (Daly City, Educational attainment was categorized as less than high school, CA). Genesys lists include >100 million US households from high school graduate, some college or vocational training, or InfoUSA List Install and Experian Insource consumer databases, college graduate. States of residence were classified as belonging which in turn draw from multiple sources, including telephone to the Stroke Belt or non-Belt. directories, automobile and motorcycle registrations, real estate The main outcome for the present analyses was incident listings, and driver’s license data. The lists were stratified with cognitive impairment as defined by each participant’s most respect to age, race, sex, and geographic region to accommodate recent score on the Six-Item Screener (SIS).19 Designed for ei- the REGARDS sampling strategy.17 The cohort consists of ther in-person or telephone administration, the SIS is a test of 30,239 US residents aged 45 years, with 16,934 from Stroke global cognitive function derived from the widely used Mini- Belt states (Alabama, Arkansas, Georgia, Louisiana, Mississippi, Mental State Exam (MMSE).20 Items assess recall of a 3-item North Carolina, South Carolina, and Tennessee) and 13,305 word list and temporal orientation (year, month, day of the from the remaining 40 contiguous states and the District of week). The upper limit of reliability for the SIS may be pre- Columbia (collectively, the non-Belt). A modification of stand- sumed to be capped by the test–retest reliability of the MMSE ardized methods recommended by Morton and colleagues18 (0.80–0.95 for both cognitively intact and impaired adults in was used to determine telephone participation rates in the absence of illness-induced changes21). In a prior study, the REGARDS, with an adjustment for telephone numbers called SIS was validated against the MMSE, list learning tasks, and <15Â. The cooperation rate was 49%; this calculation repre- diagnoses of dementia and cognitive impairment-no dementia sents the number of recruited participants divided by all poten- (CIND) in a community sample of 344 AA adults and an eth- tial participants for whom eligibility was confirmed. The nically diverse clinical sample
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