Five-year survival after first-ever stroke and related prognostic factors in the Perth Community Stroke Study.

BACKGROUND AND PURPOSE: Few community-based studies have examined the long-term survival and prognostic factors for death within 5 years after an acute first-ever stroke. This study aimed to determine the absolute and relative survival and the independent baseline prognostic factors for death over the next 5 years among all individuals and among 30-day survivors after a first-ever stroke in a population of Perth, Western Australia. METHODS: Between February 1989 and August 1990, all individuals with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event. RESULTS: Three hundred seventy patients with first-ever stroke were registered, and 362 (98%) were followed up at 5 years, by which time 210 (58%) had died. In the first year after stroke the risk of death was 36.5% (95% CI, 31.5% to 41.4%), which was 10-fold (95% CI, 8.3% to 11.7%) higher than that expected among the general population of the same age and sex. The most common cause of death was the index stroke (64%). Between 1 and 5 years after stroke, the annual risk of death was approximately 10% per year, which was approximately 2-fold greater than expected, and the most common cause of death was cardiovascular disease (41%). The independent baseline factors among 30-day survivors that predicted death over 5 years were intermittent claudication (hazard ratio [HR], 1.9; 95% CI, 1.2 to 2.9), urinary incontinence (HR, 2.0; 95% CI, 1. 3 to 3.0), previous transient ischemic attack (HR, 2.4; 95% CI, 1.4 to 4.1), and prestroke Barthel Index <20/20 (HR, 2.0; 95% CI, 1.2 to 3.2). CONCLUSIONS: One-year survivors of first-ever stroke continue to die over the next 4 years at a rate of approximately 10% per year, which is twice the rate expected among the general population of the same age and sex. The most common cause of death is cardiovascular disease. Long-term survival after stroke may be improved by early, active, and sustained implementation of effective strategies for preventing subsequent cardiovascular events.

Trends in the incidence, severity, and short-term outcome of stroke in perth, Western Australia.

BACKGROUND AND PURPOSE: This report describes trends in the key indices of cerebrovascular disease over 6 years from the end of the 1980s in a geographically defined segment of the city of Perth, Western Australia. METHODS: Identical methods were used to find and assess all cases of suspected stroke in a population of approximately 134 000 residents in a triangular area of the northern suburbs of Perth. Case fatality was measured as vital status at 28 days after the onset of symptoms. Data for first-ever strokes and for all strokes for equivalent periods of 12 months in 1989-1990 and 1995-1996 were compared by age-standardized rates and proportions and Poisson regression. RESULTS: There were 355 strokes in 328 patients and 251 first-ever strokes (71%) for 1989-1990 and 290 events in 281 patients and 213 first-ever strokes (73%) for 1995-1996. In Poisson models including age and period, overall trends in the incidence of both first-ever strokes (rate ratio=0.75; 95% confidence limits, 0.63, 0.90) and all strokes (rate ratio=0.73; 95% confidence limits, 0.62, 0.85) were obviously significant, but only the changes in men were independently significant. Case fatality did not change, and the balance between hemorrhagic and occlusive strokes in 1995-1996 was almost indistinguishable from that observed in 1989-1990. CONCLUSIONS: Our results, which are the only longitudinal population-based data available for Australia for key indices of stroke, suggest that it is a change in the frequency of stroke, rather than its outcome, that is chiefly responsible nationally for the fall in mortality from cerebrovascular disease.

Long-term risk of first recurrent stroke in the Perth Community Stroke Study.

BACKGROUND AND PURPOSE: Few community-based studies have examined the long-term risk of recurrent stroke after an acute first-ever stroke. This study aimed to determine the absolute and relative risks of a first recurrent stroke over the first 5 years after a first-ever stroke and the predictors of such recurrence in a population-based series of people with first-ever stroke in Perth, Western Australia. METHODS: Between February 1989 and August 1990, all people with a suspected acute stroke or transient ischemic attack of the brain who were resident in a geographically defined region of Perth, Western Australia, with a population of 138 708 people, were registered prospectively and assessed according to standardized diagnostic criteria. Patients were followed up prospectively at 4 months, 12 months, and 5 years after the index event. RESULTS: Three hundred seventy patients with a first-ever stroke were registered, of whom 351 survived >2 days. Data were available for 98% of the cohort at 5 years, by which time 199 patients (58%) had died and 52 (15%) had experienced a recurrent stroke, 12 (23%) of which were fatal within 28 days. The 5-year cumulative risk of first recurrent stroke was 22.5% (95% confidence limits [CL], 16.8%, 28.1%). The risk of recurrent stroke was greatest in the first 6 months after stroke, at 8.8% (95% CL, 5.4%, 12.1%). After adjustment for age and sex, the prognostic factors for recurrent stroke were advanced, but not extreme, age (75 to 84 years) (hazard ratio [HR], 2.6; 95% CL, 1.1, 6.2), hemorrhagic index stroke (HR, 2.1; 95% CL, 0.98, 4.4), and diabetes mellitus (HR, 2.1; 95% CL, 0.95, 4.4). CONCLUSIONS: Approximately 1 in 6 survivors (15%) of a first-ever stroke experience a recurrent stroke over the next 5 years, of which 25% are fatal within 28 days. The pathological subtype of the recurrent stroke is the same as that of the index stroke in 88% of cases. The predictors of first recurrent stroke in this study were advanced age, hemorrhagic index stroke, and diabetes mellitus, but numbers of recurrent events were modest. Because the risk of recurrent stroke is highest (8.8%) in the first 6 months after stroke, strategies for secondary prevention should be initiated as soon as possible after the index event.

Migrant suicide rates in Australia and in country of birth.

BACKGROUND: Various studies from Australia, Canada and the United States have shown significant rank correlations between the suicide rates of immigrants and those of their country of birth (COB). This study compares the rank ordering of age standardized suicide rates of immigrants in Australia for two periods, 1961-70 and 1979-90: (a) between each period; and (b) with their COB for each period. METHODS: Data were obtained from the World Health Organization Annual Statistics and from the Australian Bureau of Statistics. Comparisons were made for 11 countries from England and Wales, Ireland and Europe, for which there was a sufficiently large number of immigrant suicides to warrant statistical analysis. RESULTS: The data showed considerable heterogeneity in rates of immigrants from various countries, with increased rates in Australia compared with their COB. There were consistently significant Spearman rank correlations between the rates after immigration and those in their COB for each period, and between rates in the two periods for both immigrants and for their COB, despite increases in suicide rates, and considerable socio-economic demographic changes between the various countries over that time span. CONCLUSIONS: The findings are used to argue two conclusions: (i) the important influence of premigrant social and cultural experiences in subsequent suicide rates in immigrants in their host country; and (ii) to support the case for the reliability of using international suicide data for comparative epidemiological research.

Validation of an Italian translation of the 30-item General Health Questionnaire for use in Australia.

A validity study of an Italian translation of the GHQ-30 was conducted on a sample of 96 Italian-born subjects in the community in Perth, Western Australia, using the shortened version of the Present State Examination as the gold standard for a "case" of non-psychotic psychiatric morbidity. The 96 subjects were a subsample of a study of 1109 subjects seen in a community survey, in which 45.8% had a score above 4 on the GHQ-30. It was found that 5/6 was the most appropriate cut-off point. At this level the sensitivity was 81.2%, the specificity 79.7%, the positive predictive value 66.7%, the negative predictive value 89.5% and the overall misclassification rate 19.8%. Adjusting the results to truly reflect the lower case-prevalence rate in the community, using a method suggested by Goldberg, the corresponding values were 57.7%, 92.6%, 66.7%, 89.5% and 14.6%. It was concluded that this version of the GHQ-30 is suitable for use in the Italian-born, in the community and in general practice in Australia, using a cut-off point of 5/6.

Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study.

Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28-item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM-III criteria. The GHQ-28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ-28 having an overall superiority. The performance of all 3 scales for screening post-stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.

Prevalence of depression after stroke: the Perth Community Stroke Study.

BACKGROUND: The Perth Community Stroke Study (PCSS) was a population-based study of the incidence, cause, and outcome of acute stroke. METHOD: Subjects from the study were assessed initially, by examination and interview, and at four- and 12-month follow-ups to determine differences in prevalence of depression between the sexes and between patients with first-ever and recurrent strokes. RESULTS: The prevalence of depressive illness four months after stroke in 294 patients from the PCSS was 23% (18-28%), 15% (11-19%) major depression and 8% (5-11%) minor depression. There were no significant differences between the sexes or between patients with first-ever and recurrent strokes. With a non-hierarchic approach to diagnosis of those with depression, 26% of men and 39% of women had an associated anxiety disorder, mainly agoraphobia. Nine per cent of male and 13% of female patients interviewed had evidence of depression at the time of the stroke. Twelve months after stroke 56% of the men were still depressed (40% major and 16% minor), as were 30% of the women (12% major and 18% minor). CONCLUSION: The prevalence of depression after stroke was comparable with that reported from other studies, and considerably less than that reported from in-patient and rehabilitation units.

Anxiety disorders after stroke: results from the Perth Community Stroke Study.

BACKGROUND: The prevalence of anxiety disorders in 294 patients who survived to four months in the Perth Community Stroke Study (Perth, Australia), and a follow-up of these patients at 12 months, are presented. METHOD: Diagnoses are described both in the usual DSM hierarchic format and by a non-hierarchic approach. Adoption of the hierarchic approach alone greatly underestimates the prevalence of anxiety disorders. RESULTS: Most cases were of agoraphobia, and the remainder were generalised anxiety disorder. The prevalence of anxiety disorders alone was 5% in men and 19% in women; in community controls, it was 5% in men and 8% in women. Adopting a non-hierarchic approach to diagnosis gave a prevalence of 12% in men and 28% in women. When those who showed evidence of anxiety disorder before stroke were subtracted, the latter prevalence was 9% in men and 20% in women. CONCLUSION: One-third of the men and half of the women with post-stroke anxiety disorders showed evidence of either depression or an anxiety disorder at the time of the stroke. At 12 month follow-up of 49 patients with agoraphobia by a non-hierarchic approach, 51% had recovered, and equal proportions of the remainder had died or still had agoraphobia. The only major difference in outcome between those with anxiety disorder alone and those with comorbid depression was the greater mortality in the latter.

Suicide in the multiethnic elderly population of Australia, 1979-1990.

Australia is a multiethnic society with 25% of its elderly population born outside the country. Rates and methods, gender, and country of birth are given for all suicides aged 65 and over in Australia during the 12-year period of 1979-1990. There was a marked heterogeneity in rates and methods of suicide among the various migrant groups. The data also showed that the suicide rates of migrants were mostly higher than in their country of origin. Migrants born in countries with high suicide rates generally had high rates in Australia, and vice versa. Possible reasons for this finding are discussed. Factors influencing rates and methods of suicide in elderly migrants appeared to have much in common with factors operating in migrants of all age groups.

Ascertaining the true incidence of stroke: experience from the Perth Community Stroke Study, 1989-1990.

OBJECTIVE: To determine the age and sex specific incidence, and case fatality of stroke in Perth, Western Australia. DESIGN AND SETTING: A population-based descriptive epidemiological study. SUBJECTS: All residents of a geographically defined segment of the Perth metropolitan area (population 138,708) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, inclusive. MAIN OUTCOME MEASURES: Definite acute "first-ever-in-a-lifetime" (first-ever) and recurrent stroke classified according to standard definitions and criteria. RESULTS: During the 18-month study period, 536 stroke events occurred among 492 patients, 69% of which were first-ever strokes. The crude annual event rate for all strokes was 258 (95% confidence interval 231-285) per 100,000, and the overall case fatality at 28 days was 24% (95% CI, 20%-28%). The crude annual incidence for first-ever strokes was 178 (95% CI, 156-200) per 100,000; 189 (95% CI, 157-221) per 100,000 in males and 166 (95% CI, 136-196) per 100,000 in females. The corresponding rates, age-adjusted to the "world" population, were 132 (95% CI, 109-155) for males and 77 (95% CI, 60-94) for females. CONCLUSIONS: In contrast to mortality rates for ischaemic heart disease, the incidence of stroke in Australia appears little different from that for several other Western countries. For both males and females the incidence of stroke rises exponentially with increasing age. Although the sex-dependent difference in the risk of stroke is greatest in middle age, males are at greater risk of stroke even among the most elderly. To determine the incidence of stroke accurately, population-based studies of stroke need exhaustive and overlapping sources of case ascertainment. If only cases admitted to hospital had been used, we would have underestimated the rate of stroke among the most elderly by almost 40%. We estimate that approximately 37,000 people, about 50% of whom are over the age of 75, suffer a stroke each year in Australia.

Determining the incidence of different subtypes of stroke: results from the Perth Community Stroke Study, 1989-1990.

OBJECTIVE: To determine the incidence and case fatality of seven distinct subtypes of stroke in Perth, Western Australia. DESIGN AND SETTING: A population-based descriptive epidemiological study. SUBJECTS: All residents of a geographically defined segment of the Perth metropolitan area (estimated population 138,708 persons) who had a stroke or transient ischaemic attack between 20 February 1989 and 19 August 1990, inclusive. MAIN OUTCOME MEASURES: The following subtypes of stroke were classified according to standard clinical, radiological and pathological criteria: types of cerebral infarction, namely, large artery (thrombotic) occlusive infarction (LAOI), cerebral embolic infarction (EMBI), lacunar infarction (LACI) and boundary zone infarction (BZI); primary intracerebral haemorrhage (PICH); subarachnoid haemorrhage (SAH); and stroke of undetermined cause. RESULTS: Over the 18-month study period 536 stroke events were registered, of which 86% (95% confidence interval, 83%-89%) had a defined "pathological" diagnosis on the basis of computed tomographic scanning, magnetic resonance imaging or necropsy. Cerebral infarction accounted for 71% of cases (95% CI, 68%-75%), PICH 11% (95% CI, 9%-14%) and SAH 4% (95% CI, 2%-5%). The 382 cases of cerebral infarction included LAOI (in approximately 71%), EMBI (15%), LACI (10%) and BZI (5%). While the incidence of all subtypes of stroke increased with age, there were age and sex differences in their proportional frequency, management and prognosis: patients with PICH, SAH and EMBI were more likely to be admitted to hospital, and these conditions carried the highest early case fatality. Over all, the 28-day case fatality was 24% (95% CI, 20%-28%), but varied from 0 for LACI and BZI, to 37% (95% CI, 15%-59%) for SAH and 35% (CI, 23%-47%) for PICH. CONCLUSIONS: In this study, we found considerable differences in incidence rates, the effect of age and sex on incidence rates, and prognosis for the different subtypes of stroke. Hospital-based studies are likely to be selectively biased by emphasising strokes that are severe and require admission to hospital. These data have important implications in the design and evaluation of clinical trials of therapy for stroke.

Looking beyond the 1:10,000 ratio of psychiatrists to population.

The frequently quoted ratio of 1:10,000 psychiatrists to population originated in Canada in 1962 and was later adopted as the minimum by the American Psychiatric Association. Since then both Canada and the United States have found this ratio to be inadequate. Canada has since advocated an optimal target ratio of 1:6,500, but recommended a more attainable pragmatic ratio of 1:8,000 for the foreseeable future. The Royal Australian and New Zealand College of Psychiatrists' recently recommended range of 1:7,500 to 1:10,000 is applauded. Reasons are given why a reasonable upper limit to the ratio of psychiatrists to population is desirable.

A study of coroner's records of suicide in young people, 1986-88 in Western Australia.

Coroner's records of 25 consecutive suicides aged 15-19 years and 43 aged 20-24 years were compared with 68 suicides aged 45-59 years to identify associated clinical and psychosocial factors. Male: female ratios were 2.6:1, 5.1:1 and 3.5:1 respectively. The most common method of suicide in males in all three age groups was CO poisoning using motor vehicles. In females the teenage group used mainly active methods, whilst in the 20-24 and 45-49 years age groups the most common method was overdosage. Over 90% of each age group had some identifiable psychiatric symptomatology. In each age group the commonest symptoms were minor affective symptoms. In each group the pattern was mainly of associated multiple rather than single psychosocial factors. In each group disruption of interpersonal relationships (boy-girlfriend, de facto, marital, family) was the predominant stressor. Compared with the 45-59 year group the following associated factors were significantly greater in (a) 15-19 years: personality/conduct disorders, unemployment and legal/disciplinary problems, and (b) 20-24 years: drug abuse and unemployment. Although the two younger groups had significantly more unemployment than the older group, only the 20-24 years group had significantly more unemployment compared with community age norms. Preventive implications of the findings are discussed.

Relationship between alcohol consumption and attempted suicide morbidity rates in Perth, Western Australia, 1968-1984.

Per adult (greater than or equal to 15 years) consumption of beer, wine, spirits, and absolute alcohol for a 17-year period (1968-1984) was related to the attempted suicide morbidity rates in the Perth urban area of Western Australia. For both males and females aged 15-39 years, Mann-Whitney U tests showed that during the years of highest spirits consumption, the highest rates for attempted suicide occurred. A similar finding also applied to 15-39-year-old males for wine. The effect of a rapidly rising blood alcohol level, together with a preselection factor as to the personal characteristics of persons who consumed the higher alcohol content drinks, may explain the results, which need to be confirmed by clinical studies of the type of alcoholic beverage consumed by persons prior to attempting suicide.

The prognosis of depression in old age.

The 12-month outcome of 103 elderly depressed patients treated by psychiatrists in Perth, Western Australia, was good in 32-47% of cases, depending upon the stringency of the outcome criteria used. A higher than expected mortality was found, especially in men. No clear association was found between 12-month outcome and a variety of clinical variables at index admission, including chronic physical illness, severity of depression, and severe life events during follow-up. As the statistical power of this and other studies is small, it would be unwise at present to draw definite conclusions about the role of possible risk factors in the prognosis of depressed elderly. Vigorous treatment of the depressive illness and adequate after-care are important.

The impact of criteria selection on prevalence rates.

In spite of major advances in the past 10 years in the development of standardized instruments for reliable psychiatric case detection, many selection factors can influence prevalence rates, impairing the compilation of comparable epidemiological data from different settings. This is especially so in the aged. Such factors include relatively small variations in the wording of questionnaires, the sophistication and training of interviewers, availability of an informant history, duration of symptoms and diagnostic hierarchies. Many different measuring instruments and diagnostic criteria are currently used to diagnose depressive illness in the elderly. It is not clear how these compare in estimating prevalence rates. There are no agreed reliable criteria for dementia, especially mild dementia: different criteria systems give widely differing prevalence rates. Gender, education and social class can influence the scores on some tests of cognition. More uniform generally accepted measures and criteria of major psychiatric syndromes in the elderly, must be developed if epidemiological approaches are to contribute to further major advances in our understanding of psychiatric syndromes in the aged.

Screening the elderly in the community for psychiatric disorder.

The use of the 30-item GHQ as a screening instrument in a community population aged 70 years and older was examined. An acceptable sensitivity (70%) and specificity (84%) was obtained. As in the younger age groups, the GHQ was not good at detecting chronic, generalised anxiety disorders. The GHQ is best used in combination with the MMSE to screen out cases of dementia in an elderly population.

Relationship between male pancreatitis morbidity and alcohol consumption in Western Australia, 1971-84.

Acute pancreatitis morbidity rates for Western Australian men aged 20 to 39 years, and over 40 years, were related to per adult (greater than or equal to 15 years) alcohol consumption, using the Mann-Whitney U test. A significant result was obtained for the young men. The male 20 years and over chronic pancreatitis morbidity rate was also significantly related to alcohol consumption. Various reasons for the results are discussed, and in particular from the view point that changes in the level of alcohol consumption appear to affect subsequent pancreatitis morbidity rates.