Year: 2012
Type: article
Study design: Systematic Review
Abstract: T here has been recent interest in sex differences in stroke with a focus on the first 3 months after stroke. 1 We recently reported that females had more severe strokes, higher short-term mortality, and different management in comparison to males.This was explained by females' greater age and prevalence of comorbidities at stroke onset, 2 findings supported by a recent review.3 Others have suggested that being female is a risk factor for poorer outcomes in the acute period independent of age and other covariates, 1 raising the possibility of a sex bias in the diagnosis or treatment of stroke in females.Alternatively, biological differences between the sexes could influence outcome.For example, differences in muscle strength could explain worse functional outcomes in females.4 Despite this recent interest, there has been little discussion of sex differences with regard to outcome in the longer term after stroke.This review addresses this gap, exploring sex differences in (1) functional outcomes, also known as "activity limitations" and historically as "disability"; (2) handicap, also known as "restriction of participation"; and (3) quality of life. MethodsWe used a systematic search strategy to identify relevant literature.We searched PubMed, EBSCO/CINAHL, and Embase for full-text, English language articles published up to August 2011.All searches included the terms "stroke," "cerebrovascular," "cerebral infarction" OR "cerebral ischemia/ischemia" and "intracerebral hemorrhage/ hemorrhage."For full details of our search strategy, the online-only data supplement.The titles of articles identified were examined and studies not focused on stroke or assessing the relevant outcomes were excluded.Abstracts were examined, selecting studies that: (1) were hospitalbased with consecutive ascertainment or population-based incidence studies; (2) reported functional outcome, handicap, or quality of life;(3) were conducted Ն12 months after stroke because most recovery will occur before this time 5 ; and (4) reported results according to sex.A study was excluded if it: (1) was hospital-based with consecutive ascertainment but excluded certain patients, because such studies are more prone to selection bias; or (2) was based in a rehabilitation hospital because sex differences in discharge destination might have made results less generalizable. 1 All studies meeting these inclusion and exclusion criteria, irrespective of sample size or completeness of follow-up, were included. Results and DiscussionFunctional outcomes refer to an individual's ability to execute activities of daily living (ADL).In stroke, these outcomes are closely related to the severity and type of neurological impairment.They are generally assessed at the level of personal ADL (PADL) such as walking, feeding, and bathing.Instrumental ADL is an extension of PADL to more complex tasks such as housekeeping and social interaction.6 Restoring these functions is a focus of rehabilitation because they are strongly associated with independent living.In a previous review, Jongbloed 7 concluded that sex was not a predictor of function after stroke from the 7 studies available at that time, a view supported by a recent review of predictors of ADL 3 months after stroke.8 In both, limited detail was provided with respect to the adjustments made for confounding.We identified 21 studies of PADL 9 -30 and 5 of instrumental ADL 10,11,19,20,31 that met our inclusion criteria (Table 1).See http://stroke.ahajournals.orgfor further details of the included studies (online-only Data Supplement Figure I; online-only Data Supplement Table I).The most common instruments were the modified Rankin Scale and the Barthel Index, each widely used with reasonable reliability and validity in stroke populations.32,33 There were 4 studies specifically designed to identify sex differences in PADL with all finding females had worse functional outcomes after stroke.9,13,21,22 All studies adjusted for age, 2 adjusted for stroke severity, 21,22 and 2 adjusted for vascular risk factors.13,21 Among studies not designed to examine sex differences, 5 reported that females had worse outcome than males in unadjusted analyses 10 and independent of age, 11,16,23,24 stroke severity, 23,24 prestroke disability, 23 comorbidities, 24 depression, 11 living alone, 11 recurrent stroke, 11 and cognitive impairments.11 In contrast, others reported no association between sex and long-term functional outcomes in unadjusted analyses 11,12,20 or after adjusting for age, 16,18,[25][26][27][28][29][30][31] socioeconomic factors, 29 stroke severity, 17,18,25-27,29 -31 prestroke disability, 16,25,27 treatment, 27 mood, 18 and comorbidities.15,17,26,29 There were fewer examinations of instrumental ADL by sex.10,11,19,20,31 Only the study by Feigin et al 11 adjusted for potential confounding factors.They reported that females had lower Frenchay Activities Index scores than males, but this did not persist in a model with age, dependency in PADL, and cognitive problems.It is possible that the sex difference in Frenchay Activities Index scores may have remained if PADL was not included in the model.Of the
Source: Stroke
Institutions: University of Tasmania, Monash University
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2051293896