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Depression and diabetes mellitus multimorbidity is associated with loss of independence and dementia poststroke

Ouk M, Wu C, Colby-Milley J, Fang J, Zhou L, Shah BR, Herrmann N, Lanctot KL, Linkewich E, Law M, Swartz RH, Kapral MK, Black SE, MacIntosh BJ, Edwards JD, Swardfager W. Stroke. 2020; 191(3):396-404. Epub 2020 Oct 14. DOI:

Background and Purpose — Many patients with ischemic stroke present with multiple comorbidities that threaten survival and recovery. This study sought to determine the risks of adverse long-term stroke outcomes associated with multimorbid diabetes mellitus and depression.

Methods — Retrospective analysis of prospectively collected data on consecutive patients without premorbid dementia admitted from the community for a first-ever acute ischemic stroke to comprehensive stroke centers across Ontario, Canada (2003–2013). Premorbid histories of diabetes mellitus and depression were ascertained within 5 years before stroke admission. Adjusted hazard ratios (aHR [95% CI]) of admission to long-term care, incident dementia, readmission for stroke or transient ischemic attack and all-cause mortality, over time among those discharged back into the community poststroke.

Results — Among 23 579 stroke admissions, n=20 201 were discharged back into the community. Diabetes mellitus and depression were associated with synergistic hazards of admission to long-term care (X2=5.4; P=0.02) over a median follow-up of 5.6 years. This interaction was observed among women specifically; depression multimorbidity showed particularly high hazards of admission to long-term care (aHRDepression=1.57 [1.24–1.98]) and incident dementia (aHRDepression=1.85 [1.40–2.44]) among women with diabetes mellitus. In the whole cohort, diabetes mellitus and depression were associated individually with long-term care admission (aHRDiabetes=1.20 [1.12–1.29]; aHRDepression=1.19 [1.04–1.37]), incident dementia (aHRDiabetes=1.14 [1.06–1.23]; aHRDepression=1.27 [1.08–1.49]), stroke/transient ischemic attack readmission (aHRDiabetes=1.18 [1.10–1.26]; aHRDepression=1.24 [1.07–1.42]), and all-cause mortality (aHRDiabetes=1.29 [1.23–1.36]; aHRDepression=1.16 [1.05–1.29]).

Conclusions — The risks of dementia and needing long-term care in the years after surviving a stroke were particularly elevated among women when premorbid diabetes mellitus and depression occurred together. Long-term stroke recovery strategies might target high-risk patients with mood and metabolic multimorbidity.