Abstract

This study aimed at estimating the prevalence of stroke in older adults in Brazil, and at identifying the sociodemographic, health-related, health service-related, and environmental factors associated with independence in daily activities. Across-sectional, population-based study (Brazilian Longitudinal Study of Aging 2015-2016) was conducted. 536 individuals (≥ 50 years), from 9,412 participants, have had stroke and were included. Prevalence of stroke was 5.3% among individuals aged 50 years and over, increasing up to 8.0% among individuals aged 75 years and over, showing a dissimilar pattern between sex. Independence was associated with walking speed (Prevalence Ratio (PR) 2.72, 95%CI: 1.96 to 3.77), physical activity (PR 1.24; 95%CI: 1.04 to 1.47) and use of walking devices (PR 0.63; 95%CI: 0.41 to 0.96). A significant interaction was found between walking speed plus home adaptations and performance of daily living activities (PR 3.42; 95%CI: 1.04 to 11.29). The probability of independence was 40% among slow walkers (< 0.4 m/s), increasing up to 70% among fast walkers (> 0.8 m/s), and to 90% among those who also have home adaptations. Faster walking speed combined with home adaptations was the main factor associated with long-term independence after stroke.

Key words:
Activities of daily living; Cerebrovascular disease; Gait; Prevalence; Rehabilitation

Resumo

Objetivou-se estimar a prevalência do acidente vascular cerebral (AVC) em brasileiros mais velhos, bem como identificar fatores sociodemográficos, de saúde, de serviços de saúde e ambientais associados à independência em atividades de vida diária. Trata-se de um estudo transversal de base populacional (Estudo Longitudinal da Saúde de Idosos Brasileiros 2015-2016). Dos 9.412 participantes, 536 indivíduos (≥ 50 anos) tiveram AVC e foram incluídos. A prevalência do AVC foi de 5,3% em indivíduos com 50 anos e mais, aumentando para 8% entre indivíduos com 75 anos e mais, com padrão dissimilar entre sexo. A independência foi associada à velocidade da marcha (razão de prevalência [RP] 2,72, IC95%: 1,96-3,77), atividade física (PR 1,24; IC95%: 1,04-1,47) e uso de dispositivos auxiliares de marcha (RP 0,63; IC95%: 0,41-0,96). Encontrou-se interação significativa para velocidade da marcha, adaptações no domicílio e a independência (RP 3,42; IC95%: 1.04-11.29). A probabilidade de independência foi de 40% nas velocidades mais baixas (< 0,4 m/s), e nas velocidades mais elevadas (> 0,8 m/s) foi de 70%, aumentando para 90% quando há adaptações no domicílio. A velocidade rápida da marcha e a adaptação no domicílio foram os principais fatores associados à independência a longo prazo após o AVC.

Palavras-chave:
Atividades de vida diária; Doença cerebrovascular; Marcha; Prevalência; Reabilitação

Introduction

Stroke is the second cause of death and a leading cause of long-term disability worldwide¹1 Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler 3rd ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2015 update : a report from the American Heart Association. Circulation 2015; 131(4): e29-322.^,22 Norrving B, Kissela B. The global burden of stroke and need for a continuum of care. Neurology 2013; 80(3 Suppl. 2): S5-S12., with incidence rates predominantly higher among individuals aged over 50 years³3 Kissela BM, Khoury JC, Alwell K, Moomaw CJ, Woo D, Adeoye O, Flaherty ML, Khatri P, Ferioli S, De Los Rios La Rosa F, Broderick JP, Kleindorfer DO. Age at stroke: temporal trends in stroke incidence in a large, biracial population. Neurology 2012; 79(17):1781-1787.. Stroke incidence has declined in the past four decades in high-income countries, but its incidence has doubled in older individuals living in low- and middle-income countries⁴4 Ferri CP, Schoenborn C, Kalra L, Acosta D, Guerra M, Huang Y, Jacob KS, Llibre Rodriguez JJ, Salas A, Sosa AL, Williams JD, Liu Z, Moriyama T, Valhuerdi A, Prince MJ. Prevalence of stroke and related burden among older people living in Latin America, India and China. J Neurol Neurosurg Psychiatry 2011; 82(10):1074-1082.

5 Prince MJ, Wu F, Guo Y, Gutierrez Robledo LM, O'Donnell M, Sullivan R, Yusuf S. The burden of disease in older people and implications for health policy and practice. Lancet 2015; 385(9967):549-62.^-66 Santana NM, Santos Figueiredo FW, Melo Lucena DM, Soares FM, Adami F, Lucena DMM, Correa JA. The burden of stroke in Brazil in 2016: an analysis of the Global Burden of Disease study findings. BMC Res Notes 2018; 11(1):735.. Worldwide, stroke accounted for 12% of the burden of disability-adjusted life years, in 2010⁵5 Prince MJ, Wu F, Guo Y, Gutierrez Robledo LM, O'Donnell M, Sullivan R, Yusuf S. The burden of disease in older people and implications for health policy and practice. Lancet 2015; 385(9967):549-62., mainly concerning men and those aged 70 years and over⁶6 Santana NM, Santos Figueiredo FW, Melo Lucena DM, Soares FM, Adami F, Lucena DMM, Correa JA. The burden of stroke in Brazil in 2016: an analysis of the Global Burden of Disease study findings. BMC Res Notes 2018; 11(1):735.. As the world’s population ages and the survival rates after stroke increase, a higher number of individuals is expected to experience limitations to perform activities of daily living, such as walking and bathing.

Given the heterogeneity of stroke, the “one size fits all” approach is ineffective for implementing worthwhile interventions. This means that some individuals who have had stroke may benefit from specific interventions, while some individuals may benefit from others, based upon personal and environmental characteristics. Therefore, comprehending the epidemiological characteristics in sub-groups of individuals with stroke, and identifying factors related to a long-term independence in activities of daily living can help target intervention to the patients who will most benefit⁷7 Harvey RL. Predictors of functional outcome follow ing stroke. Phys Med Rehabil Clin N Am 2015; 26(4): 583-598.^,88 White J, Magin P, Attia J, Sturm J, McElduff P, Carter G. Predictors of health-related quality of life in community-dwelling stroke survivors: a cohort study. Fam Pract 2016; 33(4):382-387.. Ideally, we would identify factors, which reliably explain the ability to perform those activities, such as walking across a room, dressing, bathing, eating, get-in and up the bed, and toileting⁹9 Lino VTS, Pereira SRM, Camacho LAB, Ribeiro Filho ST, Buksman S. Cross-cultural adaptation of the Independence in Activities of Daily Living Index (Katz Index). Cad Saude Publica 2008; 24(1):103-112.. This information would be useful to optimize rehabilitation, to improve the design and analysis of clinical trials, and to accurately inform patients of likely outcomes and prognosis¹⁰10 Coupar F, Pollock A, Rowe P, Weir C, Langhore P. Predictors of upper limb recovery after stroke: a systematic review and meta-analysis. Clin Rehabil 2012; 26(4):291-313.. There have been two systematic reviews, which examined factors associated with mobility¹¹11 Craig LE, Wu O, Bernhardt J, Langhore P. Predictors of poststroke mobility: systematic review. Int J Stroke 2011; 6(4):321-327. and upper limb recovery¹⁰10 Coupar F, Pollock A, Rowe P, Weir C, Langhore P. Predictors of upper limb recovery after stroke: a systematic review and meta-analysis. Clin Rehabil 2012; 26(4):291-313. after stroke, based upon small cohort studies. Most studies, however, included a limited variety of factors, had incomparable outcomes, focus on early-treatment after stroke, did not examine the influence of environmental factors, and constrained the results to a single activity (mostly walking), leading to unconvincing clinical recommendations. In addition, the sample in most exploratory studies was typically not randomly selected and may not, therefore, be fully representative of the stroke population.

The aims of the present study were to estimate the prevalence of stroke and to identify the factors associated with independence to perform activities of daily living in a nationally representative, population-based study of individuals aged 50 years and over. The specific research questions were: (1) What is the prevalence of stroke among community-dwelling individuals aged 50 years and over, and in sub-groups stratified by age and sex?; (2) Which factors are associated with long-term independence to perform activities of daily living after stroke?

Methods

Design

A cross-sectional study was conducted. Baseline data of individuals who have had a stroke was extracted from the Brazilian Longitudinal Study of Aging (ELSI-Brazil), which is a nationally representative, population-based cohort study of individuals aged 50 years and over, conducted between 2015 and 2016.

A probabilistic sample design, which applied a sampling procedure combining geographical stratification and a two- or three-stage clustering, based upon the population size, was conducted, considering 70 municipalities from the five great Brazilian geographical regions. The cities were the primary sample units, followed by census tracts and households. The 2015-2016 ELSI-Brazil followed the standards set by the Declaration of Helsinki and was approved by the ethics board of the Oswaldo Cruz Foundation, Minas Gerais (CAAE 34649814.3.0000.5091). All participants signed an informed consent form.

Participants and procedures

All residents in the selected households aged 50 years and over were eligible. Individual interviews integrated a broad range of topics related to individuals’ sociodemographic characteristics, health-related characteristics, health services, house characteristics, and home adaptations. A comprehensive set of physical measurements was also carried out at the respondents’ home. The standardized study procedures are detailed in the ELSI-Brazil operations manual (available at the ELSI-Brazil homepage: http://elsi.cpqrr.fiocruz.br/en/). Detailed information of the ELSI-Brazil was previously published¹²12 Lima-Costa M, Andrade F, Souza Jr P, Neri AL, Duarte YAO, Castro-Costa E, Oliveira C. The Brazilian Longitudinal Study of Aging (ELSI-BRAZIL): objectives and design. Am J Epidemiol. 2018; 187(7):1345-1353.. Ten thousand individuals aged 50 years and over were identified as potential participants of the ELSI-Brazil, and 9,412 individuals agreed to participate and were used to estimate prevalence. Five hundred thirty-six (536) individuals had a medical diagnosis of stroke and were, therefore, included in the further analyses.

Outcomes

Prevalence of stroke among individuals aged 50 years and over was estimated using the standard population at the individual-level and adjusted for age and education⁵5 Prince MJ, Wu F, Guo Y, Gutierrez Robledo LM, O'Donnell M, Sullivan R, Yusuf S. The burden of disease in older people and implications for health policy and practice. Lancet 2015; 385(9967):549-62., and to allow further comparisons. Overall and age- and education-adjusted prevalence was stratified by age cut-offs (i.e., 50+ years, 60+ years, 65+ years, and 75+ years) and sex (i.e., female and male), and reported as percentages using the total population (9,412 participants). These cut-offs were used to allow comparisons with international data⁴4 Ferri CP, Schoenborn C, Kalra L, Acosta D, Guerra M, Huang Y, Jacob KS, Llibre Rodriguez JJ, Salas A, Sosa AL, Williams JD, Liu Z, Moriyama T, Valhuerdi A, Prince MJ. Prevalence of stroke and related burden among older people living in Latin America, India and China. J Neurol Neurosurg Psychiatry 2011; 82(10):1074-1082.^,55 Prince MJ, Wu F, Guo Y, Gutierrez Robledo LM, O'Donnell M, Sullivan R, Yusuf S. The burden of disease in older people and implications for health policy and practice. Lancet 2015; 385(9967):549-62.^,1313 Minicuci N, Naidoo N, Corso B, Rocco I, Chatterji S, Kowal P. Data resource profile: cross-national and cross-study sociodemographic and health-related harmonized domains from SAGE plus CHARLS, ELSA, HRS, LASI and SHARE (SAGE+ Wave 2). Int J Epidemiol 2019; 48(1): 4-14j..

The combined performance in six activities of daily living(i.e., walking across a room, dressing, bathing, eating, get-in and up the bed, and toileting),derived from the previously cross-cultural adapted Katz index⁹9 Lino VTS, Pereira SRM, Camacho LAB, Ribeiro Filho ST, Buksman S. Cross-cultural adaptation of the Independence in Activities of Daily Living Index (Katz Index). Cad Saude Publica 2008; 24(1):103-112., was the outcome of interest, measured by a self-reported interview. A proxy was invited when participants were unable to answer the questions. Those measurement procedures have been widely used in epidemiological studies¹⁴14 Vermeulen J, Neyens JC, Van Rossum E, Spreeuwenberg MD, Witte LP. Predicting ADL disability in community-dwelling elderly people using physical frailty indicators: A systematic review. BMC Geriatr 2011; 11:33. and all activities showed sensibility higher than 85% with the observation of health-professionals¹⁵15 Rebouças M, Coelho-Filho JM, Veras RP, Lima-Costa M, Ramos RL. Validity of questions about activities of daily living to screen for dependency in older adults. Rev Saude Publica 2017; 51:84.. The participants were asked to rate their performance on each activity using a Likert scale (1 = no difficulty, 2 = little difficulty, 3 = great difficulty or 4 = unable to perform). The outcome of interest was dichotomized into independent or dependent. Participants who reported no difficulty or little difficulty to perform all six activities were classified as independent, and participants who reported great difficulty or were unable to perform one of the six activities were classified as dependent.

Associated factors

Potential factors were grouped as follows: sociodemographic characteristics, health-related characteristics, health services, and environment assistance.

Sociodemographic factors included: sex (female or male); age (years); education (0-3, 4-7, 8 or more years of schooling); and marital status (married/living with a partner or not married (i.e. single/divorced/widowed).

Health-related factors included:time since first stroke (years);walking speed, measured using the average of two performances during the 3-meter timedwalking test (m/s)¹³13 Minicuci N, Naidoo N, Corso B, Rocco I, Chatterji S, Kowal P. Data resource profile: cross-national and cross-study sociodemographic and health-related harmonized domains from SAGE plus CHARLS, ELSA, HRS, LASI and SHARE (SAGE+ Wave 2). Int J Epidemiol 2019; 48(1): 4-14j., which shows high test-retest reliability, similar to a 6-meter course¹⁶16 Lyons JG, Heeren T, Stuver SO, Fredman L. Assessing the agreement between 3-meter and 6-meter walk tests in 136 community-dwelling older adults. J Aging Health 2015; 27(4):594-605.; falls in the past 12 months (yes or no); chronic conditions, e.g.,hypertension, lung disease or cancer (number of conditions); body mass index, classified according to age¹⁷17 Lipschitz DA. Screening for nutritional status in the elderly. Prim Care 1994; 21(1):55-67.^,1818 World Health Organization (WHO). Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000; 894: i-xii, 1-253. (normal or altered); and physical activity, measured using the short version of the International Physical Activity Questionnaire¹⁹19 Matsudo S, Araújo T, Matsudo V, Andrade D, Andrade E, Oliveira LC, et al. International Physical Activity Questionnaire (IPAQ): study of validity and reliability in Brazil. Rev Bras Ativ Fis Saude 2001; 6(2):5-18. (sedentary or active, according to the time (up to 150 minutes per week) spent on walking, moderate activities and vigorous activities)²⁰20 Peixoto SV, Mambrini JVM, Firmo JOA, Loyola Filho AI, Souza Junior PRB, Andrade FB, Lima-Costa MF. Physical activity practice among older adults: Results of the ELSI-Brazil. Rev Saude Publica 2018; 52(Suppl. 2):5s..

Health services factors included: hospitalization in the past 12 months (no or yes); medical visits in the past 12 months (no or yes); private health plan (no or yes); and use of rehabilitation services, i.e., physical therapy, in the past 90 days (no or yes).

Environment assistance factors included: home adaptations for people with limited mobility, e.g., handrails in the bathroom or ramps (no or yes); and use of walking devices, e.g., walker, cane, or crutches (no or yes).

Statistical analysis

Age- and education-adjusted prevalence of stroke was estimated using the standard population at individual-level and stratified by sex. Categorical data were reported using percentages, and continuous variables were reported using means and standard deviation (SD). Poisson regression models were used to estimate the prevalence ratios (PR) and their 95% confidence intervals to investigate the associations between each factor and independence to perform activities of daily living. Poisson regression provides direct estimates for the prevalence ratios that can be easily interpreted by non-epidemiologists.²¹21 Barros AJD, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3:21.Differences by grouped factors were performed separately, setting the level of significance at0.20 to ensure that potential adjusting factors were included. Associated factors from the initial analysis were included in the fully adjusted model using forward method and the level of significance was set at 0.05.F-corrected Wald statistic goodness-of-fit test were implemented to assess model fit after fitting the Poisson regression final model.

The predicted probability of independence according to the participants’ walking speed was provided, based on the fully adjusted model. The exposed-population attributable fraction to walking speed was estimated according to the cutoffs proposed by Perry et al.²²22 Perry J, Garrett M, Gronley JK, Mulroy SJ. Classification of walking handicap in the stroke population. Stroke 1995; 26(6):982-989.: < 0.4 m/s (housebound), 0.4m/s to 0.8 m/s (limited community ambulators), and > 0.8 m/s (unlimited community ambulators). Multiplicative interaction between walking speed and environment assistance factors were tested to examine whether interactions modify independence to perform activities of daily living. All analyses accounted for the complex survey design, included survey weights, and correction for subsampling. Analyses were performed using Stata 13 SE (Stata-Corp., College Station, Texas, USA).

Results

Flow of participants through the study

Five hundred thirty-six (536) individuals (255 men, 48%) from the initial 9,412 participants had a medical diagnosis of stroke and were, therefore, included in the present study. They had a mean age of 69 years (SD 11) and a mean time since the onset of the first stroke of ten years (SD 11). The level of walking disability (i.e., comfortable walking speed) ranged from 0 to 1.5 m/s, covering the spectrum of walking disability. Sixty-seven participants were unable to perform the walking test and had their walking speeds registered as 0.0 m/s. Thirty-nine participants refused to perform the walking test and were, therefore, excluded from analyses. Most of the participants were classified as independent to perform the six included activities either combined (n = 359, 67%), or separately: walking across a room (n = 441, 82%), dressing (n = 394, 74%), bathing (n = 425, 79%), eating (n = 484, 90%), getting-in and up the bed (n = 403, 76%), and toileting (n = 460, 86%).

Prevalence of stroke

The overall prevalence of stroke among individuals aged 50 years and over was 5.3% (95%CI: 4.7 to 5.9). Prevalence increased with age, achieving 6.1% (95%CI: 5.4 to 6.9) among individuals aged 60 years and over, and 8% (95%CI: 4 to 12) among individuals aged 75 years and over. A higher age- and education-adjusted prevalence was found in men aged 50 years and over (6.1%; 95%CI: 5.2 to 6.9), compared with women aged 50 years and over (4.7%; 95%CI: 3.9 to 5.4), which was maintained up to individuals aged 65 years and over. (Table 1).

Factors associated with independence to perform activities of daily living

Overall, eight potential factors were associated with independence to perform activities of daily living, in grouped analyses: two sociodemographic factors (education and marital status), two health-related factors (walking speed and physical activity), two health services factors (hospitalizations and medical visits), and two environment assistance factors (home adaptations and use of walking devices) (Table 2). In addition, age (p = 0.25) and falls in the past 12 months (p = 0.22), which were marginally associated with independence and previously suggested as important factors associated with independence²³23 Drummond A, Pimentel WRT, Pagotto V, Menezes RL. Disability on performing daily living activities in the elderly and history of falls: an analysis of the National Health Survey, 2013. Rev Bras Epidemiol 2020; 23:e200055., were also included in the fully adjusted model.

Three factors were independently associated with independence to perform activities of daily living in the fully adjusted model. A positive association was found between performance of daily living activities with walking speed (PR 2.72, 95%CI: 1.96 to 3.77), and with physical activity (PR 1.24; 95%CI: 1.04 to 1.47). A negative association was found between performance of daily living activities and use of walking devices (PR 0.63; 95%CI: 0.41 to 0.96) (Table 3).

A significant interaction was found between walking speed plus home adaptations and performance of daily living activities (PR 3.42; 95%CI: 1.04 to 11.29, p = 0.04). This means that the predicted probability of independence significantly varied according to walking speed and home adaptations. Among individuals with walking speed > 0.8 m/s, the predicted probability was significantly higher among those with home adaptations (93%; 95%CI: 83 to 100), in comparison with those with no home adaptations (72%; 95%CI: 66 to 79). Among individuals with walking speeds between 0.4 and 0.8 m/s, the predicted probability was 53% (95%CI: 51 to 56), and among individuals with walking speeds < 0.4 m/s, the predicted probability was 39% (95%CI: 33 to 44), regardless of home adaptations. Detailed information in Figure 1.

Discussion

This study aimed at estimating the prevalence of stroke among older adults and identifying the factors associated with independence to perform activities of daily living, based upon a cohort with 9,412 individuals. Overall, prevalence of stroke was 5.3% among individuals aged 50 years and over, increasing up to8% among individuals aged 75years and over, in 2015-2016. Faster walking speed combined with home adaptations enhance the probability of long-term independence after stroke.

This study examined stroke prevalence among older individuals, since90% of strokes occur among people over 50 years.²⁴24 Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics - 2018 update: a report from the American Heart Association. Circulation 2018; 137(12):e67-e492. The findings are in accordance with previous studies⁶6 Santana NM, Santos Figueiredo FW, Melo Lucena DM, Soares FM, Adami F, Lucena DMM, Correa JA. The burden of stroke in Brazil in 2016: an analysis of the Global Burden of Disease study findings. BMC Res Notes 2018; 11(1):735.^,2424 Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics - 2018 update: a report from the American Heart Association. Circulation 2018; 137(12):e67-e492., which demonstrated that stroke prevalence increases with advancing age in both men and women. In addition, the results highlighted that stroke prevalence among older adults aged 65 years and over was one of the highest across low- and middle-income countries⁴4 Ferri CP, Schoenborn C, Kalra L, Acosta D, Guerra M, Huang Y, Jacob KS, Llibre Rodriguez JJ, Salas A, Sosa AL, Williams JD, Liu Z, Moriyama T, Valhuerdi A, Prince MJ. Prevalence of stroke and related burden among older people living in Latin America, India and China. J Neurol Neurosurg Psychiatry 2011; 82(10):1074-1082.. According to the Prospective Studies Collaboration meta-analyses, occurrence of stroke is considerably reduced when systolic blood pressure is controlled²⁵25 Lewington S, Clarke R, Qizilbash N, Peto R, Collins R, Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360(9349):1903-1913.. Brazil demonstrates relatively high levels of prevention and monitoring of older people with hypertension due to a continuum of care from primary health teams (i.e. home visits, groups of physical activity, and free medication supply). However, blood pressure control is negatively influenced by low levels of schooling ²⁶26 Macinko J, Leventhal DGP, Lima-Costa MF. Primary care and the hypertension care continuum in Brazil. J Ambul Care Manage 2018; 41(1):34-46., poor health behaviors, such as sedentary lifestyle and alcohol consumption²⁷27 Oliveira J, Firmo A, Peixoto SV, Souza-Junior PRB, Andrade FB, Lima-Costa MF, Mambrini JVM. Health behaviors and hypertension control: the results of ELSI-BRASIL. Cad Saude Publica 2019; 35(7):e00091018., and non-compliance to medication treatment²⁸28 Torres J, Neri A, Ferrioli E, Lourenço RA, Lustosa LP. Difficulty in taking medication and stroke among older adults with systemic arterial hypertension: The Fibra Study. Cien Saude Colet 2021; 26(Suppl. 3):5089-5098..

An important finding of this study was that the age-related percentage increase on stroke prevalence had a dissimilar pattern between men and women. Prevalence linearly increased with aging among men but was roughly stabilized among women. Men are more likely to experience a stroke than women because of unhealth habits, such as alcoholism and smoking, which are risk factors for cardiovasculardiseases²⁴24 Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, Chiuve SE, Cushman M, Delling FN, Deo R, de Ferranti SD, Ferguson JF, Fornage M, Gillespie C, Isasi CR, Jiménez MC, Jordan LC, Judd SE, Lackland D, Lichtman JH, Lisabeth L, Liu S, Longenecker CT, Lutsey PL, Mackey JS, Matchar DB, Matsushita K, Mussolino ME, Nasir K, O'Flaherty M, Palaniappan LP, Pandey A, Pandey DK, Reeves MJ, Ritchey MD, Rodriguez CJ, Roth GA, Rosamond WD, Sampson UKA, Satou GM, Shah SH, Spartano NL, Tirschwell DL, Tsao CW, Voeks JH, Willey JZ, Wilkins JT, Wu JH, Alger HM, Wong SS, Muntner P; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics - 2018 update: a report from the American Heart Association. Circulation 2018; 137(12):e67-e492. and ineffective blood pressure control²⁶26 Macinko J, Leventhal DGP, Lima-Costa MF. Primary care and the hypertension care continuum in Brazil. J Ambul Care Manage 2018; 41(1):34-46.. On the other hand, among individuals aged 75 years and over, prevalence was at the highest level, and became similar in men and women. Because in Brazil, the current life expectancy is 80 years for women and 72 years for men (www.ibge.gov.br), there are more women with stroke living in later years. Overall, these results suggest that additional health strategies should be used for preventing stroke among men, and for increasing health monitoring and rehabilitation of older men and women, who have had a stroke.

The results indicated that individuals who walk faster, without assistive devices and are physically active might have less limitation to perform activities of daily living. All those factors have the potential to be enhanced even at chronic stages after stroke. Rehabilitation and exercise programs at Primary Health Care could focus on improving walking speed, as it showed to be the strongest factor for long-term independence after stroke. Relatively low-cost strategies such as walking training, and circuit training, which could be delivered individually or in groups, have positive effects on walking speed after stroke²⁹29 Nascimento LR, Oliveira CQ, Ada L, Michaelsen SM, Teixeira-Salmela LF. Walking training with cueing of cadence improves walking speed and stride length after stroke more than walking training alone: a systematic review. J Physiother 2015; 61(1):10-15.

30 English C, Hillier SL, Lynch EA. Circuit class therapy for improving mobility after stroke. Cochrane Database Syst Rev 2017; 2010(7):CD007513.^-3131 Nascimento LR, Flores LC, de Menezes KKP, Teixeira-Salmela LF. Water-based exercises for improving walking speed, balance, and strength after stroke: a systematic review with meta-analyses of randomized trials. Physiotherapy 2020; 107:100-110.. Unless the paretic upper limb is severely disabled, it is reasonable to believe that walking independence potentially increases the number of activities performed either at home or in the community. In addition, clinical measures of walking speed may be used for developing early interventions to help reduce the risk and burden of limitations on activities of daily living in older adults³²32 Heiland EG, Welmer AK, Wang R, Santoni G, Algleman S, Fratiglioni L, Qiu C. Association of mobility limitations with incident disability among older adults: a population-based study. Age Ageing 2016; 45(6):812-819.. In our sample, the probability of independence in activities of daily living was around 40% among individuals categorized as housebound (walking speed < 0.4 m/s). This probability increased to about 70% among individuals who walk at faster speeds, and to around 90% among those who also have home adaptations. In addition, evidence suggests that individuals who walk faster tend to improve levels of physical activity and reject walking assistive devices³³33 Aguiar LT, Martins JC, Nadeau S, Britto RR, Teixeira-Salmela LF, Faria CDCM. Efficacy of interventions to improve physical activity levels in individuals with stroke: a systematic review protocol. BMJ Open 2017; 7(1):e12479.^,3434 Nascimento LR, Ada L, Rocha GM, Teixeira-Salmela LF. Perceptions of individuals with stroke regarding the use of a cane for walking: a qualitative study. J Bodyw Mov Ther 2019; 23(1):166-170.. Therefore, health public strategies aiming at motivating able-bodied older adults to increase walking speed and levels of physical activity should be adopted for prevention of stroke and rehabilitation of disabilities related to stroke.

In Brazil, the National Health Promotion Policy and the Active Aging Policy³⁵35 Brasil. Centro Internacional de Longevidade. Enevelhecimento ativo: um marco político em resposta a` revolução da longevidade. Rio de Janeiro: Centro Internacional de Longevidade; 2015. have included physical activity as one of the public priority axes for promoting social participation and preventing chronic diseases, but a comprehensive long-term care policy for older adults is still needed³⁶36 Neumann LTV, Albert SM. Aging in Brazil. Gerontologist 2018; 58(4):611-617.. The results of this study suggested that a combination of faster walking speed and home adaptations might potentialize independence to perform daily living activities. Therefore, further health public strategies should include not only rehabilitation of physical disabilities, but also promote evaluations and modifications of the living environment, easily implemented by professionals from primary health care. Previous studies³⁷37 Wahl HW, Fänge A, Oswald F, Gitlin LN, Iwarsson S. The home environment and disability-related outcomes in aging individuals: what is the empirical evidence? Gerontologist 2009; 49(3):355-367. have indicated that home environment adaptations positively impact functioning at older ages, but they have been used as a treatment rather than a preventive approach³⁸38 Welti LM, Beavers KM, Mampieri A, Rapp SR, Ip E, Shumaker SA, Beavers DP. Patterns of home environmental modification use and functional health: The Women's Health Initiative. J Gerontol A Biol Sci Med Sci 2020; 75(11):2119-2124..

Study strengths and limitations

The current study has strengths and limitations. A major strength was a population-based, nationally representative sample derived from seventy municipalities from the five regions of Brazil. This ensures the external validity to the Brazilian community-dwelling older adults who have had a stroke and help guiding policymaking. Furthermore, this is the first nationally representative Brazilian study with older adults that included direct measures of walking speed and measures of environmental factors. On the other hand, this study only used baseline data, which did not allow causal relationships, and walking speed was not normalized by participants’ length of lower limb or height. In addition, although self-reported information is the most valid method to access attitudes³⁹39 Korb KA. Self-report questionnaires: can they collect accurate information. J Educat Fundations 2011; 1., there are potential biases inherent to the method, that could have influenced individuals’ responses regarding performance ofactivities of daily living and level of physical activity.

Conclusion

In conclusion, this study revealed that prevalence of stroke was 5.3% among individuals aged 50 years and over, increasing up to 9.9% among individuals aged 75 years and over. Prevalence of stroke gradually increased with aging among men, but quickly increased among women aged 75 years and over. Faster walking speed combined with home adaptations was the main factor associated with long-term independence after stroke. Health public strategies should focus on improving walking activity and home environment aiming at long-term independence after stroke.

References

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