Diabetes Mellitus Is Associated With Poor In-Hospital and Long-Term Outcomes in Young and Midlife Stroke Survivors

Abstract

Background The incidence of ischemic stroke has increased among adults aged 18 to 64 years, yet little is known about relationships between specific risk factors and outcomes. This study investigates in-hospital and long-term outcomes in patients with stroke aged <65 years with preexisting diabetes mellitus. Methods and Results Consecutive patients aged <65 years admitted to comprehensive stroke centers for acute ischemic stroke between 2003 and 2013 were identified from the Ontario Stroke Registry. Multinomial logistic regression was used to estimate adjusted odds ratio (OR [95% CI]) of in-hospital mortality or direct discharge to long-term or continuing care. Cox proportional hazards regression was used to estimate the adjusted hazards ratio (aHR [95% CI]) of long-term mortality, readmission for stroke/transient ischemic attack, admission to long-term care, and incident dementia. Predefined sensitivity analyses examined stroke outcomes among young (aged 18-49 years) and midlife (aged 50-65 years) subgroups. Among 8293 stroke survivors (mean age, 53.6±8.9 years), preexisting diabetes mellitus was associated with a higher likelihood of in-hospital death (adjusted OR, 1.46 [95% CI, 1.14-1.87]) or direct discharge to long-term care (adjusted OR, 1.65 [95% CI, 1.07-2.54]). Among stroke survivors discharged (N=7847) and followed up over a median of 6.3 years, preexisting diabetes mellitus was associated with increased hazards of death (aHR, 1.68 [95% CI, 1.50-1.88]), admission to long-term care (aHR, 1.57 [95% CI, 1.35-1.82]), readmission for stroke/transient ischemic attack (aHR, 1.37 [95% CI, 0.21-1.54]), and incident dementia (aHR, 1.44 [95% CI, 1.17-1.77]). Only incident dementia was not increased for young stroke survivors. Conclusions Focused secondary prevention and risk factor management may be needed to address poor long-term outcomes for patients with stroke aged <65 years with preexisting diabetes mellitus.

Keywords: dementia; diabetes mellitus; ischemic; longitudinal; midlife; stroke; young.

Figure 1

Flow chart showing the participants who were included in this study after accounting for exclusions by previous medical conditions, missing and duplicate data, study criteria, and ages <18 and >65 years. Diabetes mellitus was ascertained by all available Ontario Diabetes Database records that preceded the stroke admission. A total of 8293 participants were available to test the in‐hospital outcomes. There were 4 outcomes tested among the stroke survivors who were discharged alive. LTC indicates long‐term care; and TIA, transient ischemic attack.

Figure 2

Cumulative incidence curves (fractional units) are shown as a function of time after discharge among all stroke survivors. The panels (top to bottom) show 3 of the long‐term outcomes of interest: readmission for stroke/transient ischemic attack (TIA), admission to long‐term care (LTC), and incident dementia, respectively. Stroke and preexisting diabetes mellitus increased the risk of an event in all 3 of these outcomes compared with stroke and no diabetes mellitus. The x axis shows the longitudinal follow‐up period in years. Individuals with stroke and preexisting diabetes mellitus are represented by a red line, whereas individuals with stroke and no diabetes mellitus are represented by the blue lines. Corresponding CIs are shown as the shaded color area. Numeric data denote the proportion of people who do or not reach the event proportion at successive years after discharge.