Lovett, Nicola Georgia; (2019) More reliable recognition and quantification of existing risk factors for stroke and dementia. Doctoral thesis (M.D(Res)), UCL (University College London).

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Abstract

Cerebrovascular disease and dementia are responsible for the majority of severe cognitive and functional decline seen in the older population in the UK. They have an overlapping risk factor profile, of which modifiable factors and existing treatments are already available and in use in common clinical practice. Therefore, I choose to focus on some of these factors, namely blood pressure, atrial fibrillation and delirium. I used data from the Oxford Vascular Study to assess whether a centralised telemetric Home Blood Pressure Monitoring (HBPM) system was acceptable, feasible, safe and an effective method of managing blood pressure post TIA and non-disabling stroke. I assessed the relationship between rates of residual hypertension on awake and nocturnal Ambulatory Blood Pressure Monitoring (ABPM) and HBPM with markers of hypertensive arteropathy and determined the rates of nocturnal hypertension and abnormal diurnal BP using 24h-ABPM. I also conducted a systematic review of studies of newly detected pAF post TIA and compared this with the rate found amongst the OXVASC population. I collated and analysed data from a general medical in-patient cohort to ascertain the rates of delirium and associated factors. I also used this data to develop a pragmatic risk score to assess for delirium based upon factors suggested by NICE guidelines. I found that centralised HBPM was acceptable to patients and a safe and effective method of managing BP achieving good long term control. I found residual nocturnal hypertension was more common than residual daytime hypertension but did not find that it was a major risk factor for recurrent stroke or cardiovascular events. I identified new pAF in 12.5% of patients post TIA or minor ischaemic stroke and that delay in cardiac monitoring did not affect sensitivity of pAF detection with 5 days of monitoring being a sufficient duration to identify cases of pAF. I found the rate of delirium was 20% of acute medical admissions rising to a third of those aged ≥75 years. Delirium was associated with increased mortality, institutionalisation and dependency but not with increased risk of re-admission on follow-up. I developed a delirium susceptibility score which was reliable for both incident and prevalent delirium. The score was pragmatic, relying on factors available at the point of admission making it suitable for use early in admission. Though this work I have been able to identify more reliable methods of recognition and quantification for existing risk factors for stroke and dementia allowing already well established treatment strategies to be targeted to the correct the population. However, further work is needed to develop these ideas and translate them into everyday clinical practice.

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