1. Stroke i Finnmark, Norge 1998 Riskfaktorer, Klinisk bild, Ettårsuppföljning av förstagångsattacker Fjernundervisning 30. April 2002 Sven-Mårten Samuelsson, avd. overlege, prof Avd. for fysikalsk medisin og rehabilitering, Kirkenes sykehus, Universitetet i Tromsø

2. County of Finnmark Population ~ 75 000 Inhabitants Municipalities 19

4. Life Expectancy at Birth in Norway 1993 - 1997 Range Norway

5. Purpose Stroke Register Population-based Incidence 28-Day Case-Fatality Rate and One-Year Survival Clinical Database - Treatment - at the Acute Stage - Functional Outcome - after 3 and 12 Months - Risk Factors - Medical History

6. Methods From April 1998 Registration of New Events of Stroke in Finnmark - ’Hot pursuit’ – Registration during Hospitalisation at the Hospitals of Hammerfest and Kirkenes - Contact with Other Hospitals - Postal Contacts with District Physicians - Population Statistics Follow-up - Postal Questionnaires - Phone Calls

7. Data collected Personal Data, Ethnicity, Job History, Medical History, Smoking, Alcohol Use Clinical Data Data Needed for Classification: CT Scan etc. Scales: Rankin, Scandinavian Stroke Scale, Barthel ADL Scale Frenchay, Life Quality, Burden of Relatives

8. Classification Subtype of Stroke - Subarachnoidal Haemorrhage - Intracerebral Haemorrhage - Cerebral Infarction OSCP-Classification

9. Registered Events April 1998 – March 1999 First-ever Strokes (n) 141 (75%) Men (n) 75 (53%) Women (n) 66 (47%) Recurrent Strokes (n) 48 (25%) Total (n) 189 Other Conditions (n) 133 (TIA, suspected but not verified stroke etc)

10. Classification First-ever Strokes Recurrent Strokes Total % Subarachnoidal Haemorrhage 6 2 8 4.2 Intracerebral Haemorrhage 16 5 21 11.1 Cerebral Infarction 115 41 156 82.5 Unspecified 4 - 4 2.1 Total 141 48 189100

11. Some Risk Factors (First-ever Strokes)

12. Smoking Habits (First-ever Strokes)

14. Obesitas + Alkohol + Inaktivitet Statens helseundersøkelser av 40-42-åringer, Finnmark 1996-97 Menn Kvinner BMI 26,5 25,2 Høyest i Finnmark Bruk av alkohol 2,7 l/år 1,3 l/år Nest høyest i Finnmark etter Akershus Fysisk inaktive 21% 28% (I fylkene 20-29% 24-36%)

15. Sickness Pension before Onset of Stroke % Mean Age (Range) Men 48 55.0 (16-69) Women 42 54.9 (38-65)

16. Contact < 3 Hours With a physician 57.0% With a hospital 27.1%

17. To Hospital < 3 Hours Municipality n % Hammerfest 17 47 Loppa 5 20 Porsanger 7 43 Måsøy 6 17 Tana 6 33 Nordkapp 6 17 Vardø 6 33 Vadsø 9 11 Sør-Varanger 25 32 Nesseby 2 - Kvalsund 7 29 Berlevåg 1 - Båtsfjord 4 25 Gamvik 1 - Lebesby 4 25 Karasjok 1 - Alta 29 21 Hasvik - - Kautokeino 5 20

18. Age at Onset of First-ever Stroke Mean Median Men 67.1 (24-91) 69.9 Women 75.0 (41-95) 77.7

19. Initial Hospital Stay ( Days) Mean Median Men 13.4 (0-64) 10.0 Women 12.9 (0-44) 10.5

20. Complications (%) during the Initial Inhospital Stay Urinary tract infection 23.9 Recurrence of stroke 2.1 Urinary incontinence 22.5 Fracture 1.4 Pneumonia 13.4 Urin. outlet obstruct. 1.4 Heart failure 9.9 Limb contractures 1.4 Other types of infection 8.5 Pressure sores 0.7 Atrial fibrillation 4.9 Deep venous throm- Pain in paretic shoulder 3.5 bosis/pulm. embol. -

21. Men (n=74) % Women (n=66) % Total (n=140) % Home 50.0 43.9 47.1 Dept. of Rehab. 9.5 6.1 7.9 Other Type of Rehab. Care 2.7 - 1.4 Service Flat - 1.5 0.7 Nursing Home 25.7 36.4 30.7 Dead 12.2 12.1 Destination at Discharge (First-ever Strokes)

22. Course According to Rankin Scale First-ever Strokes (n = 141)

23. Course According to Rankin Scale First-ever Strokes (n = 141)

24. MenWomen pMean/MedianMin-Max Before admittance 19.8/2018.4/20 0.002 14-202-20 At admittance 12.1/178.9/8 0.010-20 After 3 months 17.5/2012.9/16< 0.0001 3-200-20 After 12 months 17.8/2015.4/17 0.00011-20 Barthel ADL Index in Men and Women

25. Barthel ADL Index ( Mean Score)

26. Fatality Rate (%) At Discharge 12.1 At 28 Days 13.4 At 3 Months 17.0 At 12 Months 24.1

27. Severity at Onset Fatality Rate at l2 Months (Rankin Scale) % Slight (n=46) 10.9 Moderate (n=23) 26.1 Severe (n=72) 31.9 Fatality Rate (%) at 12 Months in Relation to Severity at Onset

28. Rankin Scale at onset Rankin Scale at 12 months Dead Better No diff Worse -3 -2 -1 +1 +2 +3 Slight (n=46) - - - 35 4 2 - 5 Moderate (n=23) - - 13 1 3 - 6 Severe (n=35) 15 12 6 - 2 Very severe (n=37) 3 5 8 - 21 Severity at Follow-up Compared to Onset

29. Regional hosp Other hosp Rehab depart Nursing home Days Pat. Days Pat. Days Pat. Days Pat. n % n % n % n % At acute stage 209 14.8 1645 100 - - - - After acute stage < 3 months 36 2.8 196 12.0 606 14.1 2320 34.5 < 12 months 186 9.7 425 26.1 871 18.3 9280 42.3 Acute + < 12 months 395 24.7 2070 100 871 18.3 9280 42.3 Days in Hospitals (n) and Nursing Homes (n) at the Acute Stage and within 3 and 12 Months (Pat. = proportion of patients, %)

30. Conclusions 1 Population-Based Study 141 Events of First-Ever Stroke in Finnmark in 1998 Only 27% to Hospital within 3 Hours

31. Conclusions 2 Mean Age at Onset Men: 67 years, Women: 75 years Sickness Pension before the Stroke Men: 48%, Women: 42% Very High Risk Factors for Cardiovascular Disease

32. Conclusions 3 Severe Attacks 51% at Onset Complications, especially Urinary Tract Infections, are Numerous Some Complications are probably Underestimated Primary Outcome: 47% at Home, 9% further Rehabilitation, 31% Nursing Home, 12% Fatal

33. Conclusions 4 Outcome Worse in Women and in Higher Age Groups Fatality Rate at 12 Months: 24% Fatality Rate at 12 Months is related to Severity at Onset 50% of Survivors have Improved after 12 Months