Journal of Neurology · Nov 20, 2025

Progression of cognitive and functional decline before and after stroke: evidence from four prospective cohort studies across 23 countries

By Cai Y, Duan C, Wen S et al.

BACKGROUND AND PURPOSE: Previous studies had inconsistent results and often lacked pre-stroke cognitive assessments, hindering differentiation between stroke-related decline and normal ageing. To address this, we aimed to explore cognitive and functional change trajectories before and after stroke across countries. METHODS: This international population-based cohort study analyzed data from four nationally representative longitudinal studies across 23 countries: CHARLS, ELSA, HRS, and SHARE. A two-level growth model was used to estimate post-stroke cognitive trajectories, compared with those of stroke-free individuals. RESULTS: 69,013 participants from four longitudinal cohorts were included and 2,106 participants had their first-ever stroke. Compared with stroke-free participants, stroke patients had faster pre-stroke cognitive decline, with adjusted differences in annual decline ranging from - 0.033 to - 0.049 SD/y across cognitive domains. Stroke correlated with an acute global cognitive drop (pooled β = - 0.319 [95% CI - 0.467 to - 0.276]) and accelerated subsequent decline (pooled β = -0.039 SD/y). Post-stroke declines in memory (- 0.015 SD/y), orientation (- 0.033 SD/y), and executive function (- 0.004 SD/y) were observed. Recurrent stroke linked to worse post-stroke decline; exclusion of these cases reduced estimated acute and pre-stroke decline by 23.05% and 13.79%, respectively. In stroke-free individuals, vascular risk factors and social isolation correlated with steeper cognitive decline, consistent across European, North American and Asian cohorts. CONCLUSIONS: Our findings demonstrate that stroke links to acute reduction and ongoing accelerated decline in cognitive/functional abilities, starting pre-stroke and continuing post-stroke. This underscores the need to include multidimensional outcome measures in stroke care and emphasizes prioritizing cognitive health in stroke prevention and post-stroke management.

doi.org/10.1007/s00415-025-13511-4 PubMed 41264137 Populations