Background and purpose: Several factors predict functional status after stroke, but most studies have included hospitalized patients with limited follow-up. We hypothesized that patients with ischemic stroke experience functional decline over 5 years independent of recurrent stroke and other risk factors.

Methods: In the population-based Northern Manhattan Study, patients > or =40 years of age with incident ischemic stroke were prospectively followed using the Barthel Index at 6 months and annually to 5 years. Baseline stroke severity was categorized as mild (National Institutes of Health Stroke Scale <6), moderate (6 to 13), and severe (> or =14). Follow-up was censored at death, recurrent stroke, or myocardial infarction. Generalized Estimating Equations provided ORs and 95% CIs for predictors of favorable (Barthel Index > or =95) versus unfavorable (Barthel Index <95) functional status after adjusting for demographic and medical risk factors.

Results: Of 525 patients, mean age was 68.6+/-12.4 years, 45.5% were male, 54.7% Hispanic, 54.7% had Medicaid/no insurance, and 35.1% had moderate stroke. The proportion with Barthel Index > or =95 declined over time (OR, 0.91; 95% CI, 0.84 to 0.99). Changes in Barthel Index by insurance status were confirmed by a significant interaction term (beta for interaction=-0.167, P=0.034); those with Medicaid/no insurance declined (OR, 0.84; P=0.003), whereas those with Medicare/private insurance did not (OR, 0.99; P=0.92).

Conclusions: The proportion of patients with functional independence after stroke declines annually for up to 5 years, and these effects are greatest for those with Medicaid or no health insurance. This decline is independent of age, stroke severity, and other predictors of functional decline and occurs even among those without recurrent stroke or myocardial infarction.