Efficacy of repetitive transcranial magnetic stimulation for improving motor and cognitive function in elderly patients after stroke

Stroke is a leading cause of long-term disability in older adults. Motor impairment often co-occurs with post-stroke cognitive impairment (PSCI), limiting independence and rehabilitation responsiveness. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive neuromodulation technique that may enhance recovery when combined with conventional rehabilitation. This retrospective cohort study enrolled consecutive stroke patients aged ≥ 65 years who received rehabilitation between June 2021 and June 2025. Participants received conventional rehabilitation alone (control, n = 163) or conventional rehabilitation plus sequential dual-target rTMS (rTMS, n = 151) for 4 weeks (20 sessions; ipsilesional primary motor cortex [M1] followed by left dorsolateral prefrontal cortex [DLPFC]). The prespecified primary outcome was the change in the 100-point Fugl–Meyer Assessment motor score (FMA) from baseline (T0) to the end of treatment (T1). Global cognition (Abbreviated Mental Test Score [AMTS]), activities of daily living (Modified Barthel Index [MBI]), disability (modified Rankin Scale [mRS]), 3-month outcomes (T2), and safety were secondary or exploratory outcomes. Confounding was addressed using multivariable regression and stabilized inverse-probability-of-treatment weighting (IPTW). The groups were broadly similar at baseline, although modest imbalances in BMI and education category were identified by standardized differences and were included in adjusted analyses. At T1, the rTMS group had a greater unadjusted improvement in FMA (14.2 ± 8.8 vs. 10.1 ± 8.6; P < 0.001). In multivariable analysis, adjunctive rTMS remained associated with greater ΔFMA at T1 (adjusted mean difference, 3.74; 95% CI, 1.89–5.59; P < 0.001), and the IPTW estimate was similar (3.86; 95% CI, 2.04–5.68). Adjusted analyses also supported a greater ΔAMTS at T1 (0.49; 95% CI, 0.23–0.75; P < 0.001). Associations persisted at T2 and were directionally consistent for MBI and mRS. Adverse events were infrequent, no seizures occurred, and interpretation was restricted to appropriately screened patients without major rTMS contraindications. Among appropriately screened, lower-risk elderly stroke patients, adjunctive sequential dual-target rTMS was associated with greater motor recovery and modest improvements in global cognition and functional outcomes. Because treatment allocation was nonrandomized and treatment time was not matched, these findings do not establish a causal or target-specific effect.