Age and Ageing Advance Access originally published online on April 3, 2007
Age and Ageing 2007 36(3):242-244; doi:10.1093/ageing/afm041
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Why stroke patients don't like Mondays (or Saturdays or Sundays)
Acute stroke can occur at any age, but remains primary a disorder of older people, and thus is highly relevant for discussion in the pages of Age and Ageing. The past two decades have witnessed important advances in the care of patients with acute ischaemic and haemorrhagic stroke, for example, most acute receiving hospitals in the United Kingdom now have a specialist stroke unit, and physiological monitoring is becoming the norm rather than exception. However, as evidenced by the findings of the 2004 National Sentinel Stroke Audit (SSA), many aspects of acute stroke care in England, Wales and Northern Ireland fall short of the recommended standards [1]. Indeed, the paper by Rudd and colleagues based on data from the SSA and published in this issue, highlights continuing problems with access to appropriate acute stroke care depending on the patient's age and the day of the week on which they are admitted to hospital [2].Although stroke medicine is now a recognised medical speciality in its own right, the majority of stroke care in the United Kingdom continues to be provided by geriatricians. One of the stated aims of the UK Government's National Service Framework for Older People was to end ageism in the National Health Service [3]. Any possibility of age discrimination in the hospital management of acute stroke must, therefore, be of concern to the readers of this journal. The SSA implies bias against older stroke patients, with people aged over 85 years less likely to receive care on an acute stroke unit [2]. Some caution is required in interpreting these findings, since the case note data collection form allowed individual clinicians to determine patient suitability for various interventions without external verification, thus introducing a degree of subjectivity. The ‘no, but’ question may not provide sufficient case mix adjustment when dealing with frail older patients with complex physical or psychiatric co-morbidities that might preclude admission to an acute stroke ward. Collection of additional data on co-existing medical conditions should be considered for the next round of the SSA. It is possible that some stroke units are forced to operate implicit or explicit admission criteria due to lack of resources, for example, excluding patients with advanced cognitive impairment. In developing a solution to such issues, we agree with Rudd and colleagues that resources for acute stroke care should be improved in order to avoid rationing simply on the grounds of age. Furthermore, in order to meet the needs of older people we would submit that there is a critical need to maintain and indeed increase the involvement of geriatricians in acute stroke care.
The establishment of acute stroke units has led to significant improvements in the quality of many aspects of patient care, and this is reflected in the findings of the SSA. Although the overall benefits of acute stroke unit care are obvious [4], more evidence is required to determine whether equally good outcomes are achieved for specific sub-groups such as the very frail and aged. It is clear that older people admitted to hospital with stroke remain less likely to undergo brain imaging, even if cared for on a specialist unit. One of the benefits of co-ordinated acute stroke care is that it facilitates the delivery of hyperacute treatments such as thrombolysis. Eligible patients admitted within 3 h of symptom onset are fast-tracked through the system and usually undergo urgent brain imaging before direct admission to the stroke unit. However, older people may not have access to this rapid pathway to an early CT scan and stroke unit admission. Very few stroke patients aged over 80 years have actually been treated with thrombolytic agents [5]. The eligibility criteria for the SITS-MOST register of stroke patients thrombolysed in Europe were restricted by the licensing approval for alteplase, which could only be administered to patients aged less than 80 years [6]. We would recommend that use of thrombolysis in eligible patients be added to the early care assessment standards for future rounds of the SSA.
In terms of secondary stroke prevention, the findings of the SSA are impressive, with 97% of patients with ischaemic stroke receiving antithrombotic therapy by the time of discharge. Nevertheless, fewer older patients are given their first dose of aspirin within 48 h of symptom onset, presumably reflecting delays in brain imaging. Rudd's data also show that statins are less likely to be prescribed for very old stroke patients. Clinical trial evidence is lacking for the benefits of statin therapy in nonagenarians and in many individual cases, issues of prognosis, concordance and life expectancy may mean such treatment is not appropriate.
However, older people should not be excluded from advances in stroke care purely on the basis of age. In this era of evidence-based medicine, the safety and efficacy of both hyperacute and secondary preventive treatments for stroke in older people must be established and we cannot continue to rely on extrapolation from clinical trials of younger cohorts. It is encouraging that the on-going Third International Stroke Trial (IST3) of thrombolysis has no upper age limit for inclusion into the study [7]. It can only be hoped that the newly established UK Stroke Research Network [8] can use its influence on both academic investigators and the pharmaceutical industry to promote the inclusion of eligible older people into other hyperacute, acute and secondary prevention trials. Our own work shows that older stroke patients who were approached regarding participation in clinical trials were just as likely to agree as younger people [9].
The finding of reduced or delayed access to acute stroke care and early brain imaging for patients of all ages admitted at weekends and on bank holidays will be no surprise to many NHS clinicians. Recent audit data from our hospital suggests that Wednesday is the most fortunate day of the week to have a stroke, since patients admitted on that day were most likely to have their CT scan within 24 h; those unlucky enough to come into hospital on Monday, may have to wait in a scanning queue with those admitted over the weekend (M. Amin, personal communication). Unlike myocardial infarction, ‘brain attack’ is not yet considered a comparable medical emergency, and thus most stroke services are not configured to deliver 24/7 acute care. Significant gaps in provision of acute stroke care have been highlighted in previous national reports [10]. Drivers for change may include the recent report by the National Director for Heart Disease and Stroke, advocating a hub and spoke arrangement akin to that now in operation for acute MI, with eligible patients receiving hyperacute treatment in highly specialised stroke centres before transfer back to their local hospital for further management and rehabilitation [11]. This model is likely to be emphasised in the forthcoming Department of Health stroke strategy document, due to be released in autumn 2007. However, the government's vision of rapid round-the-clock specialist stroke care in centres of excellence will not be achieved without major reconfiguration and expansion of services, requiring substantial financial investment and attitudinal change amongst healthcare staff.
In the rush to develop new models of stroke care designed to deliver hyperacute treatments to the minority, commissioners of stroke services must not lose sight of the needs of the majority. Diverting new or existing resources from the majority will not benefit the older stroke victim. All stroke patients, irrespective of age or day of admission to hospital, should be guaranteed high-quality care on a specialist stroke unit, with timely and appropriate investigation, treatment and rehabilitation. Otherwise, when your grandmother has a stroke, just hope that it doesn't happen over a holiday weekend.
1 Senior Lecturer in Geriatric Medicine, University of Newcastle, UK
2 Professor of Clinical Geriatrics, University of Newcastle, Director, North East Stroke Research Network, UK
* To whom correspondence should be addressed Email: janice.oconnell{at}chs.northy.nhs.uk
References
- The Intercollegiate Working Party for Stroke. National Clinical Guidelines for Stroke (2004) 2nd edition. London: Royal College of Physicians of London. http://www.rcplondon.ac.uk/.
- Rudd AG, Hoffman A, Down C, Pearson M, Lowe D. Access to stroke care in England, Wales and Northern Ireland: the effect of age, gender and weekend admission. Age Ageing. doi:10.1093/ageing/afm007.
- Department of Health. National Service Framework for Older People. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/fs/en (last accessed 21 February 2007).
- Stroke Unit Trialists' Collaboration. The Cochrane Library. (2007) (1). Chichester, UK: John Wiley and Sons. Organised inpatient (stroke unit) care for stroke (Cochrane Review).
- Ford GA. Thrombolysis for stroke in the over 80s. Age Ageing. (2004) 33:95–97.
[Free Full Text] - Wahlgren N, Ahmed N, Davalos A, et al. Thrombolysis with alteplase in the safe implementation of Thrombolysis in stroke–monitoring study (SITS-MOST): an observational study. Lancet (2007) 369:275–82.[CrossRef][Medline]
- The Third International Stroke Trial (IST 3). http://www.dcn.ac.uk/ist3 (last accessed 21 February 2007).
- UK Stroke Research Network. http://www.uksrn.ac.uk (last accessed 21 February 2007).
- O'Brien RG, Johnston DE, Palmer L, O'Connell JE, Gray CS. Participation in clinical trials for acute stroke by older people. Abstract presented at the BGS autumn meeting 2006.
- National Audit Office. Reducing Brain Damage: Faster Access to Better Stroke Care (2005) London: Department of Health. http://nao.org.uk/publications/hbnao_reports.
- Department of Health. Mending Hearts and Brains. Clinical Case for Change: Report by Professor Roger Boyle, National Director for Heart Disease and Stroke (2005) London: Department of Health. http://www.dh.gov.uk/PublicationsAndStatistics/Publications.
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