Age and Ageing Advance Access originally published online on April 29, 2008
Age and Ageing 2008 37(4):473-475; doi:10.1093/ageing/afn096
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Stroke in the very old: clinical presentations and outcomes
SIR—The number of people aged 80 and above is growing faster than any other age group. In 2006, people aged 80 and over were approximately 19% of the population in developed countries and around 10% in developing countries. In 2050, these figures are projected to be 29 and 18% in developed and developing countries respectively [1]. The octogenarian population has an average annual growth rate twice as high as the growth rate of the population group of over 60 years of age. Stroke will unavoidably be a major problem of this age as one-third of incidence is in this group [2]. In the UK, about 130,000 people suffer a stroke each year, almost 80% of the cases occur over the age of 65, and nearly half the strokes occur over the age of 75 [3]. Although the Oxford Vascular Study showed a decrease in the incidence of first-ever stroke by 40% over 20 years from 1981–84 to 2002–04, which means the drop of stroke incidence to approximately 88,000 patients per year, the overall incidence in patients aged
85 did not significantly change compared to the change of incidence in the younger patients [4, 5]. Moreover, the incidence rate in patients aged 85 was 12 times higher than the younger (16.36 versus 1.33 per 1,000 per year). Stroke in the very old (age 80 years) might be different from younger patients. The aim of this study was to investigate and compare demographics, risk factors, clinical presentations and clinical outcomes in two groups of patients with stroke, those aged 80 and over and those younger than 80 years. Data were collected prospectively from all patients with a confirmed diagnosis of acute stroke admitted to the Acute Stroke Unit (ASU), John Radcliffe Hospital, Oxford, between July 2006 and March 2007. The patient characteristics, clinical presentations, clinical outcomes and discharge destination were all collected. The data were compared between two age groups, less than 80 years and above 80 years of age. The National Institute of Health Stroke Scale (NIHSS) was calculated from the qualitatively recorded neurological examination in patients whose NIHSS were not measured quantitatively. Use of an estimated NIHSS has been shown to have a high degree of reliability and validity [6].
There were 178 ischaemic strokes, 22 haemorrhagic strokes and 14 transient ischaemic attacks. There were 111 patients aged <80 with the mean age of 66.9 (±11.8) years, and 103 patients aged 80 with the mean age of 85.2 (±4.3) years. Females comprised 66 out of 103 in the very old, and 47 out of 111 in the counterpart (P = 0.001). The very old were more likely to have a higher pre-morbid modified Rankin Score (mRS 2–5) (59.2% versus 21.6%, P < 0.0005), tended to live alone (47.6% versus 35.1%, P = 0.065), had more frequent history of hypertension (64.1% versus 50.5%, P = 0.044), and were less likely to currently drink alcohol (4.9% versus 14.4%, P = 0.019) or smoke (2.9% versus 11.7%, P = 0.014). For patients with known onset of stroke (69 patients in the very old, and 76 patients in the other), the very old presented to the hospital later (265 versus 105 min; P < 0.0005). Twelve of the total 214 patients developed stroke while they were in hospital and were not included in analysis of time to presentation. Patient characteristics are summarised in Table 1.
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The very old presented to the hospital more frequently with falls (14.4 versus 32%, P = 0.002), reduced mobility (0.9 versus 6.8%, P = 0.030) and less frequently with sensory symptoms (6.3 versus 0%, P = 0.015). Chief complaints and clinical findings are shown in Table 2. The median estimated NIHSS was 7 in patients aged under 80 and 8 in the very old (P = 0.376). Time from hospital arrival to CT scan tended to be longer in the very old (395 versus 205 min, P = 0.132), and thrombolysis tended to be utilised less in the very old (5.8 versus 9.0%, P = 0.376).
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The very old were discharged home less often (61.3 versus 45.6%, P = 0.022), had higher in-hospital mortality (7.2 versus 17.5%, P = 0.022) and were less likely to be independent at discharge (50.5 versus 27.2%, P < 0.005).
Strokes in the very old have a different clinical picture upon presentation to the hospital. More very old patients were female, had hypertension, had poor pre-morbid mRS, reported less drinking and smoking, presented to hospital later and presented with atypical clinical manifestations such as falls and reduced mobility. Possible explanations for late presentation to the hospital could be from non-recognition of stroke symptoms by physicians and other healthcare providers due to atypical presentation and living status. In this study, 47.6% of the very old lived alone compared to 35.1% in the younger counterpart. The percentage of the elderly living alone is 19 and 39% for men and women in developed countries, respectively, and 5 and 9% in developing countries [1]. These figures were projected to markedly increase in the future and have the potential to impact on the time of presentation and long-term care of the stroke patients.
In terms of service provided, the very old tended to have a CT head scan slightly later (395 versus 205 min) and less received thrombolysis (6 versus 10 patients). The main reason for a lower rate of thrombolysis in the very old in this study is because the very old were less likely to fit eligible criteria. For example, patients had extensive pre-existing white-matter disease, poor pre-morbid mRS and cognitive impairment of which the risk of thrombolysis outweighed the benefit. Moreover, evidence-based treatment regarding thrombolysis in patients aged 80 and above still requires randomised controlled trials. Evidence might be provided by the results of the MRC Third International Stroke Trial (IST-3) as a consequence of there being no upper age limit in this trial [7].
A systematic review regarding stroke thrombolysis in the very old showed that if patients received thrombolysis, the likelihood for symptomatic intracerebral haemorrhage was similar in patients aged under and over 80 years of age [8]. However, the studies of thrombolysis in the very old have not been randomised controlled trials, hence the implementation of results should be done very cautiously. At least, however, most of the study results do not advise against the use of thrombolysis in octogenarian stroke.
How can the results of this study be implemented? Is there anything modifiable? Increasing the awareness of the public, physicians and other healthcare providers of atypical presentations of stroke in the very old, strategies to shorten the time to hospital arrival and time from arrival to CT head scan, and more studies on thrombolysis in the very old have the potential to change stroke outcomes in this group of patients.
- Patients 80 years or older:
- Were more commonly female, lived alone, had a poor pre-morbid mRS, and were hypertensive.
- Were more likely to present to hospital late, presented with falls and reduced mobility.
- Had a higher in-hospital mortality and were less likely to be discharged home with independent status.
- Were more commonly female, lived alone, had a poor pre-morbid mRS, and were hypertensive.
None.
1 Acute Stroke Programme, Nuffield Department of Clinical Medicine, Level 7, John Radcliffe Hospital, Oxford, OX3 9DU, UK
2 Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
3 Oxford Brookes University, UK
4 Oxford Stroke Unit, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK
* To whom correspondence should be addressed E-mail: siwmp{at}mahidol.ac.th
References
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[Abstract/Free Full Text] - Bamford J, Sandercock P, Dennis M, et al. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 1. Methodology, demography and incident cases of first-ever stroke. J Neurol Neurosurg Psychiatry (1988) 51:1373–80.
[Abstract/Free Full Text] - UK National Statistics. Population Estimates. last accessed 17 November 2007. http://www.statistics.gov.uk/CCI/nugget.asp?ID=6.
- Rothwell PM, Coull AJ, Giles MF, et al. Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet (2004) 363:1925–33.[CrossRef][Web of Science][Medline]
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[Abstract/Free Full Text] - The Third International Stroke Trial (IST 3). last accessed 18 July 2007. http://www.dcn.ed.ac.uk/ist3/.
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