Epidemiology and Outcomes of Ischemic Stroke and Transient Ischemic Attack in the Adult and Geriatric Population
Introduction
In 1996, the Food and Drug Administration approved recombinant tissue-type plasminogen activator (tPA) for the acute treatment of ischemic stroke, with further expansion of treatment guidelines over the years.1, 2, 3, 4 There is now little question that tPA is an efficacious treatment for stroke and leads to improved outcomes in the studied populations; however, efficacy and outcomes within certain groups is still a source of much debate. One such group is patients aged 80 years and older (≥80), who are often excluded from current, as well as landmark trials. As a result, there is less quality evidence regarding stroke in this demographic. Given this lack of quality evidence, the Food and Drug Administration labeled advanced age (as defined by those ≥80 years old) as a potential risk factor for the administration of tPA especially within the 3- to 4.5-hour window5, 6—a label which can perpetuate the notion that age increases risks and worsens outcomes in those affected by ischemic stroke.
While treatment of acute stroke should be based on medical considerations and guidelines, it is not uncommon for physicians to determine stroke treatment of the elderly with a degree of bias or personal beliefs on patient outcomes. This issue is further compounded by the lack of quality evidence. The elderly are more likely to present with poor functional status or dementia, conditions that may affect whether or not they are treated despite unclear evidence if those conditions affect outcomes.7 Even a patient's age, without other risk factors, can give physicians concern despite no clear contraindication.8 This may lead physicians to be less aggressive when treating elderly patients. Previous studies have looked at rates of complications in the elderly such as risk of intracerebral hemorrhage, but minimal research has gone into functional status after discharge or disposition, which is arguably more important measures than simply treatment complications. Given the ageing of the general population and the increased likelihood that more patients aged 80 years and older will present with stroke, it is clear that more research needs to be done in this area.
In this study, we sought to determine the differences in baseline characteristics and risk factors between younger and elderly patients, as well as treatment delivered, overall improvement and outcomes for the elderly. We hope that by doing so, we can start to bridge the gap in physician bias toward treating elderly patients and ischemic stroke.
Section snippets
Methods
Subjects: We selected patients from Mount Sinai Beth Israel's stroke database. This database contains information on all patients admitted to our institution with the diagnosis of TIA, ischemic stroke, and intracerebral hemorrhage (ICH). The stroke log contains deidentified information, with each patient assigned a unique identification number during the data upload. The database fulfills the requirements of the New York State Department of Health and the Get with the Guidelines Stroke9
Demographics and Comorbidities
There were 1457 patients admitted to our institution for TIA or ischemic stroke between the years of 2010 and 2015; 968 were aged less than 80 years old and 487 patients were 80 years and older. There were a greater number of males in the younger group with 58% of younger patients being male and only 42% being female. In the older group, this proportion reversed and there were 68% females and only 32% males.
Data on comorbidities causing stroke such as hypertension, hyperlipidemia, diabetes,
Discussion
Approximately 1500 patients were admitted to our institute for transient ischemic attack or stroke during the years of 2010 and 2015. The demographics for that group in terms of reversal of men and women between older and younger groups were expected given the longer lifespan of women compared to their male counterparts. The higher average NIHSS for older patients may be in part explained by higher rates of atrial fibrillation and coronary artery disease, which predisposes patients to
Conclusion
Tissue-type plasminogen activator is the only approved treatment for ischemic stroke, and despite guidelines warning of potential risks to patients over 80 years of age, this should not prevent them from receiving appropriate and timely treatment. While it may be important to discuss certain risks with patients and their families, namely long-term neurological deficits and the need for continued care, the conversation should not center around the risks of age and tPA itself. More research is
Acknowledgments
The authors would like to thank David Lucido for his assistance in data analysis. The authors report no conflicts of interest.
References (22)
- et al.
Why are eligible thrombolysis candidates left untreated
Am J Prev Med
(2006) - et al.
Thrombolytic therapy for acute stroke in the elderly: an emergent condition in developing countries
J Stroke Cerebrovasc Dis
(2011) - et al.
Older stroke patients with high stroke scores have delayed door-to-needle times
J Stroke Cerebrovasc Dis
(2016) - et al.
Older age does not increase risk of hemmorhagic complications after intravenous and/or intra-arterial thrombolysis for acute stroke
J Stroke Cerebrovasc Dis
(2008) - et al.
Age 80 years is not associated with increased hemorrhagic transformation after stroke thrombolysis
J Clin Neurosci
(2012) Tissue plasminogen activator for acute ischemic stroke: the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group
N Engl J Med
(1995)- et al.
Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke
N Engl J Med
(2008) - et al.
Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials
Lancet
(2004) - et al.
The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the Third International Stroke Trial [IST-3]): a randomised controlled trial
Lancet
(2012) - et al.
Guideline for he early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Stoke
(2013)
Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: a statement for healthcare professionals from the American Heart Association/Ameircan Stroke Association
Stroke
Cited by (40)
Prevalence of stroke in the elderly: A systematic review and meta-analysis
2023, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementA Comparison of Acute Ischemic Stroke Patients Discharged to Inpatient Rehabilitation vs a Skilled Nursing Facility: The Paul Coverdell National Acute Stroke Program
2023, Archives of Physical Medicine and RehabilitationChronic intermittent hypoxia worsens brain damage and sensorimotor behavioral abnormalities after ischemic stroke: Effect on autonomic nervous activity and sleep patterns
2023, Brain ResearchCitation Excerpt :Our results revealed that stroke combined with SA affected autonomic activity and sleep patterns, which some of the factors can be discuss in the future. Stroke often occurs in older individuals (Navis et al., 2019; Wang et al., 2017), that the prevalence was approximately 4.94 % (Xia et al., 2019). The functions of the autonomic nervous system change with age reflected in cardiovascular function.
Hemispheric stroke: Mood disorders
2021, Handbook of Clinical NeurologyCitation Excerpt :The case-fatality rate in the United States and other advanced nations is close to 20%, making stroke one of the major causes of death and a leading cause of disability. The incidence of stroke is greatest after age 65 (see Bonita, 1992; Navis et al., 2019). Notwithstanding steady improvements in stroke prevention and the advent of new treatment methods, such as dissolving the clot with tissue plasminogen activator and intravascular thrombectomy, stroke, and its consequences remain a leading health problem (Katan and Luft, 2018).
Referral to Community-Based Rehabilitation Following Acute Stroke: Findings from the COMPASS Pragmatic Trial
2024, Circulation: Cardiovascular Quality and Outcomes
This work was supported in part through the resources and staff expertise provided by the Department of Vascular Neurology at Mount Sinai Beth Israel.