Epidemiology and Outcomes of Ischemic Stroke and Transient Ischemic Attack in the Adult and Geriatric Population

https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.09.013Get rights and content

Abstract

Background: Rate of ischemic strokes and transient ischemic attacks (TIAs) increases with age. There is lack of evidence on how age affects treatment strategies and outcomes. Our aim is to compare epidemiology of ischemic strokes and TIAs in adult and geriatric populations including risk factors, treatment delivered, and outcomes. Design: We designed a retrospective cross-sectional review of patients admitted to neurology with diagnosis of stroke or TIA from 2010 to 2015. Obtained variables were: age, sex, risk factors, acute therapy, National Institutes of Health Stroke Scale on admission and discharge, and disposition. Means, confidence intervals, or percentages were calculated as appropriate. Results: Around 1,457 patients were divided into two groups: younger than 80 (n = 968) and 80 and older (n = 487). Rates of stroke and TIA were similar across younger and older groups (11% versus 12% TIA and 89% versus 88% stroke, respectively). Younger patients had lower admission National Institutes of Health Stroke Scale (mean 4.64 versus 7.84 in older group) and greater improvement on discharge (mean change −1.51 versus −1.29 accordingly). Older patients received tissue-type plasminogen activator (tPA) more often than younger patients, but no difference in rates of thrombectomy between groups. Older patients were more likely to have hypertension, atrial fibrillation, coronary artery disease, and less likely to be a smoker. On discharge, younger patients with stroke were discharged home or to acute rehab more frequently, regardless of tPA administration. Conclusions: Older patients had more comorbidities, received tPA more often, and had worse outcomes regardless of use of intravenous tPA or thrombectomy, and were more frequently institutionalized after discharge.

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.

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    This work was supported in part through the resources and staff expertise provided by the Department of Vascular Neurology at Mount Sinai Beth Israel.

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