Prevention and management of stroke in very elderly patients

Global Burden of Stroke Attributable to Low Physical Activity/High Body Mass Index Among People Aged 55 Years and Older

BACKGROUND

This study aimed to quantify the global stroke burden attributable to low physical activity and high body mass index in adults aged ≥55 years using data from the Global Burden of Disease 2019 study.

METHODS

We extracted data on stroke mortality, disability-adjusted life years, and risk factor exposure from the Global Burden of Disease 2019 study for people aged ≥55 years. We calculated the population-attributable fraction and absolute number of stroke cases and disability-adjusted life years attributable to low physical activity and high body mass index by location, age group, sex, and year.

RESULTS

Globally, body mass index and physical inactivity-attributable stroke burden have declined modestly since 1990, but with diverging escalatory regional trajectories. Population growth and aging drive this rising burden.

CONCLUSIONS

Multidimensional, context-specific strategies focused on modifiable lifestyle risks are imperative to address the modest declines and escalatory regional trajectories in body mass index and physical inactivity-attributable stroke burden.

Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a subgroup analysis of the CHANCE-2 trial

OBJECTIVES

Evidence of the optimal antiplatelet therapy for elderly patients who had a stroke is limited, especially those elder than 80 years. This study aimed to explore the efficacy and safety of dual antiplatelet therapy (DAPT) in old-old patients compared with younger patients in the ticagrelor or Clopidogrel with aspirin in High-risk patients with Acute Non-disabling Cerebrovascular Events-II (CHANCE-2) trial.

METHODS

CHANCE-2 was a randomised, double-blind, placebo-controlled trial in China involving patients with high-risk transient ischaemic attack or minor stroke with CYP2C19 loss-of-function alleles. In our substudy, all enrolled patients were stratified by age: old-old (≥80 years), young-old (65-80 years) and younger (<65 years). The primary outcomes were stroke recurrence and moderate to severe bleeding within 90 days, respectively.

RESULTS

Of all the 6412 patients, 406 (6.3%) were old-old, 2755 (43.0%) were young-old and 3251 (50.7%) were younger. Old-old patients were associated with higher composite vascular events (HR 1.41, 95% CI 1.00 to 1.98, p=0.048), disabling stroke (OR 2.43, 95% CI 1.52 to 3.88, p=0.0002), severe or moderate bleeding (HR 8.40, 95% CI 1.95 to 36.21, p=0.004) and mortality (HR 7.56, 95% CI 2.23 to 25.70, p=0.001) within 90 days. Ticagrelor-aspirin group was associated with lower risks of stroke recurrence within 90 days in younger patients (HR 0.68, 95% CI 0.51 to 0.91, p=0.008), which was no differences in old-old patients.

CONCLUSION

Elderly patients aged over 80 in CHANCE-2 trial had higher risks of composite vascular events, disabling stroke, severe or moderate bleeding and mortality within 90 days. Genotype-guided DAPT might not be as effective in old-old patients as in younger ones.

TRIAL REGISTRATION NUMBER

NCT04078737.

Precision medicine in stroke: towards personalized outcome predictions using artificial intelligence

Stroke ranks among the leading causes for morbidity and mortality worldwide. New and continuously improving treatment options such as thrombolysis and thrombectomy have revolutionized acute stroke treatment in recent years. Following modern rhythms, the next revolution might well be the strategic use of the steadily increasing amounts of patient-related data for generating models enabling individualized outcome predictions. Milestones have already been achieved in several health care domains, as big data and artificial intelligence have entered everyday life.

The aim of this review is to synoptically illustrate and discuss how artificial intelligence approaches may help to compute single-patient predictions in stroke outcome research in the acute, subacute and chronic stage. We will present approaches considering demographic, clinical and electrophysiological data, as well as data originating from various imaging modalities and combinations thereof. We will outline their advantages, disadvantages, their potential pitfalls and the promises they hold with a special focus on a clinical audience. Throughout the review we will highlight methodological aspects of novel machine-learning approaches as they are particularly crucial to realize precision medicine. We will finally provide an outlook on how artificial intelligence approaches might contribute to enhancing favourable outcomes after stroke.

Silver Jubilee of Stroke Thrombolysis With Alteplase: Evolution of the Therapeutic Window

In 1995, the results of a landmark clinical trial by National Institute of Neurological Disorders and Stroke (NINDS) made a paradigm shift in managing acute cerebral ischemic stroke (AIS) patients at critical care centers. The study demonstrated the efficacy of tissue-type plasminogen activator (tPA), alteplase in improving neurological and functional outcome in AIS patients when administered within 3 h of stroke onset. After about 12 years of efforts and the results of the ECASS-III trial, it was possible to expand the therapeutic window to 4.5 h, which still represents a major logistic issue, depriving many AIS patients from the benefits of tPA therapy. Constant efforts in this regards are directed toward either speeding up the patient recruitment for tPA therapy or expanding the current tPA window. Efficient protocols to reduce the door-to-needle time and advanced technologies like telestroke services and mobile stroke units are being deployed for early management of AIS patients. Studies have demonstrated benefit of thrombolysis guided by perfusion imaging in AIS patients at up to 9 h of stroke onset, signifying “tissue window.” Several promising pharmacological and non-pharmacological approaches are being explored to mitigate the adverse effects of delayed tPA therapy, thus hoping to further expand the current tPA therapeutic window without compromising safety. With accumulation of scientific data, stroke organizations across the world are amending/updating the clinical recommendations of tPA, the only US-FDA approved drug for managing AIS patients. Alteplase has been a part of our neurocritical care and we intend to celebrate its silver jubilee by dedicating this review article discussing its journey so far and possible future evolution.

Gender differences in major adverse cardiovascular outcomes among aged over 60 year-old patients with atherosclerotic cardiovascular disease: A population-based longitudinal study in Taiwan

Atherosclerotic cardiovascular disease (ASCVD) including cerebrovascular disease (CVD), coronary artery disease (CAD), and peripheral arterial disease (PAD), contributes to the major causes of death in the world. Although several studies have evaluated the association between gender and major adverse cardiovascular outcomes in old ASCVD patients, the result is not consistent. Hence, we need a large-scale study to address this issue.This retrospective cohort study included aged over 60 year-old patients with a diagnosis of ASCVD, including CVD, CAD, or PAD, from the database contained in the Taiwan National Health Insurance Bureau during 2001 to 2004. The matched cohort was matched by age, comorbidities, and medical therapies at a 1:1 ratio. A total of 9696 patients were enrolled in this study, that is, there were 4848 and 4848 patients in the matched male and female groups, respectively. The study endpoints included acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, in-hospital mortality, and so on. In multivariate Cox regression analysis in matched cohort, the adjusted hazard ratios (HRs) for female group in predicting acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality were 0.67 (P < .001), 0.73 (P = .0015), 0.78 (P < .001), 0.59 (P < .001), and 0.77 (P = .0007), respectively.In this population-based propensity matched cohort study, age over 60 year-old female patients with ASCVD were associated with lower rates of acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality than male patients. Further prospective studies may be investigated in Taiwan.

Prevention and Treatment of Acute Stroke in the Nonagenarians and Beyond: Medical and Ethical Issues

PURPOSE OF REVIEW

As one of the fastest growing portions of the population, nonagenarians will constitute a significant percentage of the stroke patient population in the near future. Nonagenarians are nevertheless not specifically targeted by most clinical guidelines. In this review, we aimed to summarise the available evidence guiding stroke prevention and treatment in this age group.

RECENT FINDINGS

Several recent observational studies have shown that the benefits of anticoagulation for the oldest old patients with atrial fibrillation may outweigh the bleeding risk. A sub-analysis of the IST-3 trial has shown for the first time that thrombolysis treatment in acute ischaemic stroke may be beneficial and safe even in octogenarian patients and older. Several recent observational studies have assessed thrombolysis in nonagenarians. The latest of these has shown better disability outcomes without increased rates of symptomatic intracerebral haemorrhage with thrombolysis. Nonagenarian stroke patients may benefit from similar preventative and therapeutic strategies as their younger counterparts. A few important exceptions include primary prevention using aspirin or statins. Patient selection is nevertheless essential given the increased adverse event rates. Patient preference should play a key role in the decision-making process. Clinical trials including more nonagenarian patients are required to yield more robust evidence.

Stroke in the elderly

Stroke remains the second leading cause of death in the world, and its prevalence is projected to rise in the United States and globally. The main driver for increased stroke prevalence is aging of the population; however, best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Furthermore, considerable gaps in knowledge exist for stroke prevention and treatment in elderly and very elderly patients. In this chapter, we discuss various aspects of stroke care in the elderly, including the evidence that guides stroke prevention and treatment. We focus on the challenges in managing stroke in the very elderly including the paucity of data to guide management. The sections span the continuum of stroke care, from primary prevention to management of stroke complications. Finally, we highlight the most significant unanswered questions regarding stroke care in the elderly.

Secondary prevention and lifestyle indices after stroke in a long-term perspective

OBJECTIVES

To describe the long-term perspective regarding prevalence of risk factors, secondary stroke prevention, and lifestyle indices after stroke.

METHODS

From a population-based one-year cohort (n = 416), we performed an observational study of 145 survivors at 16 months and 10 years after stroke (age 27-97 years) regarding secondary prevention including reaching acceptable treatment goals; nutritional status with focus on underweight; and the lifestyle indices: living situation, level of dependence, and self-assessed health condition.

RESULTS

Ten years after stroke, 50% of the subjects with hypertension diagnosis and 55% of those without hypertension diagnosis were within the blood pressure goal <140/90 compared with 32% (P = .008) and 37% (N.S.) at 16 months. Acceptable HbA1c levels among subjects with diabetes mellitus diagnosis increased from 35% to 45% (N.S.). Among those without diabetes diagnosis, satisfactory HbA1c levels decreased from 98% to 79% (P < .001). Underweight increased from 9% to 17% (P = .019). Among patients with cerebral infarction, the prevalence of atrial fibrillation increased from 22% to 29% (P = .004), and treatment with oral anticoagulants from 75% to 78% (N.S.). Acceptable LDL cholesterol levels increased from 59% to 80% (P = .033) among subjects on lipid lowering treatment, and from 18% to 40% among untreated (P = .010). At 10 years, 90% still lived in their own home. Health condition was reported as good/very good/excellent by 65%. Age, female sex, and living situation were associated with intensity of secondary prevention measures and underweight.

CONCLUSIONS

The proportion of individuals within treatment goals improved over time, but secondary prevention still needed additional consideration 10 years after stroke.

Rehabilitation in oldest-old stroke patients: a comparison within over 65 population

BACKGROUND

Considering the demographic trend, characterized by a marked aging due to the increase in life expectancy and the improvement in medical care, in the next future elderly patients will represent the majority of stroke victims with a strong impact on rehabilitative services.

AIM

To investigate and characterize differences in functional outcome in elderly patients after stroke.

DESIGN

Observational study.

SETTING

Post-acute inpatient rehabilitation.

POPULATION

Subjects aged ≥65 years with acute (i.e. within 30 days from onset) ischemic or hemorrhagic stroke.

METHODS

At admission, all patients underwent neurological and clinical examination, functional evaluation and laboratory assessment. Comorbidities and clinical complications during hospital stay were recorded. Functional status was evaluated by means of the Functional Independence Measure (FIM) administered at admission and discharge. All patients underwent neuromotor rehabilitation, and speech therapy in case of aphasia, once a day, six days per week.

RESULTS

The study enrolled 402 patients, who were stratified in three groups according to age: 145 patients in Group 1, the young-old (65-74.9 years, G1), 206 in Group 2, the middle-old (75-84.9 years, G2) and 51 in Group 3, the oldest-old (≥85 years, G3). At discharge, FIM total scores increased significantly for all the groups (P<0.001); however FIM gains, as well as the efficiency parameters derived from FIM were significantly lower in G3 when compared with G1 and G2. G3 showed a significantly higher rate of comorbidities and a higher presence of pressure sores; infections occurred mainly in G2 and G3. Hospitalization was significantly longer for G1 and G2 with respect to G3, while mortality rates were significantly higher in G2 and G3 with respect to G1. The variables that predicted functional outcome were age, previous stroke, stroke severity and functional status at admission.

CONCLUSIONS

Despite advancing age seems to be associated with a reduced effectiveness of the rehabilitation process and a greater number of complications, intensive rehabilitation can produce significant functional gains for all stroke survivors, regardless of age.

CLINICAL REHABILITATION IMPACT

Understanding the specificity of this population will offer older subjects targeted interventions and, for health systems, better allocation of resources and the development of more effective approaches.

Acupuncture lowering blood pressure for secondary prevention of stroke: a study protocol for a multicenter randomized controlled trial

Background

Stroke is the prime cause of morbidity and mortality in the general population, and hypertension will increase the recurrence and mortality of stroke. We report a protocol of a pragmatic randomized controlled trial (RCT) using blood pressure (BP)-lowering acupuncture add-on treatment to treat patients with hypertension and stroke.

Methods

This is a large-scale, multicenter, subject-, assessor- and analyst-blinded, pragmatic RCT. A total of 480 patients with hypertension and ischemic stroke will be randomly assigned to two groups: an experimental group and a control group. The experimental group will receive “HuoXueSanFeng” acupuncture combined with one antihypertensive medication in addition to routine ischemic stroke treatment. The control group will only receive one antihypertensive medication and basic treatments for ischemic stroke. HuoXueSanFeng acupuncture will be given for six sessions weekly for the first 6 weeks and three times weekly for the next 6 weeks. A 9-month follow-up will, thereafter, be conducted. Antihypertensive medication will be adjusted based on BP levels. The primary outcome will be the recurrence of stroke. The secondary outcomes including 24-h ambulatory BP, the TCM syndrome score, the Short Form 36-item Health Survey (SF-36), the National Institute of Health Stroke Scale (NIHSS), as well as the Barthel Index (BI) scale will be assessed at baseline, 6 weeks and 12 weeks post initiating treatments; cardiac ultrasound, carotid artery ultrasound, transcranial Doppler, and lower extremity ultrasound will be evaluated at baseline and 12 weeks after treatment. The safety of acupuncture will also be assessed.

Discussion

We aim to determine the clinical effects of controlling BP for secondary prevention of stroke with acupuncture add-on treatment.

Trial registration

ClinicalTrials.gov, ID: NCT02967484. Registered on 13 February 2017; last updated on 27 June 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2171-5) contains supplementary material, which is available to authorized users.

Management of acute ischaemic stroke in patients with dementia

An estimated 10% of stroke patients have an underlying dementia. As a consequence, health professionals often face the challenge of managing patients with dementia presenting with an acute stroke. Patients with dementia are less likely to receive thrombolysis (0.56-10% vs. 1-16% thrombolysis rates in the general population), be admitted to a stroke unit or receive some types of care. Anticoagulation for secondary stroke prevention is sometimes withheld, despite dementia not being listed as an exclusion criterion in current guidelines. Studies in this population are scarce, and results have been contradictory. Three observational studies have examined intravenous thrombolysis for treatment of acute ischaemic stroke in patients with dementia. In the two largest matched case-control studies, there were no significant differences between patients with and without dementia in the risks of intracerebral haemorrhage or mortality. The risk of intracerebral haemorrhage ranged between 14% and 19% for patients with dementia. Studies of other interventions for stroke are lacking for this population. Patients with dementia are less likely to be discharged home compared with controls (19% vs. 41%) and more likely to be disabled (64% vs. 59%) or die during hospitalization (22% vs. 11%). The aim of this review was to summarize current knowledge about the management of ischaemic stroke in patients with pre-existing dementia, including organizational aspects of stroke care, intravenous thrombolysis, access to stroke unit care and use of supportive treatment. Evidence to support anticoagulation for secondary prevention of stroke in patients with atrial fibrillation and antiplatelet therapy in nonembolic stroke will be discussed, as well as rehabilitation and how these factors influence patient outcomes. Finally, ethical issues, knowledge gaps and pathways for future research will be considered.

[Epidemiology of stroke in Irkutsk: the data of the territorial population register (2009-2013)]

AIM

To study the changes in the main epidemiological induces of stroke in Irkutsk over 2009-2013.

MATERIAL AND METHODS

To obtain significant epidemiological data, a unified method of territorial/population register was used. Stroke morbidity and mortality among persons aged over 25 years is presented.

RESULTS

The highest indices of morbidity among men (5,6 per 1000 population) were recorded in 2010, among women (3,9 per 1000 population) in 2009. Stroke morbidity decreased by 28% in women of Irkutsk over the 5-year period. Indices of morbidity among men did not change during the period of the study and were higher compared to nationwide RESULTS: Mortality indices demonstrated a trend to a reduction: the mortality from stroke decreased by 2-fold over the 5 years.

CONCLUSION

The decrease in stroke mortality among men and women (both in Irkutsk and Russia in whole) is a logical consequence of a complex approach to the problem as well as opening of specialized vascular centers and secondary prevention of stroke.

Characteristics and Outcomes of Very Elderly Enrolled in a Prehospital Stroke Research Study

BACKGROUND AND PURPOSE

Greater numbers of individuals aged ≥80 years enjoy a high quality of life, yet historically stroke trials have excluded this population. We aimed to describe a population of very elderly successfully enrolled into an acute stroke trial and compare their characteristics and outcomes with the younger cohort.

METHODS

We analyzed consecutive patients enrolled <2 hours of symptom onset in a prehospital stroke treatment trial, the FAST-MAG clinical trial (Field Administration of Stroke Therapy-Magnesium). We gathered demographic, treatment, and outcome data for nonelderly (<80 years old), very elderly (≥80 years old), and extreme elderly (≥90 years old). We describe key differences in the population of elderly and the impact of their inclusion on the clinical trial.

RESULTS

Of 1700 participants in FAST-MAG, there were 1210 nonelderly, 490 very elderly, and 60 extreme elderly subjects. Very elderly stroke patients successfully enrolled in a research study were more likely to be women, white, and have an ischemic mechanism rather than an intracerebral hemorrhage. Although the very elderly had generally poorer outcomes, 4 in 10 were functionally independent at 90 days.

CONCLUSIONS

Inclusion of the very elderly population in acute stroke clinical trials would both significantly increase study participation and generalizability of future acute stroke clinical trials.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.

[Stroke epidemiology in Irkutsk according to the territorial population register]

AIM

To study the dynamics of main epidemiological indices of stroke in Irkutsk in 2009-2013 and to compare the results with those in Russia.

MATERIAL AND METHODS

The study was based on the data of the clinical/epidemiological analysis of stroke in open population of men and women in Irkutsk, the data analysis was performed using SAS 8.0.

RESULTS

The territorial population register showed changes in disease and death rates for all stroke cases in the group of 25-74 years old both in men and women. The morbidity in men did not significantly exceed that in Russia. In the period of 5 years, the morbidity in women decreased by 28%. The stable trend towards the decrease in deaths from stroke in men and women was observed. During the observational period it decreased two-fold.

Intravenous Tissue Plasminogen Activator Improves the Outcome in Very Elderly Korean Patients with Acute Ischemic Stroke

Background and Purpose

In a recent pooled analysis of randomized clinical trials (RCTs), intravenous tissue plasminogen activator (TPA) improves the outcome in patients aged ≥80 years. However, it is uncertain whether the findings are applicable to clinical practice in Asian populations.

Methods

From a multicenter stroke registry database of Korea, we identified patients with acute ischemic stroke who were aged ≥ 80 years. Using multivariable analysis and propensity score (PS)-matched analyses, we assessed the effectiveness and safety of intravenous TPA within 4.5 hours.

Results

Among 2,334 patients who met the eligible criteria, 236 were treated with intravenous TPA (mean age, 83±5; median NIHSS, 13 [IQR, 8-17]). At discharge, the TPA group compared to the no-TPA group had a favorable shift on the modified Rankin Scale (mRS) score (multivariable analysis, OR [95% CI], 1.51 [1.17-1.96], P=0.002; PS-matched analysis, 1.54 [1.17-2.04], P=0.002) and was more likely to achieve mRS 0-1 outcome (multivariable analysis, 2.00 [1.32-3.03], P=0.001; PS-matched analysis, 1.59 [1.04-2.42], P=0.032). TPA treatment was associated with an increased risk of symptomatic intracranial hemorrhage (multivariable analysis, 5.45 [2.80-10.59], P<0.001; PS-matched analysis, 4.52 [2.24-9.13], P<0.001), but did not increase the in-hospital mortality (multivariable analysis, 0.86 [0.50-1.48], P=0.58; PS-matched analysis, 0.88 [0.52-1.47], P=0.61).

Conclusions

In the setting of clinical practice, intravenous TPA within 4.5 hours improved the functional outcome despite an increased risk of symptomatic intracranial hemorrhage in very elderly Korean patients. The findings, consistent with those from pooled analysis of RCTs, strongly support the use of TPA for this population.

Polypharmacy among inpatients aged 70 years or older in Australia

OBJECTIVES

To investigate medication changes for older patients admitted to hospital and to explore associations between patient characteristics and polypharmacy.

DESIGN

Prospective cohort study.

PARTICIPANTS AND SETTING

Patients aged 70 years or older admitted to general medical units of 11 acute care hospitals in two Australian states between July 2005 and May 2010. All patients were assessed using the interRAI assessment system for acute care.

MAIN OUTCOME MEASURES

Measures of physical, cognitive and psychosocial functioning; and number of regular prescribed medications categorised into three groups: non-polypharmacy (0-4 drugs), polypharmacy (5-9 drugs) and hyperpolypharmacy (≥ 10 drugs).

RESULTS

Of 1220 patients who were recruited for the study, medication records at admission were available for 1216. Mean age was 81.3 years (SD, 6.8 years), and 659 patients (54.2%) were women. For the 1187 patients with complete medication records on admission and discharge, there was a small but statistically significant increase in mean number of regular medications per day between admission and discharge (7.1 v 7.6), while the prevalence of medications such as statins (459 [38.7%] v 457 [38.5%] patients), opioid analgesics (155 [13.1%] v 166 [14.0%] patients), antipsychotics (59 [5.0%] v 65 [5.5%] patients) and benzodiazepines (122 [10.3%] v 135 [11.4%] patients) did not change significantly. Being in a higher polypharmacy category was significantly associated with increase in comorbidities (odds ratio [OR], 1.27; 95% CI, 1.20-1.34), presence of pain (OR, 1.31; 1.05-1.64), dyspnoea (OR, 1.64; 1.30-2.07) and dependence in terms of instrumental activities of daily living (OR, 1.70; 1.20-2.41). Hyperpolypharmacy was observed in 290/1216 patients (23.8%) at admission and 336/1187 patients (28.3%) on discharge, and the proportion of preventive medication in the hyperpolypharmacy category at both points in time remained high (1209/3371 [35.9%] at admission v 1508/4117 [36.6%] at discharge).

CONCLUSIONS

Polypharmacy is common among older people admitted to general medical units of Australian hospitals, with no clinically meaningful change to the number or classification (symptom control, prevention or both) of drugs made by treating physicians.

Can blood pressure be lowered safely in older adults with lacunar stroke? The Secondary Prevention of Small Subcortical Strokes study experience

OBJECTIVES

To determine safety and tolerability of lowering blood pressure in older adults with lacunar stroke.

DESIGN

Cohort study.

SETTING

The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial, which compared the efficacy of two systolic blood pressure (SBP) targets (<130 mmHg and 130-149 mmHg) for secondary stroke prevention.

PARTICIPANTS

Of 3,020 SPS3 participants, 494 aged 75 and older at baseline were used in these analyses.

MEASUREMENTS

Rates of side effects related to lowering SBP and clinical outcomes, including stroke recurrence and vascular death, were examined.

RESULTS

Older participants achieved SBP levels similar to those of younger participants (mean SBP of 125 mmHg and 137 mmHg in lower and higher SBP target groups, respectively). At least once during the approximately 3.5 years of follow-up, 21% reported dizziness, and 15% reported lightheadedness when standing; the only significant difference between the younger and older groups was unsteadiness when standing (23% vs 32% respectively, P < .001). There was no difference according to treatment group. In younger adults, recurrent stroke was less likely in the lower than the higher SBP group (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.59-1.01) but not in older participants (HR = 1.01, 95% CI = 0.59-1.73), although the interaction was not significant (P = .39). The lower SBP target was associated with a significant reduction in vascular death in older participants (HR = 0.42, 95% CI = 0.18-0.98), with a significant interaction between age and SBP group (P = .049).

CONCLUSION

Except for unsteadiness when standing, there was no difference according to age in individuals with lacunar stroke with respect to side effects potentially related to lowering blood pressure. Although the lower SBP target was not associated with lower likelihood of recurrent stroke, these exploratory analyses suggested a possible benefit related to vascular death.

[An analysis of the work of vascular service in Smolensk from 2009 to 2014]

MATERIAL AND METHODS

Report of the regional vascular service center of Smolensk work and work of vascular service of Smolensk region were analyzed. The aim of the study is to analyze work of the vascular service in Smolensk and Smolensk region in 2009-2014.

RESULTS AND CONCLUSION

Mortality and morbidity in patients with cardio-vascular diseases in Smolensk Region are higher than in other regions of Russia. Recently a number of patients hospitalized to vascular service centers are increased. Infectious complications (pneumonia, bedsores, pyoderma) take lead place in mortality. Nowadays it's very important to solve the problem with prophylaxis of infectious complications in patients with acute ischemic stroke, also to solve problem with rehabilitation in patients with mild and severe motor disorders and disorders of praxis, gnosis. Continuous training of doctors and nurses in regional vascular service centers is needed. It will increase quality of medical service and improve rehabilitation prognosis in patients with ischemic stroke.

Safety of intravenous thrombolysis for ischaemic stroke in Asian octogenarians and nonagenarians

BACKGROUND

symptomatic intracerebral haemorrhage (ICH) is a major concern of intravenous thrombolysis (IVT) for ischaemic stroke. Asians are considered more vulnerable to ICH than non-Asians. Reports on safety of IVT for Asian octogenarians and nonagenarians are limited.

AIMS

the aims of our study were to compare the safety of IVT between octogenarians and nonagenarians and between Asian and Western patients.

METHODS

patients receiving IVT for ischaemic stroke were prospectively registered from four hospitals in Taiwan. Octogenarians and nonagenarians were recruited for analysis. The primary safety outcome measure was symptomatic ICH. The secondary outcome measure was 3-month mortality. We searched the literature on IVT for ischaemic stroke for comparison.

RESULTS

from January 2007 to December 2012, a total of 186 (18.3%) ischaemic stroke patients aged 80 and older, including 166 octogenarians and 20 nonagenarians, were recruited from 1,018 patients receiving IVT. Nine (4.8%) of recruited patients had symptomatic ICH, all in the octogenarian group (5.4%). Three-month mortality was 14.1% in recruited patients and without difference between the two age groups (P = 0.558). The results were comparable with reports on Western octogenarians and nonagenarians in the literature.

CONCLUSION

octogenarians and nonagenarians receiving IVT have a similar safety outcome. Asian octogenarians and nonagenarians receiving IVT for ischaemic stroke are not at higher risk of symptomatic ICH and mortality than Western patients.

Third International Stroke Trial 3: an update

PURPOSE OF REVIEW

The third International Stroke Trial (IST-3) was a randomized controlled trial of thrombolysis with intravenous recombinant tissue plasminogen activator in patients with acute ischemic stroke within 6 h of onset. It sought to determine whether a wider variety of patients might benefit from treatment than were eligible under the prevailing European Union approval for the drug, especially among those aged over 80 years.

RECENT FINDINGS

The entry criteria were broad, and there was no upper age limit for inclusion; over half the 3035 patients were aged over 80 years. For the types of patient recruited in IST-3, despite the early hazards (chiefly of fatal intracerebral hemorrhage), thrombolysis within 6 h did not affect longer-term survival and improved functional outcome. Benefit was greatest among patients treated within 3 h, and benefit did not appear to be diminished among elderly patients or those with severe stroke.

SUMMARY

These results should, therefore, encourage clinicians to: consider thrombolytic treatment for a wider variety of patients (particularly those aged over 80 years); treat those with more severe strokes; reinforce their efforts to increase the proportion of ischemic strokes treated within 3 h; and, have greater confidence that mortality is not increased by treatment.

VIDEO ABSTRACT

http://links.lww.com/CONR/A23.

Quality indicators in acute stroke care: a prospective observational survey in 13 Italian regions

BACKGROUND AND AIMS

Quality monitoring has great relevance in stroke care. The Project "How to guarantee adherence to effective interventions in stroke care" aimed to estimate adherence to acute-phase guidelines in stroke care in Italy.

METHODS

A prospective observational study was performed in 27 hospitals of 13 Italian Regions. Adherence to 15 process indicators was evaluated, comparing also stroke units (SU) with conventional wards. An overall score of care, defined as the sum of achieved indicators, was calculated. A multilevel hierarchical model described performance at patient, hospital and regional level.

RESULTS

Overall, 484 consecutive stroke patients (mean age, 73.4 years; 52.7 % males) were included. Total score ranged from 2 to 15 (mean 8.5 ± 2.4). SU patients were more often evaluated with the National Institutes of Health Stroke Scale (NIHSS) within 24 h, had more frequently an assessment of pre- and post-stroke disability, and a CT scan the same or the day after admission. Regional-hospital- and patient-level variability explained, respectively, 25, 34, and 41 % of total score variance. In multivariate models, patients >80 years vs. younger showed a change in total score of -0.45 (95 % CI -0.79 to -0.12), and those with NIHSS ≥14 vs. ≤5 of -0.92 (95 % CI -1.53 to -0.30). A negative change means a worse adjusted average adherence to process indicators. SU admission increased total score of 1.55 (95 % CI 0.52-2.58).

CONCLUSIONS

Our data confirm the need of quality monitoring in stroke care. Although SU patients showed a better adherence to quality indicators, overall compliance was unsatisfactory.

Prognosis of elderly patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention in 2001 to 2011: A report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) registry

BACKGROUND

Elderly patients constitute a growing part of the population presenting with ST-elevation myocardial infarction (STEMI). The use of primary percutaneous coronary intervention (PCI) in this high-risk population remains poorly investigated.

METHODS

Using the Swedish Coronary Angiography and Angioplasty Registry (SCAAR), we identified consecutive patients with STEMI 80 years or older undergoing primary PCI during a 10-year period. Temporal trends in care and 1-year prognosis were investigated, and long-term outcome was compared with a reference group of patients with STEMI aged 70 to 79 years. Relative survival was calculated by dividing the observed survival rate with the expected survival rate of the general population. Adjusted end points were calculated using Cox regression.

RESULTS

In total, 4,876 elderly patients with STEMI were included. During the study period, average age and presence of comorbidity increased, as well as the use of antithrombotic therapy. Procedural success remained constant. One-year mortality was exclusively reduced between the most recent vs the earliest cohort, whereas the risk of reinfarction, heart failure, stroke, and bleeding remained similar. The risk of death was higher for elderly patients early after PCI, after which the prognosis was slightly better compared with the general population. Long-term risk of adverse events increased markedly with age.

CONCLUSIONS

The prognosis of patients older than 80 years treated with primary PCI for STEMI was relatively unchanged during the 10-year inclusion period, despite changes in patient characteristics and treatment. Advanced age increased the risk of adverse events, but survivors of the early phase after PCI had a slightly improved prognosis compared with the general population.

Thrombolysis and reperfusion: advanced understanding of early management strategies in acute ischemic stroke

Currently, intravenous (IV) thrombolysis within 3 hours from stroke onset is the only approved treatment in acute ischemic stroke (AIS). Although effective, the definition of therapeutic time window and appropriate patient selection still remains controversial. Notably, early endovascular treatment strategies may serve as an adjunct therapy for time window extension in AIS. In this article, we review the safety and efficacy of IV thrombolysis in AIS as it pertains to the optimal time window, the selection of eligible patients, and in combination with endovascular treatment. Combined clinical application of IV thrombolysis and endovascular therapy may improve the therapeutic outcomes for AIS patients.

The effect of time to treatment on outcome in very elderly thrombolysed stroke patients

BACKGROUND

Intravenous thrombolysis is beneficial in, even very elderly, acute ischemic stroke patients. However, while the relation between treatment benefit and treatment delay (onset time to treatment) in patients younger than 80 years is well known, it is uncertain in the very elderly.

AIMS

This analysis aims at examining this relationship in the elderly, and to provide a comparison with the derived relationship in younger patients as a check of validity.

METHODS

We assessed the interaction between age, onset time to treatment, and thrombolysis exposure by analyzing the modified Rankin scale score distribution or mortality rate at 90 days, among patients registered in a trials archive. We established whether the effect of alteplase changes with onset time to treatment, by treating onset time to treatment as a continuum in a multivariate logistic regression model.

RESULTS

Data were available for 3063 patients, of whom 2341 were thrombolysed. Five hundred ninety-seven patients were aged >80, of whom 352 were thrombolysed. Among patients aged >80, no significant interaction of outcome with onset time to treatment was observed (P = 0·4650), but the estimated slope of the decay in benefit with onset time to treatment was comparable with that established for younger patients. Analyzing the entire dataset, there was an interaction between onset time to treatment and alteplase treatment (P = 0·0159), but neither between age and onset time to treatment (P = 0·7098) nor between age and alteplase treatment (P = 0·0755).

CONCLUSIONS

In this nonrandomized comparison, the relationship of benefit and safety with thrombolysis across onset time to treatment in very elderly stroke patients was comparable with that in their younger counterparts. Across the investigated time span of 3·5 h, we can safely treat with the same time window as we use for younger patients.

Traumatology of the facial skeleton in octogenarian patients: a retrospective analysis of 96 cases

AIM

The aim of this retrospective study was to evaluate the frequency and distribution of maxillofacial trauma patients over 80 years, with regard to type and environment of accidents as well as treatment and complications.

PATIENTS AND METHODS

Data for 94 patients (96 cases; aged 80-94 years) with maxillofacial fractures were retrospectively analysed.

RESULTS

Data of 30 male and 64 female patients with an average age of 85 years were analysed. In 90% of the study population, the cause of fractures was a fall, followed by traffic accidents (9%) and assault (1%). Seventy-two patients had fractures of the midface, 10 had factures of the mandible, 9 had fractures of both the midface and mandible and 5 had fractures of the neurocranium and midface. Surgical intervention was required in 57% of the patients. Post-operative complications were: four cases of diplopia, two cases of infected plates, four cases of lower eyelid ectropion and in one case a retrobulbar haematoma.

CONCLUSION

Facial trauma in the elderly can often be treated conservatively unless the patient complains of functional problems. Due to co-morbidities, special attention should be paid to hypertension, anticoagulant agents and the surgical approach.

Elderly patients and intra-arterial stroke therapy

Ischemic stroke disproportionately affects the elderly, particularly those over the age of 80 years. Rates of stroke are expected to increase over the next several decades due to increasing numbers of elderly individuals, making understanding stroke treatment in this population an imperative. The only proven acute stroke therapy is early reperfusion, accomplished through intravenous or intra-arterial means. Intra-arterial stroke therapy (IAT) offers higher recanalization rates than intravenous tissue plasminogen activator, but has yet to show clear superiority over intravenous tissue plasminogen activator alone. Existing data suggest that elderly stroke patients suffer worse outcomes following IAT, despite similar rates of recanalization and symptomatic intracranial hemorrhage. This article reviews the application of IAT in the elderly population and summarizes the available studies that investigate the response of elderly patients to IAT.

Relação entre depressão e desequilíbrio postural em idosos que sofreram acidente vascular encefálico

INTRODUÇÃO: A incidência de Acidente Vascular Encefálico (AVE) aumenta com o envelhecimento e duplica a cada década de vida a partir dos 55 anos de idade. Entre as complicações decorrentes de um AVE estão o desequilíbrio postural e a depressão. OBJETIVOS: Avaliar e correlacionar equilíbrio postural e depressão em idosos com e sem AVE. MATERIAIS E MÉTODOS: Foram avaliados 38 sujeitos (19 com AVE e 19 sem AVE). O equilíbrio foi avaliado pela Escala de Equilíbrio de Berg e a depressão pela Escala de Depressão de Yesavage. RESULTADOS: Idosos com AVE apresentaram depressão quando comparados com idosos sem a doença (p < 0,0001). O risco de cair em idosos com AVE foi 102 vezes maior do que em idosos sem AVE. Houve correlação entre depressão e equilíbrio (r = -0,55; p = 0,01). CONCLUSÃO: Pacientes idosos com sequelas de AVE apresentam maior desequilíbrio e maior depressão, quando comparados com idosos de mesma faixa etária sem a doença.

Atrial fibrillation and thromboprophylaxis in heart failure: the need for patient-centered approaches to address adherence

Atrial fibrillation is a common arrhythmia in heart failure and a risk factor for stroke. Risk assessment tools can assist clinicians with decision making in the allocation of thromboprophylaxis. This review provides an overview of current validated risk assessment tools for atrial fibrillation and emphasizes the importance of tailoring individual risk and the importance of weighing the benefits of treatment. Further, this review provides details of innovative and patient-centered methods for ensuring optimal adherence to prescribed therapy. Prior to initiating oral anticoagulant therapy, a comprehensive risk assessment should include evaluation of associated cardiogeriatric conditions, potential for adherence to prescribed therapy, frailty, and functional and cognitive ability.

Trends in cancer diagnoses among inpatients hospitalized with stroke

BACKGROUND

Cancer, by conferring a hypercoagulable state, may lead to an ischemic stroke. Relatively little is known about the prevalence and evolution of cancer among stroke patients over the last decade.

METHODS

We used the Nationwide Inpatient Sample to identify discharges with any InternationalClassification of Diseases, Ninth Revision, diagnosis code for cancer and ischemic stroke from 1997 to 2006. We then calculated age-adjusted yearly acute ischemic stroke hospitalization rates among adult populations with and without cancer.

RESULTS

Prevalence of cancer among hospitalized stroke patients increased from 1997 to 2006 (N = 31,075 [9.1% of all ischemic stroke hospitalizations] to 34,138 [10.6%], P < .0001). The most common types of cancer among hospitalized stroke patients in 1997 and 2006 were prostate (21% versus 19%), breast (19% versus 19%), gastrointestinal (16% versus 13%), and colorectal (13% versus 13%). Over the decade there was a significant decrease in the prevalence of stroke hospitalizations (slope -3.02, 95% confidence interval -3.69 to -2.34), but not among cancer patients (slope 1.35, 95% confidence interval -0.88 to 3.58).

CONCLUSION

About 1 in 10 hospitalized ischemic stroke patients in the United States has comorbid cancer, and there has been a slight rise in this rate over the last decade. This is likely due to enhanced survival from better cancer treatments, but further study is warranted.

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

BACKGROUND

Thrombolysis is of net benefit in patients with acute ischaemic stroke, who are younger than 80 years of age and are treated within 4·5 h of onset. The third International Stroke Trial (IST-3) sought to determine whether a wider range of patients might benefit up to 6 h from stroke onset.

METHODS

In this international, multicentre, randomised, open-treatment trial, patients were allocated to 0·9 mg/kg intravenous recombinant tissue plasminogen activator (rt-PA) or to control. The primary analysis was of the proportion of patients alive and independent, as defined by an Oxford Handicap Score (OHS) of 0-2 at 6 months. The study is registered, ISRCTN25765518.

FINDINGS

3035 patients were enrolled by 156 hospitals in 12 countries. All of these patients were included in the analyses (1515 in the rt-PA group vs 1520 in the control group), of whom 1617 (53%) were older than 80 years of age. At 6 months, 554 (37%) patients in the rt-PA group versus 534 (35%) in the control group were alive and independent (OHS 0-2; adjusted odds ratio [OR] 1·13, 95% CI 0·95-1·35, p=0·181; a non-significant absolute increase of 14/1000, 95% CI -20 to 48). An ordinal analysis showed a significant shift in OHS scores; common OR 1·27 (95% CI 1·10-1·47, p=0·001). Fatal or non-fatal symptomatic intracranial haemorrhage within 7 days occurred in 104 (7%) patients in the rt-PA group versus 16 (1%) in the control group (adjusted OR 6·94, 95% CI 4·07-11·8; absolute excess 58/1000, 95% CI 44-72). More deaths occurred within 7 days in the rt-PA group (163 [11%]) than in the control group (107 [7%], adjusted OR 1·60, 95% CI 1·22-2·08, p=0·001; absolute increase 37/1000, 95% CI 17-57), but between 7 days and 6 months there were fewer deaths in the rt-PA group than in the control group, so that by 6 months, similar numbers, in total, had died (408 [27%] in the rt-PA group vs 407 [27%] in the control group).

INTERPRETATION

For the types of patient recruited in IST-3, despite the early hazards, thrombolysis within 6 h improved functional outcome. Benefit did not seem to be diminished in elderly patients.

FUNDING

UK Medical Research Council, Health Foundation UK, Stroke Association UK, Research Council of Norway, Arbetsmarknadens Partners Forsakringsbolag (AFA) Insurances Sweden, Swedish Heart Lung Fund, The Foundation of Marianne and Marcus Wallenberg, Polish Ministry of Science and Education, the Australian Heart Foundation, Australian National Health and Medical Research Council (NHMRC), Swiss National Research Foundation, Swiss Heart Foundation, Assessorato alla Sanita, Regione dell'Umbria, Italy, and Danube University.

Update on the third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke and baseline features of the 3035 patients recruited

Background

Intravenous recombinant tissue plasminogen activator (rtPA) is approved in Europe for use in patients with acute ischaemic stroke who meet strictly defined criteria. IST-3 sought to improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of rtPA in acute ischaemic stroke, and to determine whether a wider range of patients might benefit.

Design

International, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rtPA in acute ischaemic stroke. Suitable patients had to be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracranial haemorrhage and stroke mimics.

Results

The initial pilot phase was double blind and then, on 01/08/2003, changed to an open design. Recruitment began on 05/05/2000 and closed on 31/07/2011, by which time 3035 patients had been included, only 61 (2%) of whom met the criteria for the 2003 European approval for thrombolysis. 1617 patients were aged over 80 years at trial entry. The analysis plan will be finalised, without reference to the unblinded data, and published before the trial data are unblinded in early 2012. The main trial results will be presented at the European Stroke Conference in Lisbon in May 2012 with the aim to publish simultaneously in a peer-reviewed journal. The trial result will be presented in the context of an updated Cochrane systematic review. We also intend to include the trial data in an individual patient data meta-analysis of all the relevant randomised trials.

Conclusion

The data from the trial will: improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of iv rtPA in acute ischaemic stroke; provide: new evidence on the balance of risk and benefit of intravenous rtPA among types of patients who do not clearly meet the terms of the current EU approval; and, provide the first large-scale randomised evidence on effects in patients over 80, an age group which had largely been excluded from previous acute stroke trials.

Trial registration

ISRCTN25765518

Demographic and stroke-related factors as predictors of quality of acute stroke care provided by allied health professionals

Background:

We recently indicated that patient age on its own is not a determinant of quality of allied health care received after an acute stroke. It has not been tested whether other non-age variables influence care decisions made by allied health professionals. This paper explores demographic and stroke-related variables that are putatively associated with the quality of care provided to acute stroke patients by allied health professionals.

Methods:

Data were retrospectively audited from 300 acute stroke patient records regarding allied health care. Compliance with each of 20 indicators of allied health care quality was established. The influence of various demographic and stroke-related variables on each performance indicator was examined. We undertook a series of analyses using univariate logistic regression models to establish the influence of these variables on care quality.

Results:

Patient age had a significant correlation with only one process indicator (early mobilization). Seven variables, including stroke severity and level of dependence, were associated with patient age. The majority of these age proxies had significant associations with process indicator compliance. Correlations between non-age variables, in particular stroke severity and comorbidity, suggest the potential for complex confounding relationships between non-age variables and quality of allied health care.

Conclusion:

Compliance with individual indicators of allied health care was significantly associated with variables other than patient age, and included stroke severity, previous independence, comorbidities, day of admission, stroke unit admission, and length of stay. The inter-relationships between these non-age variables suggest that their influence on quality of care is complex.

Age and gender as predictors of allied health quality stroke care

Background:

Improvement in acute stroke care requires the identification of variables which may influence care quality. The nature and impact of demographic and stroke-related variables on care quality provided by allied health (AH) professionals is unknown.

Aims:

Our research explores the association of age and gender on an index of acute stroke care quality provided by AH professionals.

Methods:

A retrospective clinical audit of 300 acute stroke patients extracted data on AH care, patients’ age and gender. AH care quality was determined by the summed compliance with 20 predetermined process indicators. Our analysis explored relationships between this index of quality, age, and gender. Age was considered in different ways (as a continuous variable, and in different categories). It was correlated with care quality, using gender-specific linear and logistic regression models. Gender was then considered as a confounder in an overall model.

Results:

No significant association was found for any treatment of age and the index of AH care quality. There were no differences in gender-specific models, and gender did not significantly adjust the age association with care quality.

Conclusion:

Age and gender were not predictors of the quality of care provided to acute stroke patients by AH professionals.

Patients' age as a determinant of care received following acute stroke: a systematic review

BACKGROUND

Evidence-based care should improve acute stroke outcomes with the same magnitude of effect for stroke patients of all ages. However, there is evidence to suggest that, in some instances, older stroke patients may receive poorer quality care than younger patients.Our aim was to systematically review evidence of the quality of care provided to patients with acute stroke related to their age. Quality of care was determined by compliance with recommended care processes.

METHODS

We systematically searched MEDLINE, CINAHL, ISI Web of Knowledge, Ageline and the Cochrane Library databases to identify publications (1995-2009) that reported data on acute stroke care process indicators by patient age. Data extracted included patient demographics and process indicator compliance. Included publications were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool, and a comparison was made of the risk of bias according to studies' findings. The evidence base for reported process indicators was determined, and meta-analysis was undertaken for studies with sufficient similarity.

RESULTS

Nine from 163 potential studies met the inclusion criteria. Of the 56 process indicators reported, eleven indicators were evidence-based. Seven of these indicators (64%) showed significantly poorer care for older patients compared to younger ones, while younger patients received comparatively inferior care for only antihypertensive therapy at discharge. Our findings are limited by the variable methodological quality of included studies.

CONCLUSION

Patients' age may be a factor in the care they receive after an acute stroke. However, the possible influence of patients' age on clinicians' decision-making must be considered in terms of the many complex issues that surround the provision of optimal care for older patients with acute stroke.

The International Stroke Trial database

Background

We aimed to make individual patient data from the International Stroke Trial (IST), one of the largest randomised trials ever conducted in acute stroke, available for public use, to facilitate the planning of future trials and to permit additional secondary analyses.

Methods

For each randomised patient, we have extracted data on the variables assessed at randomisation, at the early outcome point (14-days after randomisation or prior discharge) and at 6-months and provide them as an analysable database.

Results

The IST dataset includes data on 19 435 patients with acute stroke, with 99% complete follow-up. Over 26.4% patients were aged over 80 years at study entry. Background stroke care was limited and none of the patients received thrombolytic therapy.

Conclusions

The IST dataset provides a source of primary data which could be used for planning further trials, for sample size calculations and for novel secondary analyses. Given the age distribution and nature of the background treatment given, the data may be of value in planning trials in older patients and in resource-poor settings.

Recent age- and gender-specific trends in mortality during stroke hospitalization in the United States

BACKGROUND

Advancements in diagnosis and treatment have resulted in better clinical outcomes after stroke; however, the influence of age and gender on recent trends in death during stroke hospitalization has not been specifically investigated. We assessed the impact of age and gender on nationwide patterns of in-hospital mortality after stroke.

METHODS

Data were obtained from all US states that contributed to the Nationwide Inpatient Sample. All patients admitted to hospitals between 1997 and 1998 (n=1 351 293) and 2005 and 2006 (n=1 202 449), with a discharge diagnosis of stroke (identified by the International Classification of Diseases, Ninth Revision procedure codes), were included. Time trends for in-hospital mortality after stroke were evaluated by gender and age group based on 10-year age increments (<55, 55-64, 65-74, 75-84, >84) using multivariable logistic regression.

RESULTS

Between 1997 and 2006, in-hospital mortality rates decreased across time in all sub-groups (all P<0·01), except in men >84 years. In unadjusted analysis, men aged >84 years in 1997-1998 had poorer mortality outcomes than similarly aged women (odds ratio 0·93, 95% confidence interval=0·88-0·98). This disparity worsened by 2005-2006 (odds ratio 0·88, 95% confidence interval=0·84-0·93). After adjusting for confounders, compared with similarly aged women, the mortality outcomes among men aged >84 years were poorer in 1997-1998 (odds ratio 0·97, 95% confidence interval=0·92-1·02) and were poorer in 2005-2006 (odds ratio 0·92, 95% confidence interval=0·87-0·96), P=0·04, for gender × time trend.

CONCLUSIONS

Over the last decade, in-hospital mortality rates after stroke in the United States have declined for every age/gender group, except men aged >84 years. Given the rapidly ageing US population, avenues for boosting in-hospital survival among very elderly men with stroke need to be explored.

‘Where are we Now with Intravenous Thrombolysis for Acute Ischaemic Stroke’?

The publication of the updated individual patient data meta-analysis of the larger randomised trials of intravenous rt-PA for acute ischaemic stroke has re-opened the debate about how the treatment should be used in routine practice, and what information can be expected to emerge in the next 2-3 years from the ongoing trials [the largest of which is the Third International Stroke Trial (IST-3)].

Management of depression in elderly stroke patients

Poststroke depression (PSD) in elderly patients has been considered the most common neuropsychiatric consequence of stroke up to 6-24 months after stroke onset. When depression appears within days after stroke onset, it is likely to remit, whereas depression at 3 months is likely to be sustained for 1 year. One of the major problems posed by elderly stroke patients is how to identify and optimally manage PSD. This review provides insight to identification and management of depression in elderly stroke patients. Depression following stroke is less likely to include dysphoria and more likely characterized by vegetative signs and symptoms compared with other forms of late-life depression, and clinicians should rely more on nonsomatic symptoms rather than somatic symptoms. Evaluation and diagnosis of depression among elderly stroke patients are more complex due to vague symptoms of depression, overlapping signs and symptoms of stroke and depression, lack of properly trained health care personnel, and insufficient assessment tools for proper diagnosis. Major goals of treatment are to reduce depressive symptoms, improve mood and quality of life, and reduce the risk of medical complications including relapse. Antidepressants (ADs) are generally not indicated in mild forms because the balance of benefit and risk is not satisfactory in elderly stroke patients. Selective serotonin reuptake inhibitors are the first choice of PSD treatment in elderly patients due to their lower potential for drug interaction and side effects, which are more common with tricyclic ADs. Recently, stimulant medications have emerged as promising new therapeutic interventions for PSD and are now the subject of rigorous clinical trials. Cognitive behavioral therapy can also be useful, and electroconvulsive therapy is available for patients with severe refractory PSD.