Stroke in the Elderly ppt

W orld Stroke Academy 1 Stroke in the Elderly Stephen Davis, Kennedy Lees, Richard Lindley Stroke in the Elderly W orld Stroke Academy 2 Table of contents 1. Impact, burden and risk factors 3 1.1. Prevalence and incidence 4 1.2. Role of age in outcomes and burden 6 1.3. Ageing-related risk factors 10  1.4. Deningtheelderlypopulation 11 1.5. Summary 13 1.6. References 15 2. Acute stroke care 16 2.1. Intravenous alteplase therapy 17 2.2. Very elderly in clinical trials 18 2.3. Outcomes of thrombolytic therapy in the elderly 20 2.4. Newer treatments for stroke 23 2.5. Current recommendations for the elderly 25 2.6. Summary 26 2.7. References 28 3. Long-term care 30 3.1. Fundamentals of long-term post-stroke care 31 3.2. Age-related disparities in treatment 38 3.3. Challenges of rehabilitation and the elderly 41 3.4. Long-term and palliative care 43 3.5. Summary 45 3.6. References 47 Stroke in the Elderly Stroke in the Elderly W orld Stroke Academy 3 1. Impact, burden and risk factors 1. Impact, burden and risk factors W orld Stroke Academy 4 1. Impact, burden and risk factors 1.1 Prevalence and incidence ▪ According to the World Health Organisation (WHO), approx- imately 15 million people suffer from stroke each year (1). ▪ Of these, 5 million die and another 5 million are permanently disabled (Figure 1). 1. Impact, burden and risk factors Learning objectives ● Gain insight into the prevalence, incidence and economic impact of stroke in the elderly. ● Learn about the role of age in stroke outcomes and burden. ● Be aware of the age-related risk factors for stroke. ● Provide a denition for the elderly population, and know what challenges are involved in this process. Figure 1: Stroke is common worldwide 15 million people suffer from stroke each year W orld Stroke Academy 5 ▪ Cardiovascular diseases (stroke and ischaemic heart disease) are the leading cause of death in the world. ▪ Stroke alone is the second leading cause of death, responsible for 5.7 million deaths in 2004 and translating to 9.7% of all deaths worldwide. ▪ Mortality rates for coronary heart disease and acute myocardial infarction continue to decrease, but mortality rates for stroke  havenotchangedsignicantlyduringthepast10years. ▪ Around the world, the majority of strokes (75% to 89%) occur in those over 65 years of age (Figure 2) (2, 3). ▪ For each decade of life after age 55, the stroke rate doubles in both men and women (4). 1. Impact, burden and risk factors Figure 2: Majority of strokes occur in those aged >65yrs The majority of strokes occur in the over 65s W orld Stroke Academy 6 1. Impact, burden and risk factors 1.2 Role of age in outcomes and burden ▪ Stroke is the 6 th leading cause of disability or burden worldwide in terms of DALYS (disability-adjusted life years) (1). ▪ This represents a loss of 46.6 million years of healthy life (1). ▪ Stroke also ranks as the third most common cause of burden in middle- and high-income countries, following depressive disorders and ischaemic heart disease (1). ▪ These 3 diseases are predicted to move up the rankings to become 3 of the 4 leading causes of disease and injury burden by 2030 (1). ▪ In a study of individuals aged 65 and older in 7 low- and middle- income countries (including China, India, Cuba, Dominican Republic, Venezuela, Mexico, and Peru), stroke was found to be the second-largest contributor to disability, following dementia (5). Figure 3: Contribution of stroke to disability Stroke is the 6 th leading cause of disability or burden worldwide W orld Stroke Academy 7 1. Impact, burden and risk factors ▪ Paralysis or weakness of the limbs was also found to be a large contributor to disability, although many of these cases were thought to be related to stroke (5). ▪ Furthermore, it was found that in these 7 countries, stroke was the 4 th most common diagnosis, following hypertension, diabetes and dementia (5). ▪ An ageing population will increase the prevalence of stroke and its associated burden. ▪ By 2050, the global population over 60 years of age is projected to approach 2 billion, compared with 629 million in 2002 (Figure 4) (6). ▪ 54% of those aged >60 years reside in Asia; 24% in Europe. ▪ The fastest growing segment of the older population is people  aged≥80years,whichcomprised12%oftheworldpopulation in 2002 and is projected to reach 19% in 2050 (6). Figure 4: The ageing population will increase the burden of stroke globally With the aging population, the prevalence of stroke will increase W orld Stroke Academy 8 1. Impact, burden and risk factors ▪ Thenumberofcentenarians(≥100years)isprojectedto increase 15-fold (6) ▪ The management of stroke in the elderly is becoming an important consideration for healthcare professionals and providers, not only because of increasing incidence and prevalence, but also due to poorer outcomes in this age group. – Medical outcomes following stroke, such as disability and mortality, have been noted to worsen with age. – Those over 80 years of age, who have a stroke, are more likely to die in hospital and less likely to have favourable long-term recovery compared to younger survivors. – A study by Olindo and colleagues, of all patients with    rst-everstroke,observedthatthose≥85yearsofagehad    signicantly greater disability approximately 1 week after    stroke and signicantly higher mortality during the rst 2 months after stroke compared with those <85 years (Figure 5) (7).   – Among those who survived the rst 2 months, older survivors were more likely to have moderate to severe disability than younger survivors (7). – Poor health and pre-stroke disability in the elderly may contribute to the poorer outcome in this age group (7).   – Thesendingsdemonstratethattheelderlyrequireaccess    tohighqualitystrokecareifoutcomesaretobeimproved. The elderly require access to high-quality stroke care Outcomes after a stroke tend to worsen with age W orld Stroke Academy 9 1. Impact, burden and risk factors ▪ Post-stroke differences between elderly and younger survivors persist following stroke. ▪ Results from the Copenhagen Stroke Study showed that survival  issignicantlyloweramongthose≥85yearsofagecompared with younger survivors through more than 5 years after stroke (Figure 5) (8). Figure 5: Differences in survival persist for years following stroke ▪ Elderly survivors are more likely to experience certain post- stroke disabilities compared with younger survivors, including (9): – Confusion – Paralysis   – Languagedecits – Swallowing problems – Urinary incontinence W orld Stroke Academy 10 1. Impact, burden and risk factors 1.3 Ageing-related risk factors ▪ Therearesignicantageing-relatedriskfactorsforstroke,and  riskfactorprolesandmechanismsofischaemicinjurydiffer between younger and elderly patients (Figure 6) (10). ▪ The incidence of ischaemic stroke is higher in men <80 years compared with women, whereas after 80 years of age, women have a higher incidence (4,8) ▪ Riskfactorsforischaemicstroke,suchasatrialbrillation, congestive heart disease, and carotid artery stenosis, increase sharply with age (10). ▪ In addition, age-related changes within the central nervous system may render the elderly more sensitive to ischaemic damage (10). ▪ Axonal pathways are injured in most strokes and contribute  importantlytoclinicaldecits(10). ▪ Central nervous system atrophy that begins in midlife may reduce cerebrovascular reserves, leaving the brain more  susceptibletovascularinsufciencyandischaemicinjuryto these pathways (11). Figure 6: Risk factors for rst-ever stroke in the elderly Risk factor proles for stroke differ between elderly and younger patients [...]... very elderly patients in the NINDS and other trials, analysis of the randomised controlled trial data in this sub-population is equivocal ▪▪ It reveals comparable benefits from treatment in the young and elderly cohorts after adjusting for differences in prognostic factors such as baseline severity (Figure 2) (7) 18 2 Acute stroke care World Stroke Academy ▪▪ In a pooled analysis of alteplase therapy,... after age 55, the stroke rate doubles in both men and women Self assessment 1.2 Which of these statements concerning the access of elderly stroke patients to investigations and treatment are correct? ● ● ● ● ● 14 The use of investigations during inpatient care is much higher among older survivors Significantly fewer survivors 85 years of age or older receive brain imaging, Doppler examination, echocardiogram,... of the following statements concerning the prevalence and incidence of stroke are correct? ● ● ● ● ● According to the World Health Organisation (WHO), approximately 15 million people suffer from stroke each year Stroke alone is the leading cause of death Mortality rates for stroke continue to decrease Around the world, the majority of strokes (75% to 89%) occur in those over 65 years of age For... outcomes were comparable in elderly and younger cohorts The unadjusted numbers for the modified Rankin scores are slightly lower in the elderly cohort; however, more of the elderly patients with severe stroke were allocated to alteplase intervention rather than placebo (7) Figure 2: Outcomes for alteplase versus placebo in randomised controlled trials by age 19 2 Acute stroke care World Stroke Academy 2.3... thrombolytic therapy in the elderly ▪▪ ▪▪ VISTA reveals that alteplase benefits are comparable in young and old patients An analysis of patients in the large Virtual International Stroke Trials Archive, VISTA reveals that the benefit of alteplase therapy is comparable in elderly and young patients and extends across the range of possible outcomes (Figure 3) (7) This analysis not only showed the influence... with ischemic stroke: a guideline from the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Inter disciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational... called Early use of Existing PREventive Strategies for Stroke or EXPRESS, evaluated the phased introduction of early assessment and treatment of TIA or minor stroke and found that early initiation of existing, evidencebased treatments after TIA or minor stroke was associated with an 80% reduction in the 90-day risk of recurrent stroke in all patients who were referred to the study clinic (Figure 2) (4)... prognosis for very old stroke patients The Copenhagen Stroke Study Age Ageing 2004; 33(2):149-154 9 DiCarlo A, Lamassa M, Pracucci, et al Stroke in the very old: clinical presentation and determinants of 3-month functional outcome: A European perspective European BIOMED Study of Stroke Care Group Stroke 1999;30(11):2313-2319 10 Chen RL, Balami JS, Esiri MM, et al Ischemic stroke in the elderly: an overview... cautious in offering treatment or because intracerebral pressure effects are less serious in older patients with some brain atrophy 2 Acute stroke care World Stroke Academy 2.4 Newer treatments for stroke ▪▪ Newer stroke treatments have limited safety and efficacy data Intra-arterial finbrinolysis ▪▪ The second Prolyse in Acute Cerebral Thromboembolism study (PROACT-II), which looked at inter-arterial... relieve swelling secondary to cerebral artery infarction, also lack data in elderly patients ▪▪ The DESTINY (14), DECIMAL (15) and HAMLET (16) trials of hemicraniectomy for cerebral infarction each excluded patients over 60 years of age (Figure 5) 23 2 Acute stroke care World Stroke Academy ▪▪ ▪▪ DESTINY-II is looking at the effects of hemicraniectomy in stroke patients >60 years After the observed . W orld Stroke Academy 1 Stroke in the Elderly Stephen Davis, Kennedy Lees, Richard Lindley Stroke in the Elderly W orld Stroke Academy 2 Table. Acute stroke care 16 2.1. Intravenous alteplase therapy 17 2.2. Very elderly in clinical trials 18 2.3. Outcomes of thrombolytic therapy in the elderly