The consensus statement  was proposed by the chairperson in the session, Associate Professor Sigrun Braekken, Oslo, and the session secretary dr Johan Lökk, Stockholm, together with the speakers in the session. The statement was then finally approved by the participants of the meeting, after listening to the different presentations.

The speakers in this session were Professor Gary A Ford, Newcastle and Professor Yngve Gustafson, Umeå

Is there sufficient evidence to recommend specific treatment protocols for the use of pharmacological interventions on the elderly stroke patient?

Background

Stroke in the very old is common and increasing. Many very old patients have pre-stroke disability and co-morbidity. Complications following stroke, such as infection, depression, malnutrition, falls and fractures and adverse effects of treatment are more frequent with unfavourable effects on stroke outcome.

This group of patients present a major challenge to stroke services, yet clinical trials include few patients in this age group. The benefit of treatments expressed as relative risk reductions tend to be reduced in older people because of increased ‘noise’ from co-morbidity. Older patients benefit from organised stroke care and should not be denied access to specialised stroke care. The absolute benefits of treatments in older people can be greater than for the young due to greater absolute baseline risk. The risk of serious adverse drug effects is increased in the very old. Older people with stroke are more heterogeneous than younger people with respect to health status, co-morbidities, existing drug treatment, and views on treatment.

Acute stroke in the very old carries a high likelihood of death or survival with significant long term disability. Therefore risk/benefit issues are more complex and treatment decision making required more detailed individualisation in older compared to most younger people with stroke.

Ischaemic stroke – acute treatment

Thrombolysis

There are few data from randomised controlled trials on the risks and benefits of thrombolysis in the over 80ies. Observational data comparing outcomes in selected older patients, without significant pre-stroke disability treated with thrombolysis indicate a similar, possibly slightly increased risk of symptomatic intracerebral haemorrhage (SICH) compared to younger patients (1). Although the natural history of older people is worse, they should not be denied the consideration of thrombolysis. There is insufficient evidence to support a recommendation of routinely offering thrombolysis to patients older than 80 years. It is reasonable to consider offering thrombolytic treatment to selected very old patients who are not at high risk of bleeding from other characteristics (high blood pressure, diabetes, previous stroke, severe stroke) and not cognitively impaired, severely handicapped of suffering from major co-morbidity (Grade C).
Further data from randomised controlled trials are required to define risks and benefits in other >80 year old stroke patient groups.

Antiplatelet treatment

Benefits of early aspirin use following acute ischaemic stroke are maintained in the over 75 year old age group (2; Grade B).

Ischaemic stroke – secondary prevention

Very old stroke patients, particularly with disability or frailty have either been underrepresented or excluded from secondary prevention studies. Subgroup analyses of primary prevention studies have generally shown benefits of preventing cardiovascular events in the very old; blood pressure lowering in patients > 80 years, cholesterol lowering > 75 years, aspirin treatment and warfarin for atrial fibrillation > 75 years (3, Grade B). The optimal blood pressure and cholesterol levels in the very old stroke patients have not been identified.

There is an increased incidence of adverse treatment effects in older people notably intracranial and gastrointestinal bleeding with warfarin or anti-platelet drugs (4, Grade B).

Where prevention of recurrent cardiovascular events is judged appropriate it is reasonable to offer blood pressure lowering, cholesterol lowering and anti-platelet drugs to the very old stroke patient where the risk of adverse drug effects makes the risk-benefit ratio favourable (5, Grade C).

Anticoagulation with warfarin in the very old stroke survivor with atrial fibrillation may be offered where the benefits of stroke prevention outweigh the risk of haemorrhage, i.e., falls, previous history of bleeding, high blood pressure (6, Grade B). 

General considerations

Management of the very old stroke patient should included prevention, detection and treatment of post-stroke complications. Treatment of the very old stroke patients need to be individualised and based on a comprehensive clinical assessment, consideration of potential drug interactions, documentation of previous adverse drug reactions, careful monitoring for adverse drug effects, altered pharmacokinetics and pharmacodynamics, level of disability and cognitive function, life expectancy, overall aims of treatment and patients’ wishes and needs (7, Grade C).

References:

1. Engelter ST, Bonati LH, Lyrer PA. Intravenous thrombolysis in stroke patients of > or = 80 versus < 80 years of age--a systematic review across cohort studies. Age Ageing 2006 Nov;35(6):572-80

2. Chen ZM, Sandercock P, Pan HC, Counsell C, Collins R, Liu LS, Xie JX, Warlow C, Peto R. Indications for early aspirin use in acute ischemic stroke : A combined analysis of 40 000 randomized patients from the chinese acute stroke trial and the international stroke trial. On behalf of the CAST and IST collaborative groups. Stroke 2000 Jun;31(6):1240-9

3. Wenger NK, Lewis SJ, Herrington DM, Bittner V, Welty FK; Treating to New Targets Study Steering Committee and Investigators. Outcomes of using high- or low-dose atorvastatin in patients 65 years of age or older with stable coronary heart disease. Ann Intern Med. 2007 ;147:1-9

4. Fang MC, Chang Y, Hylek EM, Rosand J, Greenberg SM, Go AS, Singer DE. Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med. 2004;141:745-52

5. Ramsay SE, Whincup PH, Wannamethee SG, Papacosta O, Lennon L, Thomas MC, Morris RW. Missed opportunities for secondary prevention of cerebrovascular disease in elderly British men from 1999 to 2005: a population-based study. J Public Health (Oxf). 2007;29:251-7

6. Hart RG. Atrial fibrillation and stroke: four treatment controversies. Curr Treat Options Neurol. 2005;7:491-8