(Stroke. 1997;28:729-735.)
© 1997 American Heart Association, Inc.
Articles |
Comparison of Stroke Features and Disability in Daily Life in Patients With Ischemic Stroke Aged 55 to 70 and 71 to 85 Years
From the Memory Research Unit and Stroke Unit, Department of Neurology, University of Helsinki (Finland).
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Abstract |
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Background and Purpose This study compared stroke features and poststroke disability in two age groups of patients with ischemic stroke: younger (55 to 70 years) and older (71 to 85 years). Stroke has an impact on daily living in many areas, but whether risk factors, stroke features, and poststroke disability differ between young and old patients with stroke is not so well established.
Methods A cohort of 486 ischemic stroke patients aged 55 to 85 years admitted consecutively to the Helsinki University Central Hospital (Finland) between December 1, 1993, and March 31, 1995, were examined 3 months after the index stroke. Structured medical, neurological, and radiological (MRI or CT) examinations, mental status, and emotional examination and interview of a close informant were done. Prestroke and poststroke activities of daily living were assessed with five scales: the Index of ADL, Instrumental Activities of Daily Living Scale, Functional Activities Questionnaire, Blessed Functional Activities Scale, and Barthel Index.
Results History of cardiac failure (P<.001), atrial fibrillation (P<.001), and cardioembolic stroke (P=.011) was more frequent in the older age group, whereas stroke due to large-artery atherosclerosis (P=.048) was more common in the younger age group. The older patients more often had major dominant stroke syndrome (P=.018).
Comparison of activities of daily living before and after stroke showed that the older age group deteriorated significantly more than the younger age group after adjustment for sex, education, and living conditions (Barthel Index, P=.005; other scales, P<.0001).
Conclusions The stroke patients in young and old age groups had different risk profiles and stroke features. The older stroke patients were more dependent and disabled beforehand, and after stroke they were relatively even more dependent than the patients in the younger age group. Because older patients already constitute the majority of stroke victims, the importance of early active diagnosis, treatment, rehabilitation, and guidance is stressed.
Key Words: aging • activities of daily living • disability evaluation
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Introduction |
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The risk factors and outcome of ischemic stroke have been extensively studied among young patients but not in older ones, who constitute the majority of stroke victims. Furthermore, the importance of older stroke victims is growing because of the changes in the age structure of western populations. The annual incidence of atherothrombotic brain infarction approximately doubles with each successive decade of age.1 The effect of age on the risk of brain infarction is well established.2 3 4 5 6 7 Arterial hypertension is a major risk factor for stroke, and its incidence increases with increasing age. Both systolic and diastolic arterial blood pressure independently relate to the risk of brain infarction. Cardiac embolic stroke, atrial fibrillation, and cardiac failure are more frequent in older than younger patients with stroke.8 9 10
However, whether risk factors and stroke features differ between old and young stroke patients is still not well established. Stroke causes considerable disability, need for rehabilitation and support, and considerable economic impact. Whether poststroke disability and its effects on ADL differ between young and old patients is not known in detail.
Our aim was to examine risk factors, ischemic stroke features, and poststroke disability in two age groups (55 to 70 years and 71 to 85 years) in a large consecutive stroke cohort. Our design improves previous studies by examining stroke features, cognition, emotion, and several ADL simultaneously.
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Subjects and Methods |
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Patients
We focused on consecutive native Finnish persons with any ischemic stroke aged 55 to 85 years living in the city of Helsinki, Finland. All the patients with suspected acute CVD admitted to the emergency ward of the Helsinki University Central Hospital were identified by daily survey of admissions between December 1, 1993, and March 31, 1995. The ward is responsible for primary acute stroke management in the city of Helsinki. The patients had been examined by the neurologist in charge at the emergency ward. We reviewed in detail all the charts of the subjects with suspected CVD to locate those with probable CVD, which was defined as sudden or rapidly evolving transient or permanent symptoms or signs indicating focal or global neurological dysfunction of suspected vascular origin.11
A total of 1622 patients with probable CVD were identified during the 16-month period, and after review, 175 did not fulfill the current criteria for stroke.11 12 13 14 15 16 Of the remaining 1447 patients with stroke, we excluded 229 patients with intracerebral hemorrhage and 69 patients with subarachnoid hemorrhage.
Of the 1149 patients with ischemic stroke, we further excluded those younger than 55 years (n=258), older than 85 years (n=88), those not living in the city of Helsinki (n=158), and those not speaking the Finnish language (n=3). A total of 642 patients fulfilled the given inclusion criteria and were invited to a follow-up visit 3 months after the index stroke. Reasons for nonenrollment were 71 deaths before the 3-month examination (11.1%), 82 refusals by the patient or the patient's physician (12.8%), and 3 who were not identified (0.5%). Thus, 85.1% (486/571) of the living patients were included in the Helsinki Stroke Aging Memory (SAM) cohort.
The 85 patients who refused or were not identified were compared with the 486 patients included in the SAM cohort. The mean±SD age in the former group was 79.2±7.68 and in the SAM cohort 71.2±7.6 years (NS); 67.1% and 49.2% were women (P=.023), and 60.0% and 16.8% were hospitalized at the time of examination (P=.0001), respectively.
The study was approved by the ethics committee of the Department of Neurology, University of Helsinki (Finland), and the subjects and/or their relatives gave informed consent.
General Clinical Assessment
Three months after the index stroke, the subjects in the SAM
cohort underwent a structured medical and neurological history based on
review of all available hospital charts, interview of the subject and
knowledgeable informants, and a structured clinical and neurological
examination made by board-certified neurologists (T.P., R.V.). In
addition, all the cases were reviewed by a senior neurologist (T.E.).
The examination included basic laboratory examinations and MRI of the
head or, in cases of MRI contraindications or refusal, CT of the head.
In the neurological examination, special attention was paid to factors
and features related to dementia and stroke, similar to the method of
the Memory Research Unit, Department of Neurology, University of
Helsinki,17 and the Columbia University Stroke Data
Bank.18
In each patient, the case history was obtained regarding arterial
hypertension, symptomatic hypotension, cardiac failure, coronary heart
disease, any cardiac arrhythmia, atrial fibrillation, history of
myocardial infarction, diabetes, high total cholesterol, history of
smoking, and use of alcohol. History of hypertension was defined as
systolic blood pressure 
160 mm Hg and diastolic blood pressure
95 mm Hg. Diabetes was defined as previously documented
diagnosis, current use of insulin or oral hypoglycemic medication, or
fasting blood glucose >7.0 mmol/L; total cholesterol was
considered high at >6.5 mmol/L. History of previous CVD included
history of any CVD, transient ischemic attack, ischemic
stroke, subarachnoid hemorrhage, and intracerebral hemorrhage.
Stroke Type, Localization, and Syndromes
Types of ischemic stroke were classified according to
the TOAST criteria into large-artery atherosclerosis, cardioembolism,
small-vessel occlusion (lacunar), and stroke of other determined or
undetermined etiology.19 Localization of the stroke was
divided into right hemispheric, left hemispheric, and bilateral, as
well as anterior (carotid), posterior (vertebrobasilar), and
anteroposterior circulation.11 12 13 14 15 16 20 Further stroke
syndromes assessed included major dominant and nondominant hemispheric,
minor dominant and nondominant hemispheric, deep/lacunar, brain
stem/cerebellar, and unknown.18
Clinical mental status examination performed by the neurologist assessed the following domains included in the definition for dementia according to the DSM-III-R of the American Psychiatric Association21 : short-term memory, long-term memory, executive functions, abstract thinking, judgment, aphasia, apraxia, agnosia, constructional and visuospatial abilities, and personality change. The clinical cognitive assessment included the Folstein Mini-Mental State Examination (MMSE; maximum, 30),22 the Modified Mini-Mental State Examination (3MS; maximum, 100),23 and selected brief cognitive tests (test of similarities, fluency with four-legged animal category, ornament drawing, apraxia, and agnosia), taking into account the physical limitations and results of the Clock-Drawing Test. Aphasia was assessed clinically using the Acute Aphasia Screening Protocol.24 For each cognitive domain, we used normative values based on a random Finnish-speaking healthy community sample for those under and over 75 years of age (Reference 2525 and R. Ylikoski, T. Erkinjuntti, R. Sulkava, K. Juva, R. Tilvis, and J. Valvanne, unpublished data, 1996). A total of 451 patients were testable. In addition, the neurologist completed the Clinical Dementia Rating26 and the Global Deterioration Scale (maximum, 7).27
Assessment of emotional functions included the DSM-IV checklist for major depression28 and the Alzheimer's Disease Assessment Scale noncognitive part (ADAS–noncognitive scale; maximum, 50)29 completed by the neurologist.
Assessment of Social Functions
Ability to work, ability to perform instrumental ADL, and ADL
were assessed based on the interview of the patient and a knowledgeable
informant, as well as the neurologist's evaluation. The assessments
reflected the prestroke and poststroke functions estimated 3 months
after the index stroke. The scales used included the Index of ADL
(rating from 1 to 7),30 the IADL (maximum,
8),31 the FAQ (maximum, 30),32 and the BFAS
(maximum, 17).33 34 In addition, the neurologist completed
the BI (maximum, 100).35 Stroke-related impairment was
also assessed using the Schwab England Scale (maximum,
100%),36 the Rankin scale (maximum, 5),37
and the Scandinavian Stroke Scale (maximum, 58).38
Education was divided into two categories: low with 0 to 6 years and high with more than 6 years of formal education.
Data Analysis and Statistics
We compared two age groups, those aged 55 to 70 years and
those aged 71 to 85 years. A 
2 test was used for
categorical data and pooled t test for continuous data. The
differences before and after stroke in ADL scales were studied with
ANOVA of repeated measures. A multivariate analysis with the same
method was used to find out whether age group is an independent
correlate of worsening measured with the different ADL scales adjusted
to sex, education, and living alone. The statistics were made using the
BMDP and SAS programs.39 40
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Results |
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Compared with the younger group aged 55 to 70 years (n=219), the patients in the older group aged 71 to 85 years (n=267) were more often women (58.8% versus 37.9%, P<.0001), more often had lower education (35.2% versus 26.5%, P=.039), and more often lived alone (50.1% versus 38.4%, P=.007) (Table 1
).
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Patients in the older group more frequently had cardiac failure,
coronary heart disease, any cardiac arrhythmia, and atrial fibrillation
(Table 1
). On the other hand, the younger group more often had a
history of high total cholesterol, smoking, and use of alcohol at least
once a week. The two patient groups did not differ in regard to
previous histories of CVD.
Cardioembolic stroke was more frequent in the older group (16.5%
versus 8.7%, P=.011), but stroke was related more often to
large-artery atherosclerosis in the younger group (21.9% versus
15.0%, P=.048) (Table 2). On the TOAST
classification, 60% of the index strokes were classified as stroke of
undetermined etiology. The two age groups did not differ in regard to
stroke localization. However, the older patient group more frequently
had major dominant syndrome, indicating lesions in the left middle
cerebral artery territory (21.5% versus 13.2%,
P=.018).
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Poststroke cognitive decline was observed in 69.7% of the patients in
the older age group compared with 58.9% in the younger group
(P=.014) (Table 3). The corresponding figures
for prestroke cognitive decline were 15.7% and 9.1%, respectively
(P=.03). Dementia according to the DSM-III-R definition was
observed in 90 patients, in 23.5% (57/267) of the older patients and
in 15.9% (33/219) of those in the younger group (P=.044).
Accordingly, more severe decline in cognitive abilities between the two
age groups was demonstrated using the MMSE, 3MS, and Clinical Dementia
Rating scales (Table 3). Aphasia estimated with the Acute Aphasia
Screening Protocol did not differ between the groups.
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Frequency of DSM-IV-R major depression was equal in the two age groups, but higher scores in the ADAS–noncognitive scale reflected more frequent behavioral problems in the older age group (P=.001).
Poststroke disability was more pronounced in the patients aged 71 to 85
years than in those aged 55 to 70 years as assessed with the Rankin
Scale (2.0 versus 2.5, P<.0001), Schwab England Scale
(72.3% versus 83.3%, P<.0001), and Scandinavian Stroke
Scale (51.4 versus 53.5, P=.024) (Table 3).
Stroke-related changes in social functions are summarized in Table 4. When the poststroke scores were subtracted from the
prestroke ones, the relative change in impairment within each scale was
significantly larger in the older patient group. The BI was an
exception, showing only borderline significance (P=.055).
These changes are further illustrated in the Figure. The
differences between the two age groups remained significant in all the
four ADL scales (ADL, IADL, FAQ, and BFAS) when adjusted for sex,
education, and living alone. In the older age group, a significantly
higher percentage of patients were living in an institution 3 months
after stroke (20.6% versus 12.3%, P=.015).
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Discussion |
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In the present study, the ADL ability worsened after stroke relatively more in the older than in the younger age group of patients with ischemic stroke. In addition, different risk profiles and stroke types between the two age groups could be detected.
Our stroke cohort was composed of consecutive stroke patients entering a University Central Hospital responsible for primary care of all cases with acute stroke in a defined geographic area. We were able to investigate 85% of the stroke survivors. The nonparticipants were older, more often female, and more often hospitalized 3 months after stroke. This may in fact have slightly influenced the comparison made in the present study, but the selection bias is comparable with other similar stroke cohorts.41 42
Arterial hypertension, a major risk factor for stroke, was equally common in both age groups. High blood pressure also contributes to heart disease, which highlights the need for appropriate treatment of arterial hypertension in older patients.43 Cardiac failure, coronary heart disease, any cardiac arrhythmia, and atrial fibrillation were more common in the older age group; cardioembolism was also (21.9% versus 15.0%). On the other hand, stroke due to large-artery atherosclerosis was more frequent in the younger group.
In the diagnosis of stroke type, we used the TOAST classification designed for clinical drug trials.19 Altogether, 60% of the patients were diagnosed as having stroke of undetermined etiology. This is due mainly to the strict algorithm used in TOAST. However, we may have missed some cases with cardioembolism; in the present series, the frequency was 13%, but in some previous series it was 20% to 25%. The major dominant stroke syndrome was more frequent in the older group, indicating more frequent lesions in the left middle cerebral artery territory, a frequent site for cardioembolism. This highlights the need to examine stroke etiology in older patients with stroke to prevent further cardioembolism.
In a hospitalized stroke cohort of patients aged 60 years and over, any cognitive decline was reported in 78%41 and DSM-III-R dementia was reported in 26.3% of those studied 3 months after stroke.42 In the present study, any poststroke cognitive decline (69.7% versus 58.9%, P=.014) and DSM-III-R dementia (23.5% versus 15.8%, P=.044) were more common in the older age group. Thus, frequency of cognitive decline increased with increasing age, as shown before.41 Depression has been reported in 25% to 30% of stroke patients44 ; in the present study, the frequency of DSM-IV major depression was 17.6% in the older and 15.5% in the younger age group (NS).
Comparison of the prestroke and poststroke changes in the five different ADL scales shows that the social functioning in older patients worsened significantly more than that in the younger ones. The older age group was also more dependent in ADL functions before stroke, but they were even more dependent after stroke than the younger age group. These differences remained significant for the four ADL scales (Index of ADL, IADL, FAQ, and BFAS) when adjusted for sex, education, and living alone. The BI also showed borderline significance.
Previous studies have focused on outcome in terms of living at home and being ADL independent.45 46 47 48 49 However, to our best knowledge the present study is the first to examine the effects of stroke on scores of different widely used ADL scales.
Older patients constitute the majority of stroke victims, and stroke seems to affect older patients more in terms of ADL. Care and support of poststroke conditions have a growing impact on healthcare expenditures, especially as the age structure of the population is changing. Well-organized management of older stroke patients results in a significantly better outcome.50 This challenges us to provide well-organized stroke management with early and active rehabilitation, guidance, and support of older stroke patients.
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Selected Abbreviations and Acronyms |
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Acknowledgments |
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This work has been supported in part by grants from the Medical Council of the Academy of Finland (Helsinki), the Clinical Research Institute, Helsinki University Central Hospital (Helsinki), and the Finnish Alzheimer Foundation for Research (Helsinki), Finland. Drs T. Pohjasvaara and R. Vataja are supported by the Clinical Research Institute, Helsinki University Central Hospital. Dr T. Erkinjuntti is supported by the Medical Council of the Academy of Finland (Helsinki) and the Finnish Alzheimer Foundation for Research (Helsinki). We thank Vesa Kuusela, senior research officer, Statistics Finland (Helsinki) and Seppo Sarna, PhD, Department of Public Health, University of Helsinki (Finland) for the statistical support and review.
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Footnotes |
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Reprint requests to Dr T. Erkinjuntti, Memory Research Unit, Department of Neurology, University of Helsinki, Haartmaninkatu 4, 00290 Helsinki, Finland.
Received October 31, 1996; revision received December 26, 1996; accepted December 26, 1996.
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 Y. Fukukawa, C. Nakashima, S. Tsuboi, N. Niino, F. Ando, S. Kosugi, and H. Shimokata The Impact of Health Problems on Depression and Activities in Middle-Aged and Older Adults: Age and Social Interactions as Moderators J. Gerontol. B. Psychol. Sci. Soc. Sci., January 1, 2004; 59(1): P19 - 26. [Abstract] [Full Text] [PDF]
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S. Olindo, P. Cabre, R. Deschamps, C. Chatot-Henry, P. Rene-Corail, P. Fournerie, M. Saint-Vil, F. May, and D. Smadja Acute Stroke in the Very Elderly: Epidemiological Features, Stroke Subtypes, Management, and Outcome in Martinique, French West Indies Stroke, July 1, 2003; 34(7): 1593 - 1597. [Abstract] [Full Text] [PDF]
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A. Di Carlo, M. Lamassa, M. Baldereschi, G. Pracucci, A. M. Basile, C. D.A. Wolfe, M. Giroud, A. Rudd, A. Ghetti, and D. Inzitari Sex Differences in the Clinical Presentation, Resource Use, and 3-Month Outcome of Acute Stroke in Europe: Data From a Multicenter Multinational Hospital-Based Registry Stroke, May 1, 2003; 34(5): 1114 - 1119. [Abstract] [Full Text] [PDF]
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M. Martiskainen, T. Pohjasvaara, J. Mikkelsson, R. Mantyla, T. Kunnas, P. Laippala, E. Ilveskoski, M. Kaste, P.J. Karhunen, and T. Erkinjuntti Fibrinogen Gene Promoter -455 A Allele as a Risk Factor for Lacunar Stroke Stroke, April 1, 2003; 34(4): 886 - 891. [Abstract] [Full Text] [PDF]
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K. Tilling, J. A.C. Sterne, A. G. Rudd, T. A. Glass, R. J. Wityk, and C. D.A. Wolfe A New Method for Predicting Recovery After Stroke Stroke, December 1, 2001; 32(12): 2867 - 2873. [Abstract] [Full Text] [PDF]
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K. Uchino, D. Billheimer, and S. C. Cramer Entry Criteria and Baseline Characteristics Predict Outcome in Acute Stroke Trials Stroke, April 1, 2001; 32(4): 909 - 916. [Abstract] [Full Text] [PDF]
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M. Lamassa, A. Di Carlo, G. Pracucci, A. M. Basile, G. Trefoloni, P. Vanni, S. Spolveri, M. C. Baruffi, G. Landini, A. Ghetti, et al. Characteristics, Outcome, and Care of Stroke Associated With Atrial Fibrillation in Europe : Data From a Multicenter Multinational Hospital-Based Registry (The European Community Stroke Project) Stroke, February 1, 2001; 32(2): 392 - 398. [Abstract] [Full Text] [PDF]
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J. Carod-Artal, J. A. Egido, J. L. Gonzalez, and E. Varela de Seijas Quality of Life Among Stroke Survivors Evaluated 1 Year After Stroke : Experience of a Stroke Unit Stroke, December 1, 2000; 31(12): 2995 - 3000. [Abstract] [Full Text] [PDF]
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R. Mantyla, T. Pohjasvaara, R. Vataja, O. Salonen, H. J. Aronen, C.-G. Standertskjold-Nordenstam, M. Kaste, and T. Erkinjuntti MRI Pontine Hyperintensity After Supratentorial Ischemic Stroke Relates to Poor Clinical Outcome Stroke, March 1, 2000; 31(3): 695 - 700. [Abstract] [Full Text] [PDF]
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A. Di Carlo, M. Lamassa, G. Pracucci, A. M. Basile, G. Trefoloni, P. Vanni, C. D. A. Wolfe, K. Tilling, S. Ebrahim, and D. Inzitari Stroke in the Very Old : Clinical Presentation and Determinants of 3-Month Functional Outcome: A European Perspective Stroke, November 1, 1999; 30(11): 2313 - 2319. [Abstract] [Full Text] [PDF]
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R. Mantyla, H. J. Aronen, O. Salonen, T. Pohjasvaara, M. Korpelainen, T. Peltonen, C.-G. Standertskjold-Nordenstam, M. Kaste, and T. Erkinjuntti Magnetic Resonance Imaging White Matter Hyperintensities and Mechanism of Ischemic Stroke Stroke, October 1, 1999; 30(10): 2053 - 2058. [Abstract] [Full Text] [PDF]
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 I Sanchez-Blanco, C Ochoa-Sangrador, L Lopez-Munain, M Izquierdo-Sanchez, and J Fermoso-Garcia Predictive model of functional independence in stroke patients admitted to a rehabilitation programme Clinical Rehabilitation, June 1, 1999; 13(6): 464 - 475. [Abstract] [PDF]
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T. Pohjasvaara, A. Leppavuori, I. Siira, R. Vataja, M. Kaste, and T. Erkinjuntti Frequency and Clinical Determinants of Poststroke Depression Stroke, November 1, 1998; 29(11): 2311 - 2317. [Abstract] [Full Text] [PDF]
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L. Zhu, L. Fratiglioni, Z. Guo, H. Aguero-Torres, B. Winblad, and M. Viitanen Association of Stroke With Dementia, Cognitive Impairment, and Functional Disability in the Very Old : A Population-Based Study Stroke, October 1, 1998; 29(10): 2094 - 2099. [Abstract] [Full Text] [PDF]
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G. Grimby, E. Andren, Y. Daving, and B. Wright Dependence and Perceived Difficulty in Daily Activities in Community-Living Stroke Survivors 2 Years After Stroke : A Study of Instrumental Structures Stroke, September 1, 1998; 29(9): 1843 - 1849. [Abstract] [Full Text] [PDF]
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T. Pohjasvaara, T. Erkinjuntti, R. Ylikoski, M. Hietanen, R. Vataja, and M. Kaste Clinical Determinants of Poststroke Dementia Stroke, January 1, 1998; 29(1): 75 - 81. [Abstract] [Full Text] [PDF]
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R. Mantyla, T. Erkinjuntti, O. Salonen, H. J. Aronen, T. Peltonen, T. Pohjasvaara, and C.-G. Standertskjold-Nordenstam Variable Agreement Between Visual Rating Scales for White Matter Hyperintensities on MRI : Comparison of 13 Rating Scales in a Poststroke Cohort Stroke, August 1, 1997; 28(8): 1614 - 1623. [Abstract] [Full Text]
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