Intracerebral Hemorrhage in the Very Old
Future Demographic Trends of an Aging Population
Background and Purpose—In most European societies and in the United States, the percentage of patients ≥80 years has been rising over the past century. The present study was conducted to observe this demographic change and its impact on patients with intracerebral hemorrhage (ICH).
Methods—We reviewed patients' data with the diagnosis of ICH from January 2007 to December 2009. All data were collected out of a prospective stroke registry covering the entire state of Hesse, Germany. Incidence rates and absolute numbers of patients with ICH for 2009 to 2050 were calculated.
Results—Of 3448 patients, 34% had an age ≥80 years. Hospital mortality was 35.9% for patients ≥80 years and 20.0% for patients <80 years. Unfavorable outcome (modified Rankin Scale score >2) was more often found in patients ≥80 years compared with patients <80 years (84.9% versus 74.8%). By the year 2050, the proportion of all patients with ICH ≥80 years will be 2.5-fold higher than in 2009. The total number of ICH cases will increase approximately 35.2% assuming that ICH probability stays the same. The number of patients who die in the hospital will increase approximately 60.2%. The total number of patients with severe disability due to ICH will increase approximately 36.8%.
Conclusions—If current treatment strategies according to age remain unchanged, an increase of in-hospital mortality and a higher proportion of patients who need lifelong care after ICH can be expected in the coming decades.
Intracerebral hemorrhage (ICH) is associated with the highest mortality and morbidity rates of all strokes.1 In recent years, the hospitalization rate for ICH has been increasing, whereas mortality and outcome rates remained unchanged.2 The number of individuals ≥80 years has been rising over the last decade in most European societies3 and in the United States.4 ICH incidence increases with advanced age and over the last decades, no drop in ICH incidence was detected.5
In Germany, the total population will decrease from 81 735 000 in 2009 to 73 608 000 in 2050.6 Nevertheless, the population ≥80 years will increase from 4 133 000 to 10 223 000 in this time period.
The aim of the present study is to observe mortality rates and outcome rates in the very old and to project the impact of the demographic change on the future number of patients with ICH up to the Year 2050.
We reviewed patients' data with the diagnosis of ICH from 2007 to 2009. All data were collected out of a prospective stroke registry covering the entire state of Hesse, Germany. The stroke registry is based on a state law for quality assurance measurement, and the registration is mandatory for all patients with stroke in the state of Hesse, Germany. All patients were registered anonymously. Neither institutional board approval nor informed consent was required.
For the present analysis, only patients with the following diagnoses were included: deep hematoma ICD-10: I61.0), lobar hematoma (ICD-10: I61.1), brain stem hematoma (ICD-10: I61.3), cerebellar hematoma (ICD-10: I61.4), and hematomas at multiple localizations (ICD-10: I61.6).
The population projections for the Year 2050 were deduced from the Hessian Bureau of Statistics.7 Incidence rates per age, the total number of patients with ICH, operative procedures, in-hospital mortality, and patients with an unfavorable outcome at discharge were calculated for the Year 2009. The estimated numbers of patients were calculated for the Year 2050. Unfavorable outcome was defined as modified Rankin Scale >2.
Matching the inclusion criteria, 3448 patients were included in the present analysis. The baseline characteristics of the cohort are listed in Table 1.
Mean age was 72±13 years. Thirty-four per cent were ≥80 years at ICH onset. In-hospital mortality was 35.9% in patients ≥80 years compared with 20.0% in patients <80 years. Unfavorable outcome was more often observed in patients ≥80 years. The proportion of any neurosurgical operative therapy after ICH was significantly lower in patients ≥80 years when compared with patients <80 years.
The total number of inhabitants in the state of Hesse, Germany, will decrease markedly from 2009 to 2050 (Table 2).7 However, in the Year 2050, the proportion of individuals ≥80 years will be 2.5-fold higher than in 2009. These demographic changes will affect the age distribution of patients with ICH. In 2050, >60% of all patients with ICH will have an age ≥80 years.
Assuming that ICH incidence stays the same, the total number of patients with ICH will increase approximately 35.2% from 2009 to 2050 due to the changing age distribution in the observed population. If mortality rates for ICH remain unchanged, the total number of patients who die in the hospital after ICH will increase approximately 60.2%. The number of patients with high morbidity (modified Rankin Scale score >2) at hospital discharge will raise approximately 36.8%.
Despite a higher number of patients with ICH, the total proportion of operative procedures for ICH will decrease from 23.3% in 2009 to 16.7% in 2050.
Case fatality was high in patients >75 years.5 In a recent publication, no significant difference in mortality rate for the geriatric patients with ICH compared with younger patients with ICH was observed in a small sample size.8 In our data, we found significantly higher in-hospital mortality rates for patients with ICH ≥80 years compared with patients <80 years.
Similar results were reported for the functional outcome after ICH. In the very old, the proportion of patients with moderate or severe neurological deficit at hospital discharge is high.9 This observation is in accordance with our results.
In our data, operative therapy was restrictive in the very old compared with patients with an age <80 years. Nonetheless, the reported rates of operative procedures for ICH represent the current operative management of patients with ICH after the Surgical Trial in Intracerebral Haemorrhage (STICH I) Trial10 in central Germany.
The estimated demographic changes of patients with ICH in the state of Hesse, Germany, are not directly comparable to other European societies. The estimated proportion of inhabitants ≥80 years in 2050 will range from 7.3% in Ireland up to 14% in Germany.3 Nevertheless, population aging will be a future challenge for the healthcare economy in most European societies. The total number of individuals ≥80 years in the European Union will raise approximately 144% from 2010 to 2050.3 In this context, more patients with ICH will be admitted to hospitals in the European Union in the coming decades. This future challenge will also affect the United States, where the number of patients with ICH will double up to the Year 2050.11
Over the last decades, stable incidence rates of ICH in the very old were noted.5 If future patients with ICH will be presented with fewer comorbidities, so that more patients will be eligible for operative procedures after ICH, we may have underestimated the number of treated patients in the future.
Demographic changes will lead to an increase of the total number and the number of older patients with ICH in the future. Future therapeutic trials with a focus on the very old are required.
- Received November 14, 2011.
- Revision received November 21, 2011.
- Accepted November 29, 2011.
- © 2012 American Heart Association, Inc.
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