Stroke Prevention in the Very Elderly
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Stroke remains a common cause of death and disability in the very elderly (here defined as those aged 80 years and older), with about a third of all stroke occurring in this age bracket in high-income countries.1 There is uncertainty on the exact pattern of stroke type in extreme old age, because of potential poor ascertainment of very frail and institutionalized older people in prior studies. However, epidemiological and clinical trial data demonstrate an important increase in atrial fibrillation (AF) cardioembolic stroke in the very elderly.2,3 Important causes of hemorrhagic stroke in the very elderly are cerebral amyloid angiopathy and anticoagulant-related hemorrhagic stroke.4,5 Preventing, or delaying, stroke will be an important component in compressing morbidity, or increasing healthy life expectancy. For devotees of evidence-based medicine (including this author), the prevention of stroke in the very elderly is complex because of 3 main reasons: first, older people have been largely excluded by design (or by accident) from many randomized controlled trials (RCTs)6; second, the underlying causes of stroke change with aging; and final, there is a large body of evidence from geriatric medicine that potentially conflicts with usual stroke preventative measures, for example, data on frailty, polypharmacy, and falls.7
The exclusion of older people from RCTs is well known and has many causes. The age limit of 75 years in the statin trials was based on a misinterpretation of the early epidemiology,6 the 80-year-old age limit in the ECASS thrombolysis trials (European Cooperative Acute Stroke Study) was probably related to the practical organization of German neurology units at the time, when those aged 80 years were usually admitted under general medicine, and therefore the stroke neurologists simply had no access to these patients. Exclusion criteria that include the common diseases …