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Older stroke patients are undertreated

Cerebrovascular disease is a common cause of morbidity and mortality. Only coronary disease kills more people. Moreover, it is primarily a disease of the elderly with 80% of strokes occurring in those over the age of 64.

The notion of cardiovascular rather than just coronary risk is now more prevalent in our way of thinking. As a result, cerebrovascular disease is receiving more attention than before. It is also accepted that aggressive primary and secondary prevention can be as effective for stroke as it is for coronary disease.

However, a large practice-based study in the BMJ has highlighted a worrying trend.1

It found that elderly patients are less likely to receive appropriate pharmacological interventions after stroke compared with younger people. Such interventions are likely to be equally effective across all age groups.

Data were analysed on 12,830 patients aged 50 years and above from 113 general practices in England. All participants had a stroke between 1995 and 2005. To be included in the analysis they had to have survived for the first 30 days following the stroke. Most patients were admitted to hospital (85-90%) with a mean time to discharge of 30 days. This parameter allowed accurate assessment of primary care prescribing. The coding of stroke was incomplete with most classified as unspecified but in view of the relatively low incidence of haemorrhagic stroke the authors felt that this was unlikely to have a significant impact on their findings.

The number of patients taking antihypertensives, lipid lowering drugs and antithrombotics was recorded and the odds of receiving such secondary prevention agents were determined in a multivariant analysis according to age, sex and socioeconomic status. All cause mortality from 31 days after stroke and within the first year was noted.

The results showed that only 25.6% of men and 20.8% of women received pharmacological secondary prevention. There was no significant variation according to socioeconomic status or sex although when individual drug therapy was looked at women were less likely to receive lipid lowering drugs and antithrombotics.

Elderly patients, aged 80-89, were significantly less likely to receive treatment compared with younger patients, aged 50-59, with an odds ratio of 0.53 (95% CI 0.41-0.69, P<0.001). For those aged 90 or more the OR was 0.13 (0.08 to 0.21, P<0.001). This was primarily due to differences in lipid lowering therapy OR 0.44, (95% CI 0.33-0.59, P<0.001) for patients aged 80-89 and 0.12 (0.08 to 0.19, P<0.001) for those aged 90 or over. Importantly, secondary prevention reduced the risk of death by up to 50% in the first 12 months after an event (hazard ratio 0.5, 95% CI 0.42-0.59, P<0.001). On average patients who received treatment had a 5.7% risk of dying within one year compared with 11.1% for those who did not receive treatment.

This trial suggests that elderly patients with cerebrovascular disease are being suboptimally treated. These findings were further supported by another, smaller, trial published in the Postgraduate Medical Journal.2

This was a single centre trial involving 379 patients referred to a specialist rapid access neurovascular clinic with suspected cerebrovascular disease, not felt to warrant admission, between 2004 and 2006.

In all, 250 patients had a confirmed event of which 60% were <75 years of age and 40% >75. The results showed that younger patients were more likely to undergo MR imaging (24% vs 4% P<0.01), carotid Doppler imaging (92% vs 76% P<0.01) and echocardiography (29% vs 13% P<0.01). CT imaging was carried out more quickly in younger patients (P<0.01). There was no difference in the delivery of pharmacological secondary prevention but the elderly group were less likely to receive non-pharmacological interventions such as dietary (P=0.02) and weight loss/exercise advice (P<0.01). Both groups experienced substantial delays, median 24 days, from symptom onset to assessment.

These studies highlight the need for prompt and aggressive intervention irrespective of the patient's age at presentation.


Dr Peter Savill
GPwSI Cardiology, Southampton

Interventions are likely to be equally effective across all age groups

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