Skip to main content
SpringerLink
Log in

Treatment of Stroke in Older Patients

A State of the Art Review

  • Drug Therapy
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Summary

The treatment of stroke in older patients is the rule rather than the exception in most parts of the world. Thus, an understanding of the effects of aging on pharmacological aspects of treatment, recovery and rehabilitation is very important. A considerable amount of work has now been completed looking for therapeutic interventions that might ameliorate the effects of stroke disease. Sadly, none has yet proved to be effective, but much is still awaited.

In contrast, recent work has clarified the place of treatment in stroke prevention, particularly in hypertension and atrial fibrillation, which should help reduce the burden of stroke disease. In addition, it is now clear that well organised stroke care can dramatically reduce mortality and disability. The state of art in stroke treatment is now encapsulated in the multidisciplinary stroke unit and well coordinated hospital and community care.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Sandercock P. Managing stroke: the way forward. BMJ 1993; 307: 1297–8

    PubMed  CAS  Google Scholar 

  2. Bamford J, Sandercock P, Dennis M, et al. A prospective study of acute cerebrovascular disease in the community: the Oxford Community Stroke Project 1981–86. J Neurol Neurosurg Psychiatry 1988; 51: 1373–80

    PubMed  CAS  Google Scholar 

  3. Wolf PA, Agostino RB, O’Neal A, et al. Secular trends in stroke incidence and mortality (the Framingham Study). Stroke 1992; 23: 1551–5

    PubMed  CAS  Google Scholar 

  4. Oxford Community Stroke Project. Incidence of stroke in Oxfordshire: first year’s experience of a community stroke register. BMJ 1983; 287: 713–7

    Google Scholar 

  5. Ebrahim S. Clinical epidemiology of stroke. Oxford: Oxford University Press, 1990: 14–6

    Google Scholar 

  6. Jorgensen HS, Nakayama H, Raaschou HO, et al. Silent infarction in acute stroke patients. Stroke 1994; 25: 97–104

    PubMed  CAS  Google Scholar 

  7. Fujikawa T, Yamawaki S, Touhouda Y. Incidence of silent cerebral infarction in patients with major depression. Stroke 1993; 24: 1631–4

    PubMed  CAS  Google Scholar 

  8. Langton Hewer R. Rehabilitation after stroke. Q J Med 1990; 76: 659–74

    PubMed  CAS  Google Scholar 

  9. Astrup J, Symon L, Siejbo BK. Thresholds in cerebral ischaemia: the ischaemic penumbra. Stroke 1981; 12: 723–5

    PubMed  CAS  Google Scholar 

  10. Heiss WD. Therapeutic rationale for acute stroke. In: Clifford Rose F, editor. Stroke: epidemiological, therapeutic and socio-economic aspects. London: Royal Society of Medicine, 1986:45–55

    Google Scholar 

  11. Heiss WD. Experimental evidence of ischaemic thresholds and functional recovery. Stroke 1992; 23: 1668–72

    PubMed  CAS  Google Scholar 

  12. Randall JB, Hoff JT. In: Weinstein PR, Faden AI, editors. Protection of the brain from ischaemia. Baltimore: Williams and Wilkins, 1990:67–73

    Google Scholar 

  13. Wardlaw JM, Warlow CP. Thrombolysis in acute stroke: does it work? Stroke 1992; 23: 1826–39

    PubMed  CAS  Google Scholar 

  14. Harper GD, Castleden CM. Drug therapy in patients with recent stroke. Br Med Bull 1990; 46: 181–201

    PubMed  CAS  Google Scholar 

  15. Pickard JD, Murray GD, Illingworth R, et al. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ 1989; 298: 636–42

    PubMed  CAS  Google Scholar 

  16. TRUST Study Group. Randomised, double-blind, placebo controlled trial of nimodipine in acute stroke. Lancet 1990; 336: 1205–9

    Google Scholar 

  17. Walgren NG, MacMahon DG, DeKeyser J, et al. for INWEST Study Group. Intravenous Nimodipine West European Trial of Nimodipine in the treatment of acute ischaemic stroke. Cerebrovasc Dis. In press

  18. Paci A, Ottaviano P, Trenta A, et al. Nimodipine in acute ischaemic stroke: a double blind controlled study. Acta Nerol Scand 1989; 80: 282–6

    CAS  Google Scholar 

  19. Barer DH, Cruikshank JM, Ebrahim SB, et al. Low dose β-blockade in acute stroke (‘Best Trial’): an evaluation. BMJ 1988; 296: 737–41

    PubMed  CAS  Google Scholar 

  20. Hall ED, Pazara KE, Braugler JM. The 21-aminosteroid lipid peroxidation inhibitor protects against cerebral ischaemia in gerbils. Stroke 1988; 19: 997–1002

    PubMed  CAS  Google Scholar 

  21. Meyer JS, Shimazu K, Fukuuchi Y, et al. Impaired neurogenic cerebrovascular control and dysautoregulation after stroke. Stroke 1973; 4: 169–86

    PubMed  CAS  Google Scholar 

  22. Strangaard S. Cerebral blood flow and antihypertensive drugs in the elderly. Acta Med Scand 1983; 676 Suppl.: 103–9

    Google Scholar 

  23. Hayashi S, Nehls DG, Kieck CF, et al. Beneficial effects of induced hypertension on experimantal stroke in awake monkeys. J Neurosurg 1984; 60: 151–7

    PubMed  CAS  Google Scholar 

  24. Mori S, Sadoshima S, Fujii K, et al. Decrease in cerebral blood flow with blood pressure reductions in patients with chronic stroke. Stroke 1993; 24: 1376–81

    PubMed  CAS  Google Scholar 

  25. Powers WJ. Acute hypertension after stroke. Neurology 1993; 43: 461–7

    PubMed  CAS  Google Scholar 

  26. Palomaki H, Kaste M. Regular light to moderate intake of alcohol and the risk of ischemic stroke. Is there a beneficial effect? Stroke 1933; 24: 828–32

    Google Scholar 

  27. Ebrahim S. The clinical epidemiology of stroke. Oxford: Oxford University Press, 1990: 3–29

    Google Scholar 

  28. Camargo Jr CA. Moderate alcohol consumption and stroke: the epidemiological evidence. Stroke 1989; 20: 1611–5

    PubMed  Google Scholar 

  29. Shinton R, Sagar G. Lifelong exercise and stroke. BMJ 1993; 307: 231–4

    PubMed  CAS  Google Scholar 

  30. MacMahon S, Peto R, Cutler J, et al. Blood pressure, stroke and coronary heart disease. Lancet 1990; 335: 765–74

    PubMed  CAS  Google Scholar 

  31. SHEP Co-operative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. JAMA 1991; 322: 1350–6

    Google Scholar 

  32. Dahlof B, Linholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP Hypertension). Lancet 1991; 228: 1281–4

    Google Scholar 

  33. Fotherby MD, Potter JF. Low-down on high blood pressure: care of the Elderly 1993; 5 (Oct Suppl.): s1–s8

    Google Scholar 

  34. Bulpitt CJ, Fletcher AE, Amery A, et al. The Hypertension in the Very Elderly Trial (HYVET): rational, methodology and comparison with previous trials. Drugs Aging 1994; 5: 171–83

    PubMed  CAS  Google Scholar 

  35. Stroke Prevention in Atrial Fibrillation Investigators. Stroke Prevention in Atrial Fibrillation Study: final results. Circulation 1991; 84: 527–39

    Google Scholar 

  36. Petersen P, Boysen G, Godtfredsen J, et al. Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation: the Copenhagen AFASAK study. Lancet 1989; 1: 175–9

    PubMed  CAS  Google Scholar 

  37. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med 1990; 323: 1505–11

    Google Scholar 

  38. Halperin JL, Hart RG. Atrial fibrillation and stroke: new ideas persisting dilemmas. Stroke 1988; 19: 937–41

    PubMed  CAS  Google Scholar 

  39. John RM, Swanton RH. Anticoagulants in cardiovascular disease. Br J Hosp Med 1990; 43: 207–14

    PubMed  CAS  Google Scholar 

  40. Wickramasinge LSP, Basu SK, Bansal SK. Long term anticoagulation therapy in elderly patients. Age Ageing 1988; 17: 388–96

    Google Scholar 

  41. EAFT (European Atrial Fibrillation Trial) Study Group. Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet 1993; 342: 1255–62

    Google Scholar 

  42. Hart RG, Halpetun JL. Atrial fibrillation and stroke: revisiting the delemas. Stroke 1994; 25: 1337–41

    PubMed  CAS  Google Scholar 

  43. Asplund K, Marke LA, Terent A, et al. Costs and gains in stroke prevention: European perspective. Cerebrovasc Dis 1993; 3 (1 Suppl.): 34–42

    Google Scholar 

  44. WHO Task Force on Stroke and Other Cerebrovascular Disorders. Stroke 1989; 20: 1407

    Google Scholar 

  45. American Heart Association. Guidelines for the management of transient ischaemic attacks. Stroke 1994; 25: 1320–35

    Google Scholar 

  46. Bamford J, Sandercock P, Dennis M, et al. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991; 337: 1521–6

    PubMed  CAS  Google Scholar 

  47. Sandercock PAG. Clinical diagnosis of intracranial haemorrhage using ‘Guy’s Hospital’ score. BMJ 1985; 291: 1675–7

    PubMed  CAS  Google Scholar 

  48. Poungvarin N, Viriyavejakul A, Komontri C. Siriraj stroke score and validation study to distinguish supratentorial intracerebral haemorrhage from infarction. BMJ 1991; 302: 1565–7

    PubMed  CAS  Google Scholar 

  49. Mahoney FI, Bartel DW. Functional evaluation: the Bartel index. Md State Med J 1965; 14: 61–5

    PubMed  CAS  Google Scholar 

  50. Rodgers H, Curless R, James OFW. Standardised functional assessment scales for elderly patients. Age Ageing 1993; 22: 161–3

    PubMed  CAS  Google Scholar 

  51. Gladman JRF, Lincoln NB, Adams SA. Use of the Extended ADL Scale with stroke patients. Age Ageing 1993; 22: 419–24

    PubMed  CAS  Google Scholar 

  52. van Swieten JC, Koudstaal PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19: 604–7

    PubMed  Google Scholar 

  53. Wade DT. Measurement in neurological rehabilitation. Oxford: Oxford University Press, 1992

    Google Scholar 

  54. Royal College of Physicians of London. Stroke: towards better Management. London: Royal College of Physicians, 1989: 37–9

    Google Scholar 

  55. Dennis MS, Bamford JM, Molyneux AJ, et al. Rapid resolution of signs of primary intracerebral haemorrhage in computed tomograms of the brain. BMJ 1987; 295: 379–81

    PubMed  CAS  Google Scholar 

  56. Dunbabin DW, Sandercock PAG. Investigation of acute stroke: what is the most effective strategy? Postgrad Med J 1991; 67: 259–70

    PubMed  CAS  Google Scholar 

  57. Albers GW, Comess KA, DeRook FA, et al. Transoesophageal echocardiographic findings in stroke subtypes. Stroke 1994; 25: 23–8

    PubMed  CAS  Google Scholar 

  58. Elizabeth J, Singarayar J, Ellul J, et al. Arterial oxygen saturation and posture in acute stroke. Age Ageing 1993; 24: 269–73

    Google Scholar 

  59. Rosner MJ, Coley IB. Cerebral prefusion pressure, intracranial pressure and head elevation. J Neurosurg 1986; 65: 636–41

    PubMed  CAS  Google Scholar 

  60. Wallace JD, Levy LL. Blood pressure after stroke. JAMA 1981; 246: 2177–80

    PubMed  CAS  Google Scholar 

  61. Britton M, Carlsson A, de Faire U. Blood pressure course in patients with acute stroke and matched controls. Stroke 1986; 17: 861–4

    PubMed  CAS  Google Scholar 

  62. Harper GD, Castleden CM, Potter JF. When can we diagnose hypertension after stroke? [abstract]. Age Ageing 1991; 20 (1 Suppl.): 23

    Google Scholar 

  63. Strandgaard S. Autoregulation of cerebral blood flow in hypertensive patients. Circulation 1976; 53: 720–7

    PubMed  CAS  Google Scholar 

  64. Ram CVS, Meese R, Kaplan NM, et al. Antihypertensive therapy in the elderly. Am J Med 1987; 82 Suppl. 1A: 53–7

    PubMed  CAS  Google Scholar 

  65. Strandgaard S, Paulson OB. Cerebral blood flow and its pathophysiology in hypertension. Am J Hypertens 1989; 2: 486–92

    PubMed  CAS  Google Scholar 

  66. Powers WJ. Acute hypertension after stroke. Neurology 1993; 43: 461–7

    PubMed  CAS  Google Scholar 

  67. Wardaw JM, Warlow CP. Thrombolysis in acute ischaemic stroke: does it work? Stroke 1992; 23: 1826–39

    Google Scholar 

  68. Harper GD, Haigh RA, Potter JF, et al. Factors delaying admission to hospital after stroke in Leicestershire. Stroke 1992; 23: 835–8

    PubMed  CAS  Google Scholar 

  69. Barsan WG, Brott TG, Olinger CP, et al. Early treatment for acute ischaemic stroke. Ann Intern Med 1989; 111: 449–51

    PubMed  CAS  Google Scholar 

  70. Sundt TM, Grant WC, Garcia JH. Restoration of middle cerebral artery flow in experimental infarction. J Neurosurg 1969; 31: 311–21

    PubMed  Google Scholar 

  71. Panayiotou BN, Fotherby MD, Potter JF, et al. Eligibility of acute stroke patients for pharmacological therapy. Age Ageing 1994; 23: 384–7

    PubMed  CAS  Google Scholar 

  72. Dam M, Tonin P, Casson S. The effects of long term rehabilitation therapy on poststroke hemiplegic patients. Stroke 1993; 24: 1186–91

    PubMed  CAS  Google Scholar 

  73. Wade DT, Collen FM, Robb GF, et al. Physiotherapy intervention late after stroke and mobility. BMJ 1992; 304: 609–13

    PubMed  CAS  Google Scholar 

  74. Anderson G, Vestergaard K, Riis JO. Citalopram for post-stroke pathological crying. Lancet 1993; 342: 837–9

    Google Scholar 

  75. Andersen G. Treatment of uncontrolled crying after stroke. Drugs Aging. In press.

  76. Albright AL, Barron WB, Fasick MP, et al. Continuous intrathecal baclofen infusion for spasticity of cerebral origin. JAMA 1993; 270: 2475–7

    PubMed  CAS  Google Scholar 

  77. Bridel J. Assessing the risk of pressure sores. Nursing Standard 1993; 7: 32–5

    PubMed  CAS  Google Scholar 

  78. Barer DH. The natural history and functional consequences of dysphagia after hemispheric stroke. J Neurol Neurosurg Psychiatry 1989; 52: 236–41

    PubMed  CAS  Google Scholar 

  79. Horner J, Brazer SR, Massey EW. Aspiration in bilateral stroke patients: a validation study. Neurology 1993; 43: 430–3

    PubMed  CAS  Google Scholar 

  80. DePippo KL, Holas MA, Reding MJ. Validation of the 3-oz water swallow test for aspiration following stroke. Arch Neurol 1992; 49: 1259–61

    PubMed  CAS  Google Scholar 

  81. Raha SK, Woodhouse K. The use of percutaneous endoscopic gastrostomy (PEG) in 161 consecutive elderly patients. Age Ageing 1994; 23: 162–3

    PubMed  CAS  Google Scholar 

  82. Starkstein SE, Fedoroff P, Price TR, et al. Apathy following cerebrovascular lesions. Stroke 1993; 24: 1625–30

    PubMed  CAS  Google Scholar 

  83. Ebrahim S, Nouri F, Barer D. Affective illness after stroke. Br J Psychiatry 1987; 151: 52–6

    PubMed  CAS  Google Scholar 

  84. Astrom M, Adolfsson R, Asplund K. Major depression in stroke patients: a 3-year longitudinal study. Stroke 1993; 24: 976–82

    PubMed  CAS  Google Scholar 

  85. Adshead F, Cody DD, Pitt B. BASDEC: a novel screening instrument for depression in elderly medical patients. BMJ 1992; 305: 397

    PubMed  CAS  Google Scholar 

  86. Ebrahim S. Clinical epidemiology of stroke. Oxford: Oxford University Press, 1990: 167–8

    Google Scholar 

  87. Ebrahim S. Clinical epidemiology of stroke. Oxford: Oxford University Press, 1990: 177–8

    Google Scholar 

  88. Barer DH. Dysphagia in acute stroke. BMJ 1987; 295: 1137–8

    Google Scholar 

  89. Sandercock PAG, van den Belt AGM, Lindley RI, et al. Antithrombotic therapy in acute ishaemic stroke: an overview of the completed randomised trials. J Neurol Neurosurg Psychiatry 1993; 56: 17–25

    PubMed  CAS  Google Scholar 

  90. Major ongoing stroke trials. Stroke 1994; 25: 1315-9

  91. Wells PS, Lensing AW, Hirsh J. Graduated compression stockings in the prevention of postoperative venous thrombo-embolism. Arch Int Med 1994; 154: 67–72

    CAS  Google Scholar 

  92. Ebrahim S. Clinical epidemiology of stroke. Oxford: Oxford Medical, 1990: 172–4

    Google Scholar 

  93. Antiplatelet Trialists’ Collaberation. Collaberative overview of randomised trials of antiplatelet therapy, 1: prevention of death myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994; 308: 81–106

    Google Scholar 

  94. Brown MM, Humphrey RD, on behalf of the Association of British Neurologists. Carotid endarterectomy: recommendations for management of transient ischaemic attack and ischaemic stroke. BMJ 1992; 305: 1071–4

    PubMed  CAS  Google Scholar 

  95. McCrory DC, Golstein LB, Samsa GP, et al. Predicting complications of endarterectomy. Stroke 1993; 24: 1285–91

    PubMed  CAS  Google Scholar 

  96. Meissner I, Whisnant JP, Garraway WM. Hypertension management and stroke recurrence in a community. Stroke 1988; 19: 459–63

    PubMed  CAS  Google Scholar 

  97. Hypertension Stroke Co-operative Study Group. Effect of antihypertensive treatment on stroke recurrence. JAMA 1974; 229: 409–18

    Google Scholar 

  98. Beevers DG, Fairman MJ, Hamilton M, et al. Antihypertensive treatment and the course of established cerebrovascular disease. Lancet 1973; 1: 1407–9

    PubMed  CAS  Google Scholar 

  99. Barham Carter A. Hypotensive therapy in stroke survivors. Lancet 1970; 1: 485–9

    Google Scholar 

  100. Panayiotou BN, Harper GD, Fotherby MD, et al. Interarm blood pressure difference in acute hemiplegia. J Am Geriatr Soc 1993; 41: 422–3

    PubMed  CAS  Google Scholar 

  101. Royal College of Physicians of London Working Group. Driving and stroke. In: Stroke: towards better management. London: Royal College of Physicians, 1989: 44–6

    Google Scholar 

  102. Langhorne P, Williams BO, Gilchrist W, et al. Do stroke units save lives? Lancet 1993; 342: 395–8

    PubMed  CAS  Google Scholar 

  103. Kalra L. The influence of stroke unit rehabilitation on functional recovery from stroke. Stroke 1994; 25: 821–5

    PubMed  CAS  Google Scholar 

  104. Kalra L. Does age affect benefits of stroke unit rehabilitation? Stroke 1994; 25: 346–51

    PubMed  CAS  Google Scholar 

  105. Garraway WM, Akhtar AJ, Hockey L, et al. Management of acute stroke in the elderly: follow up of a controlled trial. BMJ 1980; 281: 827–9

    PubMed  CAS  Google Scholar 

  106. Hamrin E. One year after stroke: a follow up of an experimental study. Scand J Rehabil Med 1982; 14: 114–6

    Google Scholar 

  107. Gladman JRF, Lincoln NB, DOMINO study group. Follow-up of a controlled trial of domiciliary stroke rehabilitation (DOMINO study). Age Ageing 1994; 23: 9–13

    PubMed  CAS  Google Scholar 

  108. Young JB, Forster A. The Bradford community stroke trial: results at six months. BMJ 1992; 304: 1085–91

    PubMed  CAS  Google Scholar 

  109. Payne JN, Milner PC, Saul C, et al. Local confidential inquiry into avoidable factors in deaths from stroke and hypertensive disease. BMJ 1993; 307: 1027–30

    PubMed  CAS  Google Scholar 

  110. Gladman J, Whynes D, Linclon N. Cost comparison of domiciliary and hospital based stroke rehabilitation. Age Ageing 1994; 23: 241–5

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. North Devon District Hospital, Raleigh Park, Barnstaple, North Devon, EX31 4JB, England

    Glen Harper (Consultant Physician)

Authors
  1. Glen Harper
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Harper, G. Treatment of Stroke in Older Patients. Drugs & Aging 6, 29–44 (1995). https://doi.org/10.2165/00002512-199506010-00003

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002512-199506010-00003

Keywords

Search

Navigation