ABSTRACT
Stroke is a disease that disproportionately affects the elderly. While approximately 795,000 strokes occur in the United States annually, patients older than 85 account for 17% of all stroke patients (1). The prevalence of stroke in patients 60–79 is 6.1% for men and 5.2% for women but rises to 15.8% for men and 14% for women 80 and older (1). Although stroke death rates have declined, stroke is the 5th leading cause of death in the United States and the leading cause of neurologic disability (1). Inpatient administrative data has demonstrated that despite the decline in overall stroke death rates, rates of death from stroke have not declined in men above 84 (2). It is often felt to be a fate worse than death by elderly patients.
Stroke is caused by disruption of the circulation of blood to the brain and can be ischemic due to occlusion of an artery or hemorrhagic due to rupture of an artery. Ischemia accounts for 80%–85% of stroke while hemorrhage accounts for 15%–20% (3,4). Ischemic stroke is caused primarily by atherosclerotic disease of large extracranial and intracranial vessels, occlusion of intracranial vessels by emboli from a cardiac source, and small vessel intracranial occlusive disease secondary to hypertension and diabetes (Figures 26.1 and 26.2). Hemorrhage can be intraparenchymal in the brain itself, mainly from hypertension or cerebral amyloid angiopathy, or subarachnoid from rupture of an aneurysm arising from the vessels of the circle of Willis.
The major risk factor for cerebrovascular disease in studies of patients matched for other cardiovascular risk factors is hypertension (5). Diabetes (6) and cigarette smoking also play a significant role (7), while elevation of serum lipids is less consequential for cerebrovascular disease than for coronary artery disease (8). Control of these risk factors at a young age has contributed to an impressive reduction in the incidence of stroke, but addressing these risk factors in the elderly patient still plays an important role (9). Cardiogenic embolization, particularly from nonvalvular atrial fibrillation, assumes greater importance as an etiology for stroke in the elderly patient, and strategies have been developed to reduce the incidence of stroke in these patients (10).
While prevention of stroke is the principal goal in the treatment of patients with cerebrovascular disease, medical therapy for the elderly stroke patient can enhance outcome. New treatment modalities to restore cerebral circulation with thrombolytic therapy and mechanical thrombectomy have changed the outlook on treatment of stroke.
