Stroke
Description
- Geriatric stroke differs from general stroke care in: atypical presentation, higher cardioembolic proportion, competing comorbidity, and functional/rehab trajectory dominating outcome
- Age itself is not a contraindication to thrombolysis or thrombectomy - premorbid function and comorbidity burden matter more
Epidemiology
- Incidence doubles each decade >55
- Median age of stroke ~75-80
- AF-related cardioembolic stroke proportion rises steeply with age (up to 1/3 in >80s)
- Higher case-fatality and disability per event than younger strokes - less cerebral reserve
Aetiopathogenesis
- Cardioembolic - AF (often undiagnosed until stroke), post-MI mural thrombus, valvular disease
- Large vessel - carotid/vertebral atherosclerosis
- Small vessel - chronic HTN, diabetes -> lacunar infarcts, also substrate for vascular cognitive impairment
- Watershed/hypoperfusion - sepsis, dehydration, over-treated HTN in the frail
- latrogenic - anticoagulant/antiplatelet-related haemorrhagic transformation or ICH
Diagnosis
- Atypical presentation common - confusion, falls, functional decline rather than clear focal deficit
- Delirium can mask or mimic stroke - low threshold for imaging
- CT +/- CTA as per standard pathway; do not withhold imaging or reperfusion therapy on age alone
- Swallow assessment mandatory before oral intake - aspiration risk high
- Cognition, mood, premorbid function (IADLs) - baseline for rehab goal-setting
- Assess pre-stroke frailty (Clinical Frailty Scale) - informs realistic goals, not eligibility for acute therapy per se
Management
Acute
- Thrombolysis/thrombectomy per standard criteria - large-vessel occlusion thrombectomy now extends to 24h with perfusion mismatch imaging (DAWN/DEFUSE-3 criteria), including large-core infarcts in selected patients
- Anticoagulated on DOAC/warfarin - check timing/levels before thrombolysis; does not exclude thrombectomy
Secondary prevention - individualised, not reflexive
- AF: anticoagulate - timing balances early recurrence risk vs haemorrhagic transformation
- Trend toward earlier initiation (within ~2-4 days for most non-severe infarcts) rather than the old rigid "1-3-6-14 day" rule, per recent trial evidence; large infarct/haemorrhagic transformation still delays
- DOAC preferred over warfarin; renal dose-adjust; falls risk alone is not a contraindication - stroke risk from AF usually outweighs bleeding risk from falls
- Antiplatelet (non-cardioembolic) - clopidogrel or aspirin+dipyridamole; short-term DAPT only post-TIA/minor stroke
- Statin, BP control (individualised target, avoid overcorrection precipitating hypoperfusion/falls)
- Deprescribe - drugs contributing to falls/orthostasis, sedatives
Rehabilitation
- Early mobilisation, MDT (physio, OT, SLP, dietetics)
- Stroke unit care -> reduces mortality and disability regardless of age
- Realistic goal-setting incorporating premorbid frailty and cognition
- Driving cessation assessment, home safety/OT home visit before discharge
Associations
- AF, IHD, carotid disease
- Vascular cognitive impairment/dementia - stepwise or mixed with Alzheimer pathology
- Depression - common, screen post-stroke
- Falls - post-stroke gait/balance impairment, visual field loss, neglect
- Pressure injury, aspiration pneumonia, VTE - immobility-related complications
Natural history & complications
- Higher mortality and institutionalisation than younger cohorts for equivalent lesion size
- Recurrent stroke risk highest in first year - secondary prevention adherence critical
- Functional trajectory: significant recovery over 3-6 months, plateau thereafter - but can still improve with ongoing rehab/motivation
- Post-stroke cognitive decline - assess at follow-up, distinct from acute delirium
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