Acute Stroke in Very Old People: Clinical Features and
Predictors of In-Hospital Mortality
A. Arboix, MD, L. Garcia-Eroles, MD, J. Massons, MD, M . Oliveres, and C. Targa, M D
OBJECTIVES: To examine demographic characteristics,
clinical features, neuroimaging data, and outcome of all acute
stroke events occurring in individuals aged 85 years or older.
DESIGN Collection of data from a prospective hospital-
based stroke registry.
SETTING: Between January 1986 and December 1995, the
data was collected of 2,000 stroke patients admitted consec-
utively to the department of neurology ( having 25 beds and
an acute stroke unit) of Sagrat Cor-L'Alianza Hospital of
Barcelona (an acute care, 350-bed teaching hospital serving a
population of approximately 250,000).
PARTICIPANTS AND MEASUREMENTS: For the purpose
of this study, very old patients (aged 85 years or older) were
selected (n = 262). The data of very old stroke patients were
compared with the data of patients younger than 85 years of
age (n = 1738).Predictors of in-hospital mortality based on
clinical and neuroimaging variables were recorded within 48
hours of stroke onset, and outcome variables (medical com-
plications that developed during hospitalization) were as-
sessed by multiple regression analysis.
RESULTS: The very old patients showed a significantly
greater frequency of atherothrombotic (27.5% vs 21.9%0,
P < .05) and cardioembolic infarctions (24.4%vs 26.3%,
P < .001) and a lesser frequency of stroke of unusual cause.
Acute stroke in the very old patients was more severe than in
patients younger than 85 years of age, with greater rates of
in-hospital mortality (27% vs 13.5%, P < .001), longer
duration of hospital stay (22.03 t 29.6 vs 17.5 2 21.5 days,
P < .OO1), and lesser frequency of absence of neurologic
deficit at the time of hospital discharge (21.4% vs 33.1%0,
P < .001), Altered consciousness, limb weakness, sensory
symptoms, involvement of the parietal lobe and temporal
lobe, involvement of the internal capsule (with a protective
effect), intraventricular hemorrhage, cardiac events, and re-
spiratory events were selected as independent predictors of
in-hospital mortality in the multivariate analysis.
CONCLUSIONS: Very old patients with acute stroke
showed a differential clinical profile, different frequency of
stroke subtypes, and a poorer outcome compared with stroke
patients who were younger than 85 years of age. Clinical and
neuroimaging factors that are indicative of the severity of
stroke and that were available at the time of the initial
Address correspondence and reprint requests to Adrii Arboix, MD, Acute Stroke
Unit, Department of Neurology, Hospital del Sagrat Cor, Viladomat 288,
E-08029 Barcelona, Spain.
~
JAGS 48:36-41,2000
Q 2000 by the American Geriatrics Society
diagnosis and at the time of the development of cardiac and
respiratory complications showed a predominant influence
on in-hospital mortality and may help clinicians to establish
prognosis more accurately. J Am Geriatr SOC48:36-41,
2000.
Key words: strokes; old age; mortality; prognosis; cerebro-
vascular disorders
T here are few studies on acute stroke in very old subjects
(85years of age or older), and some clinical aspects of the
natural history of cerebrovascular events in this age group are
not well defined. Furthermore, the importance of studies on
older stroke victims is growing because of the changes in the
age structure of Western populations.' Stroke causes consid-
erable disability, need for rehabilitation and support, and
considerable economic i m p a ~ t . ~ ' ~
Our aim was to examine demographic characteristics,
clinical features, neuroimaging data, and outcome of all acute
stroke events occurring in individuals aged 85 years or older
who were included in a prospective hospital-based stroke
registry. The data of very old stroke patients were compared
with the data of patients younger than 85 years of age.
Predictors of in-hospital mortality based on clinical and
neuroimaging variables were recorded within 48 hours of
stroke onset, and outcome variables (medical complications
that developed during hospitalization) were assessed by mul-
tiple regression analysis.
SUBJECTS AND METHODS
Between January 1986 and December 1995, the data of
2,000 stroke patients admitted consecutively to the depart-
ment of neurology of Sagrat Cor-L'Alianza Hospital of Bar-
celona were collected prospectively in a stroke r e g i ~ t r yOur
.~
institution is an acute care, 350-bed teaching hospital in the
city of Barcelona, serving a population of approximately
250,000. All patients with cerebrovascular disease are ini-
tially attended at the emergency room and admitted to the
department of neurology, which has 25 beds and an acute
stroke unit. Intensive care unit beds are also available. Pa-
tients are chosen for admission to the department of neurol-
ogy unit if the reason for consultation is an acute cerebrovas-
cular event occurring independently of the presence or
absence of severe concomitant medical problems. Patients
with transient ischemic attack or reversible neurologic deficit
who are evaluated on an outpatient basis are routinely re-
ferred to the emergency room for assessment. Thus, the
0002-8614/00/$3.50
JAGS JANUARY 2000-VOL. 48, NO. 1
proportion of patients experiencing minor strokes who are
not treated at the hospital is negligible. Subtypes of stroke
were classified according to the Cerebrovascular Study
Group of the Spanish Neurological Society,’ which is similar
to the National Institute of Neurological Disorders and
Stroke Classification6 and whose recommendations we have
used in previous Stroke subtypes included tran-
sient ischemic attack (TIA) (n = 239), atherothrombotic
infarct (n = 452), lacunar stroke (n = 374), cardioembolic
infarct (n = 347), infarction of undetermined origin ( n =
224), infarction of unusual etiology ( n = 76), parenchymal
hemorrhage (n = 229), subarachnoid hemorrhage (n = 35),
spontaneous subdural hematoma ( n = 23), and epidural
hematoma (n = 1).
For the purpose of this study, very old patients were
selected. All patients were admitted to the hospital within 48
hours of the onset of symptoms. On admission, demographic
characteristics, including salient features of clinical and neu-
rologic examination and results of laboratory tests (blood cell
count, biochemical profile, serum electrolytes, urinalysis),
chest radiography, and 12-lead electrocardiography were
recorded. For all patients, a brain-computed tomography
(CT) scan was performed within the first week of hospital
admission. Patients with negative CT findings underwent a
second CT scan or magnetic resonance imaging (MRI).Over-
all, 12% of patients were studied by MRI. Other investiga-
tions included arterial digital subtraction angiography in
5.4% of patients, two-dimensional echocardiography in
IS%, Doppler ultrasonography of the supraaortic trunks in
17%, and lumbar puncture in 2.3%.
Demographic variables included age and sex. Historical
features were dichotomized as being either present or absent
and consisted of history of hypertension, diabetes mellitus,
myocardial infarction or angina, rheumatic heart disease,
congestive heart failure, atrial fibrillation, smoking (>20
cigarettedday), alcohol abuse (>80 g of ethanol per day),
previous brain infarction, hyperlipidemia, renal disease, liver
cirrhosis or chronic liver disease, and chronic obstructive
pulmonary disease (COPD).Congestive heart failure, COPD,
liver dysfunction, and atrial fibrillation were also pooled and
analyzed under the single category of “previous or concomi-
tant pathologic conditions.” Clinical variables, dichotomized
as being either present or absent, included sudden onset of
symptoms (in minutes), headache, dizziness, seizures, nausea
or vomiting, altered consciousness (being drowsy, stuporous,
comatose), limb weakness (hemiparesis or hemiplegia, Bab-
inski’s sign not mandatory), sensory symptoms, hemianopia,
speech disturbances (aphasia or dysarthria), ataxia, and cra-
nial nerve palsy. Neuroimaging variables also were dichoto-
mized as being either present or absent and included frontal,
parietal, temporal, occipital, internal capsule, thalamus,
basal ganglia, pons, and cerebellum involvement. Anterior
cerebral, middle cerebral, posterior cerebral, basilar, and
vertebral topographies were recorded. Intraventricular hem-
orrhage was diagnosed by evidence of blood on the CT or
MRI scans. Stroke subtype was categorized as ischemic (i.e.,
TIA, lacunar, cardioembolic, atherothrombotic, stroke of
unusual cause, or stroke of undetermined origin) or hemor-
rhagic (i.e., parenchymal hemorrhage, subarachnoid hemor-
rhage, or spontaneous subdural or epidural hematoma). All
patients with suspected cardioembolic stroke were assessed
by a cardiologist to determine the etiologic diagnosis of a
cardiac source of emboli. Nosologic groups consisted of
ACUTE STROKE IN VERY OLD PEOPLE 37
isolated atrial dysrhythmia (atrial fibrillation, atrial flutter,
sick sinus syndrome), valvular heart disease, coronary artery
disease, nonischemic cardiomyopathy, and other cardiac dis-
orders. Outcome variables that were dichotomized as being
either present or absent included cardiac events (acute myo-
cardial infarction, heart failure, or tachyarrhythmia), vascu-
lar events, and infectious complications. Causes of death
were analyzed according to the criteria of Silver et a1.l’
Clinical characteristics, neuroimaging data, and out-
come variables of very old patients and of patients younger
than 85 years of age were compared using the chi-square (2)
test with Yates correction when necessary and the analysis of
variance.” The endpoint was vital status (alive or dead) at
the time of discharge from the hospital. Univariate analysis
for each variable in relation to vital status was assessed with
the Student’s t test and the 2 test with Yates correction when
needed.” Statistical significance was set at P < .05. Variables
were subjected to multivariate analysis with a logistic regres-
sion procedure and forward stepwise selection if P < .10 after
univariate testing. The first predictive model was based on
demographic and historical features and on clinical variables,
for a total of 8 variables; the second model was based on
demographic and historical features and on clinical and neu-
roimaging variables, for a total of 16 variables; and the third
model was based on demographic and historical features and
on clinical, neuroimaging, and outcome variables, for a total
of 19 variables. Age was used as a continuous variable with a
constant odds ratio for each year. In the three models, mor-
tality, coded as absent = 0 and present = 1, was the depen-
dent variable. The level of significance to remain in the model
was 0.15. The tolerance level was established as 0.0001. The
maximum likelihood approach was used to estimate weights
of the logistic parameters.12 The odds ratio and 95% confi-
dence intervals were calculated from the beta coefficients and
standard errors. The hypothesis that the logistic model ade-
quately fit the data was tested by means of the goodness-of-fit
2 test.13 The SPSS-PC+ l4 and BMDP” computer programs
were used for statistical analysis.
RESULTS
A total of 13.1% of the 2000 acute strokes occurred in
very old people. In the group aged 75 to 84 years, acute stroke
occurred in 37.2% of patients; in those 65 to 74 years,
28.4%; in those 55 to 64 years, 13.3%; in those 45 to 54
years, 4.4%; and in those younger than 45 years, 3.5%.
Of the 262 patients with acute stroke who were aged 85
years or older, 79 were men and 183 were women, with a
mean age of 88 (SD = 2.5) years. Cardiovascular risk factors
included hypertension in 45% of cases, atrial fibrillation in
32%, and diabetes mellitus in 14%. Ischemic stroke was
diagnosed in 227 patients and hemorrhagic stroke in 35. The
mean length of hospital stay was 22 days.
Seventy-one of the of the 262 very old patients with
stroke died, with an overall in-hospital mortality rate of
27%.The mortality rates in other age groups were as follows:
18.3%in those 75 to 84 years, 12.3%in those 65 to 74 years,
9.4% in those 55 to 64 years, 3.4% in those 45 to 54 years,
and 0% in those younger than 45 years. Causes of death
included cerebral herniation in 22 patients, pneumonia in 14,
sepsis in 14, myocardial infarction in four, sudden death in
four, recurrent brain ischemia in four, pulmonary thrombo-
embolism in two, recurrent cerebral hemorrhage in one, and
unknown in six. The mean duration of hospital stay in
38 ARBOlXETAL. IANUARY 2000-VOL. 48. NO.1 IAGS

Table 1. Results of Univariate Analysis in 262 Very Old Patients Table 1. (Continued)
with Acute Stroke According to Vital Status at Discharge
Alive Dead
Alive Dead (n = 191) (n = 71) P
(n = 191) (n = 71) P Variable, Coded (%) (%) Value
Variable, Coded (%) Value
Middle cerebral topography
Demographic features Absent 1 15 (85.2) 20 (14.8) <.001
Men 52 (65.8) 27 (34.2) <.1 Present 76 (59.8) 51 (40.2)
Women 139 (76) 44 (24) Outcome
Cardiovascular risk Cardiac events
factors Absent 189 (75) 63 (25) <.001
Heart failure Present
Absent 171 (76) 54 (24) <.006 2 (20) 8 (80)
Respiratory events
Present 20 (54.1) 17 (46) 180 (82.2) 39 (17.8)<.001
Absent
Cirrhosis/chronic liver
Present 1 1 (25.6) 32 (74.4)
disease
Infectious complications
Absent 191 (73.5) 69 (26.5) <.02
Present 0 2 (100) Absent 165 (78.6) 45 (21-4)<.001
Pathologic conditions* Present 26 (50) 26 (50)
Absent 116 (77.9) 33 (22.1) <.04
Present 75 (66.4) 38 (33.6)
Clinical findings patients who died was 27.6 (SD = 40.6) days, and in those
Nausea, vomiting who were dismissed alive, it was 19.8 (SD = 24) days (P <
Absent 182 (74.3) 63 (25.7) <.06 .002). Table 1 shows the distribution of statistically signifi-
Present 9 (52.9) 8 (47.1) cant variables among patients who died and among those
Altered consciousness
who were discharged alive from the hospital. Mean ages of
Absent 155 (88.6) 20 (1 1.4) <.001 the patients in both groups were 88.2 (SD = 2.6) versus 87.9
Present 36 (41.4) 51 (58.6)
Limb weakness
(SD = 2.7) years, respectively (P = not significant). After
Absent 56 (93.3) 4 (6.7) <.001 multivariate analysis, altered consciousness, limb weakness,
Present 135 (66.8) 67 (33.2) and sensory symptoms seemed to be independent predictors
Sensory symptoms of in-hospital death in the predictive model based on clinical
Absent 136 (85.5) 23 (14.5) <.001 variables (Table 2). In addition to these variables, involve-
Present 55 (53.4) 48 (46.6) ment of the temporal lobe and of the internal capsule (with a
Hemianopia protective effect) were selected in the predictive model based
Absent 152 (79.6) 47 (23.6) C.03 on clinical and neuroimaging data. In association with al-
Present 39 (61.9) 24 (38.1) tered consciousness and sensory symptoms, the following
Neuroimaging findings were selected in the third predictive model: cardiac events,
Parietal lobe respiratory events, parietal lobe involvement, and intraven-
involvement tricular hemorrhage. In all three models, setting a cutoff point
Absent 159 (83.2) 32 (16.8) <.001 of 0.50 for predicting vital status at the time of hospital
Present 32 (45.1) 39 (54.9) discharge resulted in the following: sensitivity of 72%, 74%,
Temporal lobe and 77%; specificity of 88%, 86%, and 89%; positive pre-
involvement dictive values of 68%, 61%, and 69%; negative predictive
Absent 161 (83.9) 31 (16.1) <.001 values of 90%, 92%, and 92%; and total correct classifica-
Present 30 (42.9) 40 (57.j) tions of 84%, 84%, and 86%, respectively. These percent-
Occipital lobe ages were not significantly improved by using an optimal cut
involvement point as indicated by receiver operating characteristics
Absent 183 (76.6) 56 (23.4) <.001 curves.16
Present 8 (34.8) 15 (65.2) The comparison of the very old group with the group
Internal capsule younger than 85 years of age is shown in Table 3. The
involvement following variables were significantly more frequent in the
Absent 152 (70.4) 64 (29.6) <.05 very old group: female gender; history of atrial fibrillation
Present 39 (84.8) 7 (15.2) and renal disease; altered consciousness, homonymous hemi-
Basal ganglia anopia, and speech disturbances; temporal lobe involvement
Absent 174 (76.7) 53 (23.3) <.001 and anterior choroidal artery topography; and atherothrom-
Present 17 (48.6) 18 (51.4) botic and cardioembolic brain infarctions. Acute stroke in the
Ischemic stroke 171 (75.3) 56 (24.7) <.03 very old patients was more severe than in patients younger
Hemorrhagic stroke 20 (57.1) 15 (42.9) than 85 years of age, with the following: greater rates of
lntraventricular in-hospital mortality; respiratory, urinary, and infectious
hemorrhage complications; longer durations of hospital stay; and a
Absent 188 (74.9) 63 (25.1) <.001 smaller proportion of patients without neurologic deficit at
Present 3 (27.3) 8 (72.7)
the time of hospital discharge.
JAGS JANUARY 2000-VOL. 48, NO. 1 ACUTE STROKE IN VERY OLD PEOPLE 39

~~ ~~

Table 2. Results of Multivariate Analysis Table 3. Comparison of Very Old Patients and Those Younger
Than 85 Years of Age with Acute Stroke
Statistical Model Odds Ratio
Based On P SE (PI (95% CI) <85 Years
Very Old of Age P
Clinical variables* Variable n = 262 (%) n = 1738 (%) Value
Altered 2.4651 0.3606 11.76 (6.80-23.85)
consciousness Demographic data
Limb weakness 2.0217 0.5941 7.55 (2.36-24.19) Age, mean (years) 88 2 2.5 70 5 11.5 <.001
Sensory 1.1182 0.3597 3.06(1.51-6.19) Female gender 183 (70) 784 (45) C.001
symptoms Cardiovascular risk
Clinical and factors
neuroimaging Atrial fibrillation 84 (32) 396 (23) <.002
variablest Nephropathy 8 (3.1) 19(1.1) <.02
Altered 2.3904 0.3848 10.92 (5.14-23.21) Clinical findings
consciousness Altered consciousness 87 (33.2) 318 (18.3) <.001
Limb weakness 2.1017 0.6148 8.18(2.45-27.30) Hemianopia 63 (24) 308 (17.7) c.02
Sensory 1.0762 0.3938 2.93 (1.36-6.35) Aphasiddysarthria 147 (56.1) 833 (47.9) c.02
symptoms Neuroimaging data
Temporal lobe 0.8262 0.3961 2.28(1.05-4.97) Parietal lobe 71 (27) 31 9 (18.4) <.001
involvement involvement
Internal capsule -1.4162 0.5639 0.24(0.08-0.73) Temporal lobe 70 (26.7) 366 (21.l) <.04
involvement involvement
Clinical, Anterior choroidal 6 (2.‘3) 9 (0.5) <.002
neuroimaging, topography
and outcome Atherothrombotic 72 (27.5) 380 (21.9) <.05
variables$ infarction
Cardiac events 2.9854 0.9992 19.79(2.79-140.31) Cardioembolic infarction 64 (24.4) 283 (16.3) <.002
Respiratory 2.7707 0.5202 15.97 (5.76-44.27) 0utcome
events Respiratory 43 (1 6.4) 109 (6.3) <.001
lntraventricular 2.6330 0.8486 13.92(2.64-73.42) complications
hemorrhage Urinary complications 40 (15.3) 145 (8.3) <.001
Altered 1.9241 0.4164 6.85 (3.03-15.49) Infectious 52 (20) 188 (11) <.001
consciousness complications
Sensory 1.5433 0.4400 4.68(1.98-11.09) Mean length hospital 22.03 2 29.6 17.5 t 21.5 <.001
symptoms stay (days)
Parietal lobe 1.0242 0.4327 2.78 (1.19-6.50) Absence of neurologic 56 (21-4) 576 (33) <.001
involvement deficit
In-hospital mortality rate 71 (27) 234 (13.5) <.001
’p = -4.2868; SE (p) = 0.61 17; goodness of fit = 2.86; degrees of freedom =
5; P = ,7213. Figures in parentheses are percentages.
t p = -4.3738; SE (p) = 0.6272; goodness of fit = 3.97; degrees of freedom =
7; P = .7831.
p = -3.8473; SE ( p ) = 0.4539; goodness of fit = 10.53; degrees of freedom = The incidence of cerebrovascular disease rises dramatically
5; P = .0614.
with the oldest old people, who have a twofold to threefold
greater incidence of stroke than do those aged 65 to 74
Table 4 shows in-hospital mortality rates by different years.’ Moreover, care and support of poststroke conditions
stroke subtypes in the group of 262 very old patients and in in this age group have a growing impact on healthcare expen-
the remaining 1738 patients. Mortality rates were signifi- ditures.
cantly greater among very old patients in the case of either In the present study, very old patients with acute stroke
ischemic brain infarction or hemorrhagic stroke as well as in accounted for 13% of the total number of patients, a percent-
the following stroke subtypes: TIA, atherothrombotic in- age greater than those of patients younger than 45 (3.5%)
farct, brain infarction of undetermined origin, and parenchy- and of patients younger than 55 (7.9%) years of age. How-
mal hematoma. ever, despite the importance of studies of those who are aged
85 years or older, these oldest old people are not usually
DISCUSSION analyzed in studies on stroke in older people that are pub-
Stroke was the leading cause of death of the very old in lished in the literature. Some studies have examined patients
Catalonia (6 million inhabitants in northeastern Spain) dur- aged 65 years or older”.’8 or those aged 70 years or old-
ing the period from 1989 to 1993, both among men (16.1%) er. 19-21 Only Asplund et a1.” have studied the characteristics
and women (19.9%).17 On the other hand, in the United of as many as 79 stroke patients aged 85 years or older.
States, as well as in o developed countries, the older Because data from very old patients have not been compiled
population is growing mber. From 1960 to 1990, the in a systematic manner, clinical features, causes of death, and
number of Americans 85 years of age or older increased by predictive factors of early mortality in very old people are
232%, whereas the total population grew by just 39%.’p2 poorly defined.
40 ARBOIXETAL. ~ _ _ _ _ _ JANUARY 2000-VOL. 48, NO.1 JAGS

Table 4. In-Hospital Mortality in Very Old Patients and Those Younger Than 85 Years of Age According to Stroke Subtype

Very Old Younger Than 85 Years of Age

Alive (n = 191) Dead (n = 71) Alive (n = 1504) Dead (n = 234)
Stroke Subtype (%I (%) (%) (%) P Value

Ischemic 171 (75) 56 (25) 1314 (88.5) 171 (11.5) <0.0001

Transient ischemic attack 23 (96) 1 (4Y 215 (100) 0 <0.04
Lacunar 38 (97.4) 1 (2.6) 332 (99) 3 (1) NS
Cardioembolic 45 (70) 19 (30) 206 (73) 77 (27) NS
Atherothrombotic 45 (62.5) 27 (37.5) 314 (82.6) 66 (17.4) <0.0002
Unusual causet 2 (67) 1 (33) 68 (93) 5 (7) NS
Undetermined origin 18 (72) 7 (28) 179 (90) 20 (10) <0.02
Hemorrhagic 20 (57) 15 (43) 190 (75) 63 (25) <0.03
Parenchymal hemorrhage 14 (50) 14 (50) 145 (72) 56 (28) c0.02
Subarachnoid hematoma 2 (67) 1 (37) 26 (81) 6 (19) NS
Subdural hematoma* 4 (100) 0 18 (95) 1 (5) NS
Epidural hematoma* 0 0 1 0 NS
Figures in parentheses are percentages. NS = not significant.
* Sepsis of respiratory origin as the cause of death.
t Horton’s arteritis (n = l ) , cerebral venous thrombosis (n = l),extrinsic compression resulting from a meningioma of the Sylvian region (n = 1).
$ Spontaneous, not resulting from injury.

In this study, very old stroke patients exhibited differ-
ences in clinical profile, with a greater frequency of acute
cerebrovascular events in women (70%) than in men (45%),
which is similar to that observed in the studies of Pohjasvaara
et aLzo (women 58.8%, men 37.9%) and Asplund et aLz2
(women 65%, men 42%).This may be explained by the fact
that women outnumber men by 2.6 to 1, with a life expect-
ancy at the age of 85 of 6.4 years for white women compared
with 5.2 years for white mem2 We also found significant
differences in the profile of cardiovascular risk factors, with a
greater occurrence of atrial fibrillation, heart failure, and
nephropathy in very old people. To our knowledge, a greater
frequency of renal function impairment in very old people has
not been reported previously. This finding, however, is in
agreement with results of the study of Wannamethee et al.,23
who showed that renal impairment in middle-aged men man-
ifested as elevated serum creatinine concentration, which was
a marker for increased risk of cerebrovascular disease in both
normotensive and hypertensive subjects. It is likely that the
elevated creatinine represents the influence of generalized
vascular disease in the kidney. Other relevant clinical findings
in very old people included greater frequency of altered
consciousness, speech disturbances, and hemianopia.
In relation to type of stroke, cardioembolic and athero-
thrombotic infarctions were significantly more frequent in
very old people than in patients younger than 85 years of age,
whereas infarctions of unusual etiology were less common.
The greater frequency of cardioembolic stroke, which is
consistent with the series of Asplund et aLz2and Pohjasvaara
et al.,” may justify, on the one hand, the greater involvement
of parietal and temporal lobes because of a greater predom-
inance of hemispheric involvement of cardioembolic infarcts
and, on the other hand, highlights the need to examine stroke
etiology in older patients to prevent further cardioembolism.
The greater frequency of atherothrombotic stroke may be
explained by the fact that the greater the age is, the more
advanced generalized atherosclerosis and greater frequency
of previous or concomitant underlying conditions there are.
By contrast, cerebral infarction of unusual etiology, which is
a frequent stroke subtype in adults younger than 45 years of
ageYz4was only diagnosed in three patients.
Acute stroke in very old people showed a poorer out-
come than in younger patients, with a lesser frequency of
absence of neurologic deficit at the time of hospital discharge,
longer hospital stays, and greater in-hospital mortality. The
poor prestroke health and greater immediate poststroke dis-
ability among older stroke patients may be the explanation
for their greater m~rtality.~’ The influence of age on mortal-
ity after stroke that was found in the univariate analysis of
this study is consistent with results of other studies.26 Our
mortality rate of 27% is similar to the 25% reported by
Asplund et a1.22 and less than the 39% reported by Lamassa
et aL2’
Eight predictive variables, easily obtainable during a
bedside examination, were independently associated with
in-hospital mortality and included altered consciousness,
limb weakness, sensory symptoms, parietal and temporal
lobe involvement, internal capsule involvement, intraventric-
ular hemorrhage, cardiac events, and respiratory events. In
our study, as in others carried out in acute stroke patients
younger than 85 years of decreased consciousness
was the main clinical predictor of early mortality, followed
by limb weakness and sensory symptoms. With regard to
neuroimaging variables, intraventricular spread of the hem-
orrhage was a significant predictive variable in our model.
This finding has also been documented by An-
other significant variable was the presence of nonlacunar
stroke in the temporal or parietal lobe, which indicates an
ischemic lesion of large size. In the study of Candelise et al.,34
visualization of ischemia in the CT scan was also a significant
predictor of bad prognosis. In contrast, a lesion in the internal
capsule showed a significant protective effect. Capsular in-
farctions are usually caused by lacunar infarcts, a type of
stroke with favorable clinical o ~ t c o m e . ~ ’ - ~ ~
In the model based on clinical, neuroimaging, and out-
come data, the presence of cardiac or respiratory complica-
tions was the main predictor of early mortality in our study,
as was already found by Broderick et al.39and, more recently,
IAGS IANUARY 2000-VOL. 48. NO. 1
by Marini et a1.4’ These findings emphasize the importance of
careful cardiac and respiratory screening in very old patients
with stroke and the early institution of treatment for concur-
rent cardiopulmonary diseases and cardiac and respiratory
events in acute stroke patients. Pickering et al?l indicated
that detection, within 2 weeks of initial stroke, of cardiac
arrhythmias (ventricular premature contractions and atrial
fibrillation) as an independent factor to recurrent stroke or
death may justify intensive cardiac evaluation and closer
monitoring of the cardiac status, as these arrhythmias seem to
portend a poorer prognosis after stroke. Pinto et al.42 also
stated that medical complications are predictors of poor
outcome (Rankin score 2 4). According to the EC Biomed
Stroke Project$3 older patients presented with swallowing
problems and incontinence significantly more often. These
findings are relevant as the majority of medical complications
are potentially treatable conditions whose prevention, early
diagnosis, and aggressive management should be pursued.
Therefore, a correct diagnosis and an appropriate and early
treatment of such complications may decrease mortality and
improve prognosis among very old people. This challenges us
to provide well organized stroke management with early and
active rehabilitation, guidance, and support of older stroke
patients.
ACKNOWLEDGMENTS
We are grateful to M. Balcells and E. Comes for their
valuable participation in the study and to Marta Pulido for
editing the manuscript and for other editorial assistance.
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From the Acute Stroke Unit, Department of Neurology, and the Intensive
Care Unit, Sagrat Cor Hospital of Barcelona, Barcelona, Spain.