Journal of Aging Research

Journal of Aging Research / 2011 / Article
Special Issue

Cerebrovascular Disorders: Role of Aging

View this Special Issue

Review Article | Open Access

Volume 2011 |Article ID 108785 |

Tommasina Russo, Giorgio Felzani, Carmine Marini, "Stroke in the Very Old: A Systematic Review of Studies on Incidence, Outcome, and Resource Use", Journal of Aging Research, vol. 2011, Article ID 108785, 6 pages, 2011.

Stroke in the Very Old: A Systematic Review of Studies on Incidence, Outcome, and Resource Use

Academic Editor: Aurel Popa-Wagner
Received16 May 2011
Accepted25 Jun 2011
Published16 Aug 2011


Background and Purpose. Stroke incidence increases with age and is likely to increase in the aging populations. We investigated incidence, outcome, and resource use in very old subjects with stroke. Methods. We performed a systematic review of available data through electronic search of the literature databases and manual search of reference lists. Data were extracted for the age groups of over 80, 80 to 84 years old, and over 85. Overall incidence rates, expressed as the number of first strokes per 1000 person-years, were estimated using Poisson regression analysis. Odds ratios for the comparisons between subjects over and under 80 were calculated with the Mantel-Haenszel method. Results. We found a high incidence of stroke in the very old. The estimated incidence rates were 20.78 (95% CI 19.69 to 21.87) in subjects over 80, 17.23 (95% CI 15.97 to 18.49) for those 80 to 85 years old, and 20.78 (95% CI 16.74 to 23.78) for those over 85. Subjects over 80 contributed 29.95% of strokes; rates were similar among genders. Thirty-day case fatality rate and occurrence of dependency were higher in subjects over 80, although associated with less frequent hospital and stroke unit admission and less diagnostic resource use. Conclusions. The contribution of very old subjects to the global burden of stroke is relevant and may require efficient dedicated stroke services.

1. Introduction

In many Western countries, subjects in the oldest age classes, usually referred as the oldest old or very old, represent the fastest to growing segment of the population and make a huge contribution to health care costs [1]. Stroke is one of the leading causes of death and of severe disability in most countries, and its incidence increases steeply with age [2]. Thus, in the forthcoming years, stroke may represent a massive epidemic, causing many disabled patients and deaths in Western countries [25]. The availability of data on incidence, classification, and prognosis of stroke in the very old and information on resource use is important to plan health services and to focus treatment strategies. However, studies in the very old are sparse, small, and differing in methodology [4, 635].

We performed a systematic review of the available evidence on incidence, outcome, and resource use of very old people with stroke.

2. Materials and Methods

In the present paper, data were identified by search of Medline and from the references of relevant articles published after 1980. Different subsets of studies were potentially eligible for different parts of this paper. The search terms “stroke”, “isch(a) emic stroke”, “intracerebral”, “intraparenchymal”, “subarachnoid”, “h(a) emorrhage” were firstly used. Then the search was refined by applying any of the following terms: “population-based”, “community-based”, “community”, “epidemiology”, “epidemiological”, “incidence”, “occurrence”, “survey”, “surveillance”, “prognosis”, “outcome”, “management”, and “resource use”. Lastly the terms “very old”, “oldest old”, “very elderly”, and “over 80” were applied for the final search refinement. Only papers published in English were reviewed. The reference list of the identified papers were also manually searched. Stroke had to be defined according to the WHO definition, that is, the occurrence of rapidly developing signs of focal or global disturbance of cerebral function, lasting longer than 24 hours or leading to death, with no apparent cause other than that of vascular origin [36].

Two of the authors reviewed all selected papers reporting data on occurrence, management, and outcome of stroke in subjects over 80 years of age, 80 to 85 years old, or over 85 years. Data on absolute and relative incidence of stroke, stroke type and demographics, outcome, diagnostic procedures, and treatment were assessed. Any repeated reporting of the same study was excluded, so that each data set was considered only once. Population-based studies performed in different period on the same population were considered only once, by using the final data assessment. Stroke type classification was considered only in those studies where CT, MRI, or autopsy findings were available for at least 80% of stroke cases. Strokes were classified into four major types: ischemic stroke (if CT or MRI within 30 days of stroke showed infarct or no relevant lesion and/or autopsy showed ischemic stroke), primary intracerebral haemorrhage (if shown on CT, MRI, or autopsy), subarachnoid haemorrhage (classified by characteristic findings in CSF analysis and/or autopsy, CT, or cerebral angiography), and undetermined stroke (no CT, MRI, autopsy, cerebral angiography, or (for subarachnoid haemorrhage only) CSF examination was done).

The incidence of first ever stroke was calculated per 1,000 person-years. Poisson regression analysis was used to compare incidence rates from different studies. Fitted values were assumed as the best estimate of the true stroke incidence in the very old. Odds ratios with 95% confidence intervals (95% CI) were calculated for mortality, dependency at the modified Rankin scale (mRS), and healthcare resource use with the Mantel-Haenszel method. Sensitivity analysis was performed by excluding those studies that produced a significant deviance change when removed from the model. Since only few studies used the classical cutoff of age 80, results were presented separately for subjects over 80, 80 to 84 years old, and over 85.

3. Results

Sixteen studies reporting data on stroke incidence in the very old were identified including altogether 2406 patients 80 years old or older with a stroke occurring over 114,074 person-years at risk. Incidence rates and confidence intervals are reported in Table 1. Only two studies reported incidence data in subjects over 80 (estimated overall incidence rate of 20.78 per 1,000 person-year; 95% CI 19.69 to 21.87), and three studies reported incidence in people aged 80 to 84 years (overall incidence 17.23/1,000; 95% CI 15.97 to 18.49). In both analyses, there was a significant heterogeneity ( ). Incidence in people over 85 was reported by 15 studies, with a significant variability among studies ( ) and rates ranging between 10.34 and 33.48 per 1,000 person-year; the estimated overall incidence rate was 20.78/1000; 95% CI 16.74 to 23.78.

StudyRate 100095% CIM/F% very old

Age over 80 years
Overall 20.7819.6921.871.0329.95

Heterogeneity ;

Age 80–84 years
Overall 17.2315.9718.491.1515.21

Heterogeneity ;

Age over 85 years
 Auckland 199119.1315.9122.350.6217.34
Overall 20.7816.7423.781.0716.78

Heterogeneity ;

Incidence was almost similar between men and women in the considered age classes of very old people (Table 1). About one-third (29.95%) of strokes occurred in subjects over 80, 15.21% between 80 and 84 years of age, and 16.78% in those over 85.

The distribution of stroke type was reported by 6 studies (Table 2). The estimated overall occurrence rates indicated that the great majority of subjects suffered from an ischemic stroke (88.27%); intracerebral hemorrhage occurred in a proportion of subjects (11.17%) similar to that of all ages subjects (13.43), while subarachnoid hemorrhage was quite rare in the very old (0.55%).

%95% CI%95% CI%95% CI


Heterogeneity ;

Overall all ages83.7513.432.82

Stroke outcome in oldest subjects was reported by two population-based and three hospital-based studies. Thirty-day case fatality rates and the proportion of dependent subjects (modified Rankin scale > 2) were reported in Figure 1. Mortality was consistently higher among subjects over 80 as compared to subjects under 80 (OR 3.07; 95% CI 2.81 to 3.35). The proportion of dependent subjects was also significantly higher among subjects over 80 in all studies, but in the L’Aquila stroke registry, with an overall OR of 1.77 (95% CI 1.57 to 1.99).

Sparse data are available on resource use by very old subjects with acute stroke (Figure 2). However, in the majority of studies, there was a general tendency to lower use of healthcare resources in subjects over 80, with a tendency to less frequent hospital and stroke unit admission and less frequent neuroimaging Doppler sonographic, echocardiographic, and angiographic studies.

4. Discussion

Data on stroke incidence, clinical and demographic characteristics, and healthcare resource use in the very old are scarce and often inconsistent. The age cut-off of 80 years was close to the average life expectancy in many Western countries and was crucial, considering the sharp drop in the general population after that age [1, 34]. However, only a few studies reported incidence of stroke in patients over 80. On the other hand, there were only moderate differences in the incidence rates among subjects 80 to 84 years old and those over 85. In fact, incidence of stroke was very high in subjects 80 to 84 years old (17.23/1,000) as well as in those over 85 (20.78/1,000).

There is a considerable heterogeneity among incidence rates in different studies. The lowest rate was reported by the study performed in Basle where death certificates were not directly searched [20]. Though lifestyle characteristics of the population and risk factors control might have influenced incidence in the elderly in different studies, rising important clues on the implementation of preventive measures, the play of competing risks in subjects over 85 and of end-cohort effects might also explain most of the differences.

As strongly recommended by several authors, we analyzed incidence of first-ever stroke only, since the inclusion of subsequent strokes, occurring in a highly selected population of stroke survivors, may produce highly biased results [37]. However, in order to estimate the true occurrence of any stroke, either first or recurrent, a 30% of events should be added, producing even more impressing incidence rates in the very old [17].

According to our estimates, subjects over 80 years of age contributed almost one third of all strokes pointing out that this small segment of the resident populations makes a relevant contribution to the global burden of stroke. Moreover, although stroke incidence is similar in very old men and women, because of the higher proportions of women in these age classes, women are likely to be responsible for an increasing number of stroke admissions in many countries with a rapidly aging population [13, 5, 34].

Besides, despite 30-day case fatality rate was much higher in subjects over 80 than in younger subjects (OR 3.07), surviving patients still showed a higher risk of dependency after stroke (OR 1.77). Therefore, very old people also contribute to stroke costs that are likely to increase as general populations get older.

In the available studies, there is a clear tendency to a lower resource use, balancing the tendency to higher costs of stroke in the very old [8, 19, 30, 32, 33]. This tendency may depend on different attitudes and traditions in health care utilization leading to inequalities in the access to health care resources, rather than on fewer requirements and may rise some ethical concern unless adequately prevented. Ad hoc services and dedicated access routes may be useful to reduce inequalities in resource use and to improve health services for the very old.

In conclusion, stroke in the very old is a very frequent condition with an unfavourable outcome, make a relevant contribution to the social burden of stroke, and may require more efficient, dedicated stroke services.


  1. A. Di Carlo, M. Lamassa, G. Pracucci et al., “Stroke in the very old: clinical presentation and determinants of 3-month functional outcome: a European perspective,” Stroke, vol. 30, no. 11, pp. 2313–2319, 1999. View at: Google Scholar
  2. C. Marini, L. Triggiani, N. Cimini et al., “Proportion of older people in the community as a predictor of increasing stroke incidence,” Neuroepidemiology, vol. 20, no. 2, pp. 91–95, 2001. View at: Publisher Site | Google Scholar
  3. C. J. L. Murray and A. D. Lopez, “Alternative projections of mortality and disability by cause 1990–2020: global burden of disease study,” The Lancet, vol. 349, no. 9064, pp. 1498–1504, 1997. View at: Publisher Site | Google Scholar
  4. R. Bonita, J. B. Broad, and R. Beaglehole, “Changes in stroke incidence and case-fatality in Auckland, New Zealand, 1981–91,” The Lancet, vol. 342, no. 8885, pp. 1470–1473, 1993. View at: Publisher Site | Google Scholar
  5. M. G. Bousser, “Stroke in women: the 1997 Paul Dudley White International Lecture,” Circulation, vol. 99, no. 4, pp. 463–467, 1999. View at: Google Scholar
  6. R. D. Brown, J. P. Whisnant, J. R. D. Sicks, W. M. O'Fallon, and D. O. Wiebers, “Stroke incidence, prevalence, and survival: secular trends in Rochester, Minnesota, through 1989,” Stroke, vol. 27, no. 3, pp. 373–380, 1996. View at: Google Scholar
  7. M. Giroud, P. Beuriat, P. Vion, P. H. D'Athis, L. Duserre, and R. Dumas, “Stroke in a French prospective population study,” Neuroepidemiology, vol. 8, no. 2, pp. 97–104, 1989. View at: Google Scholar
  8. A. Carolei, C. Marini, M. Di Napoli et al., “High stroke incidence in the prospective community-based L'Aquila registry (1994–1998): first year's results,” Stroke, vol. 28, no. 12, pp. 2500–2506, 1997. View at: Google Scholar
  9. H. Ellekjær, J. Holmen, B. Indredavik, and A. Terent, “Epidemiology of stroke in innherred, Norway, 1994 to 1996: incidence and 30-day case-fatality rate,” Stroke, vol. 28, no. 11, pp. 2180–2184, 1997. View at: Google Scholar
  10. C. S. Anderson, K. D. Jamrozik, P. W. Burvill, T. M. H. Chakera, G. A. Johnson, and E. G. Stewart-Wynne, “Ascertaining the true incidence of stroke: experience from the Perth Community Stroke Study, 1989–1990,” Medical Journal of Australia, vol. 158, no. 2, pp. 80–84, 1993. View at: Google Scholar
  11. G. Lauria, M. Gentile, G. Fassetta et al., “Incidence and prognosis of stroke in the Belluno Province, Italy: first- year results of a community-based study,” Stroke, vol. 26, no. 10, pp. 1787–1793, 1995. View at: Google Scholar
  12. J. Bamford, P. Sandercock, M. Dennis, J. Burn, and C. Warlow, “A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project—1981–86. 2. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrhage,” Journal of Neurology Neurosurgery and Psychiatry, vol. 53, no. 1, pp. 16–22, 1990. View at: Google Scholar
  13. G. D'Alessandro, M. Di Giovanni, L. Roveyaz et al., “Incidence and prognosis of stroke in the Valle d'Aosta, Italy: first-year results of a community-based study,” Stroke, vol. 23, no. 12, pp. 1712–1715, 1992. View at: Google Scholar
  14. P. Jerntorp and G. Berglund, “Stroke registry in Malmö, Sweden,” Stroke, vol. 23, no. 3, pp. 357–361, 1992. View at: Google Scholar
  15. B. S. Hansen and J. Marquardsen, “Incidence of stroke in Frederiksberg, Denmark,” Stroke, vol. 8, no. 6, pp. 663–665, 1977. View at: Google Scholar
  16. H. S. Jørgensen, A. M. Plesner, P. Hübbe, and K. Larsen, “Marked increase of stroke incidence in men between 1972 and 1990 in Frederiksberg, Denmark,” Stroke, vol. 23, no. 12, pp. 1701–1704, 1992. View at: Google Scholar
  17. S. Ricci, M. G. Celani, F. La Rosa et al., “SEPIVAC: a community-based study of stroke incidence in Umbria, Italy,” Journal of Neurology Neurosurgery and Psychiatry, vol. 54, no. 8, pp. 695–698, 1991. View at: Google Scholar
  18. B. Norrving and P. Löwenhielm, “Epidemiology of stroke in Lund-Orup, Sweden, 1983–85. Incidence of first stroke and age-related changes in subtypes,” Acta Neurologica Scandinavica, vol. 78, no. 5, pp. 408–413, 1988. View at: Google Scholar
  19. A. Di Carlo, M. Baldereschi, C. Gandolfo et al., “Stroke in an elderly population: incidence and impact on survival and daily function: the Italian Longitudinal Study on Aging,” Cerebrovascular Diseases, vol. 16, no. 2, pp. 141–150, 2003. View at: Publisher Site | Google Scholar
  20. M. Gostynski, S. Engelter, S. Papa, V. Ajdacic-Gross, F. Gutzwiller, and P. Lyrer, “Incidence of first-ever ischemic stroke in the Canton Basle-City, Switzerland: a population-based study 2002/2003,” Journal of Neurology, vol. 253, no. 1, pp. 86–91, 2006. View at: Publisher Site | Google Scholar
  21. P. M. Rothwell, J. Coull, M. F. Giles et al., “Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study),” The Lancet, vol. 363, no. 9425, pp. 1925–1933, 2004. View at: Publisher Site | Google Scholar
  22. R. L. Sacco, B. Boden-Albala, R. Gan et al., “Stroke incidence among white, black, and Hispanic residents of an urban community: the Northern Manhattan Stroke Study,” American Journal of Epidemiology, vol. 147, no. 3, pp. 259–268, 1998. View at: Google Scholar
  23. P. Harmsen, L. Wilhelmsen, and A. Jacobsson, “Stroke incidence and mortality rates 1987 to 2006 related to secular trends of cardiovascular risk factors in Gothenburg, Sweden,” Stroke, vol. 40, no. 8, pp. 2691–2697, 2009. View at: Publisher Site | Google Scholar
  24. P. L. Kolominsky-Rabas, C. Sarti, P. U. Heuschmann et al., “A prospective community-based study of stroke in Germany—the Erlangen stroke project (ESPro): incidence and case fatalità at 1, 3, and 12 months,” Stroke, vol. 29, no. 12, pp. 2501–2506, 1998. View at: Google Scholar
  25. D. Christie, “Stroke in Melbourne, Australia: an epidemiological study,” Stroke, vol. 12, no. 4, pp. 467–469, 1981. View at: Google Scholar
  26. V. L. Feigin, D. O. Wiebers, Y. P. Nikitin, W. M. O'Fallon, and J. P. Whisnant, “Stroke epidemiology in Novosibirsk, Russia: a population-based study,” Mayo Clinic Proceedings, vol. 70, no. 9, pp. 847–852, 1995. View at: Google Scholar
  27. U. Löfmark and A. Hammarström, “Evidence for age-dependent education-related differences in men and women with first-ever stroke: results from a community-based incidence study in northern Sweden,” Neuroepidemiology, vol. 28, no. 3, pp. 135–141, 2007. View at: Publisher Site | Google Scholar
  28. K. N. Vemmos, M. L. Bots, P. K. Tsibouris et al., “Stroke incidence and case fatality in southern Greece: the Arcadia stroke registry,” Stroke, vol. 30, no. 2, pp. 363–370, 1999. View at: Google Scholar
  29. J. Addo, A. Bhalla, S. Crichton, A. G. Rudd, C. McKevitt, and C. D. Wolfe, “Provision of acute stroke care and associated factors in a multiethnic population: prospective study with the South London Stroke Register,” BMJ, vol. 342, d744 pages, 2011. View at: Publisher Site | Google Scholar
  30. K. D. Palnum, P. Petersen, H. T. Sørensen et al., “Older patients with acute stroke in Denmark: quality of care and short-term mortality. A nationwide follow-up study,” Age and Ageing, vol. 37, no. 1, pp. 90–95, 2008. View at: Publisher Site | Google Scholar
  31. N. K. Mishra, N. Ahmed, G. Andersen et al., “Thrombolysis in very elderly people: controlled comparison of SITS international stroke thrombolysis registry and virtual international stroke trials archive,” BMJ, vol. 341, Article ID c6046, 2010. View at: Publisher Site | Google Scholar
  32. A. G. Rudd, A. Hoffman, C. Down, M. Pearson, and D. Lowe, “Access to stroke care in England, Wales and Northern Ireland: the effect of age, gender and weekend admission,” Age and Ageing, vol. 36, no. 3, pp. 247–255, 2007. View at: Publisher Site | Google Scholar
  33. G. Saposnik, S. E. Black, A. Hakim, J. Fang, J. V. Tu, and M. K. Kapral, “Age disparities in stroke quality of care and delivery of health services,” Stroke, vol. 40, no. 10, pp. 3328–3335, 2009. View at: Publisher Site | Google Scholar
  34. C. Marini, M. Baldassarre, T. Russo et al., “Burden of first-ever ischemic stroke in the oldest old: evidence from a population-based study,” Neurology, vol. 62, no. 1, pp. 77–81, 2004. View at: Google Scholar
  35. L. Denti, U. Scoditti, C. Tonelli et al., “The poor outcome of ischemic stroke in very old people: a cohort study of its determinants,” Journal of the American Geriatrics Society, vol. 58, no. 1, pp. 12–17, 2010. View at: Publisher Site | Google Scholar
  36. K. Aho, P. Harmsen, S. Hatano et al., “Cerebrovascular disease in the community: results of a WHO collaborative study,” Bulletin of the World Health Organization, vol. 58, no. 1, pp. 113–130, 1980. View at: Google Scholar
  37. C. Sudlow and C. P. Warlow, “Comparing stroke incidence worldwide what makes studies comparable?” Stroke, vol. 27, no. 3, pp. 550–558, 1996. View at: Google Scholar

Copyright © 2011 Tommasina Russo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Related articles

No related content is available yet for this article.
 PDF Download Citation Citation
 Download other formatsMore
 Order printed copiesOrder

Related articles

No related content is available yet for this article.

Article of the Year Award: Outstanding research contributions of 2020, as selected by our Chief Editors. Read the winning articles.