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Received 5 March 2003; accepted in revised form August 2003
Age and Ageing 2004; 33: 149–154
DOI: 10.1093/ageing/afh052
Published by Oxford University Press
Short- and long-term prognosis for very old
stroke patients. The Copenhagen Stroke Study
LARS PETER KAMMERSGAARD1, H. S. JØRGENSEN2, J. REITH2, H. NAKAYAMA2, P. M. PEDERSEN2, T. S. OLSEN1
1
Stroke Unit, Hvidovre University Hospital, Copenhagen, Denmark
Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
2
Address correspondence to: L. P. Kammersgaard, Department of Neurology, Bispebjerg Hospital, Bispebjerg Bakke 23,
DK-2400 Copenhagen, Denmark. Fax: (+45) 3531 3957. Email: [email protected]
Abstract
Background and purpose: the very old are expected to become a growing part of the stroke population in the industrialised
part of the world. The aims of this study were to evaluate clinical characteristics of patients aged 85 years or more at stroke
onset and to investigate very old age as an independent predictor of short- and long-term outcome.
Methods: in the community-based Copenhagen Stroke Study we recorded admission clinical characteristics in 1,197 consecutive stroke patients. Patients were stratiWed according to age groups on admission. Follow-up was performed at a mean of
7 years after stroke onset. By way of multiple logistic regression and survival analyses very old age was independently related
to short- and long-term mortality and nursing home placement independent of other clinical characteristics.
Results: 16% of patients were 85 years or older at the time of stroke onset. More of the very old were women (75% versus 50%,
P<0.0001), living alone (84% versus 54%, P<0.0001), had atrial Wbrillation (37% versus 15%, P<0.0001), had pre-existing disability (29% versus 22%, P = 0.04), and had more severe strokes (Scandinavian Stroke Scale score 31 versus 37 points, P = 0.004).
149
L. P. Kammersgaard et al.
Fewer very old had hypertension (25% versus 34%, P = 0.02) and diabetes (14% versus 22%, P = 0.01). In adjusted multiple
regression models, very old age predicted short-term mortality (OR 2.5; 95% CI 1.5–4.2), and discharge to nursing home or
in-hospital mortality (OR 2.7; 95% CI 1.7–4.4). Five years after stroke very old age predicted mortality or nursing home
placement (OR 3.9; 95% CI 2.1–7.3), and long-term mortality (HR 2.0; 95% CI 1.6–2.5). However, other factors such as
onset stroke severity, pre-existing disability and atrial Wbrillation were also signiWcant independent predictors of prognosis
after stroke.
Conclusions: in this study very old age per se was a strong predictor of outcome and mortality after stroke. Apart from very
old age, factors such as prestroke medical and functional status, and onset stroke severity should be taken into consideration
when planning treatment and rehabilitation after stroke.
Keywords: stroke, elderly, prognosis
Introduction
In developed countries the proportion of elderly people
reaching advanced age is expected to increase substantially
in coming years [1]. Furthermore, it is a widely held notion
that very old stroke patients have a poorer prognosis than
younger ones simply because of older age.
Few recent studies have focused on clinical characteristics
and short-term prognosis of very old stroke patients. In one
study of a population-based sample of nearly 1,000 patients it
was reported that stroke patients aged 85 years or more had
a doubled 30-day case-fatality, and that very old age was
a predictor of mortality independent of other clinical characteristics [2]. In another larger European sample of 4,499 stroke
patients, old age (≥80 years) was associated with a higher
mortality, increased disability and handicap three months after
onset [3]. But, in the latter study pre-stroke health, medical
condition, and the severity of the stroke appeared to be the
major determinants of outcome. Other authors have conWrmed the association between older age and a poorer prognosis post stroke [4]. However, in all studies no validated
neurological or functional scores were used, and prognosis
beyond the Wrst 3 months after onset in the very old stroke
patients was not considered.
Previous reports of very old age and long-term outcome
after stroke are scant. The Perth Community Stroke Study
reported age to be associated with increased long-term mortality, but in this study very old age was not particularly
studied [5]. In the Auckland Stroke Study long-term very
old (≥85 years) stroke survivors were found to have poorer
basic activities of daily living after 6 years when compared
with age-matched control subjects [6].
In this study we investigated the inXuence of very old
age on short- and long-term prognosis. In the investigation
we adjusted for basic clinical characteristics and stroke
severity at onset in order to study the independent inXuence
of very old age on the prognosis after stroke.
Methods
We included all patients with acute stroke admitted consecutively during a 25-month period in the years 1991–1993 to
the stroke unit at Bispebjerg Hospital, Copenhagen, Denmark.
The study is prospective and community-based as has
150
previously been described in detail [7, 8]. Hospital care is
free, and a very high proportion (88%) of the stroke patients
in the area were admitted to this hospital serving a welldeWned catchment area of nearly 240,000 inhabitants in the
city of Copenhagen [9]. No selection of patients was
performed with regard to age, severity of stroke, or medical
condition before admission. All treatment, rehabilitation,
and diagnostic procedures were performed within the stroke
unit. Patients were not discharged before the rehabilitation team decided that no further in-hospital improvement
could be expected. Therefore, no referral to other departments or hospitals for further rehabilitation was necessary.
Stroke was deWned according to the World Health
Organisation criteria [10]. The study does not include
patients with TIAs or subarachnoid haemorrhage. The
Scandinavian Stroke Scale (SSS) was used to assess neurological deWcit [11]. The SSS evaluates level of consciousness,
eye movement, power in arm, hand, and leg, orientation,
aphasia, facial paresis, and gait on a total score from 0 (worst)
to 58 (best) [12]. The score was recorded on admission,
weekly during hospital stay and at discharge by the same
neurologist (HSJ). At the visit for long-term follow-up, data
were prospectively recorded by another experienced neurologist (LPK) who was blinded to data obtained on admission.
For classiWcation of stroke subtype (haemorrhage or
infarction) CT was performed with a Siemens Somatom DR
scanner and the same experienced CT-scan reader read the
scans.
The following prognostic factors were investigated in
the statistical analyses: age groups (<85 years versus ≥85
years), gender, initial stroke severity (SSS), time from stroke
onset to admission, diabetes, atrial Wbrillation, ischaemic
heart disease (IHD), hypertension, claudication, previous
stroke or TIA, pre-existing disability, daily alcohol consumption and smoking. The same neurologist (HSJ) assessed all
clinical characteristics.
Diabetes was considered present if a patient had known
diabetes on admission or if plasma glucose >11 mmol/L on
admission or during the hospital stay. Atrial Wbrillation was
diagnosed if present on admission electrocardiogram. Information concerning other disabling disease was obtained on
admission and included disabling diseases other than previous
stroke (e.g. amputation, multiple sclerosis, severe dementia,
heart failure, latent or persistent respiratory insufWciency).
Short- and long-term prognosis for stroke patients
Ischaemic heart disease was present if a patient had a history
of IHD, or had IHD diagnosed during the hospital stay.
Hypertension was present if a patient received antihypertensive
treatment before admission, or if hypertension was diagnosed during hospital stay by repeated detection of blood
pressure ≥160/95 mmHg. Smoking was coded if a patient
smoked any kind of tobacco on a daily basis. Ex-smokers
were coded as non-smokers.
Follow-up
A follow-up was performed for all patients at a mean of 7 years
after stroke onset. For the patients who had died information on date of death and place of stay 5 years after stroke
onset (own home or nursing home) was obtained from the
Danish Central Registry of Persons. Through a 10-digit
identiWcation code that is unique for the individual person
and contains information about birth date, all persons staying
in Denmark can be tracked with regard to mortality data
and address. The follow-up was performed during the year
1999 ending 29 December (censoring date).
Outcome
Short-term outcome and mortality was recorded in two
ways: either as death during hospital stay, or the combined
outcome discharge rate to nursing home or death during
hospital stay. Long-term outcome was recorded as nursing
home resident or death 5 years after stroke onset.
Statistical analyses
Statistical analyses were performed with the SPSS statistical
package [13]. Univariate analyses were performed by nonparametric statistics because not all variables had a normal
distribution. The Mann–Whitney U test was used for continuous variables and Fisher’s exact test was used for categorical
values.
To Wnd independent predictors of short- and long-term
outcome, multiple logistic regression models were used,
because very old age was not the only factor being tested
[14]. All variables (including age groups) were entered in the
initial model and then removed by backward stepwise selection. Removal testing was based on the probability of the
Wald statistic. All variables with a P value >0.10 were then
excluded, and the analyses were then performed again on
the new model by the same procedure subsequently leaving
a Wnal model. To Wnd independent predictors of long-term
mortality a Cox proportional hazard model was built. Again,
backward stepwise model selection was used. To assess
whether the baseline hazard functions were proportional logminus-log plots were performed for each variable. The required
two-tailed level of signiWcance for all tests was set at 0.05.
The study was approved by the Ethics Committee of
Frederiksberg and Copenhagen, approval numbers KF/
V.100.2263/91 and KF 01–287/98.
Results
This study includes 1,197 patients with completed stroke.
Follow-up was performed at a mean of 84 (SD 7.9) months
after onset. Data on mortality and date of death were
recorded for all patients except for four patients no longer
living in Denmark.
Clinical characteristics
Table 1 gives the basic clinical characteristics of all patients.
Sixteen per cent were 85 years or older at stroke onset. Most
of the very old were women, were living alone, had atrial
Wbrillation, and had pre-existing disabling disease. Patients
aged <85 years more frequently had a daily intake of alcohol,
were daily smokers, had arterial hypertension, and diabetes.
In very old patients, strokes were rated as more severe as
measured by the SSS score.
Outcome
Among the very old, more patients were discharged to nursing
homes or died during hospital stay after stroke, 58.6% versus
31.2%, P < 0.0001. When analysed by adjusted multiple
logistic regression, independent predictors of death during
hospital stay or discharge to nursing home were very old age
(OR 2.7; 95% CI 1.7–4.4, P = 0.0001), admission stroke
Table 1. Basic characteristics
≥85
<85
P-value
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No of patients (%)
Age, years (SD)
Gender, female (%)
Time from onset to admission, days (SD)
Initial stroke severity (SD)
Living alone (%)
Daily alcohol intake (%)
Smoking (%)
Cerebral haemorrhage (%)
Atrial Wbrillation (%)
Ischaemic heart disease (%)
Hypertension (%)
Diabetes (%)
Previous stroke (%)
Previous TIA (%)
Claudication (%)
Pre-existing disability (%)
191 (16.0)
88.0 (2.8)
144/191 (75.4)
2.7 (8.3)
30.9 (17.1)
152/182 (83.5)
23/145 (15.9)
26/146 (17.8)
9/135 (6.7)
71/190 (37.4)
44/167 (26.3)
44/174 (25.3)
25/182 (13.7)
43/173 (24.9)
20/163 (12.3)
17/155 (11.0)
50/175 (28.6)
1006 (84.0)
71.7 (10.1)
506/1006 (50.3)
2.9 (9.8)
36.9 (17.3)
519/970 (53.5)
287/856 (33.5)
424/850 (49.9)
67/840 (8.0)
145/955 (14.6)
215/948 (22.7)
326/949 (34.4)
216/981 (22.0)
222/965 (23.0)
104/932 (11.2)
124/903 (13.7)
209/973 (21.5)
<0.0001
<0.0001
0.85
0.004
<0.0001
<0.0001
<0.0001
0.60
<0.0001
0.30
0.02
0.01
0.60
0.68
0.35
0.04
151
L. P. Kammersgaard et al.
severity (OR 2.7 per 10 point decrease in SSS score; 95% CI
2.3–3.1, P < 0.0001) and pre-existing disability (OR 2.1;
95% CI 1.4–3.2, P = 0.0006) (Table 2).
In-hospital mortality rate for the very old was 35.6%
versus 18.1% for the younger patients, P < 0.0001. By an
adjusted multiple logistic regression model for the dependent
variable death during hospital stay we found that the
independent predictors were very old age (OR 2.5; 95% CI
1.5–4.2, P = 0.0006) and admission stroke severity (OR 2.3
per 10 point decrease in SSS score; 95% CI 2.0–2.6,
P < 0.0001).
More very old patients were nursing home residents or
had died 5 years after stroke onset, 91.6% versus 67.6%,
P < 0.0001. In a multiple regression model, independent
predictors for long-term nursing home living or death were
very old age (OR 3.9; 95% CI 2.1–7.3, P = 0.04), stroke
severity on admission (OR 1.9 per 10 point decrease in SSS
score; 95% CI 1.7–2.3, P < 0.0001), atrial Wbrillation (OR
2.2; 95% CI 1.2–3.8, P = 0.006), and pre-existing disability
(OR 2.8; 95% CI 1.8–4.3, P = 0.001).
From Figure 1 it is evident that the mortality among the
very old is much higher all through the observation period.
The number of survivors is presented for different time
points along the x-axis. In order to adjust for differences in
the basic characteristics between the two groups we
performed Cox proportional hazard analyses. As given in
Table 3, we found that independent predictors of long-term
mortality were very old age [hazard ratio (HR) 2.0; 95% CI
1.6–2.5, P < 0.0001], stroke severity on admission (HR 1.4
per 10 point decrease in SSS score; 95% CI 1.3–1.5,
P < 0.0001) and atrial Wbrillation (HR 1.3; 95% CI 1.0 to 1.6,
P = 0.03).
Table 2. Multiple logistic regression analyses (Wnal models) of stroke outcomes and mortality
Dependent variable
Covariate
P
OR
95% CI
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Death during hospital stay or discharge to nursing home
Very old age
Stroke severity per 10 point decrease
Pre-existing disability
0.0001
< 0.0001
0.0006
2.7
2.7
2.1
1.7–4.4
2.3–3.1
1.4–3.2
Death during hospital stay
Very old age
Stroke severity per 10 point decrease
Ischaemic heart disease
0.0006
< 0.0001
0.07
2.5
2.3
1.8
1.5–4.2
2.0–2.6
0.8–3.3
Nursing home resident or death within 5 years after stroke
Very old age
Stroke severity per 10 point decrease
Atrial Wbrillation
Pre-existing disability
0.04
< 0.0001
0.006
0.001
3.9
1.9
2.2
2.8
2.1–7.3
1.7–2.3
1.2–3.8
1.8–4.3
Values of signiWcance, odds ratios, and its conWdence intervals are given for covariates, which were in the Wnal models. The value of correct classiWcation for ‘death
during hospital stay or discharge to nursing home’ was 88%, for ‘death during hospital stay’ 92%, and for ‘nursing home resident or death within 5 years after
stroke’ 79%. Overall chi-squares for all models were <0.0001.
Figure 1. Kaplan-Meier cumulative survival plots for months after stroke onset. Vertical axis gives cumulative survival, horizontal
axis gives number of months after stroke onset. Age groups: patients ≥85 years (broken line); patients <85 years (solid line);
P < 0.001 (Log rank test). Numbers in brackets denote the number of survivors.
152
Short- and long-term prognosis for stroke patients
Table 3. Cox proportional hazard analysis: (n = 904)
Dependent
variable
Covariate
P
HR
95% CI
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mortality
Very old age
Stroke severity per
10 point decrease
Atrial Wbrillation
<0.0001
2.0
1.6–2.5
<0.0001
0.03
1.4
1.3
1.3–1.5
1.0–1.6
Values of signiWcance, hazard ratios, and its conWdence intervals are given for
covariates, which were in the Wnal model. The overall chi-square for the model
was <0.0001.
Discussion
This study includes data on both short- and long-term outcome in a large unselected cohort of stroke patients. Data
on mortality and nursing home use was available for as long
as 5 years after stroke onset. Furthermore, we measured stroke
severity by a widely used and well-validated score system.
We found only three previous studies dedicated to compare clinical characteristics and outcome between older and
younger stroke patients [2–4]. However, none of these studies
used validated reproducible neurological scores of stroke
severity.
The life expectancy in the developed countries will
increase in the years to come and the elderly will constitute a
still larger part of the population. Hence, it will be still more
important to be able to predict prognosis in the elderly
stroke population.
Very old age was found to be associated with more
severe strokes, being female, having atrial Wbrillation, and
pre-existing disability. Hypertension and diabetes were less
often seen in the very old. The higher frequency of atrial
Wbrillation, a possible source of large emboli, may be one
explanation for more severe strokes among the very old
[15]. In accordance with our Wndings one study suggested
that the more severe strokes among the very old were due to
a shift from stroke caused by hypertensive arterial disease in
the young towards cardioembolic strokes in the very old [2].
Much in line with previous studies women comprised a
larger proportion of the very old in this study [3]. We found
that the frequencies of hypertension, diabetes, and smoking
were signiWcantly lower among the very old stroke patients.
This is most probably explained by a selection of patients
without these risk factors reaching advanced age.
In the present study we measured short-term outcome
in two different ways: discharge rate to nursing home, and
in-hospital mortality. Very old age was a strong independent
predictor of both outcomes. Apart from very old age other
factors contributed to poor short-term outcome in this
cohort of stroke patients. Factors such as onset stroke
severity and pre-existing disability appear to be equally as
important. These results are to some extent much in line
with previous Wndings that the reasons for the poorer shortterm prognosis in older stroke patients appear to be prestroke dependence and the severity of stroke rather than
just older age per se [2–4]. In the Framingham study population that did not exclusively investigate very old aged, acute
survival was inXuenced negatively as age increased when
corrected for stroke type and severity [16]. Similar results
for age speciWc short-term mortality were later found in
other population-based studies [17, 18].
We found only one study of long-term mortality and
very old age years after stroke in the existing literature [19].
In the Oxfordshire Community Stroke project older
patients had a worse absolute survival, but the results were
not adjusted for other basic characteristics. The Perth
Community Stroke Study found age to be associated with
increased mortality in a Wnal multivariate model for death
from any cause [5]. In the present study almost 10% of the
patients aged ≥85 years were still alive and living in their
own home 5 years after stroke onset. Furthermore, other
factors such as onset stroke severity, atrial Wbrillation, and
pre-existing disability also seem to be independent predictors of long-term outcome. When looking exclusively at
long-term mortality, the survival curve for the very old
patients continued to have a steeper slope. But this is not just
because of very old age per se. After adjustment for all factors,
long-term survival also depends on onset stroke severity, and
atrial Wbrillation; Wndings that are much in line with those
reported by Jamrozik et al. [5].
One major limitation of the present study is that we did
not monitor factors such as recurrent strokes or other cardiovascular events between inclusion and follow-up. Second,
we were not able to detect causes of mortality for those who
died. And third, even though the total number of patients
included was large, only 16% of our patients were ≥85 years
at the time of stroke onset.
Overall, very old age is a strong and independent predictor of both short- and long-term prognosis. But the prognosis
for very old aged stroke patients also depends largely on
their pre-stroke medical condition and some may be as likely
to beneWt from treatment as the younger. The prognosis for
the very old after stroke is not uniformly dismal: focus on
the treatment of other factors may improve prognosis.
Key points
• Clinical characteristics and risk factor proWle among very
old stroke patients.
• The prognostic signiWcance of being ‘very old’.
• Short- and long-term prognosis for very old stroke patients.
Acknowledgements
The authors are grateful for the enthusiastic and dedicated
support from Nurse Anja Andersson and Secretary Birgitte
Thaissen from the Department of Neurology, Bispebjerg
Hospital without whom this study would not have been
possible.
Funding
Supported by grants from the Danish Health Foundation,
the Danish Heart Foundation, Ebba Celinders Foundation,
the Independent Order of Odd Fellows, Scandinavia Lodge 2
and HjerneSagen.
153
J. L. Madsen, J. Graff
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Received 24 September 2002; accepted in revised form 12 September
2003
Age and Ageing Vol. 33 No. 2  British Geriatrics Society 2004; all rights reserved
Effects of ageing on gastrointestinal
motor function
JAN L. MADSEN, JESPER GRAFF
Department of Clinical Physiology and Nuclear Medicine 239, Hvidovre Hospital, University Hospital of Copenhagen,
Kettegård Allé 30, DK-2650 Hvidovre, Copenhagen, Denmark
Address correspondence to: J. L. Madsen. Fax: (+45) 3622 3750. Email: [email protected]
Abstract
Background: existing data on the effect of ageing on gastrointestinal motility are few. In this study, we assessed the propulsive
effect of all main segments of the gastrointestinal tract in a group of healthy older people.
Methods: 16 healthy volunteers (eight women, eight men) of mean age 81 years (range 74–85 years) participated in the
study. Gastric emptying and small intestinal and colonic transit rates were determined by gamma camera technique. The
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