Stroke

Unique to Older Adults

This section provides information to help older adults and their caregivers consider their disease or condition in conjunction with other health issues they may have.

As older adults live longer, they may have more than one chronic disease.  Or, they may have a health problem that can lead to another condition or injury if not properly managed. The older adult may also experience healthcare in various settings, such as the hospital, an assisted living facility, or at home. These situations can affect the health and function of the older adult and therefore require careful management to ensure proper care and improve or maintain quality of life.

Last Updated September 2020

Stroke and Other Medical Conditions

Stroke and Cardiovascular Disease

Older adults may have one or more cardiovascular diseases such as coronary artery disease , high blood pressure (also known as hypertension), high cholesterol, atrial fibrillation, heart failure or peripheral artery disease. They also often have life style risk factors that raise the risk for stroke, such as obesity, diabetes, a smoking habit, sedentary lifestyle, and drug or alcohol abuse.

Blood Pressure

Higher blood pressure (including systolic hypertension, an elevated upper blood pressure number) is fairly common in older adults. Treating high blood pressure lowers a person’s chance of having a stroke. It is recommended to maintain blood pressure at 130/80 or below to reduce the risk of stroke for older adults. However,  frail older adults may benefit from slightly higher blood pressure levels.  This is to prevent harms of low blood pressure, including dizziness and falls. Therefore, it is important to check with your healthcare provider to determine the appropriate blood pressure goal for you.  

Cerebral Amyloid Angiopathy

A condition known as cerebral amyloid angiopathy may cause hemorrhagic stroke even without hypertension and becomes more common with increasing age. Amyloid angiopathy refers to a build-up of proteins called amyloid on the walls of the arteries in the brain, which increases your likelihood of suffering a hemorrhagic stroke. It may also result in dementia. The cause is unknown and there is no cure. 

High Cholesterol

High cholesterol levels may be related to the risk of stroke. However, the risk of stroke prevention needs to be balanced against the side-effects of medicines and quality of life concerns. For some older adults, it may be appropriate to start a cholesterol lowering medicine at a lower dose.

Atrial Fibrillation

Atrial fibrillation refers to the rapid and irregular beating of the upper two chambers of the heart (the atria). Atrial fibrillation occurs more frequently in older people, and about half of older adults diagnosed with it are over 75 years of age. About 25% of strokes in people more than 80 years old are caused by atrial fibrillation. Women have almost double the risk compared to men. Atrial fibrillation is often treated with anticoagulation therapy (a blood thinner such as warfarin or dabigatran), antiplatelet therapy (such as aspirin), a beta blocker, or antiarrhythmic medications. These treatments depend on a person’s risk for stroke and severity of disease. For some people, a surgical approach may be appropriate. 

Stroke and Metabolic Disorders

Metabolism is the process that your body uses to get or make energy from the food you eat. Metabolic disorders occur when this process is disrupted.

Diabetes

Type 2 diabetes mellitus is a metabolic disorder. This is the most common form of diabetes in older people. It is a serious chronic disease that affects the bodys ability to keep blood sugar levels controlled. In older adults, diabetes can decrease life expectancy by an average of about 10 years. Diabetes can cause many serious disabilities, including blindness,  limb amputations, higher risk of infection, kidney and nerve damage, and memory problems. In addition, diabetes doubles the risk of stroke.

Atherosclerosis

Most older adults with diabetes may have atherosclerosis (fatty deposits in the arteries). This raises the risk of bloodvclots and ischemic stroke. Many also have high blood pressure, which also raises the chance of having a stroke. To complicate matters, older adults with diabetes who have strokes will find it more difficult to control blood sugar. 

Obesity

Obesity is defined as at being at least 20% heavier than your ideal weight. It can shorten lifespan and is a risk factor in many serious diseases such as stroke, cardiovascular disease, diabetes, and some kinds of cancer. The higher a person’s weight, the greater risk of having a stroke. This increase in stroke risk is probably linked to higher blood pressure, high cholesterol levels, and more severe atherosclerosis—all of which are more common in obese people. 

Arthritis

Arthritis itself is not a metabolic disorder, but it is one of the major sources of disability in older people. This disability can lead to obesity, which in turn further worsens arthritis, which then leads to a sedentary lifestyle and an increased risk of having a stroke. 

Stroke and Psychiatric Conditions

Delirium

Delirium is an abrupt, rapid change in mental function. It is extremely common right after a stroke, especially hemorrhagic strokes. Up to 40% of patients may develop delirium during their first week after a stroke. Unfortunately, when delirium develops after a stroke, it is often a sign of worse mental consequences, longer hospitalization, and a higher risk of death. Post-stroke rehabilitation is much more difficult in these patients. Older patients are more likely to suffer from delirium after a stroke.  

Depression

About half of stroke survivors become depressed and about one-fifth suffer a major depression requiring immediate intensive treatment. The vast majority of these patients never experienced depression before the stroke occurred. It is not yet known whether the depression is caused by the challenge of sudden disabilities, or if the stroke itself causes changes in the brain that bring on a depression. 

People who become depressed after a stroke find it more difficult to recover—both physically and mentally—from the effects of the stroke. An untreated post-stroke depression may persist for years, and is linked to an increased risk of death after a stroke. Antidepressant medications, including some of the selective serotonin reuptake inhibitors (SSRIs), are the most usual treatment for depression following a stroke. Psychologists or trained social workers can offer counseling therapy (including cognitive behavioral therapy) in addition to medication, to help improve depression. 

A stroke survivor may be experiencing depression if several of the following symptoms last for more than two weeks:
  • feelings of sadness and hopelessness
  • loss of interest in activities that used to be enjoyed
  • inability to concentrate
  • no appetite
  • sleep problems
  • loss of energy
  • thoughts of suicide
Vascular Dementia

Vascular dementia, or post-stroke dementia, is the second most common type of dementia, after Alzheimers disease. Symptoms may appear right after a stroke, or may develop gradually over a period of years. A healthcare professional will diagnose post-stroke dementia by carrying out neurological tests, asking simple questions, and using brain scans (such as a CT scan). There is no cure and it usually gets worse over time. Having a stroke doubles the likelihood of eventually suffering from dementia, and the risk increases with age. People with post-stroke dementia often require caregiver help, or nursing home placement to get assistance with self care.

Stroke and Medication Management

Older adults may experience multiple chronic medical conditions with age. Older people with multiple conditions may be taking multiple medications. For example, warfarin is a prescription medication used to treat blood clots or lower the chance of blood clots forming. Older adults may be prescribed medications such as warfarin after a stroke. However, interactions with other medications can affect how warfarin works. This can decrease its ability to prevent strokes in an individual with atrial fibrillation, or it can increase the risk of internal bleeding. Drug interactions may also make some psychiatric medications more sedating. This can impair an older adults ability to recover their lost function after a stroke.  

Older people are at increased risk for the complications of stroke treatments, such as bleeding. Depending on risk factors, medical history, and current condition (such as presence of kidney disease), your healthcare provider will weigh the risks and benefits when choosing a blood thinner and the appropriate dosage.  

Another interaction to be aware of is between prescription medications and herbal or alternative remedies. Many older people often take alternative remedies without realizing that these may also interact dangerously with prescription drugs. For instance, green tea, garlic, ginger, gingko biloba and St. Johns Wort can interact with blood thinning drugs and affect their function. Drinking alcohol can also affect metabolism and increase the impact of many types of prescription drugs. 

Have your healthcare provider review your medications carefully. This will make sure that:

  • You are not taking any unnecessary medications
  • You are taking appropriate medications for your condition
  • The dose is the lowest effective dose
  • The medications do not interact in any unwanted way
  • You are taking the medications the right way and at the right time
  • You know what possible side effects to watch out for

Managing Additional Health Problems Related to Stroke

Mobility

If a stroke has affected a person’s vision, sense of touch, or balance, or caused weakness of limbs, the risk of falling and having problems walking will be much worse. Vascular dementia or other cognitive effects of stroke may also negatively impact gait (the pattern of walking). For stroke patients, treatments to improve walking ability include strength training, balance training, or electromyographic biofeedback. Older adults may also be able to maintain independent living when trained how to properly use assistive devices such as canes or walkers.

Speech

Aphasia is the technical name for the inability to use language. It may affect speech, including understanding speech, reading, or writing. Aphasia is caused by brain damage in specific language locations of the brain and affects about one-third of stroke patients. It is especially common in older people. Aphasia is one of the most distressing and frustrating complications of stroke because it prevents communication between the person and their family and/or caregivers. Speech therapy is often helpful in improving symptoms but might not reverse the symptoms completely.

When communicating with someone with aphasia, remember that their intelligence has not changed. Some tips for improving communication include:

  • Allow plenty of time for the person to finish speaking
  • Do not finish their sentences
  • Turn off radios, TV or other sources of background noise
  • Use any other non-verbal means of communicating – gestures, drawings, facial expressions

Swallowing

Up to 70% of people who experience a stroke will have trouble swallowing as a result. This is known as dysphagia. Weakness of facial muscles can also affect chewing and therefore affect swallowing.This is a serious problem and needs to be carefully evaluated by a specially trained healthcare professional.

It is critical to manage and treat dysphagia. The healthcare provider will pay attention to diet and nutrition and use tube feeding if needed. Care is necessary to prevent aspiration (inhaling food), pneumonia, airway blockage, dehydration, malnutrition, and weight loss, particularly in frail, older people.

If a person has dysphagia due to a stroke, they will be referred to a speech language pathologist (SLP). The SLP will assess their swallowing pattern by observing their ability to eat and drink. They may also use further tests including a videofluoroscope, laryngoscopy, or other imaging techniques. Common treatment approaches include changing to foods that are easier to swallow, such as pureed foods; swallowing therapy (including exercises done alone or while swallowing, head-lift exercises, changes in position while eating); breathing exercises to reduce the risk of inhaling food; and/or using high-calorie and high-protein supplemental beverages (such as Boost or Ensure).

If a someone cannot recover the ability to swallow food enough to keep themselves well-nourished, are not sufficiently alert, or who have other severe feeding problems, feeding may have to be done by means of a feeding tube.

Dehydration

Stroke often brings on many disabilities in addition to swallowing difficulties. Weakness in arms and legs and loss of muscle control in the face are also frequent consequences of stroke. These frustrations can have a severe impact on the intake of food and fluids and may lead to dehydration. Even without stroke, older people tend to be less aware that they are thirsty, particularly if they have cognitive (thinking) problems. Conversely, dehydration itself has been implicated as a possible cause of stroke. It can also lead to constipation, kidney dysfunction, and mental problems such as confusion and seizures. There is a greater chance of death after a stroke if the patient is dehydrated.

Incontinence

After a stroke, up to 60% of hospitalized older people suffer from urinary incontinence (leakage of urine) due to an inability to control urination.

Pressure Ulcers

Weakness in limbs due to a stroke may affect a person’s ability to get out of bed. This can lead to pressure ulcers. Pressure ulcers develop due to unrelieved pressure from a bone lying against a surface when a person doesn’t move for a long period of time. The skin or soft tissue caught between the bone and the surface (such as a mattress) begins to break down. This is particularly problematic in older people because blood circulation becomes less efficient and the skin tissues become weaker with increasing age.

To prevent and treat pressure ulcers, the nursing staff at the hospital or rehabilitation facility will change the person’s position regularly. Eating a balanced diet with essential nutrients helps with prevention of and healing of pressure ulcers. The most common complications of pressure ulcers are infection, pain, and depression, which need prompt attention. Specific treatments of pressure ulcers vary depending on the type of pressure ulcers. The area affected should be kept clean and covered with a dressing, and medications for pain and infection started as needed.

Vision Loss

Stroke may be associated with a sudden loss of vision in one or both eyes. If your stroke affects your vision, you may only be able to see certain parts of your field of vision. Your perception of ordinary objects may be altered, or you may mistake the distances between objects. Reading may become difficult because you can only see part of the page. You may experience single-side “neglect” particularly when the brain damage from your stroke is localized to the right side of your brain.