Older stroke patients in Europe: stroke care and determinants of outcome

Background: in order to implement cost-effective stroke services for older patients, it is necessary to identify how stroke care is currently provided for these patients and how provision relates to outcome. Objectives: to estimate the structure and process of care, and identify independent factors associated with 3 month mortality and functional outcome in patients aged over 75 years compared with younger stroke patients across Europe. Setting: 13 hospitals in 10 European countries. Subjects and methods: 1,847 subjects with first in a lifetime stroke admitted to hospital. Sociodemographic details, acute case severity, resource use and 3-month survival and dependency were collected. Results: from a total of 1,847 patients, 1,112 patients (60%) were under 75 years. Older stroke patients were more likely to be incontinent, dysphasic, dysphagic and comatose (P < 0.001). Computed tomography scan rates were higher in younger (87%) than in older patients (79%) (P < 0.001). Access to organised stroke care was higher in older (58%) than in younger patients (51%) (P = 0.002). Median acute length of stay was longer in younger (14 days, range 7-21 days) than in older patients (11 days, range 8-22 days) (P = 0.04). Nursing time in hospital was higher in older patients (P = 0.01), whilst therapy time was higher in younger patients (P = 0.03). By 3 months, younger patients were more likely to receive outpatient care (P < 0.001), physiotherapy (P < 0.001) and occupational therapy (P < 0.001). For older stroke patients, not having a computed tomography scan (OR = 0.2, 95% confidence intervals (CI) = 0.01-0.6, P = 0.003) was significantly related to mortality at 3 months after adjusting for case mix. Access to organised stroke care was significantly associated with reduced 3-month mortality in younger patients only (OR = 0.29, 95% CI = 0.14-0.6, P < 0.001). Conclusion: stroke care varies considerably across European centres, with older people more likely to gain access to organised stroke care in many centres but less likely to receive diagnostic investigations, therapy input and outpatient review. Where there is evidence of age discrimination for access to stroke services, guidelines need to be adopted to ensure patients of all ages receive optimal evidence-based stroke care at all stages of their illness.