Don't withhold thrombolytics due to age

If a 67-year-old woman with acute ischemic stroke came to your ED two hours after onset of symptoms, you most likely would consider this patient as a candidate for treatment with intravenous tissue plasminogen activator (IV t-PA). But what if the patient were 91 years old?

Older stroke patients often are not given thrombolytics in EDs because nurses mistakenly fear it's unsafe, says Louise D. McCullough, MD, PhD, director of stroke research at Hartford (CT) Hospital. "I think ED nurses, like ED physicians and neurologists, are more hesitant to treat the elderly, especially if they are coming from an assisted living type of setting," she says.

However, a new study's findings indicate that older stroke patients can be treated safely and that therapy should not be withheld because of a patient's age. Researchers looked at 166 patients older than 80 years old who presented to Hartford's ED with acute ischemic stroke from April 2003 to December 2005. A large number of elderly patients were excluded from tPA treatment despite arriving within the allowable time frame, and older patients who were treated did not have higher risk of intracranial hemorrhage.1

Research is evidence

The study's findings are evidence that older patients can be treated safely with thrombolytic therapy in the ED, says McCullough. "This therapy should not be withheld on the basis of age," she says. "It is extremely important for nursing staff to recognize that these patients are candidates for lytic therapy."

Another study had similar findings: Researchers looked at 1,135 cases of stroke patients treated with IV t-PA and found that the risk of intracerebral hemorrhage was not higher in patients older than 80 years old.2

Despite the growing evidence, misconceptions about older stroke patients still are common in EDs, says Dawn K. Beland, RN, MSN, CCRN, CS, CNRN, coordinator of Hartford's stroke center. "There seems to be an attitude from some of the ED physicians and neurologists that treating older patients could harm them more than help them," says Beland. "In patients over 90 years old, we would see ED physicians cancel the 'stroke alert' solely based on the age of the patient."

The misconception stems from the original trial of t-PA for stroke, which automatically excluded patients over 79, says McCullough. "No one was sure if it was safe, since there was no data," she says.

The original research seemed to indicate an increased risk of hemorrhage in patients older than 77, adds Lauren Brandt, RN, MSN, CNRN, clinical director of the Neurosciences, Brain, & Spine Center at Brackenridge Hospital in Austin, TX. "Initially, a lot of EDs took that to mean it was a contraindication. Then they called it a 'relative' contraindication. Even with that, a lot of EDs never gave it," she says.

Originally, age over 77 years was listed as a contraindication in Brackenridge's ED. "Then we had it as a 'relative' exclusion. But because it was listed, physicians were still hesitant to give it to older patients," says Brandt. "Now we've taken it off, so there is no upper exclusion, and state that all ages over the age of 18 are eligible." (See the ED's inclusion/exclusion criteria for t-PA treatment.)

If the patients are unable to speak for themselves and no family is reachable, but by report, they have a reasonably good quality of life, it must be assumed that they would want treatment, says Beland. "ED nurses can be the patient's advocate by being informed about the current inclusion and exclusion criteria for thrombolytic treatment," she says.

At Hartford's ED, triage nurses were given one-to-one inservicing by the ED's nurse educator to reinforce that age is not an exclusion criteria for IV t-PA, says Beland. ED nurses at Brackenridge were re-educated on the updated protocols, says Brandt. "I lecture all new staff on stroke in general and on the protocols and strongly state that there is no contraindication [due to age]," says Brandt. "We have a couple of really good case studies with good outcomes with older individuals that I present with this information."

Age does play a role in the decision to use intra-arterial treatments for acute stroke, because patients older than 85 years old may have more intracranial or carotid atherosclerosis, notes Beland. "This brings additional risk to the procedure and makes accessing these vessels with catheters more technically difficult."

However, older stroke patients should be treated with the same urgency as the younger patients, advises McCullough. "Often the ED nurses are the ones who recognize and identify the stroke patients," she says. "Communication that the patient is a candidate for tPA — whatever their age — is key to getting these patients treated quickly."

References

  1. Zeevi N, Chhabra J, Silverman IE, et al. Acute stroke management in the elderly. Cerebrovasc Dis 2006; 23:304-308.
  2. Sylaja PN, Cote R, Buchan AM, et al. Thrombolysis in patients older than 80 years with acute ischaemic stroke: Canadian Alteplase for stroke effectiveness study. J Neurol Neurosurg Psychiatry 2006; 77:826-829.

Sources

For more information on treating older stroke patients in the ED, contact:

  • Dawn K. Beland, RN, MSN, CCRN, CS, CNRN, Stroke Center Coordinator, The Stroke Center at Hartford Hospital, 80 Seymour St., Hartford, CT 06102-5037. Telephone: (860) 545-2183, ext. 5. Fax: (860) 545-1976. E-mail: dbeland@harthosp.org.
  • Lauren Brandt, RN, MSN, CNRN, Clinical Director, Neurosciences, Brain, & Spine Center, Brackenridge Hospital, 601 E. 15th St., Austin, TX 78701. Telephone: (512) 324-7782. Fax: (512) 324-7051. E-mail: lbrandt@seton.org.
  • Louise McCullough, MD, PhD, Director of Stroke Research and Education, The Stroke Center at Hartford Hospital, MC 1840, Department of Neurology, 263 Farmington Ave., Farmington, CT 06030. Telephone: (860) 679-3186. Fax (860) 679-1181. E-mail: lmccullough@uchc.edu.