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Should tPA be given to elderly stroke patients?
Age is not a contraindication
Before ED nurses at Ridgeview Medical Center in Waconia, MN, administered tissue plasminogen activator (tPA) to a man in his 80s with obvious stroke symptoms, the neurologist was consulted and also the patient's family members, says Kathie Pulchinski, RN, ED nurse manager.
"This particular patient was very high-functioning before his stroke," says Pulchinski. "The family said they knew he would rather risk death than function with the continued neurological deficits he was exhibiting." The man ultimately had a very positive outcome, she reports.
Lauren Brandt, RN, MSN, CNS, CNRN, director of neurosciences at Seton Brain & Spine Center in Austin, TX, notes that age is not a contraindication for treatment with tPA.
"In fact, for the expanded time window, they treat up to the age of 80. Any age can be treated in the three-hour window," she says. "As long as the patient understands what the risks versus benefits are, they can be treated."
Recently, Brandt cared for a 92-year-old woman with a large right-sided stroke. "This person was independent, with a good quality of life," she says. "She had come in quickly upon onset of stroke symptoms."
The woman met criteria for intravenous tPA, and was offered treatment, says Brandt, but she refused. "When the doctor asked why she would not want to be treated, she said she had had a good life and was ready to go," she says.
After the emergency physician informed her that she most likely would not die from the stroke, but would most likely not get better, she immediately agreed to go forward with the treatment, Brandt says. "She responded remarkably well, and returned almost to baseline," she reports. (See related story on new research on elder stroke patients and clinical tip on identifying the "last known well" time, p. 80.)
For more information on caring for elder stroke patients in the ED, contact:
Study: Consider tPA for elders with stroke
Always consider older patients with stroke symptoms as potentially eligible for thrombolysis, says Salvador Cruz-Flores, MD, MPH, professor and director of the Souers Stroke Institute at St. Louis (MO). "Unless they have a known contraindication not to use it, the bottom line is, do not waste time," he says.
A recent study showed that the risk of intracerebral hemorrhage was higher in elderly stroke patients given thrombolysis, based on 1659 patients older than the age of 80.1 Only 1.05% of elders received thrombolysis, compared with 1.72% of younger patients.
The study showed that while older patients have a higher chance of dying, the use of thrombolysis itself does not seem to be the cause, says Cruz-Flores, the study's lead author. "Patients older than 80 should be evaluated as promptly as a younger patient, and should probably be considered for thrombolysis," he emphasizes.
Previous studies on the use of thrombolysis for stroke have never addressed specifically whether the treatment makes a difference in patients older than 80, according to Cruz-Flores. "The numbers of people in the age group were small, making it very difficult to determine whether the treatment is useful," he explains.
Several studies have looked at people treated with thrombolysis and compared outcomes for individuals older than 80 and younger than 80, adds Cruz-Flores. "Most show that people older than 80 have a higher chance of dying or bleeding compared to the younger counterparts," he says. "However, those treated have also a somewhat better outcome than those not treated."
ID "last known well" for elders with stroke
It is sometimes difficult to find out when an elderly stroke patient was "last known well," according to Karen Bergman, RN, neuroscience coordinator at Bronson Methodist Hospital in Kalamazoo, MI. "We must know when they were last known to be well in order to determine where in the [tissue plasminogen activator] time window we are," she says.
Many times elderly people live alone, so no one is with them to witness the onset of the symptoms, notes Bergman. "A very careful and thorough history of recent events will sometimes confirm the 'last known well' time, even though the patient was alone at the time," she says.