Pippa Tyrrell, FRCP, Salford Royal Foundation Trust and University of Manchester; UK NICE Guidelines Development Group, Acute Stroke and TIA, London, UK.
Sharon Swain,PhD, National Coordinating Centre for Chronic Conditions, Royal College of Physicians; UK NICE Guidelines Development Group, Acute Stroke and TIA, London, UK.
Anthony Rudd, FRCP, St Thomas’s Hospital London; UK NICE Guidelines Development Group, Acute Stroke and TIA, London, UK.

The investigation and management of stroke has changed beyond recognition in the last two decades. The management of frail older patients with stroke represents a particular clinical challenge. Recognition of symptoms in people with significant comorbidities may be difficult and while intensive investigation may be inappropriate for a very frail aging patient, older people can gain a great deal from expert treatment and secondary prevention following stroke.
Key words: stroke, frail older adults, ischemic stroke, intracerebral hemorrhage.

JE Simon, MB, ChB, MRCP (UK), Calgary Stroke Program, Seaman Family MR Research Centre, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
MD Hill, MD, MSc, FRCPC, Director, Stroke Unit, Associate Professor, Calgary Stroke Program, Departments of Clinical Neurosciences / Medicine / Community Health Sciences, University of Calgary, Calgary, AB.

Despite the fact that stroke is both common and devastating in older patients, very little randomized controlled data is available on the efficacy or safety of thrombolysis in older age groups. We review literature from both randomized control studies and case series data treating older patients, and look at the hemorrhage rate and mortality associated with thrombolysis. In addition, we examine risk markers, other than age, for a poor outcome. We suggest that older age alone is not a contraindication to thrombolytic therapy.

Key words: ischemic stroke, tPA, thrombolysis, hemorrhage risk.

James Kennedy, MB, MRCP(UK)
Clinical Stroke Fellow,
University of Calgary, Calgary, AB.

Alastair M Buchan, MB, FRCP
Professor of Stroke Neurology,
University of Calgary, Calgary, AB.

"It is in the nature of stroke to partly take away the use of a man's limbs and to throw him on the parish if he had no children to look to."¹

While treatments have changed since George Eliot's time, attitudes to the consequences of stroke have not. Stroke, when mild, is viewed by the elderly as a devastating event; when severe it is viewed as being worse than death itself.²

Stroke is the third most common cause of death and the leading cause of disability in most of the developed world.³ It is one of the most common causes for the elderly to be admitted to a chronic care facility, such as a nursing home. Ischemic stroke increases in incidence as people age, rising from 2.1 per 1000 for men aged 55 to 64 to 9.4 per 1000 for men aged 75 to 84.⁴ Age is also one of the major determinants of outcome from stroke. Older patients are less likely to recover than are younger patients with similar sized infarcts and, following a stroke, are more likely to decline physically than to recover.