VA Study: Age Shouldn’t Influence Post-Stroke Treatment

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By Annette M. Boyle

Neale Chumbler, PhD.

ATLANTA — Age shouldn’t be a factor in how patients are treated at the VA after experiencing a stroke.

That’s according to a study published recently in the Journal of Rehabilitation Research and Development. VA researchers found that older veterans benefit as much from preventive care as younger patients.1

“Traditionally, preventative care has not been as aggressive for older patients. This research shows it is just as important for people in the 80s as it is for those in their 50s,” said lead researcher Neale Chumbler, PhD. At the time of the study, Chumbler was with the VA’s Health Services Research and Development (HSR&D) Center of Excellence on Implementing Evidence-Based Practice at the Richard L. Roudebush VA Medical Center in Indianapolis. Now, he heads the department of health policy and management in the College of Public Health at the University of Georgia, Athens.

The historical difference in stroke treatment based on age is not purely arbitrary, but the current research indicates it may arise from a failure to adjust for stroke severity.

“We do know that age is a predictor of poor outcome after stroke,” co-author Michael S. Phipps, MD, neurovascular fellow, VA Connecticut Healthcare System and University of Connecticut/Hartford Hospital, told U.S. Medicine.

In the study, stroke severity rose significantly with age. Slightly more than 5% of patients in the study under age 55 had a retrospective National Institute of Health Stroke Scale (rNIHSS) of 10 compared with 13.5% of patients over 85. Comorbidities as measured by the Charlson Index also rose markedly with age. Patients under age 55 had an average score of 2.6, while those between 65 and 74 had a mean of 4.9 and those older than 85 had a Charlson Index of 6.8.

Stroke severity and comorbidities, not age, accounted for most of the differences in treatment and responses, the authors reported. Researchers captured the rNIHSS score on admission for all study participants, permitting the use of stroke severity as a key covariate in determining the relationship between age and quality of care.

Identifying the impact of stroke severity and comorbidities versus patient age has important clinical implications.

“While I do not think it is universal, some physicians may not be as aggressive in treating older patients with stroke due to a lower expectation of improvement,” Phipps said.  

The adaptive physical activity program for chronic stroke survivors at VA Maryland Exercise and Robotics Center of Excellence helps older patients regain physical strength. Photo from VA website.

Understanding how to treat stroke and whether certain treatments are more appropriate for patients of various ages is particularly important for the VA. In 2007, the VA admitted approximately 6,000 veterans and treated more than 61,000 unique patients as outpatients who had stroke as their primary diagnosis.

Age also is an important factor because, while two-thirds of strokes occur in patients more than 65 years of age, rates among younger people have been rising, noted co-author Huanguang Jia, PhD, a research health scientist with the Rehabilitation Outcomes Research Center, North Florida/South Georgia Veterans Health System in Gainesville, FL. In the study, 48% of patients were under the age of 65.

Treatment Goals

For stroke survivors of any age, treatment has two major goals, Jia said.

“First, prevent a secondary stroke. Second, provide effective and appropriate rehabilitation treatment to speed recovery and enhance outcomes.”

To discover whether the VA pursued these goals with equal vigor, regardless of patient age, and whether patients responded similarly to treatment across age groups, researchers evaluated the presence and achievement of five care-quality indicators (QIs):

  1. Blood pressure of less than 140/90 mm Hg for patients without diabetes or kidney disease and less than 130/80 m Hg for patients with those diseases;
  2. Serum international normalized ratio (INR) of between 2 and 3 for patients prescribed warfarin;
  3. Low-density lipoprotein (LDL) cholesterol of less than 100 mg/dL for all patients;
  4. HbA1c of less than 8% for diabetics; and
  5. Depression screening and treatment, if indicated.

The retrospective study analyzed records of 3,196 veterans who were diagnosed with ischemic stroke and received acute and postdischarge care at 127 VAMCs from Oct. 1, 2006, through Sept. 30, 2007. Data for the first six months after discharge were reviewed to determine achievement of the five QIs.

The average age of veterans in the study was 67.2,  and 97% were male.

Care Processes Vary

With no standard protocol for post-acute stroke care within the VA, physicians must consider many factors in determining appropriate treatment including physical and cognitive deficits and availability and access to services, according to the authors.

Unadjusted data showed significant disparities in treatment by age for depression, blood pressure and LDL levels. After adjustments for patient sociodemographic, clinical and facility-level characteristics, however, those differences largely disappeared, although age-related variances in INR goals remained. In particular, postdischarge INR control was much higher for patients 85 years and older. The researchers noted, however, that as the number of patients older than 80 who were eligible for anticoagulation therapy was quite small, this result may be due to chance.

While few clear disparities in treatment emerged from the study, the researchers identified some differences in care processes associated with age. Older patients were more closely monitored for LDL goal achievement; physicians more frequently screened for and treated depression and monitored blood pressure goals in younger patients.

The results of the study suggest that patients of all ages would benefit from the same after-stroke care. “Watching these important risk indicators helps prevent future complications,” said Chumbler. “Anyone who has a stroke should have these risk factors monitored” to prevent future heart attacks or additional strokes.”

Close monitoring of these five indicators can also produces other benefits.

“Timely and effective rehabilitation therapy produces better physical, cognitive and emotional function,” Jia told U.S. Medicine.

“Depression is common in stroke survivors of any age and should be treated to improve outcomes.” As many as 40% of individuals who have had a stroke develop depression, which can affect physical and cognitive function in stroke survivors.

Click to expand to new tab. For source, see reference 1. Table 2 shows the unadjusted results for each individual postdischarge QI by age categories. Overall QI performance rates varied widely (from 33.2% for screening and treatment for depression to 61.8% for LDL goal achievement). Three QIs had significant differences between the age groups: treatment of depression was higher for veterans <55 yr than for older veterans (p < 0.05) and LDL goal achievement was lower for veterans <55 yr than for their older counterparts (p < 0.05). Blood pressure goal achievement was lower for veterans 55–64 yr than for veterans 75–84 yr.

1.    Chumbler NR, Jia H, Phipps MS, Li X, Ordin D, Williams LS, Myers LJ, Bravata DM. “Postdischarge quality of care: Do age disparities exist among Department of Veterans Affairs ischemic stroke patients?” Journal of Rehabilitation Research & Development. 2013;50(2):263-72.

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