Secondary stroke prevention strategies for the oldest patients: possibilities and challenges

Older adults are not only at higher risk of experiencing stroke, but also have multiple co-morbidities that make treatment for secondary stroke prevention challenging. Very few clinical trials specifically related to secondary stroke prevention treatment efficacy have focused on the oldest-old (>or=85 years) and, therefore, evidence-based recommendations for treatment specific to this population are not available. Some of the special considerations for stroke prevention treatments in older patients include careful titration of blood-pressure-lowering drugs to avoid hypotension, the risk of haemorrhagic stroke with HMG-CoA reductase inhibitors (statins) and weighing the risk of recurrent ischaemia versus bleeding in patients taking antiplatelet or anticoagulant therapy. The risk of peri-procedural complications appears to be high with both carotid angioplasty and stenting and carotid endarterectomy in older patients with carotid stenosis. Other common issues in older patients include adverse drug events, recognizing the risk of dementia, depression and osteoporosis and deciding when to discontinue secondary stroke prevention. In this review, we provide the practitioner with the evidence related to specific approaches to secondary stroke prevention in older patients, and identify the knowledge gaps that currently limit our ability to appropriately treat this vulnerable population.