A stroke in old age is an acute circulatory disorder of the brain. There are two main forms:
- Ischemic stroke (about 85 percent): A blood clot blocks a cerebral artery. The brain tissue downstream is no longer perfused and dies within minutes to hours — unless the blood supply is restored.
- Hemorrhagic stroke (about 15 percent): A cerebral artery ruptures, blood escapes into the brain tissue, presses on surrounding structures and destroys them.
A special variant: the transient ischemic attack (TIA) — a brief circulatory disorder that resolves within 24 hours. It is a warning sign: around 10 percent of patients with a TIA suffer a complete stroke within 90 days if it is not quickly clarified and treated.
The FAST rule identifies over 80 percent of all strokes. Four steps:
- F — Face: The face. Ask the affected person to smile. Does one corner of the mouth droop?
- A — Arms: The arms. Stretch out both arms, palms upward. Does one arm sink or fail to lift?
- S — Speech: The speech. Have them repeat a simple sentence. Is the speech slurred, halting, unintelligible?
- T — Time: The time. At any one of these signs: dial 112 immediately. Do not wait, do not call the general practitioner, do not first look for a hospital. 112.
???? The most important sentence about stroke is: Time is brain. Every minute without blood supply costs about 2 million nerve cells. The minutes until the emergency doctor arrives are the most important minutes in the life of the affected person — even when the symptoms seem “not so bad”.
- Suddenly setting-in headache, often the most intense pain of one’s life (in cerebral hemorrhage)
- Sudden one-sided numbness or weakness of an arm or leg
- Sudden visual disturbance — double vision, hemianopia, blurred vision
- Sudden severe dizziness with gait or standing unsteadiness
- Sudden disturbance of consciousness or confusion
- Sudden swallowing disorder
The key word is always “sudden”. Unlike many other illnesses, a stroke sets in abruptly — often within seconds.
In an ischemic stroke the central brain area (the core region) dies within a few minutes. It is surrounded by a zone of reduced blood supply (the penumbra), in which the cells still survive — but only if the blood supply is restored in time. Modern acute therapy targets this penumbra:
- Systemic thrombolysis (rtPA, alteplase): Dissolves the clot with medication. Standard window 4.5 hours from symptom onset, longer in specific constellations.
- Mechanical thrombectomy: Catheter-assisted mechanical removal of the clot from large cerebral vessels. Time window in suitable patients up to 24 hours.
Both procedures are highly effective — the number of patients who can live independently again after thrombectomy has multiplied over the last ten years. The prerequisite is timely access to a specialized stroke unit.
A stroke unit is a specialized stroke ward with an interdisciplinary team from neurology, nursing, physiotherapy, occupational therapy, speech-and-language therapy and social work. In Germany there are over 300 certified stroke units — regional, supra-regional and tele-neurologically networked. Studies show: treatment in a stroke unit reduces mortality and the need for care compared with normal inpatient treatment.
In an emergency: the 112 control center knows the responsible stroke units and takes patients there directly. Relatives do not have to organize this.
After arrival in the clinic several processes run in parallel:
- CT or MRI of the head — distinction of ischemia vs. hemorrhage, localization of the blocked vessel
- Vascular imaging (CT angiography, MR angiography) — identification of the occlusion
- Neurological examination with a standardized scale (NIHSS)
- Laboratory values, ECG, blood pressure and heart rhythm monitoring
- Decision on thrombolysis and/or thrombectomy
- Initiation of the acute treatment
The most important stroke causes and risk factors:
- Hypertension: By far the most important modifiable risk factor. Good blood pressure control reduces the stroke risk by around 30 percent.
- Atrial fibrillation: Responsible for about 20 percent of all ischemic strokes. Consistent anticoagulation reduces the risk by 60 to 70 percent.
- Diabetes mellitus: Doubles the stroke risk.
- Dyslipidaemia: Elevated LDL cholesterol values. Statin therapy reduces the risk.
- Smoking: Doubles the risk. Stopping smoking takes effect quickly.
- Obesity and lack of movement: Important modifiable factors.
- Carotid stenosis: Narrowing of the carotid artery — in higher-grade symptomatic stenosis, surgical or interventional treatment.
- Preceding TIA: A strong warning signal that requires structured clarification.
→ On the independent significance of atrial fibrillation: Atrial fibrillation in old age.
→ On the role of diabetes as a stroke risk: Diabetes in old age.
The acute phase is only the beginning. The course depends decisively on the subsequent rehabilitation. Typical sequence:
- Acute phase (first days): Stroke unit — stabilization, first mobilization, start of physiotherapy, occupational therapy and speech-and-language therapy within 24 to 72 hours.
- Neurological early rehabilitation: Phase B — intensive, often with ventilation or a high care requirement. Specialized rehabilitation clinics.
- Continued rehabilitation: Phases C and D — continuous build-up of function and independence. Duration depending on severity 3 to 12 weeks and longer.
- Early geriatric rehabilitation: In older patients with multiple problems (stroke plus accompanying illnesses) often sensible in parallel with the neurological rehabilitation.
- Outpatient continuation: Physiotherapy, occupational therapy, speech-and-language therapy over weeks to months — the functional gain continues for up to a year.
→ On early geriatric rehabilitation: Early geriatric rehabilitation.
In older patients after a stroke, the holistic geriatric care is added to the neurological treatment:
→ On post-stroke depression and related topics: Depression in old age.
→ On the timely setting-down of one’s wishes: Advance directive.
After a stroke the risk of another is markedly increased. Secondary prevention comprises:
- Platelet aggregation inhibitors (usually acetylsalicylic acid plus clopidogrel initially, then single medication)
- In atrial fibrillation: oral anticoagulation (direct oral anticoagulants preferred)
- A statin for LDL reduction
- Blood pressure control with target values according to the individual situation
- Diabetes control
- Stopping smoking
- Regular exercise
- In carotid stenosis: evaluation for an operation or stenting
- Know the FAST rule: And apply it in an emergency. Dial 112.
- Do not initiate your own therapy: Do not give aspirin, do not push for blood pressure reduction — the hospital must first determine the type of stroke.
- Document the time of symptom onset: The exact moment when the symptoms began — decisive for the therapy window.
- Have the medication list ready: Particularly important: does the patient take anticoagulants?
- Be present during rehabilitation: Familiar people measurably promote neurological recovery.
- Watch for signs of depression: Post-stroke depression is frequent, treatable and often overlooked.
- With a TIA or “transient” symptoms, also 112: A TIA is not an “all-clear” but a warning.
- Emergency: FAST signs or other acute neurological symptoms — 112 immediately.
- TIA in the last 24 hours: Even when the symptoms have disappeared again — same day to the clinic.
- After discharge: Every three to six months a structured check of blood pressure, blood sugar, lipids, medication, functional status.
- At signs of depression: Often in the weeks and months after a stroke — have dementia or depression carefully clarified.
- At cognitive changes: The distinction between a stroke consequence and accompanying dementia — if necessary initiate dementia diagnostics.
→ On the overall evaluation after a stroke: Geriatric assessment.
