AHA/ASA Statement on Acute Stroke Care for Adults With Disability or Dementia

Megan Brooks

March 29, 2022

Adults with pre-existing dementia or disability who suffer acute ischemic stroke can benefit from endovascular therapy (EVT) or thrombolysis, the American Heart Association (AHA)/American Stroke Association (ASA) says in a scientific statement released this week.

However, limitations in available data make it hard to draw firm recommendations about the use of acute stroke therapies in this patient population at this time, the writing group cautions.

For now, they suggest a pragmatic, case-by-case approach to the use of acute stroke therapies in adults with disability/dementia.

The statement was published online March 28 in Stroke.

Evidence Gaps

Given the aging of the population, the patient population with acute stroke can be expected to increasingly comprise older adults with multiple prestroke comorbidities, including disability or dementia.

Current data suggest that roughly one-third of ischemic stroke patients have a pre-existing physical, cognitive, or intellectual disability, whereas pre-existing dementia is present in approximately one-tenth.

Current evidence on thrombolysis and EVT in patients with prestroke disability or dementia is mostly from observational studies, with inherent limitations, the writing group says.

Controlled trials evaluating outcomes for patients with premorbid disability/dementia treated with thrombolysis or EVT, compared with medical management, are scarce.

Yet there is currently no consistent evidence to support the concern that prestroke dementia/disability might be associated with an increased risk for symptomatic intracerebral hemorrhage associated with reperfusion therapy, the writing group says.

There is also no convincing evidence that reperfusion therapy is less effective in these populations, although there is some inconsistent evidence for increased mortality and reduced return to prestroke function after thrombolytic therapy in patients with prestroke dementia/disability.

For EVT, in contrast, data suggest that rates of accumulated poststroke disability (compared with return to prestroke function) appear similar for patients with and without prestroke disability.

Patients with prestroke disability or dementia have the potential to retain their prestroke level of disability when treated, "despite their generally worse prognosis overall, although this remains to be validated in higher-quality registries and clinical trials," the writing group says.

Based on their expert analysis of the best available literature, they say it "seems reasonable" to conclude that a blanket disability cutoff — such as a premorbid modified Rankin Score (mRS) of 2 — probably should not be used as a "protocolized threshold" to exclude patients with prestroke disability or dementia from acute stroke therapies.

Pragmatic Individualized Care

The writing group, chaired by Mayank Goyal, MD, PhD, University of Calgary, Alberta, Canada, offers a pragmatic approach to making decisions regarding acute stroke therapies in adults with premorbid disability/dementia across the continuum of care.

In the prestroke, nonacute setting, they recommend discussions with patients and their families that focus on quality-of-life concerns, future care preferences, and advance care planning for future emergencies, such as major stroke.

They also encourage clinicians to reflect on their own personal biases that could influence "time-pressured" decisions for patients with disability/dementia.

In the acute stroke setting, when time-critical decisions are required, the writing group offers the following advice:

  • Acknowledge the spectrum of possible outcomes; avoid thinking dichotomously in terms of "good" or "bad" outcome.

  • Disclose the potential risks of treatment in patients with disability/dementia, such as high mortality, compared with patients without prestroke disability/dementia.

  • Avoid routinely withholding therapies based solely on premorbid status, given the potential benefits of mitigating further poststroke disability.

  • Adopt patient-centered care strategies; seek to understand the patient's values, goals, and beliefs that might affect care after a stroke, recognizing these values will vary by individual and are influenced by age, ethnicity, religious beliefs, and more.

Roadmap for Future Research

"The stroke community has an obligation to generate higher-quality data to inform stroke care in this expanding population," the writing group says.

High-quality randomized controlled trials that include patients with premorbid disability/dementia will require the development of harmonized, validated strategies to measure disability and capture these data, they say.

There is also a need to develop better measures that are reliable in an acute stroke setting and that help clarify the nature of an individual patient's disability (cognitive vs physical), which is something that is currently not well captured by the mRS, they add.

As a first step toward the generation of better efficacy data, they encourage systematic measurement and tracking of prestroke versus poststroke functional outcome in patients with prestroke disability and dementia in prospective registries of acute stroke.

"Ideally, these registries should capture data on both treated and untreated patients (the latter generally missing from existing data), so that post-treatment outcomes in patients with prestroke disability/dementia may be compared with those of untreated patients of similar prestroke status," they advise.

It would also be helpful to enroll patients with prestroke disability/dementia in phase 4 trials of thrombolysis/EVT and in future trials of new therapies.

"By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, we can work toward a more inclusive paradigm of patient-centered care for this often-neglected patient population," the writing group concludes.

The Society of NeuroInterventional Surgery has endorsed the statement, and the American Academy of Neurology and American Association of Neurological Surgeons have affirmed its educational value.

This research had no commercial funding. Goyal is a consultant for Microvention, Medtronic, and Mentice. A complete list of author disclosures is available with the original article.

Stroke. Published online March 28, 2022. Abstract

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