A review published Online First and in the November edition of The Lancet Neurology reports that routine stroke prevention therapies are underused in the very elderly, but could be very effective in this age group. The article is the work of Dr Nerses Sanossian of the University of Southern California and Dr Bruce Ovbiagele of the UCLA Stroke Center and Department of Neurology, Los Angeles, CA, USA.

The average human lifespan is extending and as a result there are more individuals above 80 years old who have a high quality of life. However, these very elderly individuals are particularly vulnerable to stroke. There have been substantial advances in stroke research, with several therapeutic drugs able to enhance clinical outcomes in people with stroke or who are at risk of stroke. But still, the very elderly seem to be given fewer vascular protection interventions that have been shown to be effective in their younger counterparts. These treatments might be of benefit to this group of patients. However, there has been an under-representation of the very elderly in studies of stroke therapy. In fact, new data indicate that the use of several of these therapies in routine clinical practice in the very elderly can be useful.

The authors write in conclusion: "With the rapidly growing population of individuals above 80 years, future stroke trials need to include the very elderly to facilitate ready generalisability of results and to convince sceptical clinicians that all patients with stroke should benefit from prompt evidence-based treatment, regardless of age."

A second Lancet Neurology review discusses epilepsy in later life. It is Professor Martin Brodie, Western Infirmary, Glasgow, UK, and colleagues. They remark: "Epilepsy is most likely to develop in later life. The burden of this disorder on health-care resources will rise further as the world's population continues to age."

There is growing prevalence and potentially deep physical and psychosocial effects of new-onset epilepsy in elderly people. However shockingly, this disorder has received little research attention. There is growing agreement that future treatment strategies should move beyond symptomatic relief like seizure control. Instead, they should focus on achieving cure and prevention for those at risk. In accordance with this objective, the European scientific community has recently identified a number of research priorities. Some of the aspects that are particularly relevant to the elderly population include:

• preventing the development of epilepsy after brain trauma
• translating genetic knowledge to optimise care of patients
• reducing the life-burden of seizures
• improving treatment and prognosis

The authors write in conclusion: "Old age has become the most common time in life to develop epilepsy in high-income societies. Because of the often atypical presentation, concomitant cognitive impairment, and non-specific abnormalities in routine investigations, establishing a correct diagnosis can be particularly challenging. A multispecialty, multi-professional strategy can help to facilitate rapid diagnosis and ensure a comprehensive approach in ameliorating the physical as well as the psychosocial effects of the diagnosis of epilepsy on elderly patients and their families."

A complementary Lancet Neurology editorial comments: "The rapidly increasing elderly population poses a major challenge for future health-care systems. Many of the diseases of old age are neurological disorders, so neurological practice is likely to be disproportionately affected by an ageing society...there is a dearth of clinical trials among older people - indeed, very elderly patients are systematically excluded from many clinical trials. If we are to meet the challenge of caring for rising numbers of elderly patients in the future, more good-quality trials in older people are needed to inform clinical practice."

"Prevention and management of stroke in very elderly patients"
Nerses Sanossian, Bruce Ovbiagele
DOI: 10.1016/S1474-4422(09)70259-5

"Neurology in the elderly: more trials urgently needed"
DOI: 10.1016/S1474-4422(09)70265-0
The Lancet Neurology

Stephanie Brunner (B.A.)

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