Stroke is a common disease in the older population. Many gender differences are seen in the epidemiology, outcomes, and treatment of geriatric stroke. Although these differences are not fully understood, recognition of gender differences may help with appropriate treatment and improve outcomes.
Key words: stroke, gender, outcomes, prevention, treatment.
Introduction
Stroke is the leading cause of disability and the third leading cause of death in the United States.1 Age is the principal nonmodifiable risk factor for this disease. The incidence of stroke increases significantly with age in both men and women, with half of all strokes occurring in people over age 75, and one-third in the population over age 85. Although the entire older population is at risk for stroke, there are gender differences in the incidence by age subgroups. The incidence of stroke is higher in men up to age 75, similar in the 75-84 age group, and higher in women in the age group greater than 85.1
Despite the higher risk in men, the lifetime risk of stroke is higher in women. The Framingham study calculated lifetime risk of stroke among middle age men and women and found that the lifetime risk in women age 55 was 21% and in men age 55, 17%.2 This may be attributed to the longer life span in women. Some of these incidence and risk differences may also be biological. However, there are many other gender differences in stroke such as outcomes, risk factors, treatment, and mortality that have more complicated and unexplained underlying etiologies.
Outcomes
An easily obtainable outcome measure is stroke mortality. Using United States death certificate data in the 1995-1998 period, Ayala et al.3 found over 600,000 stroke deaths. Of these, 61% were women. However, after adjusting for age, they found stroke death rates were lower in women than in men for ischemic stroke overall. When examined by race, white women had higher stroke death risk than white men. Pooled data from multiple studies also showed that in individuals over age 70, the 1-year mortality was 24% in white men and 27% in white women, but 25% in black men and 22% in black women. Mean age of stroke death was 79.6 years, but men had a younger age at stroke death than women.1
Although mortality may not be higher in women, functional outcome may be. Di Carlo et al.4 found in a large registry that 3-month disability and handicap were higher in women after adjusting for age. In this group, women were significantly older when presenting with first stroke (74 years as compared to 69). They were also more likely to be living alone or living in an institution prior to stroke. Another study found similar results; at 3 months, women were more dependent and living in an institution after stroke than men. They postulate depression as playing a role since women are more likely to be depressed after stroke than men.5
However, another explanation could be that strokes that are more disabling occur more frequently in women. One way to evaluate if this is true is by looking at stroke subtypes. Ischemic strokes may be classified into different categories, outlined in Table 1. In a population-based study of first ischemic stroke, individuals with lacunar strokes had milder deficits compared with other subtypes. Rates of recurrent