Stroke is often seen as a condition that only affects older people. Yet the incidence of stroke in older people has actually fallen in recent decades. At the same time, rates of stroke in under-55s has been on the rise.
In England, stroke incidence among 35- to 54-year-olds rose by about 2% a year between 2001 and 2010, even as overall rates dropped. In Oxfordshire alone, stroke rates in under-55s were about 90% higher in 2010–2018 than in 1981–1986 – while rates in older people fell.
The US tells a similar story, with stroke rates in 20- to 54-year-olds rising from 34 to 62 cases per 100,000 people a year between 1993-1994 and 2020.
Globally, nearly 2.8 million people under 55 had a stroke in 2021, almost 90% of them in low- and middle-income countries. Between 2020 and 2030, it’s projected that rates of ischaemic stroke (the most common type, which is caused by a blood clot) among 20- to 39-year-olds will rise by about 12%.
What is fuelling the rise?
The rising rates of stroke in young people largely appears to be driven by things we can change.
A large international study identified ten modifiable risk factors which accounted for around 92% of strokes that occurred in people under 55. These factors included high blood pressure, physical inactivity, high cholesterol, poor diet, obesity, smoking, heart problems, diabetes, alcohol consumption and psychosocial factors (such as stress or poor mental health).
High blood pressure alone accounted for almost half of the strokes that occurred in people aged 55 and under. Lack of regular exercise accounted for more than a third.
A UK study, which looked at 1,765 people aged 18-49 who were hospitalised for a stroke, found 42% of patients had high blood pressure, 24% high cholesterol, 23% smoked and 14% had diabetes. About 7% reported recreational drug use.
Rates of obesity and diabetes have been rising in younger people for three decades. These conditions, along with high blood pressure, are often undiagnosed or undertreated in younger adults.
But left untreated, these health problems can quietly raise stroke risk. For instance, research found that under-55s with diabetes were about 3.5 times as likely to suffer a stroke or mini-stroke than those who didn’t have the condition. Those with high blood pressure were about 2.5 times as likely.
But these factors don’t explain everything. Around half of strokes in young people that were caused by a blood clot had no clear cause. Research also shows a growing number of the strokes experienced by young people have no known risk factor.
Researchers are now investigating alternative risk factors, including air pollution, autoimmune conditions and illicit drug use. Stress and overworking are also increasingly being linked to higher risk of stroke in young people.
Lack of awareness is part of the problem, too, as my systematic review showed. People who don’t see themselves as at risk are less likely to visit their doctor or change their lifestyle. Alongside risk factors that already go undetected, this may partly explain why stroke rates in younger adults haven’t fallen as they have in older people.
The signs young people miss
Stroke in younger adults can be easier to miss as well.
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A large US analysis found that people aged 18-44 were the age group most likely to be sent home from emergency departments with a missed stroke, often after complaining of dizziness or headache. A Stroke Association survey also found a quarter of stroke survivors aged 60 and under said they were initially misdiagnosed.
The signs of a stroke in younger people can sometimes be different than they are in older people. While most people will look out for symptoms such as face drooping on one side, arms that can’t both be lifted and speech that’s slurred or confused, young people don’t always fit this pattern.
Strokes at the back of the brain, which affects balance and vision rather than the face and arms, are more common in young adults. In these cases, symptoms can manifest as problems with balance or eyesight, a headache, neck pain or vertigo.
Not only can these symptoms be missed by healthcare workers, young people themselves may explain them away as a migraine, tiredness, a hangover or an inner ear problem. Symptoms can also stop after a short time. Even if they do, you should still get medical help immediately.
Speed matters. Clot-busting treatment generally has to be given within 4.5 hours of symptoms starting. The sooner it’s given, the better the outcome and recovery.
What you can do
The good news is that most strokes in younger people are linked to things we can change.
The first thing you can do to lower your risk is to know your blood pressure. High blood pressure usually has no symptoms, so it’s important to have yours checked. You should also get checked for diabetes and high cholesterol, especially if you’re overweight or have a family history of heart disease or stroke.
Lifestyle matters, too. Don’t smoke, avoid recreational drugs and keep alcohol to no more than 14 units a week. It’s also recommended you eat less salt (no more than 6g a day) and more fibre, as these will help keep your blood pressure and cholesterol down.
Exercise is also key. Aim to get at least 150 minutes of moderate activity a week, such as fast walking or cycling.
You should also take stress and long working hours seriously. Both have been linked to a higher risk of stroke in their own right, even after accounting for other risk factors such as high blood pressure and smoking.
Stroke is no longer just an older person’s problem. Knowing the signs, and acting fast, could save your life or someone else’s.
