Older Stroke Patients Receiving Inadequate Care, Studies Show

Allison Gandey

April 22, 2009

April 22, 2009 — Older people are less likely to receive high-quality stroke care compared with younger patients, researchers warn. And this is despite evidence suggesting that care is equally effective across age groups, they note. The new studies point to ageism in stroke care — the first is published online April 16 in BMJ and the second in the March issue of the Postgraduate Medical Journal.

"We found low rates of secondary drug prevention," report the BMJ study authors, led by Rosalind Raine, PhD, professor of health-services research from University College London, in the United Kingdom.

The national study was of nearly 13,000 patients from 113 primary-care practices. Only 25.6% of men and 20.8% of women received secondary prevention. "Older patients were substantially less likely to receive treatment," they note. The adjusted odds ratio for 80- to 89-year-olds compared with 50- to 59-year-olds was 0.53 (95% CI, 0.41 – 0.69).

This variation in treatmentis important, the researchers emphasize, because the receipt of secondary drug prevention for patients who survived the first 30 days after a stroke wasassociated with a 50% reduction in the hazard of dying during the first year.

Low Rates of Secondary Drug Prevention

On average, mortalitywithin the first year was 5.7% for patients receiving treatmentcompared with 11.1% for patients not receiving therapy. There was little evidence that the effect of treatment differed betweenthe social groups examined.

In addition to improving the quality of life of patients, aggressive use of drugs in secondary prevention of stroke in the elderly is likely to lower health expenditures for rehabilitating stroke victims, Rajasree Pai Ramachandra Pai, a resident at the University of Connecticut, in Storrs, added in a rapid response to the paper.

In the second study, the authors found that older patients were less likely to receive diagnostic investigations and advice for lifestyle modifications than younger patients.

"This study highlights several important deficiencies in the management of transient ischemic attack [TIA] and minor stroke, especially with respect to the rates of brain and carotid imaging and echocardiograms," report the researchers, led by Y.Y. Karen Kee, MD, from the Mayday University Hospital, in Surrey, the United Kingdom.

Scanned Less Quickly

The research team studied 379 patients referred to a neurovascular clinic. They compared people over the age of 75 years with younger patients. Investigators found older patients were more likely to be in atrial fibrillation (10.1% vs 22.8%; P = .001) and have lacunar stroke (34.7% vs 22.1%; P = .04).

They found computed tomography rates were similar in the 2 groups, but most scans were performed more quickly in younger patients. Magnetic resonance imaging (MRI) scan rates were higher in younger patients (26% vs 4%; P = .01) as were carotid Doppler imaging rates (92% vs 77%; P = .01). Younger patients were also more likely to be given advice on weight reduction (30.2% vs 12.9%; P = .01) and diet (46.3% vs 31.7%; P = .02).

"Older patients have been shown to be receptive to lifestyle modification after a stroke if given the appropriate advice," note the researchers. "This study shows that, although access to specialist assessment was similar for patients of all ages, there is still underinvestigation and poor secondary-prevention advice delivered to older patients in a neurovascular clinic."

The authors suggest: "The results of this study possibly reflect negative views, attitudes, and behavior of healthcare professionals toward older patients." They note, "It is important to ensure that older patients receive the same treatment as younger patients, especially as there is growing evidence that older patients benefit from aggressive management of their TIA or minor stroke."

The researchers have disclosed no relevant financial relationships.

BMJ. Published online April 16, 2009. Abstract

Postgrad Med J. 2009;85:115-118.Abstract