David Brill
Elderly patients are missing out on life-saving stroke prevention drugs in primary care, according to a report in the British Medical Journal.
Stroke patients aged 80 to 89 were almost half as likely to be receiving secondary prevention treatments as those aged 50 to 59, the researchers found.
This discrepancy in treatment was not justified by outcomes, however – receipt of the drugs halved mortality risk, regardless of age.
The study of 12,380 patients took place in England but carries an important message for Singapore, according to stroke expert Associate Professor Lee Kim En, senior consultant and head of the department of neurology at the National Neuroscience Institute, Singapore.
“We do not have local figures, but similar findings are expected in Singapore. This is a timely article serving as a reminder that social support must include ensuring the elderly receive their medications,” he said.
“As doctors, we have a responsibility to motivate our elderly patients to continue with treatment regardless of challenges, constraints and limitations. All primary care physicians must share this responsibility.”
The researchers reviewed data from 113 general practices to identify over-50s who had a stroke between 1995 and 2005 and survived the first 30 days. Therapy had to be initiated within 90 days of the stroke to be included in the study as secondary prevention. [BMJ 2009 Apr 16;338:b1279]
Overall treatment rates were low: 25.6 percent of men and 20.8 percent of women were receiving secondary prevention. Mortality within one year of stroke was 5.7 percent for patients receiving treatment, compared to 11.1 percent among those receiving no such therapy.
Treatment rates did not vary by socioeconomic status but dropped markedly with age – from 26.4 percent of patients aged 50 to 59, to 15.6 percent of those aged 80 to 89. Just 4.2 percent of over-90s were receiving treatment.
Lipid lowering drugs were particularly under-used in the elderly – the odds ratio for receipt of these therapies was 0.44 for 80 to 89 year-olds, compared with 50 to 59 year-olds (95 percent CI, 0.33 to 0.59; P<0.001).
The study did not explore the reasons for the observed age bias, but lead researcher Professor Rosalind Raine speculated that responsibility could lie with both patients and prescribers.
“We can’t leave an attack of clinical bias on the doors of the clinicians until we’ve really excluded all of the other explanations,” said Raine, professor of health care evaluation at University College London. “Patients are increasingly more informed, and so there is also a balance about what they’re asking for.”
Some experts have suggested that GPs may be unsure about the efficacy of secondary prevention drugs in the elderly since they are often excluded from clinical trials, she said. She noted, however, that there is a growing body of evidence – particularly from meta-analyses – to support the benefits of this practice. The mortality findings from the present study further underscore this point in a real-world, general practice population, she added.
Raine also ruled out the possibility that prescribers may be worried about adherence in the elderly, since the discrepancy was only evident for lipid lowering drugs and not for cheaper therapies such as antihypertensive and antithrombotic drugs. She expressed her concern that it could be the relative cost of the drugs which is driving this particular effect.
“It does make you wonder if lay beliefs about values of people in society are actually being transposed into the clinical situation. But I do not have evidence on which to base that – it’s only by exclusion of some of the other likely explanations,” she said.
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