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We would like to comment on the important report by Landi and colleagues about the factors associated with a reduced likelihood of receiving secondary stroke prevention treatment1 and present our own data. We have demonstrated that in community-dwelling patients with chronic atrial fibrillation, living alone or in rural areas, history of previous falls, and cognitive and functional impairments are independent factors that result in physicians prescribing aspirin instead of anticoagulants, thus disregarding the common guidelines for stroke prevention.2,3 We have also shown that in some cases it does not mean malpractice.3 In elderly patients, a geriatric assessment including a shrewd evaluation of the psychosocial conditions can guide physicians in the selection of the correct treatment, thus avoiding the risks related to anticoagulants in individuals at high risk of falls or with inability to comply with regular blood monitoring.2–5
Our data are only partially comparable with those of Landi and colleagues, since in their study a significant number of the reported undertreatment concerns aspirin and triclopidine, drugs that have an unfavourable risk–benefit ratio in comparison with anticoagulants, even when they are prescribed for individuals living alone, with a low education level and poor cognitive or functional performance. In these conditions, low compliance is not enough of a risk and does not justify undertreatment. As a matter of facts, in the clinical conditions described by Landi and colleagues, an “ageist” cultural background prevails without real clinical motivation.
The difference between the two sets of data suggests that physicians need to be taught to consider the complexity of the medical scenario and to distinguish incorrect prescribing patterns due to limitations imposed by cultural factors from the rational behavior of physicians who adopt a multidimensional model of care and avoid treatments commonly recognised as beneficial but burdened by a high cost–benefit ratio.
The data presented by Bellelli and Trabucchi confirm our findings suggesting that many older adults do not receive secondary stroke prevention treatment.1 However, we really do not believe that our results indicate only an “ageist cultural background without real clinical motivations”. Indeed, in our article we recognised that the decision of not to treat could not be considered as “undertreatment”, but it may be related to the uncertainty about the cost-effectiveness of the treatment in a frail population. These doubts are not always unrealistic, especially among frail post-stroke elderly individuals, who characteristically have a high number and complexity of associated diseases, with a concomitant higher risk of drug interactions and adverse drugs events.2 Furthermore, the reduced rate of treatment observed in our study is not only explained by potential risks in frail elderly patients, but also by uncertainties about the potential benefits.3,4 In fact, the most important evidence of antiplatelet or anticoagulant medications after cerebrovascular accidents is substantially based on non-disabling ischaemic stroke. Evidence about the benefits of secondary stroke prevention is much more limited in the frail elderly population with severe physical and/or cognitive impairment. In this respect, it is important to underline the fact that the data presented by Bellelli and Trabucchi are based on a sample of community dwelling patients with atrial fibrillation, that “per se” is an indication to treat. In contrast, our study sample, which was based on patients receiving home care programmes indicating that an important and disabling health problem was in place, included a frailer population.5 In this respect our results can not be generalised to all healthy community dwelling elderly individuals. However, we acknowledge that studies addressing the efficacy of secondary prevention treatment are needed, especially for frail and functionally impaired older individuals who have suffered a stroke.