Ageism in stroke management
Sir—The ageing of western world populations is expected to increase the burden of stroke-related disability on healthcare systems [1]. To meet this challenge, acute stroke services and rehabilitation services must provide well organised care which maximises outcomes for the growing numbers of older stroke patients.The large Danish cohort study recently published by Palnum et al. adds important data to the emerging theme that older stroke patients receive lower quality care than younger patients [2]. This finding reflects our local concerns following a clinical quality audit in an Australian stroke unit, which used quality indicators drawn from the national stroke guidelines [3]. This study found that older stroke survivors received care from allied healthcare staff which was less guideline-compliant than that provided for younger patients in the stroke unit. This lower quality care was not related to functional ability scores on admission or discharge, neither was it related to functional improvements made by older patients.
These actual practice findings are in stark conflict to the evidence that older stroke patients achieve improved clinical outcomes if provided with optimal care [4].
Most would agree that such apparent age-related inequities must be addressed urgently—but how? We are in agreement with Palnum et al. regarding the need for research to understand the extent to which ageism is at play. This research should tease ageism effects out from areas where sound clinical and ethical reasoning is influencing care decisions [2]. Understanding what is happening is an important first step in solving this issue of concern.
However we also propose that there is an equally urgent need for concurrent research aimed at developing an understanding of why age-related differences exist in stroke management. This will require in-depth qualitative exploration of stroke healthcare professionals' values, attitudes and beliefs regarding older people and their ability to recover from stroke. Similar qualitative exploration has occurred in the past to understand complex barriers in stroke management, such as tackling prevailing pessimistic staff attitudes to stroke or inequitable decisions regarding access to rehabilitation, and then to develop strategies to overcome these barriers [5].
Centre for Allied Health Evidence, Division of Health Sciences, University of South Australia, Adelaide, 5000 Australia
* To Whom correspondence should be addressed. E-mail: Julie.luker{at}unisa.edu.au
References
- Murray CJL, Lopez AD. Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet (1997) 349:1498–504.[CrossRef][Web of Science][Medline]
- Palnum KD, Petersen P, Sorensen HT, et al. Older patients with acute stroke in Denmark: quality of care and short-term mortality. A nationwide follow-up study. Age Ageing (2008) 37:90–5.
[Abstract/Free Full Text] - Luker J, Grimmer-Somers K. Factors influencing acute stroke guideline compliance: a peek inside the ‘black box’ for allied health staff. J Eval Clin Pract (2008) in press.
[Abstract/Free Full Text] - Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke (Cochrane Review). In: The Cochrane Library (2004) Chichester: John Wiley and Sons.
- McKevitt C, Redfern J, Mold F, et al. Qualitative studies of stroke. Stroke (2004) 35:199–1505.
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