Press releases Monday 13 April to Friday 17 April 2009

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(1) Study reveals substantial under-treatment of older people after stroke
(2) Poor health predicts post traumatic stress among military personnel

(1) Study reveals substantial under-treatment of older people after stroke
(Research: Sociodemographic variations in the contribution of secondary drug prevention to stroke survival at middle and older ages: cohort study)
http://www.bmj.com/cgi/doi/10.1136/bmj.b1279

Older people are less likely to receive drug treatment after a stroke compared to younger people, despite the fact that treatment is equally effective, finds a study published on bmj.com today.

There is also some indication that women may be less likely to receive treatment than men, but patients’ social and economic circumstances are not linked to differences in treatment, the findings show.

Stroke is the second most common cause of death after coronary heart disease in developed countries and 80% of cases occur in people over 64 years of age. After a stroke, patients should receive a combination of drugs to help prevent another stroke. This is known as secondary drug prevention.

The drugs used are blood pressure and cholesterol lowering drugs, and anti-clotting drugs.

Previous studies have suggested that elderly people, socially disadvantaged people and women are less likely to receive medical interventions compared to younger, affluent people and to men. So researchers based in London decided to test this theory for stroke treatment.

They analysed data for 12,830 patients aged 50 years and above from 113 general practices in England. All participants had experienced a stroke between 1995 and 2005 and had survived the first 30 days after their stroke.

Rates of secondary drug prevention were generally low – only 25.6% of men and 20.8% of women received treatment. This did not vary by socio-economic circumstances. However, older patients were substantially less likely to receive cholesterol lowering treatment (26.4% of patients aged 50-59 received treatment compared with 15.6% of patients aged 80-89 and just 4.2% of those aged 90 or more).

This variation in treatment is important, say the authors, because secondary drug prevention halved the risk of dying during the first year after a stroke (on average, patients on treatment had a 5.7% risk of death within the first year compared to 11.1% for patients not on treatment).

Survival differed between social groups and gender - the most socially disadvantaged patients had lower one year survival than the most affluent, and women had a higher likelihood of one year survival than men – but this was not due to treatment differences.

There was also little evidence that the effect of treatment differed between social groups.

Under-treatment of older people cannot be justified because older people are at least as likely to benefit from treatment as younger people, say the authors. This issue must be addressed if the Government is to fulfil its commitment to reducing health care inequalities, they conclude.

Contacts:
Rosalind Raine, Professor of Health Services Research, Department of Epidemiology & Public Health, University College London, UK
Email: r.raine@ucl.ac.uk

Military personnel with diminished mental or physical health before combat exposure are more vulnerable to developing post-traumatic stress disorder (PTSD) after deployment, finds a study published on bmj.com today.

The researchers suggest that those at risk could be offered post-traumatic stress prevention programs or even protection from stressful exposures.

Concerns have been raised about the health impact of military deployment, but it is unclear if those with decreased mental or physical health are more vulnerable to developing PTSD.

To investigate this further, a team of US researchers studied 5,410 military servicemen and women who were taking part in the Millennium Cohort Study (a large 21-year study of the health of US military personnel). All participants were free of PTSD symptoms and diagnosis at the start of the study.

Two questionnaires were used to collect data on the mental and physical health of each individual before and after combat exposure. Higher scores on the questionnaires reflected more favourable health status.

The first (baseline) questionnaire was completed between 2001 and 2003, before any of the participants had been exposed to combat. The second (follow-up) questionnaire was completed between 2004 and 2006, after participants had their first combat deployment in support of wars in Iraq and Afghanistan.

Of the 5,410 participants, 395 (7.3%) had new-onset PTSD symptoms or diagnosis at the time of follow-up. After adjusting for all other variables, individuals with the lowest baseline mental or physical health scores had two to three times the risk of developing symptoms or a diagnosis of post-traumatic stress disorder by follow-up compared with those with higher scores.

Of those with new onset symptoms or diagnosis, over half (58%) of cases occurred among those with the lowest health scores at baseline. These participants were more likely to be female, younger, less educated, not married, current smokers, problem drinkers, and enlisted.

Despite some limitations, this study shows that diminished mental or physical health status before combat deployment is strongly associated with an increased risk of PTSD after deployment, they write.

In theory, those at risk could be targeted for PTSD prevention programs, early intervention after exposure to stress, or even protection from stressful exposures, when possible. Further research is also needed to develop effective screening tools and programs to prevent PTSD, they conclude.

Contacts:
Cynthia LeardMann, Biostatistician, US Department of Defense Center for Deployment Health Research, Naval Health Research Center, San Diego, CA, USA
Email: Cynthia.LeardMann@med.navy.mil

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