Anticoagulant usage for primary stroke prevention: a general practitioner survey in local areas of metropolitan Sydney.

We assessed the hypothesis that having a non-English-speaking background (NESB), being very elderly, living alone, and having cognitive impairment were contributing factors to anticoagulant under-utilisation for atrial fibrillation in our local community. A questionnaire was mailed to 532 general practitioners (GPs) in three areas of metropolitan Sydney, Australia. The questionnaire included five case scenarios, regarding either an English-speaking background (ESB) patient, or an NESB patient, each characterised by potential barrier(s) for anticoagulant usage: being (1) elderly; (2) elderly with mild dementia; (3) elderly with mild dementia and living alone; (4) elderly with severe dementia; and (5) very elderly. The overall response rate was 34%. The percentage of GPs recommending anticoagulation was 57%, 50%, 6%, 25% and 23%, respectively, for the ESB scenario, and 48%, 32%, 4%, 14% and 18%, respectively, for the NESB scenario. Eighty-eight percent of GPs rated 'adherence to International Normalized Ration monitoring' as 'very important' in their decision. In conclusion, the factors proposed in our hypothesis were associated with a lower likelihood for anticoagulant prescription for atrial fibrillation.

Delirium within three days of stroke in a cohort of elderly patients.

OBJECTIVES: To evaluate the incidence of stroke, risk factors for stroke, and outcomes in elderly stroke patients with delirium. DESIGN: Cohort study with 12-month follow-up. SETTING: Bankstown-Lidcombe Hospital, a 450-bed teaching hospital of the University of New South Wales, Sydney, Australia. PARTICIPANTS: One hundred fifty-six stroke patients aged 65 and older recruited over 1 year. MEASUREMENTS: Incidence of delirium (defined in accordance with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria) within 3 days poststroke, length of hospital stay, discharge destination, short- and long-term mortality, Functional Independence Measure (FIM) scores, and Mini-Mental State Examination (MMSE) scores. RESULTS: Thirty-nine (25%) elderly stroke patients had delirium within 3 days after stroke. Logistic regression analysis found that older age (P=.04), hemorrhagic stroke (P=.02), metabolic disorders (P=.003), dementia prestroke (P=.02), Glasgow Coma Scale (GCS) score less than 15 on admission (P<.001), and inability to lift both arms on admission (P=.03) were independent predisposing factors for delirium. Patients who had a cardioembolic stroke (odds ratio (OR)=5.58) or total anterior circulation infarction (OR=3.42) were also more likely to develop delirium. Patients with delirium were associated with higher 6- and 12-month mortality (P<.05), lower 12-month FIM and MMSE scores, and a higher 12-month institutionalization rate. CONCLUSION: Delirium occurred frequently in acute stroke patients aged 65 and older. Factors independently associated with delirium included old age, intracerebral hemorrhage, metabolic factors, prestroke dementia, initial GCS less than 15, and inability to lift both arms on admission. Patients with delirium had higher long-term mortality and a worse functional outcome.