As a geriatrician, I enjoyed reading the report of Brass et al1 on the underuse of warfarin sodium treatment in the elderly, even in the best candidates for that type of treatment. In a previous report,2 I also analyzed reports of underuse in an effort to find an explanation for this unfortunate phenomenon. I, however, came to a different conclusion.
The authors appear to be perplexed and puzzled, offering many possible explanations. Although the problem could be multifactorial, I believe the major reason for the undertreatment is the medical neglect toward the elderly, which has been well documented during the past 20 years. Butler3 described the situation well in his Pulitzer Prize–winning publication Why Survive? Being Old in America. One would hope that the emergence of geriatric medicine within internal and family medicine would sensitize the general medical practitioners to the specific needs of the elderly and the proper means to address them. However, the evidence of this effect is lacking.