Barriers and Facilitators in Secondary Stroke Prevention Among Older Adults: An International Systematic Review of Randomized Controlled Trials

<b>Background/Objectives:</b> Secondary stroke prevention is a cornerstone of long-term recovery and healthy aging among older adults, yet adherence to preventive strategies remains suboptimal. This global systematic review aimed to synthesize evidence from randomized controlled trials evaluating interventions that support sustained secondary prevention in older adults after stroke. <b>Methods:</b> A systematic search of PubMed and Scopus databases was conducted up to April 2025, following PRISMA 2020 guidelines and registered in PROSPERO (CRD420251177501). Eligible studies included randomized controlled trials targeting adults aged 60 years or older and assessing pharmacological, behavioral, educational, rehabilitative, or technology-assisted interventions for stroke recurrence prevention. Data were narratively synthesized due to study heterogeneity, and methodological quality was appraised using the Cochrane RoB 2 tool. <b>Results:</b> Seventeen randomized trials involving approximately 17,000 participants met the inclusion criteria. Multicomponent programs integrating medication management, behavioral education, exercise, cognitive rehabilitation, and digital support consistently improved adherence, vascular risk control, and quality of life. Pharmacological strategies alone showed limited or transient benefits, underscoring the importance of patient education and sustained follow-up. Common barriers included low motivation, cognitive decline, and technological challenges, while key facilitators were personalized education, multidisciplinary coordination, and culturally adapted implementation. <b>Conclusions:</b> Effective secondary stroke prevention in older adults depends on integrated, person-centered models that combine education, behavioral reinforcement, and technology-assisted monitoring. Structured, continuous educational programs, embedded within rehabilitation and primary care, emerge as the most promising pathway to improve adherence, reduce recurrence, and promote active, autonomous aging.