The use of oral anticoagulants (warfarin) in older people. AGS Clinical Practices Committee. American Geriatric Society

Outcomes of Endoscopic Sinus Surgery in Geriatric Patients: An Institutional Study

The aim of this study was to investigate the efficacy and safety of Endoscopic Sinus Surgery (ESS) as a treatment modality for chronic rhinosinusitis refractory to maximal medical therapy in the elderly population. ESS has gained importance over the past 2-3 decades. A prospective review of outcome was done in fifty seven patients over age of 60 years who underwent ESS. They were evaluated preoperatively and postoperatively at 3, 6, and 12 months with a rigid nasal endoscopy scoring system, and the Sino Nasal Outcome Test-20 questionnaire. Data analysis was performed using the Student's t test to compare mean scores. All complications were noted. All of the patients in the study reported postoperative symptomatic improvement. And it was concluded that ESS in the geriatric population is a safe and effective treatment modality for rhinosinusitis which is refractory to medical therapy.

Detection and quantification of warfarin in pharmaceutical dosage form and in spiked human plasma using surface enhanced Raman scattering

Analytical approaches for the quantitation of warfarin in plasma are high in demand. In this study, a novel surface enhanced Raman scattering (SERS) technique for the quantification of the widely used anticoagulant warfarin sodium in pharmaceutical dosage form and in spiked human plasma was developed. The colloidal-based SERS measurements were carefully optimized considering the laser wavelength, the type of metal nanoparticles, their surface functionalization and concentration as well as the time required for warfarin to associate with the metal surface. Poly(diallyldimethylammonium chloride) coated silver nanoparticles (PDDA-AgNPs) were established as a substrate which greatly enhanced the weak warfarin Raman signal with high reproducibility. The limit of detection was calculated in both water and human plasma to be 0.56 nM (0.17 ngmL^-1) and 0.25 nM (0.08 ngmL^-1) respectively, with a high degree of accuracy and reproducibility. The proposed method is simple, economical, and easily applied for routine application requiring only small plasma samples and also could be potentially useful for pharmacokinetic research on warfarin.

Endoscopic Sinus Surgery in Patients Older than Sixty

OBJECTIVE: Rhinosinusitis is the sixth most common chronic condition of the elderly. Functional endoscopic sinus surgery (FESS) has developed over the last 20 to 30 years into a widely accepted treatment modality for chronic rhinosinusitis in adults who have failed maximal medical management. The aim of this study was investigate the safety and efficacy of FESS in the geriatric population as compared to that of the adult population.

METHODS: Retrospective review of prospective measurement of outcomes in consecutive patients over 60 years of age who underwent FESS. Fifty-six patients over 60 years of age underwent FESS and were evaluated preoperatively and postoperatively at 3, 6, and 12 months with the Sino-Nasal Outcome Test-20 (SNOT-20) questionnaire, and a rigid nasal endoscopy scoring system. Data analysis was performed using the Student's t test to compare mean scores. Any complications were noted.

RESULTS: Patients evaluated by the SNOT-20 scoring system experienced 64% improvement of symptom scores at 3 months, 73% improvement at 6 months, and 75% improvement at 12 months. Rigid nasal endoscopy scores improved by 76% at 3 months, 65% at 6 months, and 76% at 12 months. There were very few minor complications and no major complications of the surgery. These results are comparable to those of the literature that address outcomes in the adult population undergoing FESS.

CONCLUSIONS: FESS in the geriatric population is a safe and effective treatment modality for rhinosinusitis that is refractory to medical therapy. EBM rating: C.

Use of blood products in patients with anticoagulant-related major bleeding: an analysis of inhospital outcomes

PURPOSE

The impact of correcting elevated International Normalized Ratio (INR) values on inhospital mortality in patients with warfarin-associated major bleeding is presented.

METHODS

Using patient information from the database of a large U.S. health system, a retrospective analysis was conducted to (1) evaluate inpatient practice patterns in correcting INR elevations among patients hospitalized with warfarin-related intracranial hemorrhage (ICH) or non-ICH bleeding and (2) test the hypothesis that achieving INR correction, defined as an INR of ≤1.5, at any point during the hospital stay is correlated with lower inhospital mortality. Cox proportional hazards models were constructed to assess predictors of inhospital death.

RESULTS

Among the 354 patients who met the study selection criteria, INR correction was achieved in 87.9% overall (92.5% and 85.5% of patients with ICH and non-ICH bleeds, respectively). Patients whose elevated INR values were corrected had significantly lower inhospital death rates than those with uncorrected elevations: 15.3% versus 55.6% (p = 0.010) among patients with ICH and 2.0% versus 11.8% (p = 0.017) among those with non-ICH bleeds. After adjusting for baseline demographics and comorbidities, the correlation between failure to correct INR elevations and increased mortality risk was significant only for patients with ICH (hazard ratio, 8.04; 95% confidence interval, 2.07-31.18; p = 0.003).

CONCLUSION

Results of this study indicated that correction of elevated INR values was associated with a lower likelihood of inhospital death among warfarin-treated patients hospitalized for ICH or non-ICH major bleeding.

Incident long-term warfarin use and risk of osteoporotic fractures: propensity-score matched cohort of elders with new onset atrial fibrillation

Association between warfarin use and fracture risk is unclear. We examined the association between long-term warfarin use and fracture risk at the hip, spine, and wrist in elders. No significant association was found between long-term warfarin use and fracture risk, despite biological plausibility.

INTRODUCTION

Prior studies examining the association of warfarin use and osteoporotic fractures have been conflicting, potentially related to methodological limitations. Thus, we examined the association of long-term warfarin use with risk of hip, spine, and wrist fractures among older adults with atrial fibrillation, attempting to address prior methodologic challenges.

METHODS

We included men and women ≥ 65 years of age with incident atrial fibrillation and without prior history of fractures from The Health Improvement Network followed between 2000 and 2010. Long-term warfarin use was defined in two ways: (1) warfarin use ≥ 1 year; (2) warfarin use ≥ 3 years. Propensity-score matched cohorts of warfarin users and nonusers were created to evaluate the association between long-term warfarin use and risk of hip, spine, and wrist fractures separately as well as combined, using Cox-proportional hazards regression models.

RESULTS

Among >20,000 participants with incident atrial fibrillation, the hazard ratios (HR) for hip fracture with warfarin use ≥ 1 and ≥ 3 years, respectively, were 1.08 (95%CI 0.87, 1.35) and 1.13 (95% CI 0.84, 1.50). Similarly, no significant associations were observed between long-term warfarin use and risk of spine or wrist fracture. When risk of any fracture was assessed with warfarin use, no association was found [HR for warfarin use ≥ 1 year 0.92 (95%CI 0.77, 1.10); HR for warfarin use ≥ 3 years 1.12 (95%CI 0.88, 1.43)].

CONCLUSIONS

Long-term warfarin use among elders with atrial fibrillation was not associated with increased risk of osteoporotic fractures and therefore does not appear to necessitate additional surveillance or prophylaxis.

Failure to correct International Normalized Ratio and mortality among patients with warfarin-related major bleeding: an analysis of electronic health records

BACKGROUND

Delayed correction of blood clotting times as measured by the International Normalized Ratio (INR) is associated with adverse outcomes among certain patients with warfarin-related major bleeding. However, there are limited data on the association between INR correction and mortality.

OBJECTIVE

To assess factors associated with 30-day mortality and time to death in patients receiving fresh frozen plasma (FFP) for warfarin-associated major bleeding.

METHODS

A retrospective database analysis was undertaken with electronic health record data from a large integrated health system. Patients met the following criteria: major hemorrhage diagnosis; INR ≥ 2 on the day before or day of receipt of FFP; and prescription fill for warfarin within 90 days. INR correction (defined as INR ≤ 1.3) was evaluated at the last available test 1 day following the start of FFP administration. Kaplan-Meier curves and Cox proportional hazards models were constructed to assess mortality.

RESULTS

Four hundred and five patients met the selection criteria (mean age of 75 years, 54% male), and 67% remained uncorrected at 1 day following the start of FFP administration. Among all patients, 11% died within 30 days of hospital admission. An uncorrected INR was not associated with a higher risk of 30-day mortality for patients overall, but was statistically significant for the subgroup with intracranial hemorrhage (ICH) (adjusted odds ratio 2.55; 95% confidence interval 1.04-6.28).

CONCLUSIONS

Among the subgroup of major bleeding patients with warfarin-associated ICH, those not correcting to either INR ≤ 1.3 or INR ≤ 1.5 with the use of FFP have an increased rate of mortality at 30 days.

Factors associated with failure to correct the international normalised ratio following fresh frozen plasma administration among patients treated for warfarin-related major bleeding. An analysis of electronic health records

This study assessed the frequency and factors associated with failure to correct international normalised ratio (INR) in patients administered fresh frozen plasma (FFP) for warfarin-related major bleeding. This retrospective database analysis used electronic health records from an integrated health system. Patients who received FFP between 01/01/2004 and 01/31/2010, and who met the following criteria were selected: major haemorrhage diagnosis the day before to the day after initial FFP administration; INR ≥2 on the day before or the day of FFP and another INR result available; warfarin prescription within 90 days. INR correction (defined as INR ≤1.3) was evaluated at the last available test up to one day following FFP. A total of 414 patients met selection criteria (mean age 75 years, 53% male, mean Charlson score 2.5). Patients presented with gastrointestinal bleeding (58%), intracranial haemorrhage (38%) and other bleed types (4%). The INR of 67% of patients remained uncorrected at the last available test up to one day following receipt of FFP. In logistic regression analysis, the INR of patients who were older, those with a Charlson score of 4 or greater, and those with non-ICH bleeds (odds ratio vs. intracranial bleeding 0.48; 95% confidence interval 0.31-0.76) were more likely to remain uncorrected within one day following FFP administration. In an alternative definition of correction, (INR ≤1.5), 39% of patients' INRs remained uncorrected. For a substantial proportion of patients, the INRs remain inadequately or uncorrected following FFP administration, with estimates varying depending on the INR threshold used.

Measuring quality of oral anticoagulation care: extending quality measurement to a new field

BACKGROUND

Oral anticoagulation with warfarin is an increasingly common medical intervention. Despite its efficacy, warfarin is difficult to manage, contributing to potential for patient harm. Efforts to measure the quality of oral anticoagulation care have focused disproportionately on the identification of ideal candidates for warfarin therapy, with comparatively little effort in measuring the quality of oral anticoagulation care once therapy has begun. To address this gap in the literature, a MEDLINE search was conducted for all papers relevant to possible quality measures in oral anticoagulation care, including measures of structure, process, and outcomes of care.

LIMITATIONS, CONCERNS, AND CHALLENGES OF QUALITY MEASUREMENT IN ORAL ANTICOAGULATION

Because they do not have intrinsic significance, measures of structure and process should be strongly related to outcomes that matter to merit our interest. Consensus guidelines may provide useful guidance to practicing clinicians but may not represent valid process measures. Outcome measures must be studied with databases that provide sufficient statistical power to reliably demonstrate real differences between providers or sites of care.

CONCLUSION

Oral anticoagulation care, a common and serious condition, is in need of a program of quality measurement. This article suggests a research agenda to begin such a program. Previous research has established the evidence for anticoagulant therapy across a broad spectrum of indications and has helped to achieve consensus on the optimal target intensity for various indications. The next task will be to use this body of evidence to develop valid measures of the structure, process, and outcomes of oral anticoagulation care. Quality indicators provide a framework for quality improvement, two goals of which are to maximize the effectiveness of therapy and to minimize harm.

Single-point assessment of warfarin use and risk of osteoporosis in elderly men

OBJECTIVES

To determine whether warfarin use, assessed at a single point in time, is associated with bone mineral density (BMD), rates of bone loss, and fracture risk in older men.

DESIGN

Secondary analysis of data from a prospective cohort study.

SETTING

Six U.S. clinical centers.

PARTICIPANTS

Five thousand five hundred thirty-three community-dwelling, ambulatory men aged 65 and older with baseline warfarin use data.

MEASUREMENTS

Warfarin use was assessed as current use of warfarin at baseline using an electronic medication coding dictionary. BMD was measured at the hip and spine at baseline, and hip BMD was repeated at a follow-up visit 3.4 years later. Self-reported nonspine fractures were centrally adjudicated.

RESULTS

At baseline, the average age of the participants was 73.6 +/- 5.9, and 321 (5.8%) were taking warfarin. Warfarin users had similar baseline BMD as nonusers (n=5,212) at the hip and spine (total hip 0.966 +/- 0.008 vs 0.959 +/- 0.002 g/cm(2), P=.37; total spine 1.079 +/- 0.010 vs 1.074 +/- 0.003 g/cm(2), P=.64). Of subjects with BMD at both visits, warfarin users (n=150) also had similar annualized bone loss at the total hip as nonusers (n=2,683) (-0.509 +/- 0.082 vs -0.421 +/- 0.019%/year, P=.29). During a mean follow-up of 5.1 years, the risk of nonspine fracture was similar in warfarin users and nonusers (adjusted hazard ratio=1.06, 95% confidence interval=0.68-1.65).

CONCLUSION

In this cohort of elderly men, current warfarin use was not associated with lower BMD, accelerated bone loss, or higher nonspine fracture risk.

Pharmacogenetics of oral anticoagulants

The use of oral anticoagulants (OA) is problematic due to its association with hemorrhagic complications. OA metabolism relies on the CYP2C9 complex. Genetic variations compromising metabolic competence of this complex may explain the risk of excessive and hazardous anticoagulation. A pharmacogenetics-based approach to this issue could be beneficial for choosing adequate dose and duration of treatment, in addition to having a better understanding of pharmacological interactions to which OA are susceptible. However, evidence from several basic and clinical studies indicates that both a complicated system of regulation of expression of multiple genes and the influence of a wide variety of epigenetic factors could be responsible for adverse drug reactions associated with the use of OA. Emphasis on understanding the gene-environment interactions could attain new paths to facilitate the use of these important drugs in the quotidian clinical practice.

Acute pulmonary embolism in elderly: clinical characteristics and outcome

OBJECTIVE

To evaluate the clinical characteristics and outcome of acute pulmonary embolism in elderly in comparison to the younger patients.

METHODS

Study population consisted of 136 patients with a confirmed diagnosis of acute pulmonary embolism. Clinical characteristics and thromboembolic risk factors were analyzed between the elderly (> or =65 years of age) and the younger (<65 years of age) patients. In-hospital mortality was used as a measure of outcome.

RESULTS

Elderly group consisted of 70 patients (age 76.4+/-8.3 years, range 65-96 years; females 58%) and younger group of 66 patients (age 48.5+/-12 years, range 18-64 years, females 59%). Syncope was more frequent in elderly group (19% vs. 6%, P=0.03) but the symptoms of shortness of breath and pleuritic chest pain were not significantly different between groups. Malignancy was the most common risk factor for thrombo-embolism, but immobilization predominated among patients in elderly group (21% vs. 6%, P=0.01). Tachycardia was common in younger patients compared to the elderly. Ventilation-perfusion scan was used more commonly in younger patients (76% vs. 57%, P=0.02), whereas, helical computed-tomography scan was used equally in both groups. Most of the patients had lower extremity duplex study (97% in each group). Inferior vena cava filter placement was common and thrombolytic therapy rare among elderly patients. Patients in elderly group had higher in-hospital mortality (17% vs. 5%, P=0.02).

CONCLUSIONS

Syncope is a more frequent presenting symptom and immobilization a common risk factor in elderly patients with acute pulmonary embolism. In addition, they have higher in-hospital mortality.

Cognitive Impairment as Determinant for Sub-Optimal Control of Oral Anticoagulation Treatment in Elderly Patients with Atrial Fibrillation

BACKGROUND AND OBJECTIVE

Atrial fibrillation is an indication for oral anticoagulation treatment. Maintaining the International Normalized Ratio (INR) within the therapeutic range minimises thromboembolic and bleeding complications. We have investigated whether cognitive capacity affects control of anticoagulation in elderly patients with atrial fibrillation.

PATIENTS AND METHODS

A retrospective study was conducted to investigate the association between cognitive impairment and control of anticoagulation. Patients > or =70 years of age with atrial fibrillation using acenocoumarol (nicoumalone) as anticoagulant were included. All patients were monitored by the Anticoagulation Clinic in the Midden-Brabant region in the Netherlands. The cognitive function of all patients was assessed using the Mini-Mental State Examination (MMSE) on the index date. INR values were obtained from the year preceding the index date. Patients with an MMSE score <23 were defined as cognitively impaired. The primary outcome of the study was the incidence of an INR value within the therapeutic range of 2.0-3.4 during < or =70% of treatment time in the year prior to the cognitive function assessment. The secondary endpoint was the number of patients with an INR <2.0 or > or =6.0 at least once during this year. Logistic regression analysis was used to evaluate the association between cognitive function and control of anticoagulation.

RESULTS

A total of 152 patients were included in the study. An MMSE score <23 was associated with an inadequate INR control (odds ratio [OR] 2.77; 95% CI 1.13, 6.74). After correction for hospital admission and change of possibly interacting medication (both also associated with inadequate INR control), this association remained statistically significant. Significantly more patients with an MMSE score <23 had one or more INR values of six or higher (OR 3.06; 95% CI 1.14, 8.18).

CONCLUSION

In elderly people with atrial fibrillation using oral anticoagulation, an MMSE score <23 is independently associated with an inadequate INR control, mainly because of an increased number of supratherapeutic INR values. This finding should be taken into account when making decisions about use of oral anticoagulants in the elderly.

Iatrogenic prescribing in acute care: learning from our mistakes

1. The pharmacokinetics of medications (i.e., absorption, distribution, metabolism, elimination) are altered in older adults because of age-related changes in body composition, diminished vascularity, and atrophy of end-organs. 2. The result of altered pharmacokinetics is often a stronger drug effect than seen in younger adults, a longer duration of drug action, and higher risk of adverse drug effects and drug-drug interactions. 3. Nurses working with older adults should be aware of measures to prevent potential adverse drug effects, including being aware of adverse effects of drugs and that the effects of drugs in older adults are atypical; being aware that changing more than one medication or dosage at a time may make interpretation of the response more difficult; being aware that many drugs with narrow therapeutic windows can and should be monitored via serum levels, and that renal insufficiency will increase the chance of adverse drug effects for renally excreted drugs.

Evaluation of a warfarin initiation protocol for older people

A protocol for initiation of warfarin therapy, targeted specifically for older people and based on individual responses to initial warfarin doses, was evaluated in a case-control study. People within the protocol group: (i) received higher initial doses of warfarin, (ii) reached an international normalized ratio (INR) of 2 more quickly, (iii) spent more time with INR of 2-3 in the first week and (iv) were less likely to be over-anticoagulated. However, the proportion of people who reached an INR of 2 too quickly (in <4 days) was no greater. The protocol correctly predicted the maintenance dose range of warfarin in over 70% of cases.

Adverse Drug Events Involving COX-2 Inhibitors

OBJECTIVE

To describe the types and severity of adverse drug-related events (ADEs) observed in patients receiving cyclooxygenase-2 (COX-2) inhibitors and to increase the awareness of risk factors that predispose patients to ADEs associated with COX-2 inhibitors.

METHODS

A review of ADEs reported at the University of Pittsburgh Medical Center Presbyterian Hospital (UPMC-P) revealed significant events related to use of celecoxib or rofecoxib. A query of the internal ADE database was performed to identify ADEs involving COX-2 inhibitors from January 1999 to June 2002. A similar query was performed to identify ADEs involving nonselective nonsteroidal antiinflammatory drugs (NSAIDs) reported during this same time period. Utilization data were also collected.

RESULTS

Forty-eight ADEs involving 24 patients receiving COX-2 inhibitors were reported and validated via the UPMC-P ADE review process compared with 38 events in 33 patients receiving nonselective NSAIDs. The types of ADEs reported as related to COX-2 inhibitors were similar to those reported in association with nonselective NSAIDs. Forty-two percent of ADEs (n = 20) involving COX-2 inhibitors and 45% of events (n = 17) involving nonselective NSAIDs were classified as severe. All patients receiving COX-2 inhibitors and 91% of patients receiving nonselective NSAIDs exhibited risk factors that increased their risk to experience an ADE; all but 1 of these patients were receiving outpatient COX-2 inhibitor therapy.

CONCLUSIONS

The observed ADEs involving COX-2 inhibitors were similar to those associated with nonselective NSAIDs. Most events may have been preventable, highlighting the need for education regarding the appropriate use of COX-2 inhibitors.

Diagnosis and treatment of pulmonary embolism in the elderly

Pulmonary embolism (PE) is a difficult diagnosis in patients of all ages, but more so in the elderly. Nonspecific symptoms and laboratory results are often misattributed to common diseases or to age itself, and can delay or even deter the diagnosis and treatment of PE. Advanced age is sometimes mistakenly seen as a contraindication to anticoagulation and thrombolysis. Together, these factors contribute to the higher morbidity and mortality associated with PE in the elderly than in younger patients. This article reviews the risk factors, diagnosis, and treatment of PE as it applies to the elderly.

Pulmonary embolism in the elderly

The elderly are at increased risk for pulmonary embolism because of both the conditions common to this age group, and the immobility that often accompanies them. Whether aging alone represents a hypercoagulable state is unclear. The incidence of pulmonary embolism rises with age, however, as does pulmonary embolism mortality. The diagnosis of pulmonary embolism is difficult and frequently missed because elderly patients and their physicians may attribute nonspecific symptoms to underlying cardiopulmonary disease or to age itself. Routine laboratory examinations are also nonspecific. Lower extremity studies to diagnose DVT should always be pursued because a positive study results in identical treatment, without the need for further testing. D-dimer concentrations are useful when low, but are commonly elevated in the elderly because of other comorbid conditions. Lung scanning remains the most common initial study to diagnose pulmonary embolism, although spiral CT is as sensitive and specific. Pulmonary angiography should always be considered when the initial studies are nondiagnostic and clinical suspicion is high, and this test is well tolerated in the elderly. The role of newer diagnostic techniques, such as MR imaging, cannot be determined until well-designed outcomes trials are completed. Prophylaxis with appropriate pharmacologic agents or mechanical measures should be administered not only to patients undergoing hip or knee reconstruction surgery, but to all bed-ridden elderly medical and general surgery patients. Treatment for pulmonary embolism with anticoagulation reduces the mortality rate and should be administered in all elderly patients without contraindications. In addition, thrombolysis should be considered for all hemodynamically unstable patients with pulmonary embolism, regardless of age. Vena caval filters are warranted when anticoagulation is contraindicated, although evidence of the long-term benefit of these devices is lacking. At present, pulmonary embolism is underdiagnosed and undertreated in the elderly. By heightening awareness of this diagnosis and its appropriate management in this age group, considerable morbidity and mortality may be avoided.