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Anand P, Zhang Y, Ngan K, Mahesri M, Brill G, Kim DH, Lin KJ. Identifying Dementia Severity Among People Living With Dementia Using Administrative Claims Data. J Am Med Dir Assoc 2024; 25:105129. [PMID: 38977199 DOI: 10.1016/j.jamda.2024.105129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVES There is currently no reliable tool for classifying dementia severity level based on administrative claims data. We aimed to develop a claims-based model to identify patients with severe dementia among a cohort of patients with dementia. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS We identified people living with dementia (PLWD) in US Medicare claims data linked with the Minimum Data Set (MDS) and Outcome and Assessment Information Set (OASIS). METHODS Severe dementia was defined based on cognitive and functional status data available in the MDS and OASIS. The dataset was randomly divided into training (70%) and validation (30%) sets, and a logistic regression model was developed to predict severe dementia using baseline (assessed in the prior year) features selected by generalized linear mixed models (GLMMs) with least absolute shrinkage and selection operator (LASSO) regression. We assessed model performance by area under the receiver operating characteristic curve (AUROC), area under precision-recall curve (AUPRC), and precision and recall at various cutoff points, including Youden Index. We compared the model performance with and without using Synthetic Minority Oversampling Technique (SMOTE) to reduce the imbalance of the dataset. RESULTS Our study cohort included 254,410 PLWD with 17,907 (7.0%) classified as having severe dementia. The AUROC of our primary model, without SMOTE, was 0.81 in the training and 0.80 in the validation set. In the validation set at the optimized Youden Index, the model had a sensitivity of 0.77 and specificity of 0.70. Using a SMOTE-balanced validation set, the model had an AUROC of 0.83, AUPRC of 0.80, sensitivity of 0.79, specificity of 0.74, positive predictive value of 0.75, and negative predictive value of 0.78 when at the optimized Youden Index. CONCLUSIONS AND IMPLICATIONS Our claims-based algorithm to identify patients living with severe dementia can be useful for claims-based pharmacoepidemiologic and health services research.
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Affiliation(s)
- Priyanka Anand
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ye Zhang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Kerry Ngan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Brill
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA, USA
| | - Kueiyiu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Agarwal A, Mostafa MA, Ahmad MI, Soliman EZ. Exploring the Link between Anticoagulation, Cognitive Impairment and Dementia in Atrial Fibrillation: A Systematic Review. J Clin Med 2024; 13:2418. [PMID: 38673694 PMCID: PMC11051417 DOI: 10.3390/jcm13082418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Background: The impact of oral anticoagulants (OACs) on cognitive impairment and dementia in patients with atrial fibrillation (AF) is not well characterized. This systematic review aims to address this knowledge gap. Methods: SCOPUS and PubMed searches were conducted to identify articles in the English language investigating the association between the use of OACs and cognitive impairment and dementia. We excluded non-original research studies and studies that did not report data on cognitive impairment or included patients who underwent open heart surgery or had psychiatric illnesses or cancer. Results: Out of 22 studies (n = 606,404 patients), 13 studies (n = 597,744 patients) reported a reduction in cognitive impairment/dementia in those undergoing thromboprophylaxis. Using direct oral anticoagulants (DOACs) was associated with a lower incidence of cognitive impairment in 10 studies (n = 284,636 patients). One study found that patients undergoing dual therapy (n = 6794 patients) had a greater incidence of cognitive impairment compared to those undergoing monotherapy (n = 9994 patients). Three studies (n = 61,991 patients) showed that AF patients on DOACs had a lower likelihood of dementia diagnosis than those on vitamin K antagonists (VKAs). Dementia incidence was lower when VKAs were under good control. Conclusions: The use of oral anticoagulants has the potential to prevent cognitive impairment and dementia in patients with AF. Since most of the published research on this subject is observational in nature, more randomized controlled trials are needed to fully understand the effect of anticoagulants on cognitive function.
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Affiliation(s)
- Abhimanyu Agarwal
- Epidemiological Cardiology Research Center, Section on Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA; (A.A.); (M.A.M.)
| | - Mohamed A. Mostafa
- Epidemiological Cardiology Research Center, Section on Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA; (A.A.); (M.A.M.)
| | - Muhammad Imtiaz Ahmad
- Department of Medicine, Section on Hospital Medicine, Medical College of Wisconsin, Wauwatosa, WI 53226, USA;
| | - Elsayed Z. Soliman
- Epidemiological Cardiology Research Center, Section on Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA; (A.A.); (M.A.M.)
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Mitchell A, Elmasry Y, van Poelgeest E, Welsh TJ. Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review. Eur Geriatr Med 2023; 14:683-696. [PMID: 37392359 PMCID: PMC10447288 DOI: 10.1007/s41999-023-00811-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/02/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE The aim of this clinical narrative review was to summarise the existing knowledge on the use of anticoagulants and potential adverse events in older people at risk of falls with a history of atrial fibrillation or venous thromboembolism. The review also offers practical steps prescribers can take when (de-)prescribing anticoagulants to maximise safety. METHODS Literature searches were conducted using PubMed, Embase and Scopus. Additional articles were identified by searching reference lists. RESULTS Anticoagulants are often underused in older people due to concerns about the risk of falls and intracranial haemorrhage. However, evidence suggests that the absolute risk is low and outweighed by the reduction in stroke risk. DOACs are now recommended first line for most patients due to their favourable safety profile. Off-label dose reduction of DOACs is not recommended due to reduced efficacy with limited reduction in bleeding risk. Medication review and falls prevention strategies should be implemented before prescribing anticoagulation. Deprescribing should be considered in severe frailty, limited life expectancy and increased bleeding risk (e.g., cerebral microbleeds). CONCLUSION When considering whether to (de-)prescribe anticoagulants, it is important to consider the risks associated with stopping therapy in addition to potential adverse events. Shared decision-making with the patient and their carers is crucial as patient and prescriber views often differ.
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Affiliation(s)
- Anneka Mitchell
- Research Institute for the Care of Older People (RICE), Bath, UK.
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK.
- Life Sciences Department, University of Bath, Bath, UK.
| | - Yasmin Elmasry
- Pharmacy Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Tomas J Welsh
- Research Institute for the Care of Older People (RICE), Bath, UK
- Bristol Medical School, University of Bristol, Bristol, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
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Lin KJ, Singer DE, Bykov K, Bessette LG, Mastrorilli JM, Cervone A, Kim DH. Comparative Effectiveness and Safety of Oral Anticoagulants by Dementia Status in Older Patients With Atrial Fibrillation. JAMA Netw Open 2023; 6:e234086. [PMID: 36976562 PMCID: PMC10051113 DOI: 10.1001/jamanetworkopen.2023.4086] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/04/2023] [Indexed: 03/29/2023] Open
Abstract
Importance The development of an optimal stroke prevention strategy, including the use of oral anticoagulant (OAC) therapy, is particularly important for patients with atrial fibrillation (AF) who are living with dementia, a condition that increases the risk of adverse outcomes. However, data on the role of dementia in the safety and effectiveness of OACs are limited. Objective To assess the comparative safety and effectiveness of specific OACs by dementia status among older patients with AF. Design, Setting, and Participants This retrospective comparative effectiveness study used 1:1 propensity score matching among 1 160 462 patients 65 years or older with AF. Data were obtained from the Optum Clinformatics Data Mart (January 1, 2013, to June 30, 2021), IBM MarketScan Research Database (January 1, 2013, to December 31, 2020), and Medicare claims databases maintained by the Centers for Medicare & Medicaid Services (inpatient, outpatient, and pharmacy; January 1, 2013, to December 31, 2017). Data analysis was performed from September 1, 2021, to May 24, 2022. Exposures Apixaban, dabigatran, rivaroxaban, or warfarin. Main Outcomes and Measures Composite end point of ischemic stroke or major bleeding events over the 6-month period after OAC initiation, pooled across databases using random-effects meta-analyses. Results Among 1 160 462 patients with AF, the mean (SD) age was 77.4 (7.2) years; 50.2% were male, 80.5% were White, and 7.9% had dementia. Three comparative new-user cohorts were established: warfarin vs apixaban (501 990 patients; mean [SD] age, 78.1 [7.4] years; 50.2% female), dabigatran vs apixaban (126 718 patients; mean [SD] age, 76.5 [7.1] years; 52.0% male), and rivaroxaban vs apixaban (531 754 patients; mean [SD] age, 76.9 [7.2] years; 50.2% male). Among patients with dementia, compared with apixaban users, a higher rate of the composite end point was observed in warfarin users (95.7 events per 1000 person-years [PYs] vs 64.2 events per 1000 PYs; adjusted hazard ratio [aHR], 1.5; 95% CI, 1.3-1.7), dabigatran users (84.5 events per 1000 PYs vs 54.9 events per 1000 PYs; aHR, 1.5; 95% CI, 1.2-2.0), and rivaroxaban users (87.4 events per 1000 PYs vs 68.5 events per 1000 PYs; aHR, 1.3; 95% CI, 1.1-1.5). In all 3 comparisons, the magnitude of the benefits associated with apixaban was similar regardless of dementia diagnosis on the HR scale but differed substantially on the rate difference (RD) scale. The adjusted RD of the composite outcome per 1000 PYs for warfarin vs apixaban users was 29.8 (95% CI, 18.4-41.1) events in patients with dementia vs 16.0 (95% CI, 13.6-18.4) events in patients without dementia. The corresponding adjusted RD estimates of the composite outcome were 29.6 (95% CI, 11.6-47.6) events per 1000 PYs in patients with dementia vs 5.8 (95% CI, 1.1-10.4) events per 1000 PYs in patients without dementia for dabigatran vs apixaban users and 20.5 (95% CI, 9.9-31.1) events per 1000 PYs in patients with dementia vs 15.9 (95% CI, 11.4-20.3) events per 1000 PYs in patients without dementia for rivaroxaban vs apixaban users. The pattern was more distinct for major bleeding than for ischemic stroke. Conclusions and Relevance In this comparative effectiveness study, apixaban was associated with lower rates of major bleeding and ischemic stroke compared with other OACs. The increased absolute risks associated with other OACs compared with apixaban were greater among patients with dementia than those without dementia, particularly for major bleeding. These findings support the use of apixaban for anticoagulation therapy in patients living with dementia who have AF.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Daniel E. Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Katsiaryna Bykov
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lily G. Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Julianna M. Mastrorilli
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Wang PJ, Lu Y, Mahaffey KW, Lin A, Morin DP, Sears SF, Chung MK, Russo AM, Lin B, Piccini J, Hills MT, Berube C, Pundi K, Baykaner T, Garay G, Lhamo K, Rice E, Pourshams IA, Shah R, Newswanger P, DeSutter K, Nunes JC, Albert MA, Schulman KA, Heidenreich PA, Bunch TJ, Sanders LM, Turakhia M, Verghese A, Stafford RS. Randomized Clinical Trial to Evaluate an Atrial Fibrillation Stroke Prevention Shared Decision-Making Pathway. J Am Heart Assoc 2023; 12:e028562. [PMID: 36342828 PMCID: PMC9973612 DOI: 10.1161/jaha.122.028562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Background Oral anticoagulation reduces stroke and disability in atrial fibrillation (AF) but is underused. We evaluated the effects of a novel patient-clinician shared decision-making (SDM) tool in reducing oral anticoagulation patient's decisional conflict as compared with usual care. Methods and Results We designed and evaluated a new digital decision aid in a multicenter, randomized, comparative effectiveness trial, ENHANCE-AF (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention). The digital AF shared decision-making toolkit was developed using patient-centered design with clear health communication principles (eg, meaningful images, limited text). Available in English and Spanish, the toolkit included the following: (1) a brief animated video; (2) interactive questions with answers; (3) a quiz to check on understanding; (4) a worksheet to be used by the patient during the encounter; and (5) an online guide for clinicians. The study population included English or Spanish speakers with nonvalvular AF and a CHA2DS2-VASc stroke score ≥1 for men or ≥2 for women. Participants were randomized in a 1:1 ratio to either usual care or the shared decision-making toolkit. The primary end point was the validated 16-item Decision Conflict Scale at 1 month. Secondary outcomes included Decision Conflict Scale at 6 months and the 10-item Decision Regret Scale at 1 and 6 months as well as a weighted average of Mann-Whitney U-statistics for both the Decision Conflict Scale and the Decision Regret Scale. A total of 1001 participants were enrolled and followed at 5 different sites in the United States between December 18, 2019, and August 17, 2022. The mean patient age was 69±10 years (40% women, 16.9% Black, 4.5% Hispanic, 3.6% Asian), and 50% of participants had CHA2DS2-VASc scores ≥3 (men) or ≥4 (women). The primary end point at 1 month showed a clinically meaningful reduction in decisional conflict: a 7-point difference in median scores between the 2 arms (16.4 versus 9.4; Mann-Whitney U-statistics=0.550; P=0.007). For the secondary end point of 1-month Decision Regret Scale, the difference in median scores between arms was 5 points in the direction of less decisional regret (P=0.078). The treatment effects lessened over time: at 6 months the difference in medians was 4.7 points for Decision Conflict Scale (P=0.060) and 0 points for Decision Regret Scale (P=0.35). Conclusions Implementation of a novel shared decision-making toolkit (afibguide.com; afibguide.com/clinician) achieved significantly lower decisional conflict compared with usual care in patients with AF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096781.
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Affiliation(s)
- Paul J. Wang
- Stanford University Department of MedicinePalo AltoCA
| | - Ying Lu
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Amy Lin
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | | | - Samuel F. Sears
- East Carolina University Department of PsychologyGreenvilleNC
| | - Mina K. Chung
- Cleveland Clinic Foundation Department of MedicineClevelandOH
| | | | - Bryant Lin
- Stanford University Department of MedicinePalo AltoCA
| | | | | | | | - Krishna Pundi
- Stanford University Department of MedicinePalo AltoCA
| | - Tina Baykaner
- Stanford University Department of MedicinePalo AltoCA
| | - Gotzone Garay
- Stanford University Department of MedicinePalo AltoCA
| | - Karma Lhamo
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Eli Rice
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | - Rushil Shah
- Stanford University Department of MedicinePalo AltoCA
| | - Paul Newswanger
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | | | - Michelle A. Albert
- University of California San Francisco Department of MedicineSan FranciscoCA
| | | | - Paul A. Heidenreich
- Stanford University Department of MedicinePalo AltoCA
- Palo Alto Veterans Administration Health Care Department of MedicinePalo AltoCA
| | - T. Jared Bunch
- University of Utah Department of MedicineSalt Lake CityUT
| | | | - Mintu Turakhia
- Stanford University Department of MedicinePalo AltoCA
- iRhythm TechnologiesSan FranciscoCA
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Du M, Wang X, Ma F, Li F, Li H, Li F, Zhang A, Gao Y. Association between T-tau protein and Aβ42 in plasma neuronal-derived exosomes and cognitive impairment in patients with permanent atrial fibrillation and the role of anticoagulant therapy and inflammatory mechanisms. J Card Surg 2022; 37:909-918. [PMID: 35106827 DOI: 10.1111/jocs.16248] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/24/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study explores whether the differences in cognitive performance among individuals with permanent atrial fibrillation (AF) are attributable to the duration of AF and anticoagulant therapy and explores the possible inflammatory mechanism of cognitive dysfunction related to AF. METHODS A total of 260 patients aged 50-75 years without previous cerebrovascular events were enrolled in this study. These 260 patients had been divided into the AF group (140 patients) and sinus rhythm group (120 patients). In the AF group, we divided participants into cognitive impairment (CI) group (90 patients) and cognitive normal (CN) group (50 patients). In the sinus rhythm group, we also divided participants into CI group (61 patients) and CN group (59 patients). The Mini-Mental State Examination (MMSE) was used to assess the cognitive function of all participants. Neuronal-derived exosomes were enriched in peripheral blood by immunoprecipitation and were confirmed by a transmission electron microscope, nanoparticle tracking analysis, and western blot. Alzheimer's disease-pathogenic exosomal proteins and inflammatory cytokines were quantified. The association between AF and cognitive function was estimated by logistic regression analysis. ANOVA or Welch's t-test compared the difference in protein concentrations between groups. RESULTS Non-anticoagulant therapy in patients with AF was significantly associated with CI (OR = 13.99, 95% CI: 2.67-73.36, p < .01). The incidence of dementia in patients with AF > 3 years was significantly higher than in patients with AF ≤ 3 years, but there was no significant difference in total cognitive dysfunction (mild cognitive impairment [MCI] + dementia) (p = .126). The adjusted exosome concentrations of T-tau and amyloid-β protein 42 (Aβ42) in the CI group were significantly higher than in the CN group (p < .001). The serum concentrations of IL-6 and matrix metalloproteinase-9 (MMP-9) in patients with AF were higher than those in patients with sinus rhythm (p < .001). CONCLUSION Aβ42 and T-tau in peripheral blood neuronal-derived exosomes maybe be associated with the early diagnosis of CI in patients with permanent AF. However, the value of Aβ42 and T-tau for CI in patients with permanent AF still needs to be confirmed in future randomized control trials.
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Affiliation(s)
- Meiling Du
- Graduate School, Tianjin Medical University, Tianjin, China.,Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Xiaoyuan Wang
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Fei Ma
- School of Public Health, Tianjin Medical University, Tianjin, China
| | - Fangjiang Li
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Huixian Li
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Feixing Li
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Aiai Zhang
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Yuxia Gao
- Department of Cardiology, General Hospital of Tianjin Medical University, Tianjin, China
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Trymbulak K, Ding E, Marino F, Wang Z, Saczynski JS. Mobile health assessments of geriatric elements in older patients with atrial fibrillation: The Mobile SAGE-AF Study (M-SAGE). CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2020; 1:123-129. [PMID: 35265884 PMCID: PMC8890350 DOI: 10.1016/j.cvdhj.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Geriatric conditions (eg, cognitive impairment, frailty) are increasingly recognized for their impact on clinical and quality-of-life outcomes in older patients with cardiovascular disease, but are not systematically assessed in the context of clinical visits owing to time constraints. Objective To examine feasibility of remote monitoring of the physical, cognitive, and psychosocial status of older adults with atrial fibrillation (AF) via a novel smartphone app over 6 months. Methods Forty participants with AF and eligible for anticoagulation therapy (CHA2DS2VASc ≥2) enrolled in an ongoing cohort study participated in a mobile health pilot study. A 6-component geriatric assessment, including validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing, was deployed via a smartphone app and 6-minute walk test was completed using a Fitbit. Adherence to mobile assessments was examined over 6 months. Results Participants were an average of 71 years old (range 65-86 years) and 38% were women. At 1 month, 75% (30/40) of participants completed the app-based geriatric assessment and 63% (25/40) completed the 6-minute walk test. At 6 months, 52% (15/29) completed the geriatric assessment and 28% (8/29) completed the walk test. There were no differences in demographic, clinical, or psychosocial factors between participants who completed the surveys at 6 months and those who did not. Participants, on average, required less than 10 minutes of telephone support over the 6-month period. Conclusion It is feasible, among smartphone users, to use a mobile health app and wearable activity monitor to conduct serial geriatric assessments in older patients with AF for up to 6 months.
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Affiliation(s)
- Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut
- Address reprint requests and correspondence: Ms Katherine Trymbulak, Frank H. Netter M.D. School of Medicine at Quinnipiac University, 370 Bassett Rd, North Haven, CT 06473.
| | - Eric Ding
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Center for Clinical Investigation, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ziyue Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
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Shah SJ, Fang MC, Jeon SY, Gregorich SE, Covinsky KE. Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans. J Am Geriatr Soc 2020; 69:349-356. [PMID: 32989731 DOI: 10.1111/jgs.16822] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/14/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use. METHODS We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA2 DS2 -VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]). RESULTS In this study of 779 participants with AF (median age = 80 years; median CHA2 DS2 -VASc score = 4), 82% had one or more geriatric syndromes. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairments, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = -3.7%; 95% confidence interval = -1.4% to -5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia. CONCLUSION Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.
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Affiliation(s)
- Sachin J Shah
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Sun Y Jeon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
| | - Steven E Gregorich
- Division of General Internal Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kenneth E Covinsky
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
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9
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Saczynski JS, Sanghai SR, Kiefe CI, Lessard D, Marino F, Waring ME, Parish D, Helm R, Sogade F, Goldberg R, Gurwitz J, Wang W, Mailhot T, Bamgbade B, Barton B, McManus DD. Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF. J Am Geriatr Soc 2019; 68:147-154. [PMID: 31574165 DOI: 10.1111/jgs.16178] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Oral anticoagulants are the cornerstone of stroke prevention in high-risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing. DESIGN Cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) prospective cohort study. SETTING Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018. PARTICIPANTS Participants with AF age 65 years or older, CHA2 DS2 -VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65-74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244). MEASUREMENTS A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record. RESULTS A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre-frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51-1.09; frail OR = .69; 95% CI = .35-1.36; social isolation OR = .90; 95% CI = .52-1.54; depression OR = .79; 95% CI = .49-1.27; visual impairment OR = .98; 95% CI = .65-1.48; and hearing impairment OR = 1.05; 95% CI = .71-1.54). CONCLUSION Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147-154, 2019.
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Affiliation(s)
- Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Saket R Sanghai
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut
| | - David Parish
- Department of Community Medicine/ Internal Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Robert Helm
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Mercer, Georgia
| | - Robert Goldberg
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Geriatric Medicine Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts.,Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Benita Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Bruce Barton
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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10
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Cognitive Impairment Is Independently Associated with Non-Adherence to Antithrombotic Therapy in Older Patients with Atrial Fibrillation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16152698. [PMID: 31362337 PMCID: PMC6696263 DOI: 10.3390/ijerph16152698] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/24/2019] [Accepted: 07/27/2019] [Indexed: 12/17/2022]
Abstract
Atrial Fibrillation (AF) patients could reduce their risk of stroke by using oral antithrombotic therapy. However, many older people with AF experience cognitive impairment and have limited health literacy, which can lead to non-adherence to antithrombotic treatment. This study aimed to investigate the influence of cognitive impairment and health literacy on non-adherence to antithrombotic therapy. The study performed a secondary analysis of baseline data from a cross-sectional survey of AF patients’ self-care behaviors at a tertiary university hospital in 2018. Data were collected from a total of 277 AF patients aged 65 years and older, through self-reported questionnaires administered by face-to-face interviews. Approximately 50.2% of patients were non-adherent to antithrombotic therapy. Multiple logistic regression analysis revealed that cognitive impairment independently increased the risk of non-adherence to antithrombotic therapy (odds ratio = 2.628, 95% confidence interval = 1.424–4.848) after adjustment for confounding factors. However, health literacy was not associated with non-adherence to antithrombotic therapy. Cognitive impairment is a significant risk factor for poor adherence to antithrombotic therapy. Thus, health professionals should periodically assess both cognitive function after AF diagnosis and adherence to medication in older patients. Further studies are needed to identify the factors that affect cognitive decline and non-adherence among AF patients.
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11
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Søgaard M, Skjøth F, Jensen M, Kjældgaard JN, Lip GYH, Larsen TB, Nielsen PB. Nonvitamin K Antagonist Oral Anticoagulants Versus Warfarin in Atrial Fibrillation Patients and Risk of Dementia: A Nationwide Propensity-Weighted Cohort Study. J Am Heart Assoc 2019; 8:e011358. [PMID: 31138001 PMCID: PMC6585353 DOI: 10.1161/jaha.118.011358] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background It is unclear whether nonvitamin K antagonist oral anticoagulants ( NOAC s) can mitigate dementia development in atrial fibrillation. We compared dementia development among users of NOACs or warfarin in patients with atrial fibrillation with no prior neurological diagnoses. Methods and Results We conducted a Danish nationwide cohort study including 33 617 new oral anticoagulant users with nonvalvular atrial fibrillation, of which 11 052 were aged 60 to 69 years, 13 237 were aged 70 to 79 years, and 9238 were aged 80 years and older. To exclude prevalent non -oral anticoagulants- associated dementia, we considered the at-risk population of patients alive and free of dementia at 180 days following inclusion. We compared rates of new-onset dementia by age and treatment regimen using inverse probability of treatment weighting to account for confounding. Approximately 60% of patients were NOAC users and 40% were warfarin users. Mean follow-up was 3.4 years. Dementia occurred in 41 patients aged 60 to 69 years, 276 patients aged 70 to 79 years, and 441 patients aged 80 years and older. Relative to warfarin users, dementia rates were nonsignificantly lower among NOAC users aged 60 to 69 years (0.11 events/100 person-years versus 0.12 events/100 person-years; weighted hazard ratio, 0.92 [95% CI, 0.48-1.72]) and NOAC users aged 70 to 79 years (0.64 events/100 person-years versus 0.78 events/100 person-years; weighted hazard ratio , 0.86 [95% CI, 0.68-1.09]), whereas NOAC s were associated with significantly higher dementia rates (2.16 events/100 person-years versus 1.70 events/100 person-years; weighted hazard ratio , 1.31 [95% CI, 1.07-1.59]) in patients 80 years and older. Conclusions This nationwide cohort of patients with atrial fibrillation revealed no clinically meaningful difference in dementia development between users of NOACs or warfarin apart from a higher risk in NOAC users 80 years and older, which may relate to residual confounding from selective prescribing and unobserved comorbidities.
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Affiliation(s)
- Mette Søgaard
- 1 Department of Cardiology Aalborg University Hospital Aalborg Denmark.,2 Aalborg Thrombosis Research Unit Department of Clinical Medicine Faculty of Health Aalborg University Aalborg Denmark
| | - Flemming Skjøth
- 2 Aalborg Thrombosis Research Unit Department of Clinical Medicine Faculty of Health Aalborg University Aalborg Denmark.,3 Unit for Clinical Biostatistics Aalborg University Hospital Aalborg Denmark
| | - Martin Jensen
- 2 Aalborg Thrombosis Research Unit Department of Clinical Medicine Faculty of Health Aalborg University Aalborg Denmark.,3 Unit for Clinical Biostatistics Aalborg University Hospital Aalborg Denmark
| | - Jette Nordstrøm Kjældgaard
- 1 Department of Cardiology Aalborg University Hospital Aalborg Denmark.,2 Aalborg Thrombosis Research Unit Department of Clinical Medicine Faculty of Health Aalborg University Aalborg Denmark
| | - Gregory Y H Lip
- 2 Aalborg Thrombosis Research Unit Department of Clinical Medicine Faculty of Health Aalborg University Aalborg Denmark.,4 Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.,5 Aalborg Thrombosis Research Unit Department of Clinical Medicine Aalborg University Aalborg Denmark
| | - Torben Bjerregaard Larsen
- 1 Department of Cardiology Aalborg University Hospital Aalborg Denmark.,2 Aalborg Thrombosis Research Unit Department of Clinical Medicine Faculty of Health Aalborg University Aalborg Denmark
| | - Peter Brønnum Nielsen
- 1 Department of Cardiology Aalborg University Hospital Aalborg Denmark.,2 Aalborg Thrombosis Research Unit Department of Clinical Medicine Faculty of Health Aalborg University Aalborg Denmark
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12
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Madhavan M, Holmes DN, Piccini JP, Ansell JE, Fonarow GC, Hylek EM, Kowey PR, Mahaffey KW, Thomas L, Peterson ED, Chan P, Allen LA, Gersh BJ. Association of frailty and cognitive impairment with benefits of oral anticoagulation in patients with atrial fibrillation. Am Heart J 2019; 211:77-89. [PMID: 30901602 DOI: 10.1016/j.ahj.2019.01.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/15/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The incidence of cognitive impairment and frailty increase with age and may impact both therapy and outcomes in atrial fibrillation (AF). METHODS We examined the prevalence of clinically recognized cognitive impairment and frailty (as defined by the American Geriatric Society Criteria) in the Outcomes Registry for Better Informed Care in AF (ORBIT AF) and associated adjusted outcomes via multivariable Cox regression. The interaction between cognitive impairment and frailty and oral anticoagulation (OAC) in determining outcomes was examined. RESULTS Among 9749 patients with AF [median (IQR) age 75 (67-82) y, 57% male], cognitive impairment and frailty was identified in 293 (3.0%) and 575 (5.9%) patients respectively. Frail patients (68 vs 77%, P < .001) and those with cognitive impairment (70 vs 77%, P = .006) were both less likely to receive an OAC. Both cognitive impairment [HR (95% CI) 1.34 (1.05-1.72), P = .0198] and frailty [HR 1.29 (1.08-1.55), P = .0060] were associated with increased risk of death. Cognitive impairment and frailty were not associated with stroke/transient ischemic attack (TIA) or major bleeding. In multivariable analysis, there was no interaction between OAC use and cognitive impairment or frailty in their associations with mortality, major bleeding and a composite end point of stroke, non-central nervous system systemic embolism, TIA, myocardial infarction or cardiovascular death. CONCLUSION Those with cognitive impairment or frailty in AF had higher predicted risk for stroke and higher observed mortality, yet were less likely to be treated with OAC. Despite this, the benefits of OAC were similar in patients with and without cognitive impairment or frailty.
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13
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O'Caoimh R, Cornally N, McGlade C, Gao Y, O'Herlihy E, Svendrovski A, Clarnette R, Lavan AH, Gallagher P, William Molloy D. Reducing inappropriate prescribing for older adults with advanced frailty: A review based on a survey of practice in four countries. Maturitas 2019; 126:1-10. [PMID: 31239110 DOI: 10.1016/j.maturitas.2019.04.212] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/07/2019] [Accepted: 04/10/2019] [Indexed: 12/20/2022]
Abstract
The management of medications in persons with frailty presents challenges. There is evidence of inappropriate prescribing and a lack of consensus among healthcare professionals on the judicious use of medications, particularly for patients with more severe frailty. This study reviews the evidence on the use of commonly prescribed pharmacological treatments in advanced frailty based on a questionnaire of prescribing practices and attitudes of healthcare professionals at different stages in their careers, in different countries. A convenience sample of those attending hospital grand rounds in Ireland, Canada and Australia/New Zealand (ANZ) were surveyed on the management of 18 medications in advanced frailty using a clinical vignette (man with severe dementia, Clinical Frailty Scale 7/9). Choices were to continue or discontinue (stop now or later) medications. In total, 298 respondents from Ireland (n = 124), Canada (n = 110), and ANZ (n = 64) completed the questionnaire, response rate 97%, including 81 consultants, 40 non-consultant hospital doctors, 134 general practitioners and 43 others (nurses, pharmacists, and medical students). Most felt that statins (88%), bisphosphonates (77%) and cholinesterase inhibitors (76%) should be discontinued. Thyroid replacement (88%), laxatives (83%) and paracetamol (81%) were most often continued. Respondents with experience in geriatric, palliative and dementia care were significantly more likely to discontinue medications. Age, gender and experience working in nursing homes did not contribute to the decision. Reflecting the current literature, there was no clear consensus on inappropriate prescribing, although respondents preferentially discontinued medications for secondary prevention. Experience significantly predicted the number and type discontinued, suggesting that education is important in reducing inappropriate prescribing for people in advanced states of frailty.
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Affiliation(s)
- Rónán O'Caoimh
- Centre for Gerontology and Rehabilitation, University College Cork, St Finbarr's Hospital, Cork City, Ireland; Clinical Sciences Institute, National University of Ireland, Galway, Galway City, Ireland.
| | - Nicola Cornally
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork Ireland, Ireland
| | - Ciara McGlade
- Centre for Gerontology and Rehabilitation, University College Cork, St Finbarr's Hospital, Cork City, Ireland
| | - Yang Gao
- Centre for Gerontology and Rehabilitation, University College Cork, St Finbarr's Hospital, Cork City, Ireland
| | | | - Anton Svendrovski
- UZIK Consulting Inc., 86 Gerrard St E, Unit 12D, Toronto, ON, M5B 2J1 Canada
| | - Roger Clarnette
- School of Medicine and Pharmacology, University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia
| | - Amanda Hanora Lavan
- Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork City, Ireland
| | - Paul Gallagher
- Department of Geriatric Medicine, Cork University Hospital, Wilton, Cork City, Ireland
| | - D William Molloy
- Centre for Gerontology and Rehabilitation, University College Cork, St Finbarr's Hospital, Cork City, Ireland
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14
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Kamimura T. Older Adults with Alzheimer's Disease Who Have Used an Automatic Medication Dispenser for 3 or More Years. Clin Gerontol 2019; 42:127-133. [PMID: 29028462 DOI: 10.1080/07317115.2017.1347594] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This article describes four older adults with Alzheimer's disease and comorbidities who used an automatic medication dispenser (AMD) to continue pharmacotherapy for these chronic diseases and who remained at home living either alone or with an older spouse. The AMDs were used for 3 to 4.5 years. The patients scored at least 21 on the Mini-Mental State Examination, and their dosing regimen involved taking the medication once or twice per day throughout this period. The caregivers filled the devices with medications once every 1 to 2 weeks and continuously monitored the patients' conditions nearly every day. Additionally, one caregiver changed how the device is used to accommodate a participant's conditions. As a result of using the device, medication adherence remained good, and caregiver burden was reduced. The results indicate that an AMD can be used as a long-term medication management tool for some older adults with dementia when caregivers provide continued support, as described above. Further research is needed to clarify the necessary conditions for using an AMD and to identify benefits for older adults with dementia to use AMDs to take medication on a long-term basis.
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Affiliation(s)
- Tomoko Kamimura
- a Shinshu University , School of Health Sciences , Matsumoto , Japan
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15
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Fanning L, Ryan-Atwood TE, Bell JS, Meretoja A, McNamara KP, Dārziņš P, Wong IC, Ilomäki J. Prevalence, Safety, and Effectiveness of Oral Anticoagulant Use in People with and without Dementia or Cognitive Impairment: A Systematic Review and Meta-Analysis. J Alzheimers Dis 2018; 65:489-517. [DOI: 10.3233/jad-180219] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Laura Fanning
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Department of Pharmacy, Eastern Health, Melbourne, Australia
- Geriatric Medicine, Eastern Health, Melbourne, Australia
| | - Taliesin E. Ryan-Atwood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Hornsby, Australia
| | - Atte Meretoja
- Neurocenter, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Kevin P. McNamara
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Deakin Rural Health, School of Medicine and Centre for Population Health, Deakin University, Melbourne, Australia
| | - Pēteris Dārziņš
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Geriatric Medicine, Eastern Health, Melbourne, Australia
| | - Ian C.K. Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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16
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Ferguson C, Inglis SC, Newton PJ, Middleton S, Macdonald PS, Davidson PM. Barriers and enablers to adherence to anticoagulation in heart failure with atrial fibrillation: patient and provider perspectives. J Clin Nurs 2017; 26:4325-4334. [DOI: 10.1111/jocn.13759] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2017] [Indexed: 12/21/2022]
Affiliation(s)
- Caleb Ferguson
- Centre for Cardiovascular & Chronic Care; University of Technology Sydney; Sydney Australia
| | - Sally C. Inglis
- Centre for Cardiovascular and Chronic Care; Faculty of Health; University of Technology Sydney; Sydney Australia
| | - Phillip J. Newton
- Centre for Cardiovascular and Chronic Care; Faculty of Health; University of Technology Sydney; Sydney Australia
| | - Sandy Middleton
- St Vincent's Health Australia (Sydney) & Australian Catholic University; North Sydney NSW Australia
| | - Peter S. Macdonald
- Heart Transplant Program; St Vincent's Hospital; Sydney and Victor Chang Cardiac Research Institute; Darlinghurst NSW Australia
| | - Patricia M. Davidson
- Centre for Cardiovascular and Chronic Care; Faculty of Health; University of Technology Sydney; Sydney Australia
- School of Nursing; Johns Hopkins University; Baltimore MD USA
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17
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Corrao S, Argano C, Nobili A, Marcucci M, Djade CD, Tettamanti M, Pasina L, Franchi C, Marengoni A, Salerno F, Violi F, Mannucci PM, Perticone F. Brain and kidney, victims of atrial microembolism in elderly hospitalized patients? Data from the REPOSI study. Eur J Intern Med 2015; 26:243-9. [PMID: 25749554 DOI: 10.1016/j.ejim.2015.02.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 02/08/2015] [Accepted: 02/16/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND It is well known that atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with a higher risk of stroke, and new evidence links AF to cognitive impairment, independently from an overt stroke (CI). Our aim was to investigate, assuming an underlying role of atrial microembolism, the impact of CI and CKD in elderly hospitalized patients with AF. METHODS We retrospectively analyzed the data collected on elderly patients in 66 Italian hospitals, in the frame of the REPOSI project. We analyzed the clinical characteristics of patients with AF and different degrees of CI. Multivariate logistic analysis was used to explore the relationship between variables and mortality. RESULTS Among the 1384 patients enrolled, 321 had AF. Patients with AF were older, had worse CI and disability and higher rates of stroke, hypertension, heart failure, and CKD, and less than 50% were on anticoagulant therapy. Among patients with AF, those with worse CI and those with lower estimated glomerular filtration rate (eGFR) had a higher mortality risk (odds ratio 1.13, p=0.006). Higher disability levels, older age, higher systolic blood pressure, and higher eGFR were related to lower probability of oral anticoagulant prescription. Lower mortality rates were found in patients on oral anticoagulant therapy. CONCLUSIONS Elderly hospitalized patients with AF are more likely affected by CI and CKD, two conditions that expose them to a higher mortality risk. Oral anticoagulant therapy, still underused and not optimally enforced, may afford protection from thromboembolic episodes that probably concur to the high mortality.
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Affiliation(s)
- S Corrao
- Biomedical Department of Internal Medicine and Subspecialities (DiBiMIS), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy; Department of Internal Medicine 2, National Relevance and High Specialization Hospital Trust, ARNAS Civico, Di Cristina Benfratelli, Palermo, Italy.
| | - C Argano
- Biomedical Department of Internal Medicine and Subspecialities (DiBiMIS), University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy
| | - A Nobili
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - M Marcucci
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy; Department of Internal Medicine, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Milano, Italy
| | - C D Djade
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy; Scientific Direction, IRCCS Ca Granda Maggiore Policlinico Hospital Foundation, Via Pace 9, 20122 Milan, Italy
| | - M Tettamanti
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - L Pasina
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - C Franchi
- Department of Neuroscience, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Via Giuseppe La Masa, 19, 20156 Milan, Italy
| | - A Marengoni
- Department of Clinical and Experimental Science, University of Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy
| | - F Salerno
- Internal Medicine, IRCCS Policlinico San Donato, Department of Medical and Surgery, Sciences, University of Milano, Via Morandi 30, 20097 San Donato, Milan, Italy
| | - F Violi
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Viale del Policlinico 155, 00161 Roma, Italy
| | - P M Mannucci
- Scientific Direction, IRCCS Ca Granda Maggiore Policlinico Hospital Foundation, Via Pace 9, 20122 Milan, Italy
| | - F Perticone
- Department of Medical and Surgical Sciences, University "Magna Graecia" of Catanzaro, Campus Universitario di Germaneto, Viale Europa, 88100 Catanzaro, Italy
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18
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Thromboembolic Prevention in Frail Elderly Patients With Atrial Fibrillation: A Practical Algorithm. J Am Med Dir Assoc 2015; 16:358-64. [DOI: 10.1016/j.jamda.2014.12.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/05/2014] [Indexed: 11/18/2022]
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19
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Hui DS, Morley JE, Mikolajczak PC, Lee R. Atrial fibrillation: A major risk factor for cognitive decline. Am Heart J 2015; 169:448-56. [PMID: 25819850 DOI: 10.1016/j.ahj.2014.12.015] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 12/08/2014] [Indexed: 01/08/2023]
Abstract
Atrial fibrillation is a common disease of the elderly, conferring considerable morbidity and mortality related to cardiovascular effects and thromboembolic risks. Anticoagulation, antiarrhythmic medications, and rate control are the cornerstone of contemporary management, whereas ablation and evolving surgical techniques continue to play important secondary roles. Growing evidence shows that atrial fibrillation is also a risk factor for significant cognitive decline through a multitude of pathways, further contributing to morbidity and mortality. At the same time, cognitive decline associated with cryptogenic strokes may be the first clue to previously undiagnosed atrial fibrillation. These overlapping associations support the concept of cognitive screening and rhythm monitoring in these populations. New research suggests modulating effects of currently accepted treatments for atrial fibrillation on cognition; however, there remains the need for large multicenter studies to examine the effects of novel oral anticoagulants, rhythm and rate control, and left atrial appendage occlusion on long-term cognitive function.
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Affiliation(s)
- Dawn S Hui
- Center for Comprehensive Cardiovascular Care, Saint Louis University, St Louis, MO
| | - John E Morley
- Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St Louis, MO.
| | - Peter C Mikolajczak
- Center for Comprehensive Cardiovascular Care, Saint Louis University, St Louis, MO
| | - Richard Lee
- Center for Comprehensive Cardiovascular Care, Saint Louis University, St Louis, MO
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20
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Onder G, Landi F, Fusco D, Corsonello A, Tosato M, Battaglia M, Mastropaolo S, Settanni S, Antocicco M, Lattanzio F. Recommendations to prescribe in complex older adults: results of the CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) project. Drugs Aging 2014; 31:33-45. [PMID: 24234805 DOI: 10.1007/s40266-013-0134-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The occurrence of several geriatric conditions may influence the efficacy and limit the use of drugs prescribed to treat chronic conditions. Functional and cognitive impairment, geriatric syndromes (i.e. falls or malnutrition) and limited life expectancy are common features of old age, which may limit the efficacy of pharmacological treatments and question the appropriateness of treatment. However, the assessment of these geriatric conditions is rarely incorporated into clinical trials and treatment guidelines. The CRIME (CRIteria to assess appropriate Medication use among Elderly complex patients) project is aimed at producing recommendations to guide pharmacologic prescription in older complex patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes, and providing physicians with a tool to improve the quality of prescribing, independent of setting and nationality. To achieve these aims, we performed the following: (i) Existing disease-specific guidelines on pharmacological prescription for the treatment of diabetes, hypertension, congestive heart failure, atrial fibrillation and coronary heart disease were reviewed to assess whether they include specific indications for complex patients; (ii) a literature search was performed to identify relevant articles assessing the pharmacological treatment of complex patients; (iii) A total of 19 new recommendations were developed based on the results of the literature search and expert consensus. In conclusion, the new recommendations evaluate the appropriateness of pharmacological prescription in older complex patients, translating the recommendations of clinical guidelines to patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes. These recommendations cannot represent substitutes for careful clinical consideration and deliberation by physicians; the recommendations are not meant to replace existing clinical guidelines, but they may be used to help physicians in the prescribing process.
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Formiga F, Urrutia A, Veiga F. [It is time to optimize the anticoagulant therapy in elderly patients with atrial fibrillation]. Rev Esp Geriatr Gerontol 2014; 49:201-2. [PMID: 24996967 DOI: 10.1016/j.regg.2014.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 05/16/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
| | - Agustín Urrutia
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Germans Trias i Pujol, Badalona, España
| | - Fernando Veiga
- Servicio de Geriatría, Hospital Universitario Lucus Augusti, Lugo, España
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Chenot JF, Hua TD, Abu Abed M, Schneider-Rudt H, Friede T, Schneider S, Vormfelde SV. Safety relevant knowledge of orally anticoagulated patients without self-monitoring: a baseline survey in primary care. BMC FAMILY PRACTICE 2014; 15:104. [PMID: 24885192 PMCID: PMC4045910 DOI: 10.1186/1471-2296-15-104] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 05/20/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Effective and safe management of oral anticoagulant treatment (OAT) requires a high level of patient knowledge and adherence. The aim of this study was to assess patient knowledge about OAT and factors associated with patient knowledge. METHODS This is a baseline survey of a cluster-randomized controlled trial in 22 general practices with an educational intervention for patients or their caregivers. We assessed knowledge about general information on OAT and key facts regarding nutrition, drug-interactions and other safety precautions of 345 patients at baseline. RESULTS Participants rated their knowledge about OAT as excellent to good (56%), moderate (36%) or poor (8%). However, there was a discrepancy between self-rated knowledge and evaluated actual knowledge and we observed serious knowledge gaps. Half of the participants (49%) were unaware of dietary recommendations. The majority (80%) did not know which non-prescription analgesic is the safest and 73% indicated they would not inform pharmacists about OAT. Many participants (35-75%) would not recognize important emergency situations. After adjustment in a multivariate analysis, older age and less than 10 years education remained significantly associated with lower overall score, but not with self-rated knowledge. CONCLUSIONS Patients have relevant knowledge gaps, potentially affecting safe and effective OAT. There is a need to assess patient knowledge and for structured education programs. TRIAL REGISTRATION Deutsches Register Klinischer Studien (German Clinical Trials Register): DRKS00000586.Universal Trial Number (UTN U1111-1118-3464).
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Affiliation(s)
- Jean-François Chenot
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany.
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Sino CGM, Sietzema M, Egberts TCG, Schuurmans MJ. Medication management capacity in relation to cognition and self-management skills in older people on polypharmacy. J Nutr Health Aging 2014; 18:44-9. [PMID: 24402388 DOI: 10.1007/s12603-013-0359-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the medication management capacity of independently living older people (≥75 years) on polypharmacy (≥ 5 medications) in relation to their cognitive- and self-management skills. DESIGN Cross-sectional study. SETTING Two homecare organizations in the Netherlands. PARTICIPANTS Homecare clients aged 75 and older on polypharmacy (N=95). MEASUREMENTS The primary outcome measure was medication management capacity, quantified as the number of 'yes' answers (range = 0-17) on the Medication Management Capacity (MMC) questionnaire. Other measures included self-management ability (assessed with the SMAS30) and cognitive skills (assessed with the clock drawing test). RESULTS Overall, 48.4% (n= 46) of the participants were able to manage their medication by themselves at home. About 40% of the participants were unable to state the names of their medications, even with the aid of a medication list, and about 25% reported having problems with opening medication packages. Correlations were found between self-management ability (Rs = 0.473; p < 0.001), cognitive skills (Rs = 0.372; p < 0.001), and age (Rs = 0.216; p < 0.005) and Medication Management Capacity score. Self-management ability and medication management support were significantly associated with medication management capacity. CONCLUSION A considerable proportion of independently living older people who receive home care and regularly use five or more medications lack the knowledge and skills needed to independently manage their own medications. Cognition and self management ability were related to medication management capacity. Self-management ability and medication management support were predictors of medication management capacity.
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Affiliation(s)
- C G M Sino
- Carolien GM Sino, HU University of Applied Science Utrecht, Research Centre for Innovation in Health Care. The Netherlands. P.O. box 85182, 3508 AD Utrecht. www.innovationsinhealthcare.research.hu.nl. Tel: +31(0)88481 5079. Fax: +31(0)88481 0608 E-mail:
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Derevnina ES, Akimova NS, Persashvili DG, Schwartz YG. COGNITIVE DYSFUNCTION IN PATIENTS WITH ATRIAL FIBRILLATION: ASSESSING THE ROLE OF VASCULAR FACTORS. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2013. [DOI: 10.15829/1728-8800-2013-2-58-62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To study the association between the presence and type of atrial fibrillation (AF), cognitive dysfunction, and brachiocephalic artery pathology.Material and methods. In total, 54 patients with AF and 20 AF-free patients who had Functional Class I–III chronic heart failure (CHF) underwent cognitive assessment tests, echocardiography, cerebral nuclear magnetic resonance imaging, and duplex brachiocephalic ultrasound.Results. In AF patients, deteriorated parameters of memory and attention were registered. Patients with persistent AF demonstrated worse cognitive function parameters. The characteristics of short-term memory and attention, attainment of visual and motoric skills, and attention shift and span were not associated with the intima-media thickness of common carotid artery and its bifurcation.Conclusion. There is an association between the presence of AF, its type, and the severity of cognitive dysfunction, which is independent of the degree of brachiocephalic artery abnormalities.
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Affiliation(s)
| | - N. S. Akimova
- V. I. Razumovskyi Saratov State Medical University, Saratov
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Halbritter K, Beyer-Westendorf J, Nowotny J, Pannach S, Kuhlisch E, Schellong SM. Hospitalization for vitamin-K-antagonist-related bleeding: treatment patterns and outcome. J Thromb Haemost 2013; 11:651-9. [PMID: 23347087 DOI: 10.1111/jth.12148] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/15/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bleeding complications are common side effects of vitamin-K antagonist (VKA) therapy. Data on the in-hospital management and outcomes of these bleeding events are scarce and information is mostly derived from trial cohorts. OBJECTIVES The objective was to collect data on the management and clinical outcome of hospitalizations owing to VKA-related bleeding in real-world practice. PATIENTS AND METHODS We performed a multicenter observational cohort study involving 21 secondary and tertiary care hospitals in the administrative district Dresden, Saxony, Germany throughout the year 2005. All consenting patients presenting with VKA-related bleeding complications were included. No exclusion criteria applied. Data were collected at admission, at discharge and at 90 days to evaluate resource consumption, length of hospital stay and risk factors for in-hospital- and 3-month mortality. RESULTS Two hundred and ninety patients were included (median age 74 years; 50.7% male). The main indications for VKA therapy were atrial fibrillation (63.4%), prior thromboembolism (18.6%) and mechanical heart valves (11.4%), and most common bleeding localizations were large hematoma (23.1%), upper gastrointestinal (GI) tract (17.9%) and intracranial bleeding (14.1%). On hospital admission, the median International Normalized Ratio (INR) was 3.0 (range 0.9-12.5, interquartile range [IQR] 2.1-3.9). In-hospital mortality was 7.6% with impaired renal function as the most relevant risk factor. At 90 days mortality was 14.1% and 15.3% of survivors were help-dependent. CONCLUSIONS VKA-related bleeding leading to hospitalization is associated with long hospitalization, relevant resource utilization, high mortality or persistent sequlae. Patient-related factors such as impaired renal function, chronic cardiac or pulmonary disease and dementia are predictive of in-hospital and 3-month mortality.
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Affiliation(s)
- K Halbritter
- Center for Vascular Diseases and Medical Clinic III, Dresden University Hospital Carl Gustav Carus, Dresden, Germany.
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Díez-Manglano J, Bernabeu-Wittel M, Barón-Franco B, Murcia-Zaragoza J, Fuertes Martín A, Alemán A, Ollero-Baturone M. Anticoagulación en pacientes pluripatológicos con fibrilación auricular. Med Clin (Barc) 2013. [DOI: 10.1016/j.medcli.2012.05.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sonnett TE, Setter SM, Weeks DL, Borson S. Point-of-care screening to identify cognitive impairment in older adults. J Am Pharm Assoc (2003) 2012; 52:492-7. [PMID: 22825229 DOI: 10.1331/japha.2012.11012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To explore associations between results of a rapid screening tool for cognitive impairment and individual patient characteristics in a sample of patients receiving outpatient anticoagulation therapy who were not previously diagnosed with a dementia. DESIGN Descriptive, nonexperimental, cross-sectional study. SETTING Pharmacist-managed anticoagulation clinic in Spokane, WA, from June 2006 to March 2007. PARTICIPANTS 300 community-dwelling patients aged 60 years or older who had at least 6 months of outpatient anticoagulation therapy services. INTERVENTION Following informed consent, demographic, medical history, medication history, anticoagulation therapy, and cognitive screening data were recorded from participant medical records, and a participant interview was performed using a standardized questionnaire and data collection form. MAIN OUTCOME MEASURES Cognitive screening status (suggests cognitive impairment versus suggests dementia less likely) was used as an independent variable by which to compare patient demographics, medical history, medication history, and percent of out-of-range International Normalized Ratio (INR) visits. RESULTS 55 of 300 participants (18.3%) with no previous diagnosis of a cognitive impairment were classified as "suggests cognitive impairment" based on the screening test. Presence or absence of cognitive impairment differed in those needing assistance with taking medications but was not associated with other sample characteristics, including percentage of visits with out-of-range INR value, gender, in-home care needs, age, and number of medical conditions. CONCLUSION Screening at a convenient health care access point may lead to increased identification of community-dwelling elderly patients with unrecognized and undiagnosed cognitive impairment. Pharmacists are particularly well suited to conduct this screening because of the extended and frequent contact they have with patients in settings such as anticoagulation therapy clinics.
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Affiliation(s)
- Travis E Sonnett
- College of Pharmacy, Washington State University, P.O. Box 646510, Pullman, WA 99164-6510, USA.
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Khreizat HS, Whittaker P, Curtis KD, Turlo G, Garwood CL. The Effect of Cognitive Impairment in the Elderly on the Initial and Long-Term Stability of Warfarin Therapy. Drugs Aging 2012; 29:307-17. [PMID: 22462629 DOI: 10.2165/11599060-000000000-00000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Hanan S Khreizat
- Department of Pharmacy, Harper University Hospital, Detroit Medical Center, Detroit, MI, USA
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López Soto A, Formiga F, Bosch X, García Alegría J. [Prevalence of atrial fibrillation and related factors in hospitalized old patients: ESFINGE study]. Med Clin (Barc) 2011; 138:231-7. [PMID: 21940001 DOI: 10.1016/j.medcli.2011.05.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 05/14/2011] [Accepted: 05/17/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVES Atrial fibrillation (AF) is the commonest rhythm abnormality and it increases with ageing. The main objective of this study was to assess the prevalence of AF in hospitalized old patients as well as its characteristics and related clinical and therapeutic factors. PATIENTS AND METHODS Prospective, multicenter, observational study in patients aged ≥ 70 years with AF, who had been hospitalized in Internal Medicine or Geriatrics wards. All variables studied were obtained from the patients' clinical records. RESULTS Out of 3,319 evaluable patients, 922 had an AF, which represents a prevalence of 31.3% (CI 95%; 29.7-32.9). The mean age was 82 years (6.1; 69.9-101.8) and 57% were women. 88.7% of patients (818 p) had an AF before admission. AF was long-standing persistent or permanent in 728 cases (89.1%) and it was the first episode (paroxysmal or persistent) in 51 patients (6.2%). There was a clear etiology of AF in only 4.1% cases. Congestive heart failure was the commonest reason for hospitalization in our patients. Regarding the cardiovascular risk factors, 80.3% patients were hypertensive, 36.4% had dyslipemia, 38.2% had diabetes and 5% were active smokers. Associated diseases included renal insufficiency (38.1%) and chronic obstructive pulmonary disease (38.2%); in addition, 188 patients (20.4%) had suffered from cerebrovascular accidents. Finally, 67.4% patients had received antiarrhythmic drugs for their FA. Although 86.1% had received thromboembolic prevention therapy, only 54.1% were under oral anticoagulation. Finally, 6.9% patients had antiarrhythmic drugs-related side effects. CONCLUSIONS Over one third of hospitalized patients older than 70 years have AF, which is generally relapsing and permanent. Heart failure is the commonest reason for hospitalization in these patients and about 40% have an associated disease.
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Affiliation(s)
- Alfonso López Soto
- Servicio de Medicina Interna, Instituto Clínico de Medicina y Dermatología, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, España.
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Tulner LR, van Campen JPCM, Frankfort SV, Koks CHW, Beijnen JH, Brandjes DPM, Jansen PAF. Changes in under-treatment after comprehensive geriatric assessment: an observational study. Drugs Aging 2011; 27:831-43. [PMID: 20883063 DOI: 10.2165/11539330-000000000-00000] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Under-treatment is frequently present in geriatric patients. Because this patient group often suffer from multiple diseases, polypharmacy (defined as the concomitant chronic use of five or more drugs) and contraindications to indicated drugs may also frequently be present. OBJECTIVE To describe the prevalence of under-treatment with respect to frequently indicated medications before and after comprehensive geriatric assessment (CGA) and the prevalence of contraindications to these medications. PATIENTS AND METHODS The geriatric outpatients evaluated in this study had previously been included in a prospective descriptive study conducted in 2004. Demographic data, medical history, co-morbidity and medication use and changes were documented. The absence of drugs indicated for frequently under-treated conditions before and after CGA was compared. Under-treatment was defined as omission of drug therapy indicated for the treatment or prevention of 13 established diseases or conditions known to be frequently under-treated. Co-morbid conditions were independently classified by two geriatricians, who determined whether or not a condition represented a contraindication to use of these drugs. RESULTS In 2004, 807 geriatric outpatients were referred for CGA. Of these, 548 patients had at least one of the 13 selected diseases or conditions. Thirty-two of these patients were excluded from the analysis, leaving 516 patients. Before CGA, 170 of these patients were under-treated (32.9%); after CGA, 115 patients (22.3%) were under-treated. Contraindications were present in 102 of the patients (19.8%) and were more frequent in under-treated patients. After CGA, mean drug use and the prevalence of polypharmacy increased. Although 393 drugs were discontinued after CGA, the overall number of drugs used increased from 3177 before CGA to 3424 after CGA. Five times more drugs were initiated for a new diagnosis than for correction of under-treatment. CONCLUSIONS Under-treatment is significantly reduced after CGA. Patients with contraindications to indicated medicines are more frequently under-treated. CGA leads to an increase in polypharmacy, mainly because of new conditions being diagnosed and despite frequent discontinuation of medications.
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Affiliation(s)
- Linda R Tulner
- Department of Geriatric Medicine, Slotervaart Hospital, Amsterdam, the Netherlands.
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Flaker GC, Pogue J, Yusuf S, Pfeffer MA, Goldhaber SZ, Granger CB, Anand IS, Hart R, Connolly SJ. Cognitive Function and Anticoagulation Control in Patients With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2010; 3:277-83. [DOI: 10.1161/circoutcomes.109.884171] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Greg C. Flaker
- From the University of Missouri-Columbia (G.C.F.), Columbia, Mo; McMaster University (J.P., S.Y., S.J.C.), Hamilton, Ontario, Canada; Brigham and Women’s Hospital (M.A.P., S.Z.G.), Harvard Medical School, Boston, Mass; Duke University (C.B.G.), Durham, NC; VA Medical Center and University of Minnesota (I.S.A), Minneapolis, Minn; University of Texas (R.H.), San Antonio, Tex
| | - Janice Pogue
- From the University of Missouri-Columbia (G.C.F.), Columbia, Mo; McMaster University (J.P., S.Y., S.J.C.), Hamilton, Ontario, Canada; Brigham and Women’s Hospital (M.A.P., S.Z.G.), Harvard Medical School, Boston, Mass; Duke University (C.B.G.), Durham, NC; VA Medical Center and University of Minnesota (I.S.A), Minneapolis, Minn; University of Texas (R.H.), San Antonio, Tex
| | - Salim Yusuf
- From the University of Missouri-Columbia (G.C.F.), Columbia, Mo; McMaster University (J.P., S.Y., S.J.C.), Hamilton, Ontario, Canada; Brigham and Women’s Hospital (M.A.P., S.Z.G.), Harvard Medical School, Boston, Mass; Duke University (C.B.G.), Durham, NC; VA Medical Center and University of Minnesota (I.S.A), Minneapolis, Minn; University of Texas (R.H.), San Antonio, Tex
| | - Marc A. Pfeffer
- From the University of Missouri-Columbia (G.C.F.), Columbia, Mo; McMaster University (J.P., S.Y., S.J.C.), Hamilton, Ontario, Canada; Brigham and Women’s Hospital (M.A.P., S.Z.G.), Harvard Medical School, Boston, Mass; Duke University (C.B.G.), Durham, NC; VA Medical Center and University of Minnesota (I.S.A), Minneapolis, Minn; University of Texas (R.H.), San Antonio, Tex
| | - Samuel Z. Goldhaber
- From the University of Missouri-Columbia (G.C.F.), Columbia, Mo; McMaster University (J.P., S.Y., S.J.C.), Hamilton, Ontario, Canada; Brigham and Women’s Hospital (M.A.P., S.Z.G.), Harvard Medical School, Boston, Mass; Duke University (C.B.G.), Durham, NC; VA Medical Center and University of Minnesota (I.S.A), Minneapolis, Minn; University of Texas (R.H.), San Antonio, Tex
| | - Christopher B. Granger
- From the University of Missouri-Columbia (G.C.F.), Columbia, Mo; McMaster University (J.P., S.Y., S.J.C.), Hamilton, Ontario, Canada; Brigham and Women’s Hospital (M.A.P., S.Z.G.), Harvard Medical School, Boston, Mass; Duke University (C.B.G.), Durham, NC; VA Medical Center and University of Minnesota (I.S.A), Minneapolis, Minn; University of Texas (R.H.), San Antonio, Tex
| | - Inderjit S. Anand
- From the University of Missouri-Columbia (G.C.F.), Columbia, Mo; McMaster University (J.P., S.Y., S.J.C.), Hamilton, Ontario, Canada; Brigham and Women’s Hospital (M.A.P., S.Z.G.), Harvard Medical School, Boston, Mass; Duke University (C.B.G.), Durham, NC; VA Medical Center and University of Minnesota (I.S.A), Minneapolis, Minn; University of Texas (R.H.), San Antonio, Tex
| | - Robert Hart
- From the University of Missouri-Columbia (G.C.F.), Columbia, Mo; McMaster University (J.P., S.Y., S.J.C.), Hamilton, Ontario, Canada; Brigham and Women’s Hospital (M.A.P., S.Z.G.), Harvard Medical School, Boston, Mass; Duke University (C.B.G.), Durham, NC; VA Medical Center and University of Minnesota (I.S.A), Minneapolis, Minn; University of Texas (R.H.), San Antonio, Tex
| | - Stuart J. Connolly
- From the University of Missouri-Columbia (G.C.F.), Columbia, Mo; McMaster University (J.P., S.Y., S.J.C.), Hamilton, Ontario, Canada; Brigham and Women’s Hospital (M.A.P., S.Z.G.), Harvard Medical School, Boston, Mass; Duke University (C.B.G.), Durham, NC; VA Medical Center and University of Minnesota (I.S.A), Minneapolis, Minn; University of Texas (R.H.), San Antonio, Tex
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Tulner LR, Van Campen JPCM, Kuper IMJA, Gijsen GJPT, Koks CHW, Mac Gillavry MR, van Tinteren H, Beijnen JH, Brandjes DPM. Reasons for undertreatment with oral anticoagulants in frail geriatric outpatients with atrial fibrillation: a prospective, descriptive study. Drugs Aging 2010; 27:39-50. [PMID: 20030431 DOI: 10.2165/11319540-000000000-00000] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES The main aims of the study were to explore whether oral anticoagulation (OAC) for atrial fibrillation (AF) in geriatric outpatients is prescribed in accordance with international (American College of Cardiology/American Heart Association/European Society of Cardiology [ACC/AHA/ESC]) and Dutch national guidelines for the general practitioner (GP) and to identify whether age and selected co-morbid conditions are associated with undertreatment. As a secondary objective, we wanted to establish how many patients discontinue OAC because of major bleeding. METHODS In 2004, at the first visit of all patients to the geriatric day clinic of the Slotervaart Hospital in Amsterdam, the Netherlands, demographic data, Mini-Mental State Examination score, medical history, Charlson Comorbidity Index score, and data on medication use and changes were documented. The presence of AF was established by assessment of medical history information obtained by the GP, the history taken from patients and their caregivers, and the results of clinical evaluation, including ECG findings. Associations between the use of OAC, demographic data and co-morbid conditions registered in the Dutch NHG (Nederlands Huisartsen Genootschap [Dutch College of General Practitioners]) standard for GPs as risk factors for stroke or contraindications to the use of OAC were analysed. The reasons for discontinuing OAC were assessed after 4 years by requesting the information from the anticoagulation services or the GP. RESULTS At the time of the initial visit, 17.5% of the 807 outpatients had chronic AF (n = 135) or were known to have paroxysmal AF (n = 6). The mean age of the 141 patients in this cohort was 84.3 years (SD 6.2 years). Co-morbid conditions increasing the risk of stroke were present in 129 patients (91.5%). Contraindications to the use of OAC were observed in 118 patients (83.7%). Of the 116 patients with AF in their history before their visit, 57.8% were being treated with OAC at the time of their visit. After comprehensive geriatric assessment, 73 (51.8%) of the 141 patients with chronic or paroxysmal AF were continued on OAC. Of the 141 patients with chronic or paroxysmal AF, 110 (78.0%) had both extra stroke risk factors and contraindications to the use of OAC. Only increasing age was significantly and independently associated with not being prescribed anticoagulants (p < 0.001). At the 4-year follow-up, OAC had been discontinued in 5.5% of patients because of major bleeding; three patients (4.1%) taking OAC had died as a result of major bleeding, and one other patient had discontinued treatment because of a major, non-lethal bleeding episode. CONCLUSION Applying the NHG standard for appropriate prescription, and disregarding age as a risk factor or contraindication, in this population, 14 of 141 patients (9.9%) were inappropriately prescribed OAC, salicylates or no prophylaxis. Since only patient age was associated with not prescribing OAC in this study, higher age still seems to be considered the most important contraindication to anticoagulation therapy. Implementation of better models for stratifying bleeding risk in the frail elderly is needed. After 4 years, the cumulative rate of bleeding causing discontinuation of anticoagulation therapy in this usual-care study of frail older patients was not alarmingly higher than in other usual-care studies.
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Affiliation(s)
- Linda R Tulner
- Department of Geriatric Medicine, Slotervaart Hospital, Louwesweg 6, 1066 EC Amsterdam, The Netherlands.
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Dolan G, Smith LA, Collins S, Plumb JM. Effect of setting, monitoring intensity and patient experience on anticoagulation control: a systematic review and meta-analysis of the literature. Curr Med Res Opin 2008; 24:1459-72. [PMID: 18402715 DOI: 10.1185/030079908x297349] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To investigate the relationship between time spent in the recommended target International Normalised Ratio (INR) range and the setting and intensity of anti coagulant monitoring, in both treatment-experienced and treatment-naive atrial fibrillation (AF) patients receiving oral anticoagulation (OAC) therapy for the prevention of ischaemic stroke. RESEARCH DESIGN AND METHODS Systematic review of published studies on participants with atrial fibrillation on anticoagulation therapy. We compared frequent monitoring (well-controlled, according to a strict protocol) versus infrequent monitoring (frequency representative of routine clinical practice), specialised care versus usual care, and naive versus prior anticoagulant use. Meta-analysis was performed using a random effects model. RESULTS 36 studies were included, 22 (primary data) of AF patients managed in line with the consensus guidelines target INR range of 2.0-3.0, and 14 studies (secondary data) of mixed patient groups, including AF, with an INR target of 2.0-3.5. Both data sets were combined for sensitivity analysis. Pooled mean time in INR range was 59.1% (95% CI: 55.5, 62.8%) and 64.3% (95% CI: 60.5, 68.0%) for infrequent monitoring and frequent monitoring, respectively. Significantly more time was spent in range in specialist care settings compared to usual care: +11.3% (95% CI: 0.1-21.7%). Naive OAC users spent less time in range 56.5% (95% CI: 45.5-67.5%) than existing users 61.2% (95% CI: 57.2-65.2%). All of these differences were found to be significant in the sensitivity analyses. CONCLUSIONS INR control is variable and dependent on monitoring intensity and duration of anticoagulant therapy.
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Affiliation(s)
- G Dolan
- Department of Haematology, QMC Campus, Nottingham University Hospitals, Nottingham, UK.
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Abstract
Atrial fibrillation is increasingly prevalent among older adults. It causes approximately 24% of strokes in patients aged 80 to 89 years. The management of atrial fibrillation is directed at preventing thromboembolism and controlling the heart rate and rhythm. Stroke prevention is most effectively accomplished through administering anticoagulants such as warfarin, although older patients have higher hemorrhagic risk. Cognitive dysfunction, functional impairments, and increased fall risk further complicate warfarin management in elderly patients. The use of risk stratification schemes can help guide the anticoagulation decision, although the benefits of warfarin generally outweigh the risks in most older patients with atrial fibrillation. Pharmacologic rate control has been shown to result in similar outcomes compared with pharmacologic restoration of sinus rhythm and should be the initial therapy for elderly patients. Anti-arrhythmic medications should be selected based on an individual patient's coexisting medical conditions. In symptomatic patients who fail pharmacologic therapy, invasive strategies such as AV nodal ablation may help improve quality of life and symptoms, although such strategies do not obviate the need for antithrombotic therapy.
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Affiliation(s)
- Margaret C Fang
- Division of General Internal Medicine Hospitalist Group, University of California, San Francisco, CA 94143, USA.
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van Walraven C, Jennings A, Oake N, Fergusson D, Forster AJ. Effect of Study Setting on Anticoagulation Control. Chest 2006; 129:1155-66. [PMID: 16685005 DOI: 10.1378/chest.129.5.1155] [Citation(s) in RCA: 356] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND For patients receiving therapy with oral anticoagulants (OACs), the proportion of time spent in the therapeutic range (ie, anticoagulation control) is strongly associated with bleeding and thromboembolic risk. The effect of study-level factors, especially study setting, on anticoagulation control is unknown. OBJECTIVES Describe anticoagulation control achieved in the published literature. We also used metaregressive techniques to determine which study-level factors significantly influenced anticoagulation control. STUDIES All published randomized or cohort studies that measured international normalized ratios (INRs) serially in anticoagulated patients and reported the proportion of time between INRs ranging from 1.8 to 2.0 and 3.0 to 3.5. RESULTS We identified 67 studies with 123 patient groups having 50,208 patients followed for a total of 57,154.7 patient-years. A total of 68.3% of groups were from anticoagulation clinics, 7.3% were from clinical trials, and 24.4% were from community practices. Overall, patients were therapeutic 63.6% of time (95% confidence interval [CI], 61.6 to 65.6). In the metaregression model, study setting had the greatest effect on anticoagulation control with studies in community practices having significantly lower control than either anticoagulation clinics or clinical trials (-12.2%; 95% CI, -19.5 to -4.8; p < 0.0001). Self-management was associated with a significant improvement of time spent in the therapeutic range (+7.0%; 95% CI, 0.7 to 13.3; p = 0.03). CONCLUSIONS Patients who have received anticoagulation therapy spend a significant proportion of their time with an INR out of the therapeutic range. Patients from community practices showed significantly worse anticoagulation control than those from anticoagulation clinics or clinical trials. This should be considered when interpreting the results of, and generalizing from, studies involving OACs.
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Affiliation(s)
- Carl van Walraven
- Clinical Epidemiology Program, Ottawa Health Research Institute, C405, Ottawa Hospital, Civic Campus, 1053 Carling Ave, Ottawa, ON, K1Y 4E9 Canada.
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