Laurie G. Jacobs

Warfarin Pharmacology, Clinical Management, and Evaluation of Hemorrhagic Risk for the Elderly

Warfarin, a vitamin K antagonist, is currently the most extensively used oral anticoagulant world-wide. It is prescribed for a variety of indications and has undergone extensive clinical study. Still, despite wide usage and considerable accumulated data from clinical trials demonstrating efficacy for a variety of thrombotic and thromboembolic conditions, warfarin is underutilized because its management is complex for both patients and physicians. However, despite these limitations, warfarin can be managed with relative safety, even in an elderly population.

Anticoagulation for stroke prevention in elderly patients with atrial fibrillation, including those with falls and/or early-stage dementia: A single-center, retrospective, observational study

BACKGROUND Anticoagulation for stroke prevention is underused in elderly patients with nonvalvular atrial fibrillation (AF). Those with falls and/or early dementia may be at particular risk for stroke and hemorrhage. OBJECTIVE The aim of this study was to determine the prescribing patterns, risks, and benefits of anticoagulation with warfarin or acetylsalicylic acid (ASA) in elderly patients with AF at risk for stroke and hemorrhage, including those with falls and/or dementia. METHODS In this single-center, retrospective, observational study, data from patients aged > or =65 years with chronic nonvalvular AF treated at an urban academic geriatrics practice over a 1-year period were included. Eligible patients were receiving noninvasive management of AF with warfarin or ASA. Data were assessed to determine the prevalences of stroke, hemorrhage, falls, and the possible effects of anticoagulation with dementia. Outcomes events at 12 months, including time-in-therapeutic range (TTR), stroke, hemorrhage, and death, were determined. The stroke risk in each patient was estimated using the CHADS(2) (congestive heart failure, hypertension, age > or =75 years, diabetes, history of stroke or transient ischemic attack) score, and the risk for hemorrhage was estimated using the Outpatient Bleeding Risk Index. RESULTS A total of 112 patients (mean age, 82 years) were identified; 106 were included in the present analysis (80 women, 26 men); 6 were not receiving antithrombotic therapy and thus were excluded from the analysis. Warfarin was prescribed in 85% (90 patients); ASA, 15% (16). International normalized ratio testing was done frequently, with a median interval of 13.7 days between tests (92% within 28 days). No association was found between an improved TTR and the number of tests per unit of time or the number of patients per clinician. The distributions of both the CHADS(2) and Outpatient Bleeding Risk Index scores were not significantly different between the warfarin and ASA groups. The proportions of patients treated with warfarin were not significantly different between the groups with a high risk for hemorrhage and the groups at lower risk. At 12 months in the 90 patients initially treated with warfarin, the rate of stroke was 2% (2 patients); major hemorrhage, 6% (5); and death, 20% (18). Mortality was greater in patients with falls (45% [5/11]) and/or dementia (47% [8/17]) compared with those without either falls or dementia (12% [8/65]). CONCLUSIONS In this well-monitored geriatric population with chronic AF, including patients with falls and/or dementia, a high percentage were prescribed warfarin (85%), with low rates of stroke, hemorrhage, and death at 12 months despite a low TTR. Patients with falls and/or dementia had a high mortality rate (approximately 45%).

Neuropsychological strategies for detecting early dementia

As new and more effective treatments for Alzheimers disease (AD) emerge, the development of efficient screening strategies in educationally and racially diverse primary care settings has increased in importance. A set of candidate screening tests and an independent diagnostic assessment were administered to a sample of 318 patients treated at a geriatric primary care center. Fifty-six subjects met criteria for dementia. Exploratory analysis led to the development of three two-stage screening strategies that differed in the composition of the first stage or Rapid Dementia Screen, which is applied to all patients over the age of 65. The second stage, applied to those patients who screen positively for dementia, is accomplished with the Free and Cued Selective Reminding Test to detect memory impairment. Using clinical diagnosis as a gold standard, the strategies had high sensitivity and specificity for identifying dementia and performed better for identifying AD than non-AD dementias. Sensitivity and specificity did not differ by race or education. The strategies provide an efficient approach to screening for early dementia.

Fungal Urinary Tract Infections in the Elderly

SummaryThe finding of fungal growth in the urine (funguria) of elderly patients is becoming increasingly common. It has been reported in both acute and chronic care settings. Risk factors for the development of funguria include the use of broad spectrum antibiotics, corticosteroids and indwelling bladder catheters, as well as diabetes mellitus, urological abnormalities and haematological malignancies.The presence of signs and symptoms of infection are unusual and the intensity of fungal growth in culture does not correlate with outcome. Careful assessment of the patient’s clinical status should be undertaken before treatment is initiated as the majority of cases resolve when underlying risk factors are addressed.Current recommendations for treatment include bladder irrigation with amphotericin B, oral fluconazole or a single dose of intravenous amphotericin B.

Prophylactic Anticoagulation for Venous Thromboembolic Disease in Geriatric Patients

Venous thromboembolic disease (VTED) occurs commonly in geriatric medical patients, causing significant morbidity and mortality. Although VTED is preventable, prophylactic anticoagulation is underused. Awareness of the clinical risk factors that contribute to VTED in the elderly is essential for identifying candidates for prophylaxis. Iatrogenic risk factors include venous catheterization, transvenous pacemaker placement, hormone replacement therapy, and immobilization or prolonged bed rest. Medical conditions associated with increased risk include a previous episode of VTED, myocardial infarction, heart failure, severe lung disease, cancer, and neurological conditions associated with paresis. Obstacles to the widespread usage of VTED prophylaxis in geriatric medical patients include the clinically silent nature of VTED, underestimation of the risk and clinical effect of VTED in this population, and concerns about the cost and safety of anticoagulant therapy in this population. Clinical practice guidelines devised specifically for geriatric medical patients facilitate rational use of thromboprophylaxis in this population. The safety, efficacy, cost‐effectiveness, and convenience of low‐molecular‐weight heparins for thromboprophylaxis are reflected in their increasing prominence in clinical practice guidelines and clinical use.

Geriatrics Medication Management Rounds: A Novel Approach to Teaching Rational Prescribing with the Use of the Medication Screening Questionnaire

Prescribing for older adults has become increasingly complex as treatment regimens have intensified, and the use of herbal and over‐the‐counter medications has increased. This article describes an educational intervention called Geriatrics Medication Management Rounds, which uses a new and comprehensive assessment tool called the Medication Screening Questionnaire (MSQ). This case‐based interactive session is aimed at teaching trainees and postgraduate physicians and pharmacists to examine the pharmacology, potential drug and disease interactions, efficacy, adherence issues, and goals of care for a geriatric patients medication regimen.

Efficacy of inferior vena cava filters in anticoagulated patients

Summary.  Background and objectives: The benefit of an inferior vena cava (IVC) filter in addition to standard anticoagulation regimens is unknown. Methods: We examined data for patients who received IVC filters with anticoagulation (AC‐Filter) after an episode of venous thromboembolism (VTE) and compared them with data for those who received anticoagulation only (AC‐Only). Outcome measures were new pulmonary embolism (PE), recurrent deep vein thrombosis (DVT), and mortality at 90 days and at 5 years. Demographic data included age, gender, and ethnicity/race, prior thromboembolic history, cancer, serum albumin, and time in therapeutic range. In addition, subsets matched for age, gender and race/ethnicity were examined in detail. Results: AC‐Filter patients (n = 251), when compared to AC‐Only patients (n = 1377), did not differ significantly with regard to gender or cancer status, but white males in general had better outcomes. AC‐Filter patients were more likely to have had a previous history of PE or VTE (P < 0.001). In comparison to AC‐Only patients, AC‐Filter patients had lower mean serum albumin levels (3.1 ± 0.8 vs. 3.6 ±0.8 mg dL–1, P < 0.001) and were older (65 ± 16.1 years vs. 60 ± 17.5 years, P < 0.001). After stratification according to previous history of PE or VTE prior to the index VTE event, no differences in the outcome measures of new PE, recurrent DVT or mortality were identified between groups, but patients with a prior history of PE from either group were more likely to have a new PE (hazard ratio 1.9, P < 0.001). Conclusions:  These data suggest that IVC filters may not provide any substantial additional benefit for patients who can tolerate anticoagulant therapy.

PERIOPERATIVE MANAGEMENT AND REVERSAL OF ANTITHROMBOTIC THERAPY

Patients of advanced age commonly undergo invasive procedures and surgery. With the number of elderly individuals being treated with long-term anticoagulant therapy growing annually, it is not uncommon that surgery is contemplated for older adults on long-term anticoagulant therapy. This article focuses on the management of elderly patients who are on long-term anticoagulant therapy, principally with warfarin, who must undergo invasive procedures. Although no consensus has been reached regarding the perioperative management of patients on long-term anticoagulation therapy, this discussion presents the current status and some recommendations for practice.

Managing respiratory symptoms at the end of life.

Early and clear discussion and articulation of preferences about interventions with increasing burdens and diminishing benefits is helpful in identifying the goals of care and planning management for patients who have unremitting terminal illnesses. The development of respiratory symptoms such as dyspnea, cough, and hiccups is common and can often be anticipated. Aggressive evaluation and treatment should be pursued and offered to palliate symptoms at the end of life.

The sin of omission: a systematic review of antithrombotic therapy to prevent stroke in atrial fibrillation.

RATIONALE: To characterize the comparative efficacy and safety of antithrombotic therapy for the prevention of stroke in patients with atrial fibrillation.