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Factors Associated with Undertreatment of Atrial Fibrillation in Geriatric Outpatients with Alzheimer Disease

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Abstract

Background

According to international recommendations [from the American College of Cardiology/American Heart Association/European Society of Cardiology] and those of the Haute Autorité de Santé (HAS) in France, treatment with a vitamin K antagonist is recommended in patients with atrial fibrillation (AF) in the presence of a high thromboembolic risk factor [history of stroke, transient ischemic attack, systemic embolism, or valvular heart disease, or presence of a mechanical heart valve prosthesis] or at least two moderate risk factors (age ≥75 years, hypertension, congestive heart failure, or diabetes). In patients with a major contraindication, the vitamin K antagonist can be replaced by an antiplatelet agent (APA). These recommendations are not systematically observed in patients with Alzheimer disease (AD). The aim of our study was to determine the factors associated with undertreatment of AF in geriatric outpatients with AD.

Methods

Use of oral anticoagulants or APAs was studied in 66 patients with AF who were included in the French Network on Alzheimer Disease (REAL.FR) cohort, consisting of 686 outpatients living at home, supported by an informal caregiver, and suffering from Alzheimer-type dementia, with a Mini Mental Status Examination (MMSE) score between 10 and 26. First, demographic characteristics (age, sex, body mass index [BMI], living arrangements, educational level), medical conditions (comorbidity, number of medications), disability (activities of daily living [ADL], instrumental activities of daily living [IADL]), risk of falls (one-leg balance test), cognitive status (according to MMSE, Alzheimer’s Disease Assessment Scale—Cognitive Subscale [ADAS-Cog], and Clinical Dementia Rating [CDR] scores), risk factors for stroke (hypertension, history of stroke, congestive heart failure, diabetes, or age ≥75 years) and potential contraindications to oral anticoagulants (OACs) or APAs (polypharmacy, risk of falls, renal failure, gastrointestinal diseases) of patients receiving OACs were compared with those of patients receiving APAs and those of patients receiving no treatment for AF. Then the same characteristics were compared between patients receiving no treatment for AF and those receiving OACs or APAs.

Results

Only 56 % (n = 37) of patients with AF were receiving OACs or APAs at the baseline visit, of whom 18 (49 %) were receiving OACs and 19 (51 %) were receiving APAs. Bivariate analysis showed that patients receiving OACs or APAs were significantly more likely to have a history of cardiovascular disease (p = 0.005)—in particular, hypertension (p = 0.037)—less likely to be living alone and unaided (p = 0.038), and less likely to be taking nonsteroidal anti-inflammatory drugs [NSAIDs] (p = 0.001).

Conclusion

Despite the national and international recommendations, nearly half of AD patients with AF do not receive OACs or APAs. A history of cardiovascular disease—in particular, hypertension—improves access to treatment, but use of NSAIDs and living alone without home care seem to be the main factors associated with non-prescription of OACs or APAs.

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References

  1. Fuster V, Rydén LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients with Atrial Fibrillation) developed in collaboration with the North American Society of Pacing and Electrophysiology. Circulation. 2001;104:2118–50.

    PubMed  CAS  Google Scholar 

  2. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: executive summary. Circulation. 2006;114:700–52.

    Article  Google Scholar 

  3. Haute Autorité de Santé (2007). Guide—affection de longue durée 2007: fibrillation auriculaire. http://www.has-sante.fr/portail/upload/docs/application/pdf/ald_5_fibrillation_auriculaire.pdf. Accessed 22 Jul 2013.

  4. Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Guidelines for the management of atrial fibrillation. Eur Heart J. 2010;31:2369–429.

    Google Scholar 

  5. Tulner LR, Van Campen JP, Kuper IM, Gijsen GJ, Koks CH, Mac Gillavry MR, van Tinteren H, Beijnen JH, Brandjes DP. Reasons for undertreatment with oral anticoagulants in frail geriatric outpatients with atrial fibrillation: a prospective, descriptive study. Drugs Aging. 2010;27:39–50.

    Google Scholar 

  6. Vasishta S, Toor F, Johansen A, et al. Stroke prevention in atrial fibrillation: physicians’ attitudes to anticoagulation in older people. Arch Gerontol Geriatr. 2001;33:219–26.

    Article  PubMed  CAS  Google Scholar 

  7. Baker DW, Hayes RP, Massie BM, et al. Variations in family physicians’ and cardiologists’ care for patients with heart failure. Am Heart J. 1999;138:826–34.

    Article  PubMed  CAS  Google Scholar 

  8. Lipton HL, Bero LA, Bird JA, et al. Undermedication among geriatric outpatients: results of a randomized controlled trial. Ann Rev Gerontol Ger. 1992;12:95–108.

    Google Scholar 

  9. Dinh T, Nieuwlaat R, Tieleman RG, Büller HR, van Charante NA, Prins MH, Crijns HJ. Antithrombotic drug prescription in atrial fibrillation and its rationale among general practitioners, internists and cardiologists in the Netherlands—the EXAMINE-AF study: a questionnaire survey. Int J Clin Pract. 2007;61:24–31.

    Article  PubMed  CAS  Google Scholar 

  10. Deplanque D, Leys D, Parnetti L, Schmidt R, Ferro J, De Reuck J, Mas JL, Gallai V, SAFE II Investigators. Stroke prevention and atrial fibrillation: reasons leading to an inappropriate management. Main results of the SAFE II study. Br J Clin Pharmacol. 2004;57:798–806.

    Article  PubMed  Google Scholar 

  11. Chatap G, Giraud K, Vincent JP. Atrial fibrillation in the elderly: facts and management. Drugs Aging. 2002;19:819–46.

    Article  PubMed  Google Scholar 

  12. Villa A, Bacchetta A, Omboni E, et al. Underuse of antithrombotic therapy in stroke patients with chronic atrial fibrillation response. Stroke. 2000;21:2266–78.

    Article  Google Scholar 

  13. Ceresne L, Upshur RE. Atrial fibrillation in a primary care practice: prevalence and management. BMC Fam Prac. 2002;3:11.

    Article  Google Scholar 

  14. Lobo A, Launer LJ, Fratiglioni L, Andersen K, Di Carlo A, Breteler MM, Copeland JR, Dartigues JF, Jagger C, Martinez-Lage J, Soininen H, Hofman A. Prevalence of dementia and major subtypes in Europe: a collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group. Neurology. 2000;54:S4–9.

    Article  PubMed  CAS  Google Scholar 

  15. Aronow WS, Ahn C, Gutstein H. Prevalence of atrial fibrillation and association of atrial fibrillation with prior and new thromboembolic stroke in older patients. J Am Geriatr Soc. 1996;44:521–3.

    PubMed  CAS  Google Scholar 

  16. Duron E, Hanon O. Atrial fibrillation and cognitive function. Psychol Neuropsychiatr Vieil. 2010;8:209–14.

    PubMed  Google Scholar 

  17. Miyasaka Y, Barnes ME, Petersen RC, Cha SS, Bailey KR, Gersh BJ, et al. Risk of dementia in stroke-free patients diagnosed with atrial fibrillation: data from a community-based cohort. Eur Heart J. 2007;28:1962–7.

    Article  PubMed  Google Scholar 

  18. Edland SD, Rocca WA, Petersen RC, Cha RH, Kokmen E. Dementia and Alzheimer disease incidence rates do not vary by sex in Rochester, Minn. Arch Neurol. 2002;59:1589–93.

    Article  PubMed  Google Scholar 

  19. Forti P, Maioli F, Pisacane N, Rietti E, Montesi F, Ravaglia G. Atrial fibrillation and risk of dementia in non-demented elderly subjects with and without mild cognitive impairment (MCI). Arch Gerontol Geriatr. 2007;44(Suppl. 1):155–65.

    Article  PubMed  Google Scholar 

  20. Flaker GC, Pogue J, Yusuf S, Pfeffer MA, Goldhaber SZ, Granger CB, Anand IS, Hart R, Connolly SJ; Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events (ACTIVE) Investigators. Cognitive function and anticoagulation control in patients with atrial fibrillation. Circ Cardiovasc Qual Outcomes. 2010;3:277–83.

    Google Scholar 

  21. Gillette-Guyonnet S, Nourhashemi F, Andrieu S, et al. The REAL.FR research program on Alzheimer’s disease and its management: methods and preliminary results. J Nutr Health Aging. 2003;7:91–6.

    PubMed  CAS  Google Scholar 

  22. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology. 1984;34:939–44.

    Article  PubMed  CAS  Google Scholar 

  23. The definition of orthostatic hypotension, pure autonomic failure and multiple system atrophy. J Auton Nerv Syst. 1996;58:123–4.

  24. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged: the index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.

    Article  PubMed  CAS  Google Scholar 

  25. Lawton MP, Brody EM. Assessment of older people: self maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179–86.

    Article  PubMed  CAS  Google Scholar 

  26. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45:735–8.

    PubMed  CAS  Google Scholar 

  27. Vellas B, Guigoz Y, Garry PJ, et al. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition. 1999;15:116–22.

    Article  PubMed  CAS  Google Scholar 

  28. Tilly-Gentric A. Anticoagulation in permanent atrial fibrillation after 75 years of age. Rev Med Interne. 2002;23:834–9.

    Article  PubMed  CAS  Google Scholar 

  29. Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006;151:713–9.

    Article  PubMed  Google Scholar 

  30. Samsa GP, Matchar DB, Goldstein LB, Bonito AJ, Lux LJ, Witter DM, et al. Quality of anticoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities. Arch Intern Med. 2000;160:967–73.

    Article  PubMed  CAS  Google Scholar 

  31. Gage BF, Boechler M, Doggette AL, Fortune G, Flaker GC, Rich MW, et al. Adverse outcomes and predictors of underuse of antithrombotic therapy in Medicare beneficiaries with chronic atrial fibrillation. Stroke. 2000;31:822–7.

    Article  PubMed  CAS  Google Scholar 

  32. Gurwitz JH, Monette J, Rochon PA, Eckler MA, Avorn J. Atrial fibrillation and stroke prevention with warfarin in the long term care setting. Arch Intern Med. 1997;157:978–84.

    Article  PubMed  CAS  Google Scholar 

  33. Beyth RJ, Antani MR, Covinsky KE, et al. Why isn’t warfarin prescribed to patients with nonrheumatic atrial fibrillation? J Gen Intern Med. 1996;11:721–8.

    Article  PubMed  CAS  Google Scholar 

  34. Gross CP, Vogel EW, Dhond AJ, et al. Factors influencing physicians’ reported use of anticoagulation therapy in nonvalvular atrial fibrillation: a cross-sectional survey. Clin Ther. 2003;25:1750–64.

    Article  PubMed  Google Scholar 

  35. Go AS, Hylek EM, Borowsky LH, et al. Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. Ann Intern Med. 1999;131:927–34.

    Article  PubMed  CAS  Google Scholar 

  36. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864–70.

    Article  PubMed  CAS  Google Scholar 

  37. Friberg L, Hammar N, Ringh M, Pettersson H, Rosenqvist M. Stroke prophylaxis in atrial fibrillation: who gets it and who does not? Report from the Stockholm Cohort-Study on Atrial Fibrillation (SCAF-study). Eur Heart J. 2006;27:1954–64.

    Article  PubMed  Google Scholar 

  38. Mehrabian S, Duron E, Labouree F, Rollot F, Bune A, Traykov L, Hanon O. Relationship between orthostatic hypotension and cognitive impairment in the elderly. J Neurol Sci. 2010;299:45–8.

    Article  PubMed  Google Scholar 

  39. Ingelgård A, Hollowell J, Reddy P, Gold K, Tran K, Fitzmaurice D. What are the barriers to warfarin use in atrial fibrillation? Development of a questionnaire. J Thromb Thrombolysis. 2006;21:257–65.

    Article  PubMed  Google Scholar 

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Conflict of interest

The authors have no conflicts of interest that are directly relevant to the content of this article.

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Authors and Affiliations

  1. Gérontopôle de Toulouse, Département de Médecine Interne et Gérontologie Clinique, Centre Hospitalier Universitaire de Toulouse, Pavillon Junod, 170 avenue de Casselardit, 31300, Toulouse, France

    Neda Tavassoli, Amélie Perrin, Sophie Gillette, Bruno Vellas & Yves Rolland

  2. UMR 1027 INSERM, Université de Toulouse III, Toulouse, France

    Sophie Gillette, Bruno Vellas & Yves Rolland

  3. Département d’Epidémiologie, Economie de la Santé et Santé Publique, UMR 1027 INSERM, Université de Toulouse III, Centre Hospitalier Universitaire de Toulouse, Toulouse, France

    Emilie Bérard

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  1. Neda Tavassoli
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the REAL.FR Group

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Correspondence to Neda Tavassoli.

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Tavassoli, N., Perrin, A., Bérard, E. et al. Factors Associated with Undertreatment of Atrial Fibrillation in Geriatric Outpatients with Alzheimer Disease. Am J Cardiovasc Drugs 13, 425–433 (2013). https://doi.org/10.1007/s40256-013-0040-5

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