Geriatric vs. Non-Geriatric Anticoagulation Management

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Erin Robinson
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1 Geriatric vs. Non-Geriatric Anticoagulation Management Maija Sanna, MD and Sheila Naghshineh, MD Co-Directors, Anticoagulation Management November 20,

2 Overview Use of anticoagulation in the geriatric population. Geriatric specific anticoagulation concerns. UCLA s Anticoagulation Management Service (AMS) therapeutic time in range (TIR) and out of range for geriatric vs. non-geriatric population. Solutions to non-adherence and improved TIR for geriatric vs. non-geriatric patients. 2

3 Cardiovascular indications for anticoagulation are common in older adults Nonvalvular atrial fibrillation Cardioembolic stroke Valvular heart disease and prosthetic heart valves Severe left ventricular dysfunction Venous thromboembolic disease (PE and DVT) Risk at age 40 30/100,000 Risk at age 60 90/100,000 Risk at age /100,000 * Peripheral artery disease *Anderson et al Arch Intern Med

4 Case Example 86 yo female with HTN, HLD,CAD, CKD and mild cognitive impairment recently discharged from the hospital after new diagnosis of atrial fibrillation. She lives alone, does not drive, and manages her own medications. She is widowed, does not have any children but has a neighbor who helps her with grocery shopping. She ambulates with a walker. She has had 3 falls in the past year. Her medications includes lisinopril and metoprolol, atorvastatin, asa 81, and the newly prescribed warfarin at 5mg. Her INR was 2.7 on discharge 4 days ago. She now presents to your anticoagulation clinic for her initial appointment. Her INR is

5 What are your concerns about this patient? Fall risk Non-adherence (skipped doses, double-dosing) Capacity to understand treatment benefit and risks Dual blood-thinner risk (aspirin + coumadin) Co-morbidities (uncontrolled HTN) Subtherapeutic Accurate medication reconciliation (other medications not on her med list, i.e. herbals, vitamins) 5

6 Geriatric Specific Anticoagulation Concerns Polypharmacy and drug-drug interactions Medications that can Increase INR (amiodarone, azole antifungals, macrolides, quinolones, tetracyclines) Medications that can Decrease the INR (rifampicin, St. John s wort, nafcillin, diclox, sucralfate) Concurrent use of anti platelet agents and NSAIDs Cognitive impairment Incorrect dosing Missed pills or double doses Dietary noncompliance Non-adherence to follow up INR visits 6

7 Geriatric Specific Anticoagulation Concerns Poor Diet/Malnutrition Socioeconomic factors, co-morbid conditions, cognitive conditions Co morbid disease Recurrent falls and subdural hematoma Patients with an average risk of stroke (5%/yr without anticoagulation) would have to fall 300 times/year for the risk of anticoagulation related subdurals to outweigh the benefit of stroke prevention* Intracranial Hemorrhage (ICH) and hypertension Risk factors for ICH included age >75, HTN: SBP>160, hx of cerebrovascular disease, intensity of anticoagulation.** GI Bleeding risk and NSAIDs/aspirin *Man-Son-Hing et al Arch Intern Med 2003 **Hart et al. Stroke

8 HAS-BLED Bleeding Risk Score H= HTN (uncontrolled >160 mm Hg systolic)= 1 point A= Abnormal renal/liver function= 1 or 2 points S= Stroke (prior history) = 1 point B= Bleeding history or predisposition = 1 point L= Labile INR (TIR < 60%)= 1 point E= Elderly (age > 65) = 1 point D= Drugs/alcohol. Anti-platelet agents and NSAIDs= 1 point. Alcohol excess= 1 point. # of Bleeds/100 pt-yr increased with score: 0= 1.13, 1= 1.02, 2= 1.88, 3 = 3.74, 4= 8.70, 5= Pisters et al. Chest

9 80 Percent Therapeutic Time in Range (TIR) for Non-Geriatric vs Geriatric Patients at UCLA % TIR Age 9

10 Percent INR<2 for Non-Geriatric vs Geriatric patients at UCLA % INR < Age 10

11 Percent INR> 5 for Non-Geriatric vs Geriatric patients at UCLA % INR > Age 11

12 POC vs non-poc TIR for younger population 70 Ages % TIR non-poc POC 12

13 UCLA Data Summary Geriatric patients spent more TIR than younger patients 71% ages 65+ compared to 52% ages The youngest patients were more frequently in the sub therapeutic range (INR<2) 41% ages vs % for ages 31+ Supra therapeutic INRs were least frequent in the older population 0.8% in patients 65+ vs for ages The youngest patients (18-30) had higher % TIR with non-poc testing (62%) vs. POC testing (41%) 13

14 Non-Geriatric Adherence Issues Priorities (i.e. work, school) Interruptions in follow-up (i.e., travel) Higher rate of alcohol/drug misuse/abuse (binge drinking etc.) Invincibility Dietary indiscretions 14

15 Everyone: Solutions to Improve Therapeutic TIR Medication reconciliation and MD limit polypharmacy Education about diet, substance/alcohol use, and alternative meds Improve transition of care (i.e. from ER/hospital->outpatient and nursing home etc.) Customize to the capability and needs of the patient: Non-POC vs POC 18-30yo: Non-POC provides more flexibility and may increase adherence to INR testing >31 yo: POC resulted in higher TIR (possibly due to increased adherence vs. more receptive to counseling and education) 15

16 <65 years old Solutions to Improve TIR Set timer or alternate reminder methods for meds/appts Motivational interviewing to change behavior (esp yo) >65 years old Brown-bag all meds to doctor visits/pharmacy to ensure accuracy med list (herbals, vitamins, etc.) Caregiver involvement (i.e. fill pill-box, monitoring diet) 16

17 Summary Need for anticoagulation is common in geriatric population Co-morbid conditions, polypharmacy, cognitive impairment, falls may increase risk of complications Benefit of anticoagulation often outweighs the risks in this population UCLA geriatric vs. younger population: higher TIR Be creative and customize anticoagulation management to the patients needs, capacity, resources 17

18 Thanks to All our patients 4S DAWN AC Shannon Ruiz Janice Johnson Fernando Gonzalez Esther Camargo Charmaine Abregana Mahalia Bando Maria I. Morales Melissa Calito Roslyn Owens Lakeisha Williams Lorena Marquez Irma Coreas Etelvina C. Sandoval Eduardo Zaragoza Maritza Aniceto Rachel Valencia 18

Objectives. Falling Down on Warfarin Therapy. CHADS 2 Score. CHADS 2 & CHA 2 DS 2 -VASc Score. HAS-BLED Score 04/08/2014. Real World Application

Objectives. Falling Down on Warfarin Therapy. CHADS 2 Score. CHADS 2 & CHA 2 DS 2 -VASc Score. HAS-BLED Score 04/08/2014. Real World Application Falling Down on Warfarin Therapy David Andrew Jacob, PharmD Pharmacy Resident 2013-2014 Dayton VA Medical Center Dayton, Ohio Objectives Describe CHADS 2 score and the decision to anticoagulate patients