Factors associated with undertreatment of atrial fibrillation in geriatric outpatients with Alzheimer disease.
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).


CONCLUSIONS
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.
Gérontopôle de Toulouse, Département de Médecine Interne et Gérontologie Clinique, Centre Hospitalier Universitaire de Toulouse, Pavillon Junod, 170 avenue de Casselardit, 31300, Toulouse, France, tavassoli.n@chu-toulouse.fr.
Neda
N
Tavassoli
Amélie
A
Perrin
Emilie
E
Bérard
Sophie
S
Gillette
Bruno
B
Vellas
Yves
Y
Rolland
D000368:Aged; D000369:Aged, 80 and over; D000544:Alzheimer Disease / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D000553:Ambulatory Care / Q000379:methods*; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D015331:Cohort Studies; D005260:Female; D006299:Health Services for the Aged; D006801:Humans; D008297:Male; D055118:Medication Adherence; D011446:Prospective Studies; D012307:Risk Factors
D000925:Anticoagulants