While specific independent risk factors for prevention of falls could not be determined in this study due to a lack of a control group, their findings are consistent with previously identified risk factors for falling, including weakness, poor cognitive status including medication-related changes, and altered elimination. Potential interventions to prevent falls include toileting schedules for high-risk elderly patients and review of medication lists to minimize centrally acting, psychotropic, or sedating agents.
5. Kagansky N, Knobler H, Rimon E, Ozer Z, Levy S. Safety of anticoagulation therapy in well-informed older patients. Arch Intern Med; 2004;164:2044-2050
Elderly patients are increasingly likely to require long-term anticoagulation. Despite this, physicians often withhold long-term anticoagulation due to perceived risk factors for bleeding, including age, comorbidity, and cognitive or functional impairment.
This combination retrospective and prospective observational study evaluated the safety and quality of anticoagulation in elderly patients. Over a three-year span, 323 elderly patients were discharged on warfarin from a large Israeli hospital. These patients were frail and potentially “at risk”; 54% were older than age 80, 81% were uneducated, and 84% had low income. 47% were considered cognitively intact (according to MMSE) and only 34% were functionally independent. Using a multivariate analysis, the authors determined that only poor quality of anticoagulation education (OR: 8.83; 95% CI: 2.0-50.2), polypharmacy (OR: 6.14; 95% CI 1.2-42.4) and INR >3 (OR: 1.08; 95% CI 1.03-1.14) were associated with major bleeding.
This study of a “real world” population of frail, at-risk elderly patients provides important insights into risks for major bleeding resulting from warfarin therapy. Surprisingly, advanced age, cognitive impairment and markers for frailty did not confer elevated risk for major bleeding. Importantly, the study did not explicitly address patient fall risk, an often-cited reason for withholding anticoagulation therapy. Supratherapeutic anticoagulation is associated with a statistically but not clinically significant bleeding risk. Polypharmacy is increasingly unavoidable in elderly patients. However, appropriate anticoagulation therapy should be the standard of care. This study makes it clear that we need to focus our efforts on ensuring that elderly patients and their caregivers receive appropriate anticoagulation education prior to discharge from the hospital.
6. Prinssen M, Verhoeven E, Buth J, et al. A Randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. NEJM. 2004;351:1607-18.
Endovascular repair of abdominal aortic aneurysm, which involves percutaneous introduction of a graft to bridge an aortic aneurysm, has been available since the early 1990s. This procedure was initially used in patients who were felt to be at high risk for the traditional open procedure. This selection bias may have affected the outcome of earlier studies. Therefore, the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial was designed to assess outcomes in patients deemed fit to undergo either open or endovascular repair. The study was conducted at 24 centers in the Netherlands and four centers in Belgium. Three hundred and forty-five patients had abdominal aortic aneurysms of at least 5 cm and were considered eligible for either open or endovascular repair. Patients were then randomized to undergo one procedure or the other.
Surgeons experienced in both endovascular and open repair performed the procedures. Primary outcomes were 30-day mortality (defined as death during the primary hospital admission or within 30 days), severe complications, and the combination of the two. The operative mortality rate was 4.6% in the open-repair group and 1.2% in the endovascular repair group, with a risk ratio of 3.9 (95% CI, 0.9-32.9). The combined endpoint of mortality and severe complication was 9.8% in the open-repair group and 4.7% in the endovascular repair group, with a risk ratio of 2.1 (95% CI, 0.9 to 5.4). It should be noted that 90% of study patients were men. These findings indicate that endovascular repair of aortic aneurysm results in less short-term morbidity and mortality than open repair. Larger studies with longer follow up are indicated.