Continued Use of Warfarin in Veterans with Atrial Fibrillation After Dementia Diagnosis

Ariela R. Orkaby; Al Ozonoff; Joel I. Reisman; Donald R. Miller; Shibei Zhao; Adam J. Rose

doi:10.1111/jgs.14573

Continued Use of Warfarin in Veterans with Atrial Fibrillation After Dementia Diagnosis

Ariela R. Orkaby^*, Al Ozonoff, Joel I. Reisman, Donald R. Miller, Shibei Zhao, Adam J. Rose

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

33 Scopus citations

Abstract

Objectives: To determine the effectiveness of warfarin in older adults with dementia. Design: Retrospective cohort study. Setting: Department of Veterans Affairs national healthcare system. Participants: Veterans aged 65 and older (73% aged ≥75, 99% male, 91% white) who had been receiving warfarin for nonvalvular atrial fibrillation for at least 6 months, were newly diagnosed with dementia in fiscal year 2007 or 2008, and were not enrolled in Medicare Advantage (n = 2,572). Measurements: The onset of dementia was defined according to International Classification of Diseases, Ninth Revision, code. Participants were followed for up to 4 years for persistence of warfarin therapy, anticoagulation control, major hemorrhage, ischemic stroke, and all-cause mortality. Results: The average CHADS2 score was 3.3 ± 1.3. After a diagnosis of dementia, 405 individuals (16%) persisted on warfarin therapy. Unadjusted Cox proportional hazards analysis demonstrated a protective effect of warfarin in prevention of ischemic stroke (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.46–0.89, P =.008), major bleeding (HR = 0.72, 95% CI = 0.55–0.94, P =.02), and all-cause mortality (HR = 0.66, 95% CI = 0.55–0.79, P <.001). Using propensity score matching, the protective effect of continuing warfarin persisted in prevention of stroke (HR = 0.74, 95% CI = 0.54–0.996, P =.047) and mortality (HR = 0.72, 95% CI = 0.60–0.87, P <.001), with no statistically significant decrease in risk of major bleeding (HR = 0.78, 95% CI = 0.61–1.01, P =.06). Conclusion: Discontinuing warfarin after a diagnosis of dementia is associated with a significant increase in stroke and mortality.

Original language	American English
Pages (from-to)	249-256
Number of pages	8
Journal	Journal of the American Geriatrics Society
Volume	65
Issue number	2
DOIs	https://doi.org/10.1111/jgs.14573
State	Published - 1 Feb 2017
Externally published	Yes

Bibliographical note

Funding Information:
This work is supported by VA Health Services Research and Development IIR 10–374 (PI: Rose). Dr. Orkaby is supported in part by a training grant from the American Federation for Aging Research, the John A. Hartford Foundation, and the Centers of Excellence National Program. Conflict of Interest: None. Author Contributions: Study concept and design: Orkaby, Ozonoff, Miller, Rose. Acquisition of data: Reisman. Analysis and interpretation of data: All authors. Drafted manuscript: Orkaby. Statistical supervision: Ozonoff. Obtained funding: Rose. Study supervision: Rose. Revision of manuscript for important intellectual content, final approval of manuscript: All authors. Sponsor's Role: The sponsor had no role in the study.

Publisher Copyright:
© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society

Keywords

atrial fibrillation
dementia
warfarin

Access to Document

10.1111/jgs.14573

Cite this

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title = "Continued Use of Warfarin in Veterans with Atrial Fibrillation After Dementia Diagnosis",

abstract = "Objectives: To determine the effectiveness of warfarin in older adults with dementia. Design: Retrospective cohort study. Setting: Department of Veterans Affairs national healthcare system. Participants: Veterans aged 65 and older (73% aged ≥75, 99% male, 91% white) who had been receiving warfarin for nonvalvular atrial fibrillation for at least 6 months, were newly diagnosed with dementia in fiscal year 2007 or 2008, and were not enrolled in Medicare Advantage (n = 2,572). Measurements: The onset of dementia was defined according to International Classification of Diseases, Ninth Revision, code. Participants were followed for up to 4 years for persistence of warfarin therapy, anticoagulation control, major hemorrhage, ischemic stroke, and all-cause mortality. Results: The average CHADS2 score was 3.3 ± 1.3. After a diagnosis of dementia, 405 individuals (16%) persisted on warfarin therapy. Unadjusted Cox proportional hazards analysis demonstrated a protective effect of warfarin in prevention of ischemic stroke (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.46–0.89, P =.008), major bleeding (HR = 0.72, 95% CI = 0.55–0.94, P =.02), and all-cause mortality (HR = 0.66, 95% CI = 0.55–0.79, P <.001). Using propensity score matching, the protective effect of continuing warfarin persisted in prevention of stroke (HR = 0.74, 95% CI = 0.54–0.996, P =.047) and mortality (HR = 0.72, 95% CI = 0.60–0.87, P <.001), with no statistically significant decrease in risk of major bleeding (HR = 0.78, 95% CI = 0.61–1.01, P =.06). Conclusion: Discontinuing warfarin after a diagnosis of dementia is associated with a significant increase in stroke and mortality.",

keywords = "atrial fibrillation, dementia, warfarin",

author = "Orkaby, {Ariela R.} and Al Ozonoff and Reisman, {Joel I.} and Miller, {Donald R.} and Shibei Zhao and Rose, {Adam J.}",

note = "Funding Information: This work is supported by VA Health Services Research and Development IIR 10–374 (PI: Rose). Dr. Orkaby is supported in part by a training grant from the American Federation for Aging Research, the John A. Hartford Foundation, and the Centers of Excellence National Program. Conflict of Interest: None. Author Contributions: Study concept and design: Orkaby, Ozonoff, Miller, Rose. Acquisition of data: Reisman. Analysis and interpretation of data: All authors. Drafted manuscript: Orkaby. Statistical supervision: Ozonoff. Obtained funding: Rose. Study supervision: Rose. Revision of manuscript for important intellectual content, final approval of manuscript: All authors. Sponsor's Role: The sponsor had no role in the study. Publisher Copyright: {\textcopyright} 2016, Copyright the Authors Journal compilation {\textcopyright} 2016, The American Geriatrics Society",

year = "2017",

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doi = "10.1111/jgs.14573",

language = "American English",

volume = "65",

pages = "249--256",

journal = "Journal of the American Geriatrics Society",

issn = "0002-8614",

publisher = "Wiley-Blackwell Publishing Ltd",

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T1 - Continued Use of Warfarin in Veterans with Atrial Fibrillation After Dementia Diagnosis

AU - Orkaby, Ariela R.

AU - Ozonoff, Al

AU - Reisman, Joel I.

AU - Miller, Donald R.

AU - Zhao, Shibei

AU - Rose, Adam J.

N1 - Funding Information: This work is supported by VA Health Services Research and Development IIR 10–374 (PI: Rose). Dr. Orkaby is supported in part by a training grant from the American Federation for Aging Research, the John A. Hartford Foundation, and the Centers of Excellence National Program. Conflict of Interest: None. Author Contributions: Study concept and design: Orkaby, Ozonoff, Miller, Rose. Acquisition of data: Reisman. Analysis and interpretation of data: All authors. Drafted manuscript: Orkaby. Statistical supervision: Ozonoff. Obtained funding: Rose. Study supervision: Rose. Revision of manuscript for important intellectual content, final approval of manuscript: All authors. Sponsor's Role: The sponsor had no role in the study. Publisher Copyright: © 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society

PY - 2017/2/1

Y1 - 2017/2/1

N2 - Objectives: To determine the effectiveness of warfarin in older adults with dementia. Design: Retrospective cohort study. Setting: Department of Veterans Affairs national healthcare system. Participants: Veterans aged 65 and older (73% aged ≥75, 99% male, 91% white) who had been receiving warfarin for nonvalvular atrial fibrillation for at least 6 months, were newly diagnosed with dementia in fiscal year 2007 or 2008, and were not enrolled in Medicare Advantage (n = 2,572). Measurements: The onset of dementia was defined according to International Classification of Diseases, Ninth Revision, code. Participants were followed for up to 4 years for persistence of warfarin therapy, anticoagulation control, major hemorrhage, ischemic stroke, and all-cause mortality. Results: The average CHADS2 score was 3.3 ± 1.3. After a diagnosis of dementia, 405 individuals (16%) persisted on warfarin therapy. Unadjusted Cox proportional hazards analysis demonstrated a protective effect of warfarin in prevention of ischemic stroke (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.46–0.89, P =.008), major bleeding (HR = 0.72, 95% CI = 0.55–0.94, P =.02), and all-cause mortality (HR = 0.66, 95% CI = 0.55–0.79, P <.001). Using propensity score matching, the protective effect of continuing warfarin persisted in prevention of stroke (HR = 0.74, 95% CI = 0.54–0.996, P =.047) and mortality (HR = 0.72, 95% CI = 0.60–0.87, P <.001), with no statistically significant decrease in risk of major bleeding (HR = 0.78, 95% CI = 0.61–1.01, P =.06). Conclusion: Discontinuing warfarin after a diagnosis of dementia is associated with a significant increase in stroke and mortality.

AB - Objectives: To determine the effectiveness of warfarin in older adults with dementia. Design: Retrospective cohort study. Setting: Department of Veterans Affairs national healthcare system. Participants: Veterans aged 65 and older (73% aged ≥75, 99% male, 91% white) who had been receiving warfarin for nonvalvular atrial fibrillation for at least 6 months, were newly diagnosed with dementia in fiscal year 2007 or 2008, and were not enrolled in Medicare Advantage (n = 2,572). Measurements: The onset of dementia was defined according to International Classification of Diseases, Ninth Revision, code. Participants were followed for up to 4 years for persistence of warfarin therapy, anticoagulation control, major hemorrhage, ischemic stroke, and all-cause mortality. Results: The average CHADS2 score was 3.3 ± 1.3. After a diagnosis of dementia, 405 individuals (16%) persisted on warfarin therapy. Unadjusted Cox proportional hazards analysis demonstrated a protective effect of warfarin in prevention of ischemic stroke (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.46–0.89, P =.008), major bleeding (HR = 0.72, 95% CI = 0.55–0.94, P =.02), and all-cause mortality (HR = 0.66, 95% CI = 0.55–0.79, P <.001). Using propensity score matching, the protective effect of continuing warfarin persisted in prevention of stroke (HR = 0.74, 95% CI = 0.54–0.996, P =.047) and mortality (HR = 0.72, 95% CI = 0.60–0.87, P <.001), with no statistically significant decrease in risk of major bleeding (HR = 0.78, 95% CI = 0.61–1.01, P =.06). Conclusion: Discontinuing warfarin after a diagnosis of dementia is associated with a significant increase in stroke and mortality.

KW - atrial fibrillation

KW - dementia

KW - warfarin

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JO - Journal of the American Geriatrics Society

JF - Journal of the American Geriatrics Society

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ER -

Continued Use of Warfarin in Veterans with Atrial Fibrillation After Dementia Diagnosis

Abstract

Bibliographical note

Keywords

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