http://www.biomedcentral.com/bmcgeriatr/ The editor's pick of recent articles published by BMC Geriatrics 2012-04-05T00:00:00Z Background: The use of warfarin in older patients requires special consideration because of concerns with comorbidities, interacting medications, and the risk of bleeding. Several studies have suggested that warfarin may be underused or inconsistently prescribed in long-term care (LTC); no published systematic review has evaluated warfarin use for stroke prevention in this setting. This review was conducted to summarize the body of published original research regarding the use of warfarin in the LTC population. Methods: A systematic literature search of the PubMed, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library was conducted from January 1985 to August 2010 to identify studies that reported warfarin use in LTC. Studies were grouped by (1) rates of warfarin use and prescribing patterns, (2) association of resident and institutional characteristics with warfarin prescribing, (3) prescriber attitudes and concerns about warfarin use, (4) warfarin management and monitoring, and (5) warfarin-related adverse events. Summaries of study findings and quality assessments of each study were developed. Results: Twenty-two studies met the inclusion criteria for this review. Atrial fibrillation (AF) was the most common indication for warfarin use in LTC and use of warfarin for stroke survivors was common. Rates of warfarin use in AF were low in 5 studies, ranging from 17% to 57%. These usage rates were low even among residents with high stroke risk and low bleeding risk. Scored bleeding risk had no apparent association with warfarin use in AF. In physician surveys, factors associated with not prescribing warfarin included risk of falls, dementia, short life expectancy, and history of bleeding. International normalized ratio was in the target range approximately half of the time. The combined overall rate of warfarin-related adverse events and potential events was 25.5 per 100 resident months on warfarin therapy. Conclusions: Among residents with AF, use of warfarin and maintenance of INR levels to prevent stroke appear to be suboptimal. Among prescribers, perceived challenges associated with warfarin therapy often outweigh its benefits. Further research is needed to explicitly consider the appropriate balancing of risks and benefits in this frail patient population. http://www.biomedcentral.com/1471-2318/12/14 Marjorie Neidecker Aarti A Patel Winnie W Nelson Gregory Reardon BMC Geriatrics 2012, 12:14 2012-04-05T00:00:00Z 10.1186/1471-2318-12-14 Warfarin is under-prescribed among the elderly Warfarin use in long-term care patients at risk for stroke is low, despite the presence of risk factors such as atrial fibrillation, suggesting that physicians believe the risks outweigh the benefits in this population. /content/figures/1471-2318-12-14-toc.gif BMC Geriatrics 1471-2318 12 14 2012-04-05T00:00:00Z XML Background: This study sought to determine whether early allied health intervention by a dedicated Emergency Department (ED) based team, occurring before or in parallel with medical assessment, reduces hospital admission rates amongst older patients presenting with one of ten index problems. Methods: A prospective non-randomized trial in patients aged sixty five and over, conducted in two Australian hospital EDs. Intervention group patients, receiving early comprehensive allied health input, were compared to patients that received no allied health assessment. Propensity score matching was used to compare the two groups due to the non-randomized nature of the study. The primary outcome was admission to an inpatient hospital bed from the ED. Results: Of five thousand two hundred and sixty five patients in the trial, 3165 were in the intervention group. The admission rate in the intervention group was 72.0% compared to 74.4% in the control group. Using propensity score probabilities of being assigned to either group in a conditional logistic regression model, this difference was of borderline statistical significance (p = 0.046, OR 0.88 (0.76-1.00)). On subgroup analysis the admission rate in patients with musculoskeletal symptoms and angina pectoris was less for those who received allied health intervention versus those who did not. This difference was significant. Conclusions: Early allied health intervention in the ED has a significant but modest impact on admission rates in older patients. The effect appears to be limited to a small number of common presenting problems. http://www.biomedcentral.com/1471-2318/12/8 Glenn Arendts Sarah Fitzhardinge Karren Pronk Mark Donaldson Marani Hutton Yusuf Nagree BMC Geriatrics 2012, 12:8 2012-03-20T00:00:00Z 10.1186/1471-2318-12-8 Allied health assessment reduces admission rates Early assessment by an allied health team in the Emergency department reduces the rate of geriatric patients admitted to an inpatient hospital bed for common problems, specifically musculoskeletal symptoms and angina pectoris. /content/figures/1471-2318-12-8-toc.gif BMC Geriatrics 1471-2318 12 8 2012-03-20T00:00:00Z XML Background: Differentiating amnestic mild cognitive impairment (aMCI) from normal cognition is difficult in clinical settings. Self-reported and informant-reported memory complaints occur often in both clinical groups, which then necessitates the use of a comprehensive neuropsychological examination to make a differential diagnosis. However, the ability to identify cognitive symptoms that are predictive of aMCI through informant-based information may provide some clinical utility in accurately identifying individuals who are at risk for developing Alzheimer's disease (AD). Methods: The current study utilized a case-control design using data from an ongoing validation study of the Alzheimer's Questionnaire (AQ), an informant-based dementia assessment. Data from 51 cognitively normal (CN) individuals participating in a brain donation program and 47 aMCI individuals seen in a neurology practice at the same institute were analyzed to determine which AQ items differentiated aMCI from CN individuals. Results: Forward stepwise multiple logistic regression analysis which controlled for age and education showed that 4 AQ items were strong indicators of aMCI which included: repetition of statements and/or questions [OR 13.20 (3.02, 57.66)]; trouble knowing the day, date, month, year, and time [OR 17.97 (2.63, 122.77)]; difficulty managing finances [OR 11.60 (2.10, 63.99)]; and decreased sense of direction [OR 5.84 (1.09, 31.30)]. Conclusions: Overall, these data indicate that certain informant-reported cognitive symptoms may help clinicians differentiate individuals with aMCI from those with normal cognition. Items pertaining to repetition of statements, orientation, ability to manage finances, and visuospatial disorientation had high discriminatory power. http://www.biomedcentral.com/1471-2318/12/3 Michael Malek-Ahmadi Kathryn Davis Christine M Belden Sandra Jacobson Marwan N Sabbagh BMC Geriatrics 2012, 12:3 2012-02-03T00:00:00Z 10.1186/1471-2318-12-3 Detecting those at risk of Alzheimers Specific questions in an informant-rated questionnaire designed to detect Alzheimers Disease are also able to discriminate between normal memory loss and amnesic mild cognitive impairment, allowing earlier identification of those at higher risk of developing Alzheimers Disease. /content/figures/1471-2318-12-3-toc.gif BMC Geriatrics 1471-2318 12 3 2012-02-03T00:00:00Z XML