Abstract
Background
Hospital admissions resulting from traumatic intracranial haemorrhages (TIH) in older people are increasing. There are concerns regarding an increased risk of a TIH in people taking oral anticoagulants (OAC) like phenprocoumon.
Aims
The aim of this study was to estimate the incremental risk of a TIH associated with OAC in older people. Furthermore, this study explored differences in risk according to functional status.
Methods
The study took data from a large German health insurance provider and combined hospital diagnoses with data regarding drug dispensing to estimate rates of a TIH in people with and without exposure to phenprocoumon. Analyses were stratified by sex and by severe functional impairment as disclosed by the long-term care insurance provider.
Results
Overall, exposure to OAC resulted in 2.7 times higher rates of TIH. People with severe functional impairment had a higher baseline risk of TIH than people without severe functional impairment. However, the incremental risk in those exposed to OAC was similar among people with and without severe functional impairment (standardised incidence rate difference 15.73 (95% CI 7.84; 23.61) and 12.10 (95% CI 9.63; 14.57) per 10,000 person-years, respectively).
Conclusions
OAC increases the risk of TIH considerably. The incremental risk of TIH in those exposed to OAC is comparable between people with and without severe functional impairment. The presence of severe functional impairment per se should not exclude such patients from the potential benefits of OAC. For now, the prescription should be personalized based on individual fall risk factors and risk-taking behaviour.
Similar content being viewed by others
References
DiMarco JP, Flaker G, Waldo AL et al (2005) Factors affecting bleeding risk during anticoagulant therapy in patients with atrial fibrillation: observations from the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Study. Am Heart J 149:650–656. https://doi.org/10.1016/j.ahj.2004.11.015
Torn M, Bollen WLEM, van der Meer FJM et al (2005) Risks of oral anticoagulant therapy with increasing age. Arch Intern Med 165:1527. https://doi.org/10.1001/archinte.165.13.1527
Budnitz DS, Lovegrove MC, Shehab N et al (2011) Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med 365:2002–2012. https://doi.org/10.1056/NEJMsa1103053
Scowcroft ACE, Lee S, Mant J (2013) Thromboprophylaxis of elderly patients with AF in the UK: an analysis using the General Practice Research Database (GPRD) 2000–2009. Heart 99:127–132. https://doi.org/10.1136/heartjnl-2012-302843
Ogilvie IM, Newton N, Welner SA et al (2010) Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 123:638–645.e4. https://doi.org/10.1016/j.amjmed.2009.11.025
Devereaux PJ, Anderson DR, Gardner MJ et al (2001) Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study commentary: varied preferences reflect the reality of clinical practice. BMJ 323:1218. https://doi.org/10.1136/bmj.323.7323.1218
Gattellari M, Worthington J, Zwar N et al (2008) Barriers to the use of anticoagulation for nonvalvular atrial fibrillation: a representative survey of australian family physicians. Stroke 39:227–230. https://doi.org/10.1161/STROKEAHA.107.495036
Brazinova A, Mauritz W, Majdan M et al (2014) Fatal traumatic brain injury in older adults in Austria 1980–2012: an analysis of 33 years. Age Ageing. https://doi.org/10.1093/ageing/afu194
Harvey LA, Close JCT (2012) Traumatic brain injury in older adults: characteristics, causes and consequences. Injury 43:1821–1826. https://doi.org/10.1016/j.injury.2012.07.188
Bond AJ, Molnar FJ, Li M et al (2005) The risk of hemorrhagic complications in hospital in-patients who fall while receiving antithrombotic therapy. Thromb J 3:1. https://doi.org/10.1186/1477-9560-3-1
Dossett LA (2011) Prevalence and implications of preinjury warfarin use: an analysis of the national trauma databank. Arch Surg 146:565. https://doi.org/10.1001/archsurg.2010.313
Howard JL, Cipolle MD, Horvat SA et al (2009) Preinjury Warfarin Worsens outcome in elderly patients who fall from standing. J Trauma Inj Infect Crit Care 66:1518–1524. https://doi.org/10.1097/TA.0b013e3181a59728
Robinovitch SN, Feldman F, Yang Y et al (2013) Video capture of the circumstances of falls in elderly people residing in long-term care: an observational study. Lancet 381:47–54. https://doi.org/10.1016/S0140-6736(12)61263-X
Büchele G, Rapp K, König H-H et al (2016) The risk of hospital admission due to traumatic brain injury is increased in older persons with severe functional limitations. J Am Med Dir Assoc 17:609–612. https://doi.org/10.1016/j.jamda.2016.02.032
Korhonen N, Niemi S, Parkkari J et al (2013) Incidence of fall-related traumatic brain injuries among older Finnish adults between 1970 and 2011. JAMA 309:1891–1892. https://doi.org/10.1001/jama.2013.3356
Kannus P, Niemi S, Parkkari J et al (2007) Alarming rise in fall-induced severe head injuries among elderly people. Injury 38:81–83. https://doi.org/10.1016/j.injury.2006.08.027
Hartholt KA, Van Lieshout EMM, Polinder S et al (2011) Rapid increase in hospitalizations resulting from fall-related traumatic head injury in older adults in The Netherlands 1986–2008. J Neurotrauma 28:739–744. https://doi.org/10.1089/neu.2010.1488
Pilote L, Eisenberg MJ, Essebag V et al (2013) Temporal trends in medication use and outcomes in atrial fibrillation. Can J Cardiol 29:1241–1248. https://doi.org/10.1016/j.cjca.2012.09.021
Staerk L, Fosbøl EL, Gadsbøll K et al (2016) Non-vitamin K antagonist oral anticoagulation usage according to age among patients with atrial fibrillation: temporal trends 2011–2015 in Denmark. Sci Rep 6:31477. https://doi.org/10.1038/srep31477
Weitz JI, Semchuk W, Turpie AGG et al (2015) Trends in prescribing oral anticoagulants in Canada, 2008–2014. Clin Ther 37:2506–2514.e4. https://doi.org/10.1016/j.clinthera.2015.09.008
WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index
Russmann S, Gohlke-Bärwolf C, Jähnchen E et al (1997) Age-dependent differences in the anticoagulant effect of phenprocoumon in patients after heart valve surgery. Eur J Clin Pharmacol 52:31–35. https://doi.org/10.1007/s002280050245
Huber CA, Szucs TD, Rapold R et al (2013) Identifying patients with chronic conditions using pharmacy data in Switzerland: an updated mapping approach to the classification of medications. BMC Public Health. https://doi.org/10.1186/1471-2458-13-1030
Collins CE, Witkowski ER, Flahive JM et al (2014) Effect of preinjury warfarin use on outcomes after head trauma in Medicare beneficiaries. Am J Surg 208:544–549.e1. https://doi.org/10.1016/j.amjsurg.2014.05.019
Gaist D, García Rodríguez LA, Hellfritzsch M et al (2017) Association of antithrombotic drug use with subdural hematoma risk. JAMA 317:836. https://doi.org/10.1001/jama.2017.0639
Poli D, Antonucci E, Testa S et al (2011) Bleeding risk in very old patients on vitamin K antagonist treatment: results of a prospective collaborative study on elderly patients followed by Italian Centres for Anticoagulation. Circulation 124:824–829. https://doi.org/10.1161/CIRCULATIONAHA.110.007864
Gage BF, Birman-Deych E, Kerzner R et al (2005) Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall. Am J Med 118:612–617. https://doi.org/10.1016/j.amjmed.2005.02.022
Fang MC, Go AS, Chang Y et al (2010) Warfarin discontinuation after starting warfarin for atrial fibrillation. Circ Cardiovasc Qual Outcomes 3:624–631. https://doi.org/10.1161/CIRCOUTCOMES.110.937680
Rapp K, Becker C, Cameron ID et al (2012) Femoral fracture rates in people with and without disability. Age Ageing 41:653–658. https://doi.org/10.1093/ageing/afs044
Benzinger P, Becker C, Kerse N et al (2013) Pelvic fracture rates in community-living people with and without disability and in residents of nursing homes. J Am Med Dir Assoc 1:4. https://doi.org/10.1016/j.jamda.2013.03.012
Man-Son-Hing M, Nichol G, Lau A et al (1999) Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med 159:677. https://doi.org/10.1001/archinte.159.7.677
FARSEEING Consortium and the FARSEEING Meta-Database Consensus Group, Klenk J, Chiari L et al (2013) Development of a standard fall data format for signals from body-worn sensors: the FARSEEING consensus. Z Für Gerontol Geriatr 46:720–726. https://doi.org/10.1007/s00391-013-0554-0
López-López JA, Sterne JAC, Thom HHZ et al (2017) Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ. https://doi.org/10.1136/bmj.j5058
Bai Y, Guo S-D, Deng H et al (2018) Effectiveness and safety of oral anticoagulants in older patients with atrial fibrillation: a systematic review and meta-regression analysis. Age Ageing 47:9–17. https://doi.org/10.1093/ageing/afx103
Acknowledgements
We would like to thank Marianna Hanke-Ebersoll from the Allgemeine Ortskrankenkasse (AOK) for her support of our analyses.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
The study was approved by the Ethics Committee of Ulm University.
Statement of human and animal rights
Conduction of the study was in accordance with the ethical standards of the institutional ethical committee and with the 1964 Helsinki declaration and its later amendments. This article does not contain any studies animals performed by any of the authors.
Informed consent
No informed consent was obtained.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Büchele, G., Rapp, K., Bauer, J. et al. Risk of traumatic intracranial haemorrhage is increased in older people exposed to oral anticoagulation with phenprocoumon. Aging Clin Exp Res 32, 441–447 (2020). https://doi.org/10.1007/s40520-019-01215-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40520-019-01215-5