The Unrecognized Psychosocial Factors Contributing to Bleeding Risk in Warfarin Therapy

Abstract

Background and Purpose-Warfarin is an effective drug for the prevention of thromboembolism in the elderly. The major risk for patients taking warfarin is bleeding. We aimed to assess the impact of psychosocial factors, including mood, cognition, social isolation, and health literacy on warfarin instability among community-based elderly patients. Methods-A case-control study was conducted between March 2008 and June 2009 in a community-based setting. Cases were patients previously stabilized on warfarin who recorded an international normalized ratio Ն6.0. Control subjects were patients whose international normalized ratio measurement was maintained within the therapeutic range. Patient interviews investigated potential predisposing factors to elevated International Normalized Ratio levels. Results-A total of 486 patients were interviewed: 157 cases and 329 control subjects, with an approximate mean age of 75 years. Atrial fibrillation was the most common primary indication. Adjusted multivariate logistic regression revealed impaired cognition (OR, 1.9; 95% CI, 1.0 to 3.6), depressed mood (OR, 2.2; 95% CI, 1.2 to 3.9), and inadequate health literacy (OR, 4.0;95% CI, 2.1 to 7.4) were associated with increased risk of an elevated International Normalized Ratio. Conclusions-This study identified impaired cognition, depressed mood, and inadequate health literacy as risk factors for warfarin instability. These had a similar impact to well-recognized demographic, clinical, and medication-related factors and are prevalent among the elderly. These findings suggest that elderly patients prescribed warfarin should be reviewed regularly for psychosocial deficits. (Stroke. 2011;42:2866-2871.)

The relationship between knowledge, health literacy, and adherence among patients taking oral anticoagulants for stroke thromboprophylaxis in atrial fibrillation

“…found that only approximately 50% could name their condition and perceived it as a serious condition that could predispose them to a stroke. Few studies have examined whether poor DOAC knowledge leads to poor clinical outcomes; however, this has been demonstrated in those taking warfarin . Our study reveals specific deficiencies in the knowledge of both warfarin and DOAC‐taking participants.…”

Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation?

“…It has already been demonstrated that anticoagulation under-prescribing is partially explained by the fact that general practitioners would feel personally responsible for an iatrogenic hemorrhagic complication, as opposed to a cardio-embolic complication in the absence of treatment 60. In the same way, it was not possible to evaluate patients’ compliance and psychosocial factors that could significantly influence the bleeding risk 61. We think qualitative and prospective work would help to understand reasons underlying anticoagulant underuse.…”

Rationale and design of the Atrial Fibrillation health Literacy Information Technology Trial: (AF-LITT)

“…[4] Limited health literacy has been associated with worse anticoagulation as measured by time in therapeutic range for warfarin, decreased understanding of stroke prevention, and symptom severity. [3,[5][6][7][8] Like other chronic diseases, individuals with limited health literacy may have further difficulty managing self-care, negotiating specialty clinics, adhering to treatments, and accessing resources. Such challenges may be worsened by social determinants of health related to health literacy, such as socioeconomic status and access to care.…”