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Drug Res (Stuttg) 2015; 65(10): 505-514
DOI: 10.1055/s-0034-1389984
Review
© Georg Thieme Verlag KG Stuttgart · New York

Optimal Stroke Prevention in the Geriatric Patient with Atrial Fibrillation: Position Paper of an Interdisciplinary Expert Panel

P. Bahrmann
1   Institute for Biomedicine of Aging, Friedrich-Alexander-University, Nuremberg, Germany
,
M. Wehling
2   Institute of Experimental and Clinical Pharmacology and Toxicology, Clinical Pharmacology Mannheim, Medical Faculty Mannheim, Ruprecht-Karls-University of Heidelberg, Mannheim, Germany
,
D. Ropers
3   Department of Internal Medicine 2 (Cardiology), University of Erlangen, Germany
,
J. Flohr
4   General Medicine Practice, Leipzig, Germany
,
A. Leischker
5   Alexianer Krefeld Clinic for General Internal and Geriatric Medicine GmbH, Krefeld, Germany
,
J. Röther
6   Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
› Author Affiliations
Further Information

Publication History

received 03 June 2014

accepted 03 September 2014

Publication Date:
06 October 2014 (online)

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Abstract

The present position paper summarises the outcomes of an expert panel discussion held by hospital-based and office-based physicians with ample experience in the treatment of geriatric patients. The optimal approach to stroke prevention in geriatric patients with atrial fibrillation (AF) has not been adequately clarified. Despite their high risk of stroke and clear indication for anticoagulation according to established risk scores, in practice geriatric AF patients often are withheld treatment because of comorbidities and comedications, concerns about low treatment adherence or fear of bleeding events, in particular due to falls. The panel agreed that geriatric patients should receive oral anticoagulation as a rule, unless a comprehensive neurological and geriatric assessment (including clinical examination, gait tests and validated instruments such as Modified Rankin Scale, Mini-mental state examination or Timed Test of Money Counting) provides sound reasons for refraining from treatment. All patients with a history of falls should be thoroughly evaluated for further evaluation of the causes. Patients with CHADS2 score ≥ 2 should receive anticoagulation even if at high risk for falls. The novel oral anticoagulants (NOAC) facilitate management in the geriatric population with AF (no INR monitoring needed, easier bridging during interventions) and have, based on available data, an improved benefit-risk ratio compared to vitamin K antagonists. Drugs with predominantly non-renal elimination are safer in geriatric patients and should be preferred.

Key words

older patients - geriatrics - assessment - adherence - atrial fibrillation - stroke - prevention - interdisciplinary management - atrial fibrillation - anticoagulation - novel anticoagulants
 

  • References

  • 1 Camm AJ, Kirchhof P, Lip GY et al. Guidelines for the management of atrial fibrillation: The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31: 2369-2429
    CrossrefPubMedGoogle Scholar
  • 2 Heeringa J, van der Kuip DA, Hofman A et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006; 27: 949-953
    CrossrefPubMedGoogle Scholar
  • 3 Rabunal-Rey R, Monte-Secades R, Gomez-Gigirey A et al. Electrocardiographic abnormalities in centenarians: impact on survival. BMC Geriatr 2012; 12: 15
    CrossrefPubMedGoogle Scholar
  • 4 Ohlmeier C, Mikolajczyk R, Haverkamp W et al. Incidence, prevalence, and antithrombotic management of atrial fibrillation in elderly Germans. Europace 2013; 15: 1436-1444
    CrossrefPubMedGoogle Scholar
  • 5 Wann LS, Curtis AB, January CT et al. ACCF/AHA/HRS focused update on the management of patients with atrial fibrillation (Updating the 2006 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 57: 223-242
    CrossrefPubMedGoogle Scholar
  • 6 Camm A, Lip G, Atar D et al. 2012 Focused Update of the ESC Guidelines on the Management of Atrial Fibrillation. Eur Heart J 2012; 33: 2719-2747
    CrossrefPubMedGoogle Scholar
  • 7 Deutsche Gesellschaft für Geriatrie. Der geriatrische Patient (Definition). Internet http://www.dggeriatrie.de/ Accessed on 1 June 2014
    PubMedGoogle Scholar
  • 8 Savelieva I, Bajpai A, Camm AJ. Stroke in atrial fibrillation: update on pathophysiology, new antithrombotic therapies, and evolution of procedures and devices. Ann Med 2007; 39: 371-391
    CrossrefPubMedGoogle Scholar
  • 9 Goto S, Bhatt DL, Rother J et al. Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis. Am Heart J 2008; 156: 855-863 63 e2
    CrossrefPubMedGoogle Scholar
  • 10 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22: 983-988
    CrossrefPubMedGoogle Scholar
  • 11 Marini C, De Santis F, Sacco S et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke 2005; 36: 1115-1119
    CrossrefPubMedGoogle Scholar
  • 12 Lin HJ, Wolf PA, Kelly-Hayes M et al. Stroke severity in atrial fibrillation. The Framingham Study. Stroke 1996; 27: 1760-1764
    CrossrefPubMedGoogle Scholar
  • 13 Steger C, Pratter A, Martinek-Bregel M et al. Stroke patients with atrial fibrillation have a worse prognosis than patients without: data from the Austrian Stroke registry. Eur Heart J 2004; 25: 1734-1740
    CrossrefPubMedGoogle Scholar
  • 14 Singer DE, Chang Y, Fang MC et al. The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Ann Intern Med 2009; 151: 297-305
    CrossrefPubMedGoogle Scholar
  • 15 Mant J, Hobbs FD, Fletcher K et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007; 370: 493-503
    CrossrefPubMedGoogle Scholar
  • 16 Haeusler KG, Konieczny M, Endres M et al. Impact of anticoagulation before stroke on stroke severity and long-term survival. Int J Stroke 2012; 7: 544-550
    CrossrefPubMedGoogle Scholar
  • 17 Connolly SJ, Ezekowitz MD, Yusuf S et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2009; 361: 1139-1151
    CrossrefPubMedGoogle Scholar
  • 18 Patel MR, Mahaffey KW, Garg J et al. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. N Engl J Med 2011; 365: 883-891
    CrossrefPubMedGoogle Scholar
  • 19 Ntaios G, Papavasileiou V, Diener HC et al. Nonvitamin-K-antagonist oral anticoagulants in patients with atrial fibrillation and previous stroke or transient ischemic attack: a systematic review and meta-analysis of randomized controlled trials. Stroke 2012; 43: 3298-3304
    CrossrefPubMedGoogle Scholar
  • 20 Lopes RD, Crowley MJ, Shah BR et al. Stroke Prevention in Atrial Fibrillation. Agency for Healthcare Research and Quality (US); August 2013. Report No.: 13-EHC113-EF. AHRQ Comparative Effectiveness Reviews. Accessed on 1 June 2014
    PubMedGoogle Scholar
  • 21 O’Dell KM, Igawa D, Hsin J. New oral anticoagulants for atrial fibrillation: a review of clinical trials. Clin Ther 2012; 34: 894-901
    CrossrefPubMedGoogle Scholar
  • 22 Schneeweiss S, Gagne JJ, Patrick AR et al. Comparative efficacy and safety of new oral anticoagulants in patients with atrial fibrillation. Circ Cardiovasc Qual Outcomes 2012; 5: 480-486
    CrossrefPubMedGoogle Scholar
  • 23 Shibazaki K, Kimura K, Aoki J et al. Early initiation of new oral anticoagulants in acute stroke and TIA patients with nonvalvular atrial fibrillation. J Neurol Sci 2013; 331: 90-93
    CrossrefPubMedGoogle Scholar
  • 24 Ten Cate H. New oral anticoagulants: discussion on monitoring and adherence should start now!. Thromb J 2013; 11: 8
    CrossrefPubMedGoogle Scholar
  • 25 Endres M, Diener H, Röther J. Sekundärprophylaxe des ischämischern Insults. In: Diener HC. et al. Hrsg Leitlinien für Diagnostik und Therapie in der Neurologie. 5. Auflage Stuttgart: Thieme; 2012: 324-347
    Article in Thieme ConnectGoogle Scholar
  • 26 Diener H-C, Eikelboom J, Connolly SJ et al. Apixaban versus aspirin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a predefined subgroup analysis from AVERROES, a randomised trial. 101016/S1474-4422(08)70087-5 2012; 11: 225-231
    PubMedGoogle Scholar
  • 27 Connolly SJ, Eikelboom J, Joyner C et al. Apixaban in patients with atrial fibrillation. N Engl J Med 2011; 364: 806-817
    CrossrefPubMedGoogle Scholar
  • 28 Conroy SP, Ansari K, Williams M et al. A controlled evaluation of comprehensive geriatric assessment in the emergency department: the ‘Emergency Frailty Unit’. Age Ageing 2013; Epub ahead of print 23 July) 43: 109-114
    PubMedGoogle Scholar
  • 29 Ramjaun A, Nassif MO, Krotneva S et al. Improved targeting of cancer care for older patients: A systematic review of the utility of comprehensive geriatric assessment. J Geriatr Oncol 2013; 4: 271-281
    CrossrefPubMedGoogle Scholar
  • 30 Grassel E. Use of psychopathometric procedures in diagnosis of dementia exemplified by a comparison between the Mini-Mental State and the MWT/KAI (Multiple-Choice Vocabulary/General Intelligence Test Short-Form) test system. Z Gerontol 1993; 26: 268-274
    PubMedGoogle Scholar
  • 31 Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc 1992; 40: 922-935
    CrossrefPubMedGoogle Scholar
  • 32 Mainlan BJ, Amodeo S, Shulman KI. Multiple clock drawing scoring systems: simpler is better. Int J Geriatr Psychiatry 2013;
    PubMedGoogle Scholar
  • 33 Shulman KI. Clock-drawing: is it the ideal cognitive screening test?. Int J Geriatr Psychiatry 2000; 15: 548-561
    CrossrefPubMedGoogle Scholar
  • 34 Kessler J, Calabrese P, Kalbe E et al. DemTect. Ein neues Screening-Verfahren zur Unterstützung der Demenzdiagnostik. Psychol Addict Behav 2000; 6: 343-347
    PubMedGoogle Scholar
  • 35 Nikolaus T, Bach M, Specht-Leible N et al. The Timed Test of Money Counting: a short physical performance test for manual dexterity and cognitive capacity. Age Ageing 1995; 24: 257-258
    CrossrefPubMedGoogle Scholar
  • 36 Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39: 142-148
    CrossrefPubMedGoogle Scholar
  • 37 Kassenärztliche Bundesvereinigung (KVB) Hausarzt-EBM. Internet http://www.kbv.de/43707.html Accessed on 1 July 2014
    PubMed
  • 38 GeriNet Leipzig e.V. Aims and description of the network. Internet http://gerinet-leipzig.de/ Accessed on 15 Nov 2013
    PubMedGoogle Scholar
  • 39 Kirchhof P, Nabauer M, Gerth A et al. Impact of the type of centre on management of AF patients: surprising evidence for differences in antithrombotic therapy decisions. Thromb Haemost 2011; 105: 1010-1023
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Spyropoulos AC, Bauersachs RM, Omran H et al. Periprocedural bridging therapy in patients receiving chronic oral anticoagulation therapy. Curr Med Res Opin 2006; 22: 1109-1122
    CrossrefPubMedGoogle Scholar
  • 41 Hammerstingl C, Schmitz A, Fimmers R et al. Bridging of chronic oral anticoagulation with enoxaparin in patients with atrial fibrillation: results from the prospective BRAVE registry. Cardiovasc Ther 2009; 27: 230-238
    CrossrefPubMedGoogle Scholar
  • 42 Kansal AR, Zheng Y, Pokora T et al. Cost-effectiveness of new oral anticoagulants in the prevention of stroke in patients with atrial fibrillation. Best Pract Res Clin Haematol 2013; 26: 225-237
    CrossrefPubMedGoogle Scholar
  • 43 Coyle D, Coyle K, Cameron C et al. Cost-effectiveness of new oral anticoagulants compared with warfarin in preventing stroke and other cardiovascular events in patients with atrial fibrillation. Value Health 2013; 16: 498-506
    CrossrefPubMedGoogle Scholar
  • 44 Srivastava A, Hudson M, Hamoud I et al. Examining warfarin underutilization rates in patients with atrial fibrillation: Detailed chart review essential to capture contraindications to warfarin therapy. Thromb J 2008; 6: 6
    CrossrefPubMedGoogle Scholar
  • 45 Wittkowsky AK, Spinler SA, Dager W et al. Dosing guidelines, not protocols, for managing warfarin therapy. Am J Health Syst Pharm 2010; 67: 1554-1556
    CrossrefPubMedGoogle Scholar
  • 46 Coresh J, Selvin E, Stevens LA et al. Prevalence of chronic kidney disease in the United States. JAMA 2007; 298: 2038-2047
    CrossrefPubMedGoogle Scholar
  • 47 Hohnloser SH, Hijazi Z, Thomas L et al. Efficacy of apixaban when compared with warfarin in relation to renal function in patients with atrial fibrillation: insights from the ARISTOTLE trial. Eur Heart J 2012; 33: 2821-2830
    CrossrefPubMedGoogle Scholar
  • 48 Chalmers JT. F Blood pressure lowering in patients with a previous stroke. In: Mohler ER, Townsend R. (eds.) Advanced Therapy in Hypertension and Vascular Disease. 1st edition Hamilton, Ontario, Canada: B.C. Decker; 2006: 130-135
    Google Scholar
  • 49 Townsend RR. Stroke in Chronic Kidney Disease: Prevention and Management. Clinical Journal of the American Society of Nephrology 2008; 3: S11-S16
    CrossrefPubMedGoogle Scholar
  • 50 Wehling M. Morbus diureticus in the elderly: epidemic overuse of a widely applied group of drugs. J Am Med Dir Assoc 2013; 14: 437-442
    CrossrefPubMedGoogle Scholar
  • 51 Coca SG. Acute kidney injury in elderly persons. Am J Kidney Dis 2010; 56: 122-131
    CrossrefPubMedGoogle Scholar
  • 52 Chronopoulos A, Rosner MH, Cruz DN et al. Acute kidney injury in elderly intensive care patients: a review. Intensive Care Med 2010; 36: 1454-1464
    CrossrefPubMedGoogle Scholar
  • 53 Shireman TI, Mahnken JD, Howard PA et al. Development of a contemporary bleeding risk model for elderly warfarin recipients. Chest 2006; 130: 1390-1396
    CrossrefPubMedGoogle Scholar
  • 54 Behr S, Andersohn F, Garbe E. Risk of intracerebral hemorrhage associated with phenprocoumon exposure: a nested case-control study in a large population-based German database. Pharmacoepidemiol Drug Saf 2010; 19: 722-730
    CrossrefPubMedGoogle Scholar
  • 55 Samama CM. New anticoagulants: pharmacology and clinical studies. Wien Med Wochenschr 2011; 161: 54-57
    CrossrefPubMedGoogle Scholar
  • 56 Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007; 146: 857-867
    CrossrefPubMedGoogle Scholar
  • 57 Ogilvie IM, Newton N, Welner SA et al. Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 2010; 123: 638-645
    CrossrefPubMedGoogle Scholar
  • 58 Nabauer M, Gerth A, Limbourg T et al. The Registry of the German Competence NETwork on Atrial Fibrillation: patient characteristics and initial management. Europace 2009; 11: 423-434
    CrossrefPubMedGoogle Scholar
  • 59 Gladstone DJ, Bui E, Fang J et al. Potentially preventable strokes in high-risk patients with atrial fibrillation who are not adequately anticoagulated. Stroke 2009; 40: 235-240
    CrossrefPubMedGoogle Scholar
  • 60 Hylek EM, D’Antonio J, Evans-Molina C et al. Translating the results of randomized trials into clinical practice: the challenge of warfarin candidacy among hospitalized elderly patients with atrial fibrillation. Stroke 2006; 37: 1075-1080
    CrossrefPubMedGoogle Scholar
  • 61 Wallentin L, Yusuf S, Ezekowitz MD et al. Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial. Lancet 2010; 376: 975-983
    CrossrefPubMedGoogle Scholar
  • 62 Gallagher AM, Rietbrock S, Plumb J et al. Initiation and persistence of warfarin or aspirin in patients with chronic atrial fibrillation in general practice: do the appropriate patients receive stroke prophylaxis?. J Thromb Haemost 2008; 6: 1500-1506
    CrossrefPubMedGoogle Scholar
  • 63 Connolly SJ, Ezekowitz MD, Yusuf S et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-1151
    CrossrefPubMedGoogle Scholar
  • 64 Granger CB, Alexander JH, McMurray JJV et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2011; 365: 981-992
    CrossrefPubMedGoogle Scholar
  • 65 Torn M, Bollen WL, van der Meer FJ et al. Risks of oral anticoagulant therapy with increasing age. Arch Intern Med 2005; 165: 1527-1532
    CrossrefPubMedGoogle Scholar
  • 66 Friberg L, Rosenqvist M, Lip GY. Net clinical benefit of warfarin in patients with atrial fibrillation: a report from the Swedish atrial fibrillation cohort study. Circulation 2012; 125: 2298-2307
    CrossrefPubMedGoogle Scholar
  • 67 Barco S, Cheung YW, Eikelboom JW et al. New oral anticoagulants in elderly patients. Best Pract Res Clin Haematol 2013; 26: 215-224
    CrossrefPubMedGoogle Scholar
  • 68 Ruiz-Nodar JM, Marin F, Hurtado JA et al. Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implications for bleeding risk and prognosis. J Am Coll Cardiol 2008; 51: 818-825
    CrossrefPubMedGoogle Scholar
  • 69 DeEugenio D, Kolman L, DeCaro M et al. Risk of major bleeding with concomitant dual antiplatelet therapy after percutaneous coronary intervention in patients receiving long-term warfarin therapy. Pharmacotherapy 2007; 27: 691-696
    CrossrefPubMedGoogle Scholar
  • 70 Hamm CW, Bassand JP, Agewall S et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32: 2999-3054
    CrossrefPubMedGoogle Scholar
  • 71 Oldgren J, Wallentin L, Alexander JH et al. New oral anticoagulants in addition to single or dual antiplatelet therapy after an acute coronary syndrome: a systematic review and meta-analysis. Eur Heart J 2013; 34: 1670-1680
    CrossrefPubMedGoogle Scholar
  • 72 Dans AL, Connolly SJ, Wallentin L et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Circulation 2013; 127: 634-640
    CrossrefPubMedGoogle Scholar
  • 73 Dewilde WJ, Oirbans T, Verheugt FW et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013; 381: 1107-1115
    CrossrefPubMedGoogle Scholar
  • 74 El-Khoury F, Cassou B, Charles MA et al. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ 2013; 347: f6234
    CrossrefPubMedGoogle Scholar
  • 75 Poli D, Antonucci E, Testa S et al. 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 2011; 124: 824-829
    CrossrefPubMedGoogle Scholar
  • 76 Donze J, Clair C, Hug B et al. Risk of falls and major bleeds in patients on oral anticoagulation therapy. Am J Med 2012; 125: 773-778
    CrossrefPubMedGoogle Scholar
  • 77 Gage BF, Birman-Deych E, Kerzner R et al. Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall. Am J Med 2005; 118: 612-617
    CrossrefPubMedGoogle Scholar
  • 78 Man-Son-Hing M, Laupacis A. Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians' fears often unfounded. Arch Intern Med 2003; 163: 1580-1586
    CrossrefPubMedGoogle Scholar
  • 79 Man-Son-Hing M, Nichol G, Lau A et al. Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Arch Intern Med 1999; 159: 677-685
    CrossrefPubMedGoogle Scholar
  • 80 Sellers MB, Newby LK. Atrial fibrillation, anticoagulation, fall risk, and outcomes in elderly patients. Am Heart J 2011; 161: 241-246
    CrossrefPubMedGoogle Scholar
  • 81 Inamasu J, Nakatsukasa M, Miyatake S et al. Influence of warfarin and low-dose aspirin on the outcomes of geriatric patients with traumatic intracranial hemorrhage resulting from ground-level fall. Geriatr Gerontol Int 2012; 12: 667-672
    CrossrefPubMedGoogle Scholar
  • 82 Banerjee A, Lane DA, Torp-Pedersen C et al. Net clinical benefit of new oral anticoagulants (dabigatran, rivaroxaban, apixaban) versus no treatment in a ‘real world’ atrial fibrillation population: a modelling analysis based on a nationwide cohort study. Thromb Haemost 2012; 107: 584-589
    PubMedGoogle Scholar
  • 83 Steiner T, Bohm M, Dichgans M et al. Recommendations for the emergency management of complications associated with the new direct oral anticoagulants (DOACs), apixaban, dabigatran and rivaroxaban. Clin Res Cardiol 2013; 102: 399-412
    CrossrefPubMedGoogle Scholar
  • 84 Diener HC, Foerch C, Riess H et al. Treatment of acute ischaemic stroke with thrombolysis or thrombectomy in patients receiving anti-thrombotic treatment. Lancet Neurol 2013; 12: 677-688
    CrossrefPubMedGoogle Scholar
  • 85 Poli D, Antonucci E, Testa S et al. Gender differences of bleeding and stroke risk in very old atrial fibrillation patients on VKA treatment: results of the EPICA study on the behalf of FCSA (Italian Federation of Anticoagulation Clinics). Thromb Res 2013; 131: 12-16
    CrossrefPubMedGoogle Scholar
  • 86 Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC et al. Effect of Vitamin D on falls: a meta-analysis. JAMA 2004; 291: 1999-2006
    CrossrefPubMedGoogle Scholar
  • 87 Souchet E, Lapeyre-Mestre M, Montastruc JL. Drug related falls: a study in the French Pharmacovigilance database. Pharmacoepidemiol Drug Saf 2005; 14: 11-16
    CrossrefPubMedGoogle Scholar
  • 88 Cashin RP, Yang M. Medications prescribed and occurrence of falls in general medicine inpatients. Can J Hosp Pharm 2011; 64: 321-326
    PubMedGoogle Scholar
  • 89 Bonnemeier H, Bosch RF, Kohlhaussen A et al. For The Move Study G. Presentation of atrial fibrillation and its management by cardiologists in the ambulatory and hospital setting: MOVE cross-sectional study. Curr Med Res Opin 2011; 27: 995-1003
    CrossrefPubMedGoogle Scholar
  • 90 Meinertz T, Kirch W, Rosin L et al. Management of atrial fibrillation by primary care physicians in Germany: baseline results of the ATRIUM registry. Clin Res Cardiol 2011; 100: 897-905
    CrossrefPubMedGoogle Scholar