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Reply to Letter From Roca et al.dFrailty and Anticoagulation Prescription Rate for Atrial Fibrillation in the ElderlyTo the Editor: We thank Roca et al. for their interest in our recent article. In the FRAIL-AF study, 159 patients (23%) were discharged to long-term care. 1 The rate of anticoagulation among patients admitted to long-term care (59%) was lower than the average rate of anticoagulation in our sample (70%). This is consistent with Roca et al.'s observation. 2 Of note, patients who were discharged to long-term care in the FRAIL-AF study were more likely to fall compared with patients who were discharged elsewhere (59% vs 48%). They were also more likely to be diagnosed with dementia (65% vs 18%). We did not specifically query whether cognitive impairment or age affected the propensity to administer anticoagulation for atrial fibrillation or flutter. This is a topic requiring further investigation. Nor could we tease out the respective contribution of disability and frailty to the decision to anticoagulate, as there is significant overlap in the domains that are measured with the Clinical Frailty Scale.Although long-term care residents constitute a unique population with high rates of disability, their composition is heterogeneous. Many patients who are discharged home with assistance may meet criteria for long-term care admis-sion, but are able to remain in the community with family support and home care services. When assessing the risk/ benefit ratio of anticoagulating older adults with arrhythmias, we recommend that individualized bleeding and thromboembolic risk be weighed and discussed with each patient and his or her family. An informed choice about anticoagulation should align with patient priorities and preferences, and be made irrespective of the place of residence.

effects were more prevalent in gr 1 (Table 1). There were no differences in QOL in pts who received an LVAD. Conclusion: Our data demonstrated that despite very poor initial prognosis, pts who were supported by VA ECMO for RCS and survived 6 months have overall good QOL and functional status that corresponds to NYHA 1-2.Purpose: Cognitive function is fundamental to a patient's capability to continually evaluate and perform self-care activities aimed at maintaining health and quality of life (QOL). However, information on cognitive function and self-care in LVAD patients is limited. We sought to examine the patterns and changes in cognitive function and self-care capabilities of patients before and after LVAD implant, and explore the relationships among 4 domains of cognitive function (learning, memory, psychomotor speed, and executive function) and self-care capabilities. Methods: We conducted an observational study on 39 subjects supported with a continuous flow LVAD with axial design from 2 VAD Centers in Michigan. Data were collected before (baseline) and at 1, 3 and 6 months after LVAD implant. Subjects' self-care-capabilities and cognitive function were measured with the Assessment of Self-Care Agency Scale (ASAS) and Cognitive Screening Test (CST), respectively. The 24-item ASAS has a possible sum score of 24 to 120 with higher score indicating better self-care capabilities. A zero CST index, derived from 4 domains of cognitive function, indicates an absence of cognitive impairment. Data were analyzed using descriptive, repeated measures ANOVA, and correlations statistical methods. Results: Subjects had a median age of 57 years (IQR, 52 to 64) and were predominantly Caucasian (53%) males (59%) with some college education (28%), but on disability (80%), and living with family (77%). At baseline, mean ASAS and CST scores were 95.0±9.3 and 0.68±1.0, respectively. Mean scores after LVAD were: 1 month (ASAS= 97.7±14.4, CST= 0.62±0.63); 3 months (ASAS= 99.1±11.1, CST= 0.41±0.86); and 6 months (ASAS= 99.3±12.8, CST= 0.48±0.80). The changes in ASAS scores were significant (p< 0.05), but the changes in CST scores were not. Also, the negative correlations among ASAS, 4 domains of cognitive function, and CST index (r= -.05 to -.23) were not significant. Conclusion: Our data demonstrated that subjects were capable of continually evaluating and performing their self-care needs despite possible cognitive impairment. Further research is warranted to confirm our data and to understand the mechanism of the relationship between cognition and self-care. This knowledge is crucial for testing interventions tailored for optimizing LVAD patients' self-care capabilities vital to maintaining health and QOL.