Acquired bleeding disorders in the elderly

Abstract

The hemostatic balance changes with advancing age which may be due to factors such as platelet activation, increase of certain clotting factor proteins, slowing of the fibrinolytic system, and modification of the endothelium and blood flow. Generally, this predisposes the elderly to thrombosis rather than bleeding. It often necessitates antiplatelet or anticoagulation therapy, which can cause significant bleeding problems in an aging population. Additionally, changing renal function, modification in immune regulation, and a multitude of other disease processes, can give rise to acquired bleeding disorders. Bleeding can prove difficult to treat in a dynamic environment and in a population that may have underlying thrombotic risk factors.This article discusses some specific challenges of acquired bleeding arising in the elderly. The use of anticoagulation and nonsteroidal anti-inflammatory medications is prevalent in the treatment of the elderly and predisposes them to increased bleeding risk as their physiology changes. When prescribing and monitoring these therapies, it is exceedingly important to weigh thrombotic versus bleeding risks. There are additional rare acquired bleeding disorders that predominantly affect the elderly. One of them is acquired hemophilia, which is an autoimmune disorder arising from antibodies against factor VIII. The treatment challenge rests in the use of hemostatic agents in a population that is already at increased risk for thrombotic complications. Another rare disorder of intensifying interest, acquired von Willebrand syndrome, has a multitude of etiologic mechanisms. Understanding the underlying pathophysiology is essential in making a treatment decision for this disorder. Learning Objectives• To recognize that coagulation changes with age and that it may predispose elderly patients on antithrombotic therapies to bleeding • To recognize the underlying thrombotic risk and comorbidities complicating the treatment of acquired hemophilia A • To understand the various pathophysiologic mechanisms leading to Acquired Von Willebrand Syndrome and assign appropriate treatment according to that mechanism Acquired bleeding disorders in the aging population are of concern because they are not readily diagnosed. In a study, community physicians from various specialties were presented with a hypothetical older adult woman complaining of recurrent epistaxis. Although most practitioners ordered complete blood counts and activated partial thromboplastin time (aPTT) as part of their work-up, less than one-half of nonhematologists repeated a significantly prolonged aPTT and Ͻ45% consulted a hematologist. Of those, emergency medicine physicians were least likely to consult hematology. 1

Temporal trends, characteristics and outcomes of fibrinolytic therapy for ST‐elevation myocardial infarction among patients 80 years or older

“…Oxidative stress, marked accelerated atherosclerosis, vascular dysfunction and reduction in antioxidant gene expression also occur with aging, increasing the prevalence of obstructive coronary artery disease . Due to comorbidities, elderly patients are usually on medications that may increase bleeding risk . Acquired bleeding disorders, which are usually undiagnosed may also be present in the elderly, further increasing the risk of bleeding.…”

“…Acquired bleeding disorders, which are usually undiagnosed may also be present in the elderly, further increasing the risk of bleeding. Medications, renal dysfunction, acquired hemophilia or acquired von Willebrand syndrome are some factors that may augment bleeding risks in the elderly . A combination of the factors above may explain why FT is less effective, and is associated with more bleeding in the elderly .…”

Splenic Marginal Zone Lymphoma with Acquired von Willebrand Syndrome Diagnosed via Splenic Bleeding

“…Except for splenic bleeding, the bleeding tendency was mild. A careful examination of bleeding symptoms and abnormal coagulation data in elderly patients might lead to the diagnosis of AVWS and its underlying diseases, including malignancy (13). …”

Von Willebrand Disease in the elderly: clinical perspectives

“…A longitudinal bleeding history is important to distinguish a new AVWS from a patient with congenital VWD and an accompanying diagnosis of cancer, both of which can be seen more commonly in populations over 60. The diagnosis of AVWS can be challenging, since different etiologies result in different mechanisms whereby VWF is lost and can be broadly divided into immune-mediated clearance of VWF, adsorption, and shear stress 86. In the acute setting, bleeding can be managed by treatments similar to congenital VWD.…”