Geriatric Syndromes and Atrial Fibrillation: Prevalence and Association with Anticoagulant Use in a National Cohort of Older Americans

Abstract

BACKGROUND Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use. METHODS We performed a cross‐sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA2DS2‐VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]). RESULTS In this study of 779 participants with AF (median age = 80 years; median CHA2DS2‐VASc score = 4), 82% had one or more geriatric syndromes. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairments, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = −3.7%; 95% confidence interval = −1.4% to −5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia. CONCLUSION Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.

Long‐term functional outcomes and mortality after hospitalization for extracranial hemorrhage

“…We were not able to determine whether bleeding events occurred on anticoagulant or antiplatelet medications because Medicare Part D prescription data are only available for 2006 onward. However, because medication‐related bleeding events are more severe and patients taking anticoagulant and antiplatelet medications often have multimorbidity, we anticipate that bleeding hospitalizations due to medications would have an even greater impact on survival and function 40,41 . Whether and how medications affect ECH‐related disability should be a focus of future studies.…”

“…However, because medication-related bleeding events are more severe and patients taking anticoagulant and antiplatelet medications often have multimorbidity, we anticipate that bleeding hospitalizations due to medications would have an even greater impact on survival and function. 40,41 Whether and how medications affect ECH-related disability should be a focus of future studies. We accounted for patient characteristics that are associated with ECH, death and disability, and sensitivity analyses controlling for non-ECH hospitalization and time from ECH to HRS interview confirmed our primary result.…”

Long-term individual and population functional outcomes in older adults with atrial fibrillation

“…5,6 In large and nationally representative cohorts of older adults with AF, frailty, cognitive impairment, and functional impairments are common. 7,8 In the absence of longitudinal data in older adults with AF, the contribution of stroke and factors besides stroke to long-term disablement remains unclear.…”

Meaningful Evidence for Anticoagulation in the Gray (Elder) Zone

“…Independent predictors of not using anticoagulation include prior bleeding, history of fall, older age, polypharmacy, and frailty . Many older adults with AF also have 1 or more geriatric syndromes (ie, falls, loss of independence, incontinence, and cognitive impairment), which also make it less likely they will be prescribed anticoagulation . Older adults with frailty are mostly excluded from clinical trials but represent a unique group where decisions are fraught with angst.…”