The role of comprehensive geriatric assessment and functional status in evaluating the patterns of antithrombotic use among older people with atrial fibrillation

Underuse of anticoagulant therapy in hospitalized older patients: comment on the article of Wojszel et al.

“…In a retrospective study including 980 patients discharged from a geriatric acute ward in the period 2010-2013 (mean age 83 years, 60% women, mean CHA 2 DS 2 -VASc and HAS-BLED scores 4.8 and 2.1, respectively) prescription of vitamin K antagonists at discharge was independently associated with younger age, permanent/ persistent AF, home versus long-term care facility discharge, higher hemoglobin levels and CHA 2 DS 2 -VASc score, lower ADL score (better functional autonomy), and greater number of drugs at discharge [5]. Very similar findings were reported in a retrospective observational study on 399 patients consecutively admitted to the acute geriatric ward of the San Gerardo Hospital, Monza, Italy [6]: although the proportion of patients taking OAC increased from admission to discharge, OAC underuse was still significantly associated with severe functional impairment, age > 90 years, discharge to nursing homes, high bleeding risk and polypharmacy [6]. Therefore, results of the study by Wojszel et al are in keeping with previous findings, demonstrating that severe functional dependence and/or frailty status, anemia, and nursing-home discharge are consistently associated with OAC underuse.…”

“…Overall, these findings demonstrate that those variables which discourage the use of OAC in elderly hospitalized patients (severe functional dependence and/or frailty status, anemia, and nursing-home discharge) are also strongly associated with an increased short-term mortality in these patients [1,3,4,6]. Moreover, mortality in individuals not prescribed OAC is markedly higher than in those receiving OAC therapy, and not accounted for by an excess of thrombo-embolic fatal events, but rather reflecting the higher proportion of oldest old with complex comorbidities and poor health status in the untreated population [9].…”

Practical use of Direct Oral Anti Coagulants (DOACs) in the older persons with atrial fibrillation.

“…However, despite consistent evidence of clinical benefit and increasing prescription of these drugs [6], they are yet widely underused, particularly in the oldest patients [7][8][9][10][11][12][13][14]. In this review, implications of frailty and geriatric syndromes and persistent uncertainties on DOACs use in real-world older persons will be discussed, and an approach for practical use of DOACs in older patients will be proposed.…”

Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence

“…Pilotto et al have recently reported significantly lower warfarin treatment rates in community-dwelling older patients with AF at high risk of mortality according to the MPI-SVaMA (Multidimensional Prognostic IndexScheda per la Valutazione Multidimensionale delle persone adulte e Anziane) [35]. Recently, Mazzone et al have demonstrated that the decision to withhold OAT in older patients with AF relies on a mix of clinical and geriatric variables, among which functional status is particularly relevant [36]. As a whole, these data suggest that physicians are particularly reluctant to prescribe OAT in older patients with poor health and functional status, and short life-expectancy.…”

“…General considerations on oral anticoagulant therapy under-prescription in older patients with atrial fibrillation OAT is still widely underused in older subjects with AF: studies consistently demonstrate that less than half of octogenarians are currently treated with OAT [1,[4][5][6][7][8][9][10][11]24,[35][36][37][38]. Although temporary or permanent contraindications may partially account for this under-prescription [6,7], advanced age and short life-expectancy, fear of bleeding, perceived harm greater than benefit, poor health and geriatric syndromes appear to be the most common reasons why physicians withhold anticoagulants [4][5][6][7]14,[34][35][36][37]. It seems plausible that this persisting therapeutic reluctance relies on intimate skepticism that the clinical benefits demonstrated in randomized trials and observational studies may not be observed at the same extent in more vulnerable older patients.…”