Underuse of Oral Anticoagulation for Individuals with Atrial Fibrillation in a Nursing Home Setting in France: Comparisons of Resident Characteristics and Physician Attitude

Abstract

The prevalence of AF in a cohort of very old nursing home residents was 10%. Anticoagulation was prescribed in fewer than 50% of eligible cases despite high individual risk of stroke. Geriatric syndromes, especially falls and cognitive disorders, were the main reported contraindications for prescribing anticoagulants. Physicians caring for those residents wrongly thought that paroxysmal AF caused fewer thromboembolic events than permanent AF, which explains lower rates of anticoagulant prescription in individuals with paroxysmal AF.

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

“…Prescribing OAC for elderly patients with AF is often troublesome in clinical practice. In light of the discrepancy existing between the "ideal" and the "real" world, with only half of the eligible older patients with AF who actually receive OAC (Ogilvie et al, 2010;Bahri et al, 2015;De Breucker et al, 2010;Di Pasquale et al, 2013;Ertas et al, 2013;Akao et al, 2014;Scowcroft et al, 2013), it could be hypothesized that a number of factors, which are currently not included in common scoring systems, might play a relevant role in the physician's decision to prescribe OAC (Bungard, Ghali, Teo, McAlister, & Tsuyuki, 2000). For example, it has been reported that some physicians are reluctant on prescribing anticoagulation when they perceive the "futility" of OAC therapy in vulnerable elderly, and also that they are more prone to withhold these drugs when they believe that patients would refuse therapy or be noncompliant (Bungard et al, 2000).…”

“…Although several conditions have been reported to be associated with under-prescription of OAC (Bahri et al, 2015;Wang et al, 2014), reasons of underuse are not completely known; it could be hypothesized that, beyond OAC eligibility, other variables, such as socio-demographic context, co-occurrence of chronic diseases and perception of patients' non-adherence to OAC may contribute to persistent under-use of OAC.…”

Antikoagulanzientherapie im hohen Lebensalter – Was ist zu beachten?

“…Vor allem geschieht dies wegen des assoziierten Risikos für traumatisch beding te sekundäre intrakranielle und extrakranielle Häma tome [5]. Im Rahmen der ATRIAStudie (eine gemischte retrospektive und prospektive Kohortenstudie mit über 13 000 Patienten) wur de der klinische Nutzen ("net clinical benefit") einer WarfarinTherapie bei Patienten mit Vor hofflimmern quantifiziert [10].…”

“…Der klinische Nutzen war am höchsten für Patienten ≥ 85 Jahre und für diejenigen mit einem Schlag anfall in der Anamnese. In diesen beiden Grup pen überwog das Schlaganfallrisiko deutlich das Blutungs risiko [5,10]. Das alleinig erhöhte Sturzrisiko ist keine Kon traindikation für eine orale Antikoagulation: Bereits 1999 wurde in einem analytischen Entscheidungsmodell nach Markov für sturz gefährdete VorhofflimmerPatienten ≥ 65 Jahre gezeigt, dass ein mit Warfarin antikoagulierter Patient ca.…”

“…DOAK waren in der Prävention von Schlaganfäl len oder systemischen Embolien bei Vorhofflim mern allerdings effektiver als die konventionelle Therapie [20]. [5,12]. Dies gilt auch für demente Patienten, sofern eine adäquate Patien tenCompliance gewährleistet werden kann [8].…”