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Abstract

Objectives:

To assess clinicians’ prescribing practices for anticoagulation in older adults with atrial fibrillation or atrial flutter (AF/F) and determine factors common among those without anticoagulation.

Methods:

We performed a community-based retrospective cohort study of adults aged 65 years and older with a history of nonvalvular AF/F to determine the rate of oral anticoagulation utilization. We also assessed for associations between anticoagulation use and comorbid conditions and common geriatric syndromes.

Results:

A total of 3832 patients with a diagnosis of nonvalvular AF/F were included (mean [SD] age, 79.9 [8.4] years), 2693 (70.3%) of whom were receiving anticoagulation (51.7%, a vitamin K antagonist; 48.1%, a direct-acting oral anticoagulant). Patients with higher Elderly Risk Assessment index (ERA) scores, a surrogate for health vulnerability, received anticoagulation less often than patients with lower scores. The percentage of patients with a history of falling was higher among those who did not receive anticoagulation than among those who did (44.4% vs 32.8%; P < .001). Similarly, a diagnosis of dementia was more common in the no-anticoagulation group than the anticoagulation group (18.5% vs 12.7%; P < .001).

Conclusions:

A substantial proportion of older adults with AF/F do not receive anticoagulation. Those without anticoagulation had higher risk of health deterioration based on higher ERA scores and had a higher incidence of dementia and fall history. This suggests that the presence of geriatric syndromes may influence the decision to withhold anticoagulation.

Keywords

anticoagulation frailty geriatric syndrome older adult

Introduction

Oral anticoagulation, aimed at mitigation of thromboembolic risk, is a fundamental pillar in the comprehensive management of atrial fibrillation or atrial flutter (AF/F). Long-term use of a vitamin K antagonist (VKA) reduces the risk of stroke by 64% and all-cause mortality by 26%.¹ The direct-acting oral anticoagulants (DOACs) are similarly efficacious.^2
-5 Because of these clear benefits, the American Heart Association, American College of Cardiology, and Heart Rhythm Society guidelines provide strong recommendations for oral anticoagulation in all patients with AF/F deemed to be at moderate to high risk for thromboembolism.⁶ Despite this recommendation, approximately 20% to 40% of patients at moderate to high risk for thromboembolism, many of whom are older adults with multiple comorbid conditions, do not receive anticoagulation.^7
-9

Clinical decisions regarding anticoagulation therapy are challenging and require clinicians and their patients to carefully assess the risk of life-threatening bleeding, which increases with age. Adults aged 65 years and older represent a heterogeneous population, and chronologic age imparts limited information in the decision to prescribe or forego anticoagulation. This decision requires careful balance of the potential clinical benefit of stroke prevention versus bleeding risk.¹⁰ Risk stratification tools, such as CHA₂DS₂-VASc,¹¹ ORBIT,¹² and HAS-BLED,¹³ have been developed to guide decisions regarding anticoagulation use based on a person’s risk of ischemic stroke and major bleeding. These assessment tools do not account for important syndromic surrogates of clinical vulnerability and prognosis, such as frailty, multimorbidity, cognitive impairment, and falls, which are unique to this population but are powered to predict future ischemic/hemorrhagic events. These surrogates are geriatric syndromes, which are “multifactorial conditions prevalent in older adults [that] develop when an individual experiences accumulated impairments in multiple [physiologic] systems”.¹⁴ It is unknown how these geriatric syndromes influence clinical decision making and primary care clinicians’ anticoagulation prescribing patterns.

The primary aim of this study was to describe the rate of oral anticoagulation use among older adults with nonvalvular AF/F cared for in a large integrated primary care system. Secondarily, we aimed to determine any association between nonreceipt of anticoagulation and geriatric syndromes such as multimorbidity, cognitive impairment, falls, and a vulnerability/frailty surrogate.

Methods

Study Design and Cohort

This was a retrospective observational cohort study describing older adults with AF/F who were and were not receiving anticoagulation. The cohort was derived from patients empaneled to the community-based primary care practice at the main campus of a large, nonprofit, academic medical center from June 2018 through December 2020. We retrospectively searched our patient database for the records of patients aged 65 years or older with a diagnosis of AF/F (either paroxysmal or permanent). All patients with mechanical and prosthetic heart valves, mitral valve repair, mitral valve annuloplasty, and rheumatic mitral stenosis were excluded. This study was approved by the Mayo Clinic Institutional Review Board (#20-005064; October 25, 2021), and only patients who had consented to medical research review were considered for this study.

Patients empaneled to these primary care practices predominantly reside in Olmsted County, Minnesota. This practice provides primary care to more than 70% of the adults living in Olmsted County. Based on the US Census, as of July 2021, Olmsted County had a population of approximately 162 847.¹⁵ The largest racial/ethnic group in this county is non-Hispanic White (79.1%), followed by Black or African American (6.9%), Asian (6.6%), Hispanic or Latino (5.2%), and American Indian and Alaska Native (0.4%).¹⁵ Approximately 15.9% of persons in this county are aged 65 years and older; 94.5% of persons at least 25 years old have a high school graduate level of education, and 46.7% have a bachelor’s degree or higher.¹⁵

Outcomes

The primary outcome was the proportion of adults aged 65 years and older with nonvalvular AF/F treated with oral anticoagulation. For those prescribed oral anticoagulation, the anticoagulant drug class prescribed—VKA or DOAC—was recorded.

Secondary outcomes included patient-level factors associated with lack of anticoagulation. These included both clinical diagnoses based on billing codes and standard measures of bleeding risk, thromboembolic risk, and presence of common geriatric syndromes. Comorbid conditions included in this analysis were based on those incorporated into previously validated risk stratification schemas (ie, CHA₂DS₂-VASc and HAS-BLED) regarding AF/F management or death associated with aging. A comprehensive list of diagnosis/procedure codes was then compiled for each comorbid condition based on standardized lists of diagnosis and procedural codes (International Classification of Diseases [ICD], Ninth Revision and Tenth Revision codes) published by the Rochester Epidemiology Project.¹⁶

Geriatric Syndromes

We evaluated 3 geriatric syndromes (frailty/vulnerability, falls, and cognitive impairment) and the presence of multimorbidity. The Elderly Risk Assessment index (ERA), a frailty surrogate, uses administrative data from the electronic health record (EHR) to identify persons at higher risk for hospitalization and health deterioration. The ERA was previously validated in this patient population. This tool calculates a risk score on the basis of patient demographics, comorbid conditions, and health care utilization during the previous 2 years. These data are automatically derived from the EHR and require no face-to-face measurements. This tool has demonstrated that higher scores accurately identify those at highest risk for emergency department encounters, hospitalizations, and hip fractures, which are important frailty surrogates.^17,18 The Charlson Comorbidity Index (CCI) was used to assess multimorbidity in the aging population. It is a validated model used to predict risk of death from comorbid disease.¹⁹ The original CCI was used to avoid adjusting for age twice in our study.

The Rochester Epidemiology Project’s comprehensive list of ICD-9 and ICD-10 coding terms describing accidental falls was reviewed. Diagnostic codes addressing falls that precipitated the current encounter (eg, falling from a curb and falling from bed), as well as a history of falling or repeated falls were included. Falls that were not reflective of a person’s physical condition or frailty (eg, falling from a cliff) were excluded based on the authors’ collective judgment. Similarly, ICD-9 and ICD-10 codes for dementia used by the CCI macroanalysis were included as independent risk factors.

Statistical Analysis

Patients were separated into 2 groups on the basis of anticoagulation status. Descriptive statistics were used to summarize demographic data and clinical characteristics for the anticoagulation (AC) group and no-anticoagulation (N-AC) group. Comparisons between the 2 groups were assessed with Kruskal-Wallis tests for continuous variables and χ² tests for categorical variables. Multimorbidity variables (CHA₂DS₂-VASc, ERA, and CCI) were analyzed to assess correlation between the measurements using a Pearson correlation coefficient. All analyses were performed with SAS software v9.4 (SAS Institute Inc).

Results

Study Population and Primary Outcome

A total of 4336 patients were identified as aged 65 years or older with a diagnosis of AF/F during the study period; 504 of these patients were excluded (artificial heart valve, n = 486; rheumatic mitral stenosis, n = 11; and prior mitral valve repair or annuloplasty, n = 7). The final cohort included 3832 patients with a mean (SD) age of 79.9 (8.4) years (range, 65-106 years).

Of the 3832 eligible patients, 2693 (70.3%) were in the AC group (Table 1). Anticoagulation and antiplatelet medications used by all patients are shown in Supplemental Table 1. In the AC group, 51.7% (n = 1391) received a VKA and 48.1% (n = 1294) received a DOAC. In the N-AC group (n = 1139), 68% of patients (n = 775) were receiving antiplatelet monotherapy.

Table 1.

Patient Characteristics and Relevant Comorbid Conditions.^a

Characteristic	All patients (N = 3832)	Anticoagulation		P value
Characteristic	All patients (N = 3832)	No (n = 1139)	Yes (n = 2693)	P value
Age, years	79.9 (8.4)	80.6 (9.2)	79.6 (8.1)	.004^b
Sex				.73^c
Women	1777 (46.4)	533 (46.8)	1244 (46.2)
Men	2055 (53.6)	606 (53.2)	1449 (53.8)
Charlson Comorbidity Index	5 (0-22)	5 (0-22)	5 (0-22)	.30^b
ERA	9 (−1.0 to 31.0)	11 (−1.0 to 31.0)	8 (−1.0 to 31.0)	<.001^b
ERA categories				<.001^c
≤3	877 (22.9)	237 (20.8)	640 (23.8)
4-8	966 (25.2)	228 (20.0)	738 (27.4)
9-15	1024 (26.7)	318 (27.9)	706 (26.2)
≥16	965 (25.2)	356 (31.3)	609 (22.6)
CHA₂DS₂-VASc	4.8 (1.5)	4.6 (1.6)	4.9 (1.5)	<.001^b
Dementia	553 (14.4)	211 (18.5)	342 (12.7)	<.001^c
Past history
Falls	1388 (36.2)	506 (44.4)	882 (32.8)	<.001^c
CNS bleeding	103 (2.7)	44 (3.9)	59 (2.2)	.003^c
GI bleeding	552 (14.4)	214 (18.8)	338 (12.6)	<.001^c
Stroke or VTE	1453 (37.9)	345 (30.3)	1108 (41.1)	<.001^c

Abbreviations: CNS, central nervous system; ERA, Elderly Risk Assessment index; GI, gastrointestinal tract; VTE, venous thromboembolism.

Values are mean (SD), median (range), or No. of patients (%).

Kruskal-Wallis test.

χ² test.

Secondary Outcome Measures

Thromboembolic and bleeding risk

Patient characteristics and important comorbid conditions are shown in Table 1; other comorbid conditions are shown in Supplemental Table 2. Compared with the AC group, greater proportions of the N-AC group had a history of both CNS bleeding (3.9% vs 2.2%; P = .003) and gastrointestinal tract bleeding (18.8% vs 12.6%; P < .001; Table 1). The mean (SD) CHA₂DS₂-VASc score was 4.9 (1.5) in the AC group and 4.6 (1.6) in the N-AC group (P < .001). Kidney dysfunction (stage ≥3) was not associated with anticoagulation practices (Supplemental Table 2) despite a previously described association with an increased risk of bleeding.¹²

Geriatric syndromes

Patients not receiving anticoagulation had higher ERA scores (denoting greater risk of health deterioration) than did patients receiving anticoagulation. The median ERA score was 11 in the N-AC group and 8 in the AC group (P < .001; Table 1). In the N-AC group, 31.3% of patients had an ERA score of 16 or greater, compared with 22.6% in the AC group (P < .001; Table 1). Descriptive data by ERA categories, denoting increased clinical variability with higher score, are shown in Supplemental Table 3. Among patients in the highest quartile of ERA scores (≥16) 63.1% received anticoagulation, compared with 73.0% in the lowest ERA quartile (≤3; P < .001; Supplemental Table 3).

The median CCI did not differ between the AC and N-AC groups (median, 5; P = .30; Table 1). Given the overlap in the comorbid conditions incorporated into each scale, the CCI correlated closely with the CHA₂DS₂-VASc score (Pearson correlation coefficient, 0.53; P < .001) and the ERA score (Pearson correlation coefficient, 0.37; P < .001).

A history of falls was significantly more common in the N-AC group than the AC group (44.4% vs 32.8%; P < .001; Table 1). History of dementia also was more common in patients not receiving anticoagulation (18.5% vs 12.7%; P < .001; Table 1).

Discussion

In this retrospective cohort study of older adults with nonvalvular AF/F cared for by an integrated primary care practice, nearly 30% of patients at risk for embolic stroke were not receiving systemic anticoagulation. Lack of prescription for anticoagulants was more strongly associated with geriatric syndromes than with comorbidity-based scores (such as CCI). Our findings suggest that complex factors associated with frailty greatly influence clinical decisions, potentially more so than do traditional decision aides.

The observed rate of anticoagulation was about 10% higher than prior national estimates from large US databases of Medicare beneficiaries.^9,20 The increasing rate of anticoagulation temporally correlates with more widespread availability of DOACs, which offer an improved safety profile^21
-23 and ease of use. However, the rate of anticoagulation increase is only half that observed in the UK during the same time period, where the cost of DOACs is much less than in the US.^7,8,24 In their recent synthesis of outcomes of AF in frail older adults in the UK, Ritchie et al²⁵ called for improved data capture systems that would more accurately identify anticoagulation-related complications in vulnerable populations such as those residing in long-term care facilities.

This study examined the prevalence of common geriatric syndromes among older adults with nonvalvular AF/F. The cumulative effect of geriatric syndromes decreases a person’s ability to withstand stressors and maintain homeostasis. Frailty, falls, and cognitive impairment track together as recognized geriatric syndromes and undoubtedly affect provider and patient decisions surrounding anticoagulation. We found greater incidences of these syndromes among those who did not receive anticoagulation. Notably, CCI, indicating degree of multimorbidity, was similar for those with and without anticoagulation. These data reflect the nuanced difference between frailty, multimorbidity, and disability.²⁶ Furthermore, geriatric syndromes, in contrast to discrete clinical diagnoses, are not as easily captured into risk stratification scoring systems.

Other authors have sought to measure the prevalence of geriatric syndromes among populations of older adults with AF/F, typically with the use of cross-sectional studies. One study, deriving data from the Health and Retirement Study found that among participants with AF/F, 49% had falls, 28% had impaired ability to perform basic activities of daily living, and 37% had cognitive impairment, with anticoagulant use decreasing with the presence of each additional geriatric syndrome.²⁷

Numerous factors, however, may influence clinicians’ decisions to prescribe anticoagulation to vulnerable older patients. In a study by Frewen et al,²⁸ low estimation of patient life expectancy, fear of bleeding, and difficulty managing therapy were cited as clinicians’ top barriers to using anticoagulation for older multimorbid patients. Fear of bleeding complications is not unfounded but difficult to reconcile given existing data.

Although the risk of devastating gastrointestinal or intracranial hemorrhage is typically considered, among those who have had a gastrointestinal bleeding event, resumption of systemic anticoagulation is strongly associated with reduced stroke risk and improved survival.²³ In contrast, among older adults with a history of falls, use of anticoagulation was associated with a 2-fold higher risk of intracranial hemorrhage.²⁹ Another meta-analysis using a decision analytic Markov model calculated that, given the true risk of subdural hematoma after a fall, a person would need to fall nearly 295 times in a year for the risks of anticoagulation to outweigh the potential stroke reduction benefit.³⁰ For studies examining risk of fall-associated bleeding, variability in results is common given that falls and fall-related injury are often underreported and underdocumented.³¹ Risk of bleeding among those with dementia appears to be much higher. A prospective study of older patients with AF showed that for cognitively impaired persons receiving anticoagulation, the number needed to harm for major bleeding was 8.4 and for death was 17.8.³² In addition, the number needed to treat for stroke prevention was 30.9 among cognitively impaired persons and 34.9 among frail persons.³²

Our study has several limitations that affect the interpretation of our findings. First, the retrospective cohort design is inherently dependent on accurate information recorded in and extracted from the EHR. Data may be missing because of interprovider variability in coding and documentation, resulting in information bias. This is particularly problematic in the literature regarding falls and dementia in the older adult population because these conditions are frequently underdiagnosed.^33,34 However, 32.6% of our study patients had a history of falls, similar to the national prevalence of falls reported by the Centers for Disease Control and Prevention.³⁵ This suggests that the use of the standardized diagnosis and procedure codes published for the Rochester Epidemiology Project is reliable and a strength of the study. Similarly, frailty is typically identified with functional, dynamic assessments such as gait speed or hand grip strength, which are not commonly described in the EHR. Thus, we used a surrogate index (ERA) that is calculated by using administrative electronic data to demonstrate older adults’ global risk of health deterioration. Second, we did not assess individual patient preferences such as the desire to emphasize palliation and deprescribing in the setting of declining health. Third, our study population is less ethnically diverse and more highly educated than the US population overall, which affects the generalizability of our study. Our findings, however, still offer insight into anticoagulation prescription practices that are nuanced and not well described in the literature.

Our study also has several main strengths. The combined primary care practices assessed here care for more than 70% of this county’s population. The shared EHR and routine medication reconciliation standards, with contact anywhere in our health system, enable consistent recording of anticoagulants and provides internal validity of our primary end point. Additionally, these patients have broad access to comprehensive primary care and specialty consultative services, so this cohort is most likely accurately characterized with regard to diagnoses and health status, which allows for consistent measurement of potential confounders. Finally, the use of the ERA reflects numerous inputs to the patient’s health status, including social determinants of health, functional status, and intensity of health care utilization.

Conclusion

Our findings suggest that despite the wide availability of multiple anticoagulation options, nearly one-third of older adults at high risk for thrombotic stroke do not receive anticoagulation. The presence of common geriatric syndromes (frailty, falls, and dementia) was more common in those without oral anticoagulant use, and the high prevalence of these syndromes may partially explain why so many remain untreated. Although the optimal use of therapy and best strategy to identify those at highest risk for bleeding complications are unknown, there appears to be opportunity to develop risk stratification tools that include geriatric syndromes such as frailty, falls, and dementia. Validation of such tools would be needed to help patients and their health care teams make informed decisions about anticoagulation.

Supplemental Material

sj-docx-1-jpc-10.1177_21501319241243005 – Supplemental material for Anticoagulation Patterns Among Community-Dwelling Older Adults With Atrial Fibrillation

Supplemental material, sj-docx-1-jpc-10.1177_21501319241243005 for Anticoagulation Patterns Among Community-Dwelling Older Adults With Atrial Fibrillation by Meaghan Costello, Ericka E. Tung, Karen M. Fischer and Thomas M. Jaeger in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

The Scientific Publications staff at Mayo Clinic provided editorial consultation, proofreading, and administrative and clerical support. The authors have authorized Scientific Publications to submit the manuscript on their behalf and the authors have approved all statements and declarations.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by a small grant from the Division of Community Internal Medicine, Geriatrics, and Palliative Care. The funding source had no involvement in the study design, data collection, analysis or interpretation of data.

ORCID iD

Ericka E. Tung

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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