Use of Anticoagulation in Elderly Patients with Atrial Fibrillation Who Are at Risk for Falls

Candice L Garwood, PharmD BCPS; Tia L Corbett, PharmD

Disclosures

The Annals of Pharmacotherapy. 2008;42(4):523-532. 

In This Article

Abstract and Introduction

Objective: To evaluate data addressing use of anticoagulation in elderly patients with atrial fibrillation (AF), in particular those at risk of falls.
Data Sources: Primary literature was identified through PubMed MEDLINE (1966-December 2007) and EMBASE (1980-December 2007) using the search terms anticoagulation, warfarin, aspirin, elderly, falls, older persons, atrial fibrillation, bleeding, education, stroke, and use. Additional references were obtained through review of references from articles obtained.
Study Selection and Data Extraction: Clinical studies evaluating warfarin and aspirin efficacy in AF, as well as studies evaluating anticoagulation and falls, elderly patients, and bleeding were considered for inclusion. Selection emphasis was placed on randomized studies of AF and those evaluating anticoagulation and falls.
Data Synthesis: Uncertainties over the optimal treatment for elderly patients with AF still exist. Variance in the guidelines is reflected in current practice, as some discrepancies are present. Warfarin is underprescribed in elderly patients, with only about 50% of eligible patients receiving therapy. Falls are most often cited as the reason for not using anticoagulants in an elderly patient. Three risk-benefit analyses have been performed, and all found that despite risks associated with warfarin, its benefits outweigh its risks even in patients who fall. Warfarin should be used rather than aspirin or no therapy in elderly patients at risk of falls. Anticoagulation education has been shown to reduce the risk of bleeding in the elderly and should be a vital part of warfarin management.
Conclusions: The risk of falls alone should not automatically disqualify a person from being treated with warfarin. While falls should not dictate anticoagulant choice, assessment and management of fall risk should be an important part of anticoagulation management. Efforts should be made to minimize fall risk.

At present, atrial fibrillation (AF) is estimated to be present in 2.3 million individuals in the US and is projected to increase as the population ages.[1] The incidence of AF dramatically rises in patients from age 60 years onward, approaching 10% prevalence in those aged 80 years or older.[2] Overall, patients with AF have more than a fivefold increase in annual incidence of ischemic stroke in the absence of anticoagulation.[3,4] The stroke risk with AF doubles each decade after age 55 years, such that the incidence of stroke is as high as 23.5% for people 80-89 years of age who are not receiving anticoagulation. Despite these statistics, the decision to use anticoagulation in elderly patients is challenging.

Antithrombotic therapy has been shown to significantly reduce the risk of stroke. The Seventh American College of Chest Physicians (ACCP) guidelines and the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) guidelines for AF present 2 therapeutic options for stroke prevention: vitamin K antagonist or aspirin.[2,5] The American Geriatrics Society has also adopted guidelines advocating the use of the vitamin K antagonist warfarin in AF for senior adults, including those aged 75 years and older.[6] Despite guideline recommendations advocating warfarin's use, there is considerable variability in treatment with this agent, as it is associated with a significant risk for bleeding. Consequently, many physicians are cautious about using warfarin in older adults, particularly those perceived to be at risk for falls.[7,8]

The decision to use anticoagulants in elderly patients with AF at risk for falls is complex. Often there is not a single etiology that causes falls, but rather a collection of contributors. There are intrinsic and environmental factors, and a host of medications have been implicated ( Table 1 ).[9] Approximately 33% of community-dwelling seniors fall each year.[10] A history of falls is a significant risk factor for future occurrences. As such, the average patient who falls experiences 1.81 incidents per year. Approximately 10% of all falls result in serious injury including fractures, lacerations, head injury, and death.[10,11] Between 2% and 10% of patients who fall experience head trauma. The most common type of intracranial hemorrhage (ICH) that occurs with a fall is subdural hematoma (SDH), whereby bleeding occurs beneath the outermost layer of the brain (the dura). About 50% of all SDHs are due to head trauma.[11,12,13] In light of these concerns, we examine the appropriate use of warfarin in such patients.

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