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

Underuse of Warfarin

Regardless of guideline recommendations for the use of anticoagulants in elderly patients with AF, warfarin remains underprescribed in this population.[7,34,35,36,37] Only about 50% of patients eligible for warfarin anticoagulation therapy receive it.[38] Various reasons have been identified for the underuse of warfarin. One study determined that physicians tend to underestimate warfarin's benefits in AF.[16,39] Another study found that 46% of consultants and 43% of general practitioners believed that no patient older than 84 years of age should be treated with warfarin.[40] Many clinicians are very concerned about the possible adverse effects of anticoagulation therapy, while at the same time under-emphasizing its potential benefits. Additionally, physicians may choose the route of prescribing aspirin therapy for many older adults to avoid the frequent INR monitoring due to their high-volume medical practice.[8]

The risk of falls is a notable deterrent to warfarin use. General physicians and geriatricians alike have acknowledged that a risk of falls would significantly influence their prescribing of anticoagulation.[41] In a survey of 107 physicians regarding a scenario of a patient with AF who is residing in a long-term care facility, the risk of falls was cited by 98% of respondents as the number one reason why they would choose not to use warfarin.[7] A prospective observational study of 93 patients found that only half of those admitted to the hospital with AF-associated stroke were subsequently prescribed warfarin at discharge.[42] High risk of falls was cited as the reason for not using anticoagulation in 30% of those patients. Some have suggested that the risk of fall-related ICH is overestimated by physicians. This may be because ICH is a rare but dramatic occurrence, leaving an indelible impression.[43]

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