Geriatric Syndromes and Atrial Fibrillation

Prevalence and Association With Anticoagulant Use in a National Cohort of Older Americans

Sachin J. Shah, MD, MPH; Margaret C. Fang, MD, MPH; Sun Y. Jeon, MS, PhD; Steven E. Gregorich, PhD; Kenneth E. Covinsky, MD, MPH

Disclosures

J Am Geriatr Soc. 2021;69(2):349-356. 

In This Article

Abstract and Introduction

Abstract

Background: Although guidelines recommend focusing primarily on stroke risk to recommend anticoagulants in atrial fibrillation (AF), physicians report that geriatric syndromes (e.g., falls and disability) are important when considering anticoagulants. Little is known about the prevalence of geriatric syndromes in older adults with AF or the association with anticoagulant use.

Methods: We performed a cross-sectional analysis of the 2014 Health and Retirement Study, a nationally representative study of older Americans. Participants were asked questions to assess domains of aging, including function, cognition, and medical conditions. We included participants 65 years and older with 2 years of continuous Medicare enrollment who met AF diagnosis criteria by claims codes. We examined five geriatric syndromes: one or more falls within the last 2 years, receiving help with activities of daily living (ADLs) or instrumental ADLs (IADL), experienced incontinence, and cognitive impairment. We determined the prevalence of geriatric syndromes and their association with anticoagulant use, adjusting for ischemic stroke risk (i.e., CHA2DS2-VASc score [congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex]).

Results: In this study of 779 participants with AF (median age = 80 years; median CHA2DS2-VASc score = 4), 82% had one or more geriatric syndromes. Geriatric syndromes were common: 49% reported falls, 38% had ADL impairments, 42% had IADL impairments, 37% had cognitive impairments, and 43% reported incontinence. Overall, 65% reported anticoagulant use; guidelines recommend anticoagulant use for 97% of participants. Anticoagulant use rate decreased for each additional geriatric syndrome (average marginal effect = −3.7%; 95% confidence interval = −1.4% to −5.9%). Lower rates of anticoagulant use were reported in participants with ADL dependency, IADL dependency, and dementia.

Conclusion: Most older adults with AF had at least one geriatric syndrome, and geriatric syndromes were associated with reduced anticoagulant use. The high prevalence of geriatric syndromes may explain the lower than expected anticoagulant use in older adults.

Introduction

The burden of atrial fibrillation (AF) is concentrated in older adults—80% of adults with AF are 65 years and older, many with comorbid conditions that affect functioning and quality of life.[1,2] Whereas clinical guidelines recommend clinicians focus primarily on ischemic stroke risk when considering anticoagulants for thromboprophylaxis, physicians report that geriatric syndromes are important when considering anticoagulants for older adults.[3–8]

Geriatric syndromes are clinical conditions resulting from impairments in multiple organ systems and are common among older adults.[9–12] Geriatric syndromes have a substantial impact on the well-being of older adults; they are dominant determinants of death, disability, and quality of life.[12,13] Examples of geriatric syndromes include falls, impairments in activities of daily living (ADLs) and instrumental ADLs (IADLs), cognitive impairment, and incontinence. Given their significance, geriatric syndromes are increasingly acknowledged and incorporated into clinical guidelines that inform both common and complex clinical decisions, ranging from diabetes mellitus management to cancer treatment to cardiac intensive care unit care.[14–16]

Geriatric syndromes complicate anticoagulant use in AF. Geriatric syndromes are associated with a higher risk of ischemic stroke, suggesting greater anticoagulant benefit.[17,18] However, geriatric syndromes may magnify harm by both increasing the risk of anticoagulant-associated hemorrhage and limiting patients' ability to recover from major bleeding.[18–21] Additionally, geriatric syndromes are associated with reduced life expectancy, thereby limiting the potential benefit of anticoagulants.[13,22] Further, anticoagulant use can trigger additional clinic visits, laboratory testing, medication interactions, dietary restrictions, so-called nuisance bleeding, and out-of-pocket expenses—each of which may be particularly burdensome to older adults and their caregivers.[23] This phenomenon of increased benefit and increased harm complicates anticoagulant use and has been most clearly demonstrated in patients with a history of falls and frailty.[18,19,24,25]

Despite their importance to the treatment context, little is known about the prevalence of geriatric syndromes in older adults with AF. Although the prevalence of frailty has been described in multiple studies, we know little about a broad array of geriatric syndromes.[26] Geriatric characteristics were not collected during the randomized trials that inform current practice, and these features are rarely ascertained in prospective cohort studies. In this study, we describe the prevalence of geriatric syndromes among participants with AF in a nationally representative cohort of older Americans and then estimate the associations between geriatric syndromes and anticoagulant use.

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