Two studies challenge recommendations for near-universal anticoagulation in these patients.

Assessing trade-offs between stroke prevention and bleeding can be particularly challenging in older adults with atrial fibrillation (AF). Two new US observational studies address the benefits and risks of anticoagulation in older patients with frailty, cognitive impairment and dementia.

In one study, 1200 older adults with AF (mean age, 75 years; mean CHA2DS2VASc score, 4.4) were followed for two years. Anticoagulation was associated with excess major bleeding or death in cognitively impaired patients (hazard ratio [HR], 2.23), but not in cognitively intact patients (HR, 0.94). Among cognitively impaired patients, the number needed to harm with use of anticoagulation was eight, whereas the number needed to treat for stroke pre­vention was 30. Harms associated with anticoagulation also were more common in frail than nonfrail patients, but the difference was not statistically significant.

In another study, researchers examined outcomes in 15,000 nursing home residents with AF and advanced dementia (mean CHA2DS2VASc score, 6).

Anticoagulation was associated with signi­ficantly more serious bleeding (HR, 1.15) but not with lower stroke risk. Patients who received anticoagulation lived about 2.5 months longer on average, but more than half of patients in both groups died within one year.

Comment: Guidelines recommend anti­coagulation for almost all older patients with AF based on literature that under­represents adults with cognitive impair­ment and frailty. These new studies – both of which adjusted extensively for potential confounding factors – add uncertainty regarding anticoagulation in the cognitively impaired (in whom harms of anticoagulation appeared to substan­tially exceed benefits) and in patients with advanced dementia (in whom slightly extending life at the expense of excess bleeding might not align with goals of care). We can share these findings with AF patients or their caregivers who are considering anticoagulation.

Molly S. Brett, MD
Instructor in Medicine, University of Colorado, Boulder, USA.

Wang W, et al. Differential effect of anti­coagulation according to cognitive function and frailty in older patients with atrial fibril­lation. J Am Geriatr Soc 2023; 71: 394-403.

Ouellet GM, et al. Benefits and harms of oral anticoagulants for atrial fibrillation in nurs­ing home residents with advanced dementia. J Am Geriatr Soc 2023; 71: 561-568.

This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Hospital Medicine, Cardiology