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Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF
Jane S Saczynski1, Saket R Sanghai2, Catarina I Kiefe3
1Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts.
Insights
Oral anticoagulants are crucial for stroke prevention in atrial fibrillation (AF) patients. Despite common geriatric impairments like cognitive decline and frailty, these factors did not influence prescribing rates in the SAGE-AF study.
Area of Science:
- Geriatric medicine
- Cardiology
- Pharmacology
Background:
- Oral anticoagulants are vital for preventing stroke in patients with atrial fibrillation (AF).
- Geriatric impairments, including cognitive impairment and frailty, are prevalent in older AF patients.
- These impairments are often cited as reasons for withholding oral anticoagulant therapy.
Purpose of the Study:
- To systematically assess geriatric impairments in AF patients.
- To determine if geriatric impairments are associated with oral anticoagulant prescribing patterns.
Main Methods:
- Cross-sectional analysis of baseline data from the SAGE-AF prospective cohort study.
- Inclusion of 1244 participants (age ≥65) with AF and CHA 2 DS2 -VASc score ≥2.
- Geriatric assessment included validated measures of frailty, cognition, social support, depression, vision, and hearing.
Main Results:
- 42% of participants had cognitive impairment, 14% were frail, and 29% had depressive symptoms.
- Oral anticoagulants were prescribed to 86% of the cohort.
- Prescribing rates did not significantly differ based on cognitive impairment, frailty, social isolation, depression, or sensory impairments.
Conclusions:
- Geriatric impairments are common in older AF patients but do not appear to influence oral anticoagulant prescribing.
- Prescribers may be unaware of or disregard these geriatric factors when making treatment decisions.
- Further investigation is needed to understand the discrepancy between cited reasons for non-prescription and actual prescribing patterns.
Objectives:
Oral anticoagulants are the cornerstone of stroke prevention in high-risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing.
Design:
Cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) prospective cohort study.
Setting:
Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018.
Participants:
Participants with AF age 65 years or older, CHA2 DS2 -VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65-74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244).
Measurements:
A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record.
Results:
A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre-frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51-1.09; frail OR = .69; 95% CI = .35-1.36; social isolation OR = .90; 95% CI = .52-1.54; depression OR = .79; 95% CI = .49-1.27; visual impairment OR = .98; 95% CI = .65-1.48; and hearing impairment OR = 1.05; 95% CI = .71-1.54).
Conclusion:
Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147-154, 2019.
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