Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF
Division of Cardiovascular Medicine, Department of Medicine; Department of Population and Quantitative Health Sciences; Division of Geriatric Medicine, Department of Medicine; Meyers Primary Care Institute
Cardiovascular Diseases | Geriatrics | Health Services Administration | Nervous System Diseases | Psychological Phenomena and Processes
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.
atrial fibrillation, cognitive impairment, frailty, oral anticoagulants
DOI of Published Version
J Am Geriatr Soc. 2019 Oct 1. doi: 10.1111/jgs.16178. [Epub ahead of print] Link to article on publisher's site
Journal of the American Geriatrics Society
Saczynski JS, Sanghai S, Kiefe CI, Lessard DM, Marino F, Goldberg RJ, Gurwitz JH, Wang W, Barton BA, McManus DD. (2019). Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF. Population and Quantitative Health Sciences Publications. https://doi.org/10.1111/jgs.16178. Retrieved from https://escholarship.umassmed.edu/qhs_pp/1307