Canadian Journal of Cardiology 32 (2016) 270.e9 www.onlinecjc.ca
Letters to the Editor Frailty and Anticoagulation Prescription Rate for Atrial Fibrillation in the Elderly To the Editor: We read with interest the study by Lefebvre et al.1 We would like to share our experience about the specific issue of frailty and anticoagulation prescription rate for atrial fibrillation (AF) in the elderly, especially in the nursing home population. First, we have been surprised by the rate of anticoagulation found in this study, which is higher than in previous reports.2 As mentioned by Lefebvre et al.,1 that could be explained by differences in local practice or recommendations. We hypothesize that it could also result from heterogeneity in the population studied, particularly according to its geriatric status. Indeed, patients with AF and lower rates of anticoagulation tend to be those who live in long-termecare facilities after hospitalization, probably reflecting a poor general health status that includes many geriatric conditions or syndromes. Even if we do not know where patients lived before hospitalization, this result is in line with our multicentre cohort in 104 French nursing homes, including 1085 residents with AF and a mean age of 87 years.3 Of these 1085 patients, only 541 (49.9%) received anticoagulation treatment. These patients had a high prevalence of cognitive impairment (71.6%) and were dependent according to the national French tool Groupe Iso Ressource. As discussed by the authors, this high rate of dependency in nursing home populations raises questions about the definition of frailty. In a recent consensus, frailty was defined as a clinical state characterized by an increase in an individual’s vulnerability for the development of increased dependency or mortality, or both, when exposed to a stressor.4 Even if the clinical frailty scale (CFS) is a validated frailty score to predict mortality, patients with high CFS scores are probably dependent (beyond frailty) according to most tools evaluating frailty.4 Thus it seems preferable to carefully distinguish between frail and dependent patients in studies focused on the octogenarian population to reduce heterogeneity.
Second, it would be interesting to know if characteristics associated with not prescribing anticoagulants differ between long-termecare residents and individuals without disability. Despite the fact that a history of falls or bleeding is cited as the reason for not prescribing anticoagulants in the 2 studies,1,3 we have shown with an open questionnaire submitted to 298 physicians that cognitive impairment (22.6%) and advanced age (16.4%) are also often cited.3 However, the impact of these geriatric conditions on AF, oral anticoagulation therapy, and outcomes (functional and mortality) have been investigated less often. Studies are necessary to help physicians in the decision-making process in this specific population of very old individuals. Frederic Roca, MD [email protected] Oarda Bahri, MD Philippe Chassagne, MD, PhD Disclosures The authors have no conflicts of interest to disclose. References 1. Lefebvre M-CD, St-Onge M, Glazer-Cavanagh M, et al. The effect of bleeding risk and frailty status on anticoagulation patterns in octogenarians with atrial fibrillation: the FRAIL-AF study. Can J Cardiol 2016;32: 169-76. 2. Ogilvie IM, Newton N, Welner SA, Cowell W, Lip GYH. Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 2010;123:638-45. 3. Bahri O, Roca F, Lechani T, et al. Underuse of oral anticoagulation for individuals with atrial fibrillation in a nursing home setting in France: comparisons of resident characteristics and physician attitude. J Am Geriatr Soc 2015;63:71-6. 4. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc 2013;14:392-7.
http://dx.doi.org/10.1016/j.cjca.2015.08.005 0828-282X/Ó 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
Letters to the Editor Frailty and Anticoagulation Prescription Rate for Atrial Fibrillation in the Elderly To the Editor: We read with interest the study by Lefebvre et al.1 We would like to share our experience about the specific issue of frailty and anticoagulation prescription rate for atrial fibrillation (AF) in the elderly, especially in the nursing home population. First, we have been surprised by the rate of anticoagulation found in this study, which is higher than in previous reports.2 As mentioned by Lefebvre et al.,1 that could be explained by differences in local practice or recommendations. We hypothesize that it could also result from heterogeneity in the population studied, particularly according to its geriatric status. Indeed, patients with AF and lower rates of anticoagulation tend to be those who live in long-termecare facilities after hospitalization, probably reflecting a poor general health status that includes many geriatric conditions or syndromes. Even if we do not know where patients lived before hospitalization, this result is in line with our multicentre cohort in 104 French nursing homes, including 1085 residents with AF and a mean age of 87 years.3 Of these 1085 patients, only 541 (49.9%) received anticoagulation treatment. These patients had a high prevalence of cognitive impairment (71.6%) and were dependent according to the national French tool Groupe Iso Ressource. As discussed by the authors, this high rate of dependency in nursing home populations raises questions about the definition of frailty. In a recent consensus, frailty was defined as a clinical state characterized by an increase in an individual’s vulnerability for the development of increased dependency or mortality, or both, when exposed to a stressor.4 Even if the clinical frailty scale (CFS) is a validated frailty score to predict mortality, patients with high CFS scores are probably dependent (beyond frailty) according to most tools evaluating frailty.4 Thus it seems preferable to carefully distinguish between frail and dependent patients in studies focused on the octogenarian population to reduce heterogeneity.
Second, it would be interesting to know if characteristics associated with not prescribing anticoagulants differ between long-termecare residents and individuals without disability. Despite the fact that a history of falls or bleeding is cited as the reason for not prescribing anticoagulants in the 2 studies,1,3 we have shown with an open questionnaire submitted to 298 physicians that cognitive impairment (22.6%) and advanced age (16.4%) are also often cited.3 However, the impact of these geriatric conditions on AF, oral anticoagulation therapy, and outcomes (functional and mortality) have been investigated less often. Studies are necessary to help physicians in the decision-making process in this specific population of very old individuals. Frederic Roca, MD [email protected] Oarda Bahri, MD Philippe Chassagne, MD, PhD Disclosures The authors have no conflicts of interest to disclose. References 1. Lefebvre M-CD, St-Onge M, Glazer-Cavanagh M, et al. The effect of bleeding risk and frailty status on anticoagulation patterns in octogenarians with atrial fibrillation: the FRAIL-AF study. Can J Cardiol 2016;32: 169-76. 2. Ogilvie IM, Newton N, Welner SA, Cowell W, Lip GYH. Underuse of oral anticoagulants in atrial fibrillation: a systematic review. Am J Med 2010;123:638-45. 3. Bahri O, Roca F, Lechani T, et al. Underuse of oral anticoagulation for individuals with atrial fibrillation in a nursing home setting in France: comparisons of resident characteristics and physician attitude. J Am Geriatr Soc 2015;63:71-6. 4. Morley JE, Vellas B, van Kan GA, et al. Frailty consensus: a call to action. J Am Med Dir Assoc 2013;14:392-7.
http://dx.doi.org/10.1016/j.cjca.2015.08.005 0828-282X/Ó 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
