Commentary based on Shah SJ, Fang MC, Jeon SY, Gregorish SE, Covinsky KE. Geriatric syndromes and atrial fibrillation: prevalence and association with anticoagulant use in a national cohort of older Americans. J Am Geriatr Soc 2021;69:349-36.¹

Rationale for study: Atrial fibrillation (AF) is common in older adults and its prevalence increases with age.² Current treatment guidelines focus primarily on identifying those with moderate to high stroke risk, as estimated by the CHA₂DS₂VASC score, and treating them with an anticoagulant.³ Older adults also frequently have comorbid geriatric syndromes, i.e., multifactorial conditions that can result from the accumulation of impairments in multiple organ systems and disease processes. As geriatric syndromes are associated with shortened life expectancy and worsened quality of life,⁴ affected individuals may experience different benefits and harms from chronic disease treatments, such as an anticoagulant for AF, when compared to younger, healthier individuals. On one hand, older adults with AF and geriatric syndromes may not live long enough to benefit from an anticoagulant and may be more vulnerable to medication-related harms. On the other hand, these individuals may be at higher risk of stroke overall and, as a result, may obtain greater benefit from treatment with an anticoagulant. As information about geriatric syndromes has been rarely collected in clinical trials, the relative benefits and harms of anticoagulants in this vulnerable group are unclear. In this study, the authors sought to describe the prevalence of geriatric syndromes in a representative cohort of older adults with AF and determine their associations with anticoagulant use.

Funding: National Center for Advancing Translational Sciences (KL2TR001870), National Institute on Aging (P30AG044281 and P30AG015272) and National Heart, Lung, and Blood Institute (K24HL141354)

Study Cohort: United States adults aged 65 and older with AF who participated in the 2014 wave of the nationally representative Health and Retirement Study (HRS). HRS data were linked to Medicare data. Participants in this study had at least 24 months of continuous Medicare Parts A and B enrollment.

Inclusion criteria: One inpatient or two outpatient claims for AF (ICD-9 427.31) in the 24 months preceding the 2014 interview.

Exclusion criteria: Missing data on individual geriatric syndromes or anticoagulant use (less than 1%).

Study Design: Cross-sectional analysis of the associations between prevalent geriatric syndromes and anticoagulant use.

Geriatric Syndromes: Falls, impairments in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and incontinence were assessed by self-report (or proxy report if a substantial cognitive or physical impairment impeded interview participation). Cognitive impairment was assessed using the Langa-Weir method, classifying participants into three categories (intact, cognitive impairment, and dementia) based on either cognitive testing or proxy report combined with interviewer assessment.

Outcomes: The primary outcome was self- or proxy-reported affirmative response to the HRS question "Do you regularly take prescription medications other than aspirin to thin your blood or to prevent blood clots?"

Analysis: The associations between geriatric syndromes and anticoagulant use were modeled using separate log-binomial models for each individual geriatric syndrome and the count of total geriatric syndromes. The relationship between the count of geriatric syndromes and anticoagulant use was determined to be linear using the Bayesian information criterion to determine best fit. All models were adjusted for stroke risk using the CHA₂DS₂VASC score. The models were used to calculate the predicted rates of anticoagulant use and the average marginal effect (AME) of each geriatric syndrome.

Results:
Participant characteristics: This study included a total of 779 participants. The median age was 80 years (IQR 74-86), 50% were female, and 93% were white. A significant proportion of participants had cardiovascular comorbidities, including 76% with hypertension, 32% with heart failure, and 25% with previous stroke. The median CHA₂DS₂VASC score was 4 (IQR 3-5).

Geriatric Syndromes: A large majority of participants (82%) had at least one geriatric syndrome, with 49% reporting a fall in the last 2 years, 39% having difficulty or needing help with at least one ADL, 42% having difficulty or needing help with at least one IADL, 37% with cognitive impairment or dementia, and 43% with incontinence.

Outcomes: While 97% of participants met current 2019 American Heart Association / American College of Cardiology / Heart Rhythm Society (AHA/ACC/HRS) guideline criteria for anticoagulant use, only 65% reported current use. Overall, those with a greater number of geriatric syndromes were significantly less likely to report anticoagulant use. Each additional geriatric syndrome was associated with significantly less anticoagulant use (AME= -3.7%; 95% CI, -5.9% to -1.4%). Specific geriatric syndromes which were independently associated with decreased anticoagulant use included dependence in one or more ADL (AME = -9.1%; 95% CI, -17.1% to -1.2%), dependence in one of more IADL (AME=-9.0%; 95% CI, -16.6% to -1.4%), and dementia (AME= -20.3%; 95% CI, -30.1% to -10.5%).

Limitations: Ascertainment of geriatric syndromes occurred via self or proxy report, potentially contributing to an underestimation of their true prevalence due to subjects' cognitive impairment or social desirability bias. Additionally, as this study is cross-sectional, it may have underestimated the relationship between geriatric syndromes and anticoagulant use due to survivor bias.

Conclusions: Most older adults with AF have one or more geriatric syndromes. The presence of geriatric syndromes is associated with lower rates of anticoagulant use. Given this differential prescribing, evidence about benefits and harms in this vulnerable group is necessary to guide optimal anticoagulant use.

References

1. Shah SJ, Fang MC, Jeon SY, Gregorish SE, Covinsky KE. Geriatric syndromes and atrial fibrillation: prevalence and association with anticoagulant use in a national cohort of older Americans. J Am Geriatr Soc 2021;69:349-36.
2. Zhang J, Johnsen SP, Guo Y, Lip GYH. Epidemiology of atrial fibrillation: geographic/ecological risk factors, age, sex, genetics. Card Electrophysiol Clin 2021;13:1–23.
3. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart R. J Am Coll Cardiol 2019;74:104–32.
4. Koroukian SM, Schiltz N, Warner DF, et al. Combinations of chronic conditions, functional limitations, and geriatric syndromes that predict health outcomes. J Gen Intern Med 2016;31:630–37.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Hypertension, Sleep Apnea

Keywords: Geriatrics, Aged, Activities of Daily Living, Cross-Sectional Studies, Accidental Falls, Quality of Life, Atrial Fibrillation, Anticoagulants, American Heart Association, International Classification of Diseases, Life Expectancy, Retirement, Outpatients, Inpatients, Aspirin, National Institute on Aging (U.S.), Bayes Theorem, Medicare, Heart Failure, Stroke, Chronic Disease, Hypertension, Thrombosis, Dementia, Cognition, Neuropsychological Tests, Prescriptions

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