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• W1767140819 abstract "We read with interest the study by Lefebvre et al.1Lefebvre M.-C.D. 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: 169-176Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar 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.2Ogilvie I.M. Newton N. Welner S.A. Cowell W. Lip G.Y.H. Underuse of oral anticoagulants in atrial fibrillation: a systematic review.Am J Med. 2010; 123: 638-645Abstract Full Text Full Text PDF PubMed Scopus (763) Google Scholar As mentioned by Lefebvre et al.,1Lefebvre M.-C.D. 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: 169-176Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar 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-term–care 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.3Bahri 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: 71-76Crossref PubMed Scopus (78) Google Scholar 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.4Morley J.E. Vellas B. van Kan G.A. et al.Frailty consensus: a call to action.J Am Med Dir Assoc. 2013; 14: 392-397Abstract Full Text Full Text PDF PubMed Scopus (2238) Google Scholar 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.4Morley J.E. Vellas B. van Kan G.A. et al.Frailty consensus: a call to action.J Am Med Dir Assoc. 2013; 14: 392-397Abstract Full Text Full Text PDF PubMed Scopus (2238) Google Scholar 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-term–care 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,1Lefebvre M.-C.D. 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: 169-176Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 3Bahri 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: 71-76Crossref PubMed Scopus (78) Google Scholar 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.3Bahri 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: 71-76Crossref PubMed Scopus (78) Google Scholar 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. The authors have no conflicts of interest to disclose. The Effect of Bleeding Risk and Frailty Status on Anticoagulation Patterns in Octogenarians With Atrial Fibrillation: The FRAIL-AF StudyCanadian Journal of CardiologyVol. 32Issue 2PreviewOlder adults are at increased risk of atrial fibrillation (AF), its thromboembolic complications, and bleeding. A significant percentage of octogenarians do not receive anticoagulation therapy. The objective of this study was to investigate the effect of thromboembolic risk, bleeding risk, and frailty on the anticoagulation status of octogenarians hospitalized with AF. Full-Text PDF Reply to Letter From Roca et al.—Frailty and Anticoagulation Prescription Rate for Atrial Fibrillation in the ElderlyCanadian Journal of CardiologyVol. 32Issue 2PreviewWe thank Roca et al. for their interest in our recent article. In the FRAIL-AF study, 159 patients (23%) were discharged to long-term care.1 The rate of anticoagulation among patients admitted to long-term care (59%) was lower than the average rate of anticoagulation in our sample (70%). This is consistent with Roca et al.’s observation.2 Of note, patients who were discharged to long-term care in the FRAIL-AF study were more likely to fall compared with patients who were discharged elsewhere (59% vs 48%). Full-Text PDF" @default.
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