The effect of age and quality of life on doctors' decisions to anticoagulate patients with atrial fibrillation

Age and Ageing,  May, 1998  by Mark Sudlow,  Richard Thomson,  Helen Rodgers,  Stella Livinstone,  Rose Anne Kenny

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Finally, it is possible that many clinicians believe that the risks of treatment with anticoagulants rise with age per se, such that increased bleeding amongst the old offsets any gains they may have from prevention of stroke. Although many clinicians may believe that treatment is less desirable in elderly patients because of an increased risk of bleeding, there is little evidence to support this view. A recent comprehensive review of the risks of anticoagulation concluded that there were insufficient data to say whether age was or was not a risk factor for bleeding complications [19]. Although some studies have concluded that age is a risk, most have not been able to consider the many confounding factors (such as co-morbidity and polypharmacy) which may be in operation. Most studies reporting an increase in bleeding with age show only a relatively modest increase [20-22] which would be more than offset by the much greater benefits which elderly people are likely to gain from treatment, by virtue of the greater absolute reduction in stroke risk which anticoagulation gives them [7]. These considerations led the recent American College of Chest Physicians consensus conference, which has previously taken the lead in providing guidance to clinicians on the use of anticoagulants, to promote treatment of more elderly patients in their recent guidelines on the use of anticoagulants in NVAF [23].

We conclude that clinicians' decisions to use anticoagulants in NVAF are greatly affected by the patients' quality of life and by their age. Much of the apparent under-use of anticoagulants in patients with atrial fibrillation may be due to clinicians' consideration of patients' age. The effect of patients' age on clinicians' use of anticoagulants is without clear foundation, is unlikely to lead to equitable treatment of individual elderly patients and may be preventing much of the substantial overall reduction in stroke incidence which could be achieved by appropriate use of warfarin in those with atrial fibrillation.

Acknowledgements

This research was funded by a grant from the Research and Development Directorate of the former Northern Regional Health Authority. M.S. is an MRC Training Fellow in Health Services Research. We should like to acknowledge the help of those clinicians who completed the questionnaire, Ruth Dobson for her computing expertise and Joseph Hoben for his clerical skills.

Key points

* Warfarin reduces the risk of stroke in patients with atrial fibrillation but treatment appears to be underused.

* We asked clinicians in a postal questionnaire whether a patient's age and medico-social factors should affect use of this treatment and found that advanced age and severely impaired quality of life may dissuade them from using warfarin.

* Fears of the use of warfarin in advanced age are poorly supported by evidence.

* As half of patients with atrial fibrillation are over 75 years the effect of age on clinicians decisions is likely to explain much of the under-use of this treatment.