Treatment of atrial fibrillation in nursing homes: A place for direct acting oral anticoagulants?

Atrial fibrillation affects ~1 in 6 long-term nursing home residents. After an ischemic stroke hospitalization, ~2/3 of nursing home residents receive skilled nursing care and functional independence continues to decline, a process often complicated by rehospitalization and stroke recurrence. Due to advanced age and multimorbidity, anticoagulation is indicated for essentially all nursing home residents with atrial fibrillation. Yet as the severity of cognitive and/or functional deficits increases, the net clinical benefit of anticoagulation becomes less certain. Therefore, nursing home residents are most likely to be in need of supportive clinical evidence regarding anticoagulation, but least likely to have risk/benefit information from trials. Approximately half of US nursing home residents with atrial fibrillation have been treated with warfarin historically. Trial evidence in ambulatory older adults supports a large relative risk reduction (~50%) for stroke with warfarin versus aspirin and generally comparable bleeding risk. However, nursing home residents have a complex confluence of multimorbidity and polypharmacy that distinguishes them from healthier, non-institutionalized trial populations. Exemplifying this distinction, maintaining nursing home residents treated with warfarin within the therapeutic range has been a challenge historically, increasing the risk of adverse events. The direct acting oral anticoagulants may be a preferred therapeutic option for an indeterminate fraction of nursing home residents with atrial fibrillation. A review of the literature on anticoagulant use in nursing homes underscores the need for evidence on the effectiveness and safety of the direct acting oral anticoagulants specific to clinically complex older adults.