Oral Anticoagulation Treatment in the Elderly

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Abstract
ORAL anticoagulant treatment (OAT) is effective in the prevention and treatment of thromboembolic complications in patients with cardiovascular disease. Some of the indications for OAT (eg, venous thromboembolism and atrial fibrillation) are particularly frequent in elderly people, the fastest growing population of our society. More than one third of all patients included in a recent collaborative prospective Italian study were older than 70 years when they started OAT, and 8% were older than 80.1 It is uncertain whether the risk of bleeding during OAT is higher in older patients,2,3 although many physicians are persuaded that the risk of OAT is higher in the elderly.4,5 Elderly subjects have the potential to be at higher risk for bleeding complications during OAT for the following reasons: they require lower anticoagulant doses than younger subjects, mainly because of reduced metabolic clearance6; they are more likely to be taking interacting drugs; they have a higher prevalence of comorbid conditions7; and they have been reported to have increased vascular fragility, a factor that may increase the risk of intracranial bleeding.8 Noncompliance with OAT has been reported to be similar in elderly and younger patients.9 Nevertheless, noncompliance could also contribute due to the complexity of the drug regimen, or a lack of a clear understanding of the purpose of the treatment by the elderly10 who are prone to mental impairment.11 The physician is therefore faced with a dilemma. The elderly are considered to be at higher risk of bleeding during OAT, but an increasing number of elderly patients are candidates for, and could benefit from, anticoagulants; this trend is expected to increase in the future. Therefore, there is a need for reliable information on the complication rates of OAT in the elderly and the modifiable factors that are responsible for these complications.