Anticoagulants Reduce Stroke Risk in Nursing Home Residents With Atrial Fibrillation

A new report published in JAMA Network Open, entitled “Anticoagulant Outcomes in Nursing Home Residents with Atrial Fibrillation and ADL Disability,” studied 26,940 nursing home residents with atrial fibrillation and significant impairment in activities of daily living. It found that oral anticoagulant treatment was associated with a lower risk of ischemic stroke but a higher risk of major bleeding. Among the anticoagulants evaluated, apixaban demonstrated the most favorable overall benefit-risk profile.

The findings are particularly relevant because nursing home residents with atrial fibrillation who have substantial activities of daily living disability face competing risks of stroke, bleeding, and death, making decisions about anticoagulation especially complex, according to the researchers.

“Nursing home residents with atrial fibrillation and substantial functional impairment represent a particularly challenging population when considering anticoagulation,” said Kevin Pritchard, OT, PhD, occupational therapist, pharmacoepidemiologist, and post-doctoral research fellow at Hebrew SeniorLife’s Hinda and Arthur Marcus Institute for Aging Research and Harvard Medical School. “These findings highlight the difficult decisions that patients and their health care providers face when considering anticoagulation therapy. While treatment may help prevent stroke, it can also increase the risk of major bleeding, a serious complication that could leave patients with greater disability.”

As cited in the report, AF is the most common significant cardiac arrhythmia, and its prevalence increases with age. The number of nursing home residents with AF is projected to exceed 300,000 by 2030. It is substantially more prevalent among nursing home residents than in the general population, although clinical guidelines recommend oral anticoagulants to reduce stroke risk. Oral anticoagulants are often underused or discontinued in older adults, particularly in nursing homes, because of concerns about bleeding risk.

The cohort study used U.S. Medicare claims linked with the Minimum Data Set between January 1, 2013, and December 31, 2022. The study population consisted of long-term nursing home residents with nonvalvular atrial fibrillation and impairment in three or more activities of daily living.

Researchers evaluated initiation of apixaban, rivaroxaban, or warfarin compared with non-use, and assessed ischemic stroke, major bleeding, and their composite outcome. Researchers used propensity score matching to balance clinical and demographic characteristics between treatment groups and conducted additional analyses to evaluate the relative benefits and risks of anticoagulation. 

For apixaban, the rate of ischemic stroke was 14.6 per 1,000 person-years among those receiving the medication, compared with 27.6 per 1,000 person-years among those not receiving an anticoagulant. Apixaban was associated with a 47% lower rate of ischemic stroke compared with warfarin, and was associated with a 60% lower rate of major bleeding compared with rivaroxaban.

“Findings should not be interpreted as a recommendation for anticoagulation for every nursing home resident with atrial fibrillation,” said Dae Hyun Kim, MD, MPH, ScD, associate director and senior scientist at the Marcus Institute and professor of medicine at Harvard Medical School. “Rather, they provide information that may help clinicians, residents and families weigh the potential benefits and risks of treatment based on an individual's clinical circumstances, functional status, frailty and goals of care.”

In addition to Drs. Kim and Pritchard, researchers included Qiaoxi Chen, PhD, MPH, research specialist, Brigham and Women’s Hospital; Daniel Singer, MD, professor of medicine, Harvard Medical School, researcher, Massachusetts General Hospital; Chun-Ting Yang, PhD, instructor in medicine, Harvard Medical School, pharmacoepidemiologist, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital; and Joshua Kueiyu Lin, MD, ScD, MPH, associate professor of medicine, Harvard Medical School, pharmacoepidemiologist, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, practicing hospitalist, Massachusetts General Hospital.

About Hebrew SeniorLife
Hebrew SeniorLife is a national leader working to create a world where aging is defined by possibility, not limitation. We care for more than 4,500 older adults each day across seven campuses throughout Greater Boston, and offer support for families in the aging journey. Our services include in-home care, outpatient therapies, an outpatient memory clinic, short- and long-term inpatient care, hospice, independent and assisted living, and affordable housing with services. We conduct influential research on aging at our Hinda and Arthur Marcus Institute for Aging Research, which has a grant portfolio of $87 million, and train future health care workers at the Lunder CareForce Institute. Hebrew SeniorLife is a Harvard Medical School affiliate. Follow us on our blog, Facebook, Instagram, and LinkedIn.