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.