title: Residential medication management reviews of antithrombotic therapy in aged care residents with atrial fibrillation: assessment of stroke and bleeding risk.
abstract: OBJECTIVE
  Antithrombotics reduce the risk of stroke in individuals with atrial fibrillation (AF). However, optimal prescribing of antithrombotics in older people remains a challenge. The objective of this study was to assess the risk of stroke for aged care home residents with AF and to examine the pharmacist-led medication reviews on the utilization of antithrombotic therapy.
  
  
  METHODS
  This retrospective study included a random sample of de-identified residential medication management reviews (RMMRs) conducted by accredited pharmacists in aged care homes in Sydney, Australia, between August 2011 and December 2012. The study participants were 146 residents aged 65 years and older with AF living in low- and high-care residential aged care facilities. Antithrombotic therapy was examined among the residents, before and after medication review. CHADS2 , CHA2 DS2 -VASc, and HEMORR2 HAGES scoring tools were used to assess the risk of stroke and bleeding and indicate the appropriateness of antithrombotic therapy.
  
  
  CONCLUSIONS
  The mean age (±SD) of individuals was 88·4 (7·5) years, and 63·7% (n = 93) were female. The majority of residents (n = 99, 67·8%) were aged between 85 and 99 years. The mean (±SD) CHADS2 score was 3·1 (1·1), CHA2 DS2 -VASc was 4·6 (1·5), and HEMORR2 HAGES was 2·3 (1·0). All residents were classified as being at high risk of developing stroke. A total of 115 of 146 (78·8%) residents with AF were prescribed antithrombotics. There was a relatively low usage of anticoagulation (28·1%), and few recommendations from the medication review pharmacists to alter the thromboprophylactic therapy in AF. Application of the CHA2 DS2 -VASc risk tool indicated that 146 residents were eligible for antithrombotic treatments; of these, 74 (50·7%) were prescribed antiplatelets and 41 (28·1%) were prescribed anticoagulants. Of the 31 (21·2%) residents with AF were not prescribed antithrombotics, 21 (67·7%) had relative contraindications for anticoagulant treatments.
  
  
  CONCLUSIONS
  Although there was a high overall use of antithrombotic agents, the study found a reluctance to prescribe or recommend anticoagulants in eligible older people with AF, potentially due to associated contraindications and multimorbidity. The use of guideline-recommended stroke risk tools could assist medication review pharmacists in optimizing antithrombotic therapy in older adults with AF.
authors.affiliation: School of Pharmacy, University of Otago, Dunedin, New Zealand.
authors.forename: P S
authors.initials: PS
authors.lastname: Nishtala
authors.affiliation: Pharmacy, School of Medicine, University of Tasmania, Hobart, TAS, Australia.
authors.forename: R L
authors.initials: RL
authors.lastname: Castelino
authors.affiliation: Pharmacy, School of Medicine, University of Tasmania, Hobart, TAS, Australia.
authors.forename: G M
authors.initials: GM
authors.lastname: Peterson
authors.affiliation: Meditrax, Sydney, NSW, Australia.
authors.forename: P J
authors.initials: PJ
authors.lastname: Hannan
authors.affiliation: School of Pharmacy, University of Otago, Dunedin, New Zealand.
authors.forename: M S
authors.initials: MS
authors.lastname: Salahudeen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D001315:Australia; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006470:Hemorrhage / Q000139:chemically induced*; D006707:Homes for the Aged; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data; D008297:Male; D009735:Nursing Homes; D010593:Pharmaceutical Services / Q000458:organization & administration; D010595:Pharmacists / Q000458:organization & administration; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use; D012189:Retrospective Studies; D012306:Risk; D020521:Stroke / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors
keywords: aged care; antithrombotic; antithrombotic therapy; atrial fibrillation; drug utilization; elderly; fibrinolytic agents; medication review; older people; residential care