Anticoagulation in Frail Older Adults with Non-Valvular Atrial Fibrillation: Clinical Challenges and Personalized Approach

The prevalence of atrial fibrillation (AF) is increasing and often coexists with frailty. The management of anticoagulation therapy in frail older adults with AF is especially challenging due to the high risk of bleeding complications. The aim of this narrative review is to provide a comprehensive overview of current evidence about the management of anticoagulation in frail older adults with non-valvular AF. First, frailty itself should not be considered a contraindication. A comprehensive geriatric assessment is recommended to identify and potentially address conditions that may increase the risk of bleeding, such as inappropriately prescribed medications or malnutrition. Overall, the net clinical benefit remains in favour of oral anticoagulation in frail older adults, even if it decreases with increasing frailty severity. Direct Oral Anticoagulants (DOACs) show a better effectiveness and safety profile compared with Vitamin K antagonists (VKAs) in this population. Among DOACs, apixaban seems to be the safest. Also, edoxaban at a very low dosage (15 mg/day) could be an effective therapy in patients for whom the standard anticoagulation is contraindicated. Moreover, switching from VKAs to DOACs in frail older adults is a complex decision and should be personalized according to the stability of the ongoing anticoagulant therapy, the bleeding risk profile, and the severity of frailty. Finally, although further studies are required to confirm their effectiveness, factor XIa inhibitors are emerging as new promising alternative therapies because they have been associated with a lower bleeding risk compared with DOACs.