Background anticoagulation is integral to stroke prevention for atrial fibrillation (AF), but there is evidence of under-treatment in older people in long-term care (LTC). Objective to synthesise evidence on the prevalence and outcomes (stroke, mortality or bleeding) of AF in LTC and the factors associated with the prescription of anticoagulation. Methods studies were identified from Medline, CINAHL, PsycINFO, Scopus and Web of Science from inception to 31 October 2019. Two reviewers independently applied the selection criteria and assessed the quality of studies using the Newcastle Ottawa Scale. Results twenty-nine studies were included. Prevalence of AF was reported in 21 studies, ranging from 7 to 38%. Two studies reported on outcomes based on the prescription of anticoagulation or not; one reported a reduction in the ischaemic stroke event rate associated with anticoagulant (AC) prescription (2.84 per 100 person years, 95% confidence interval [CI]: 1.98–7.25 versus 3.95, 95% CI: 2.85–10.08) and a non-significant increase in intracranial haemorrhage rate (0.71 per 100 person years, 95% CI: 0.29–2.15 versus 0.65, 95% CI: 0.29–1.93). The second study reported a 76% lower chance of ischaemic stroke with AC prescription and a low incidence of bleeding (n = 4 events). Older age, dementia/cognitive impairment and falls/falls risk were independently associated with the non-prescription of anticoagulation. Conversely, previous stroke/transient ischaemic attack and thromboembolism were independently associated with an increased prescription of anticoagulation. Conclusion estimates of AF prevalence and factors associated with AC prescription varied extensively. Limited data on outcomes prevent the drawing of definitive conclusions. We recommend panel data collection and systems for linkage to create longitudinal cohorts to provide more robust evidence.

Objective To determine atrial fibrillation (AF) prevalence and temporal trends, and examine associations between AF and risk of adverse health outcomes in older care home residents. Methods Retrospective cohort study using anonymised linked data from the Secure Anonymised Information Linkage Databank on CARE home residents in Wales with AF (SAIL CARE-AF) between 2003 and 2018. Fine-Gray competing risk models were used to estimate the risk of health outcomes with mortality as a competing risk. Cox regression analyses were used to estimate the risk of mortality. Results There were 86,602 older care home residents (median age 86.0 years [interquartile range 80.8–90.6]) who entered a care home between 2003 and 2018. When the pre-care home entry data extraction was standardised, the overall prevalence of AF was 17.4% (95% confidence interval 17.1–17.8) between 2010 and 2018. There was no significant change in the age- and sex-standardised prevalence of AF from 16.8% (15.9–17.9) in 2010 to 17.0% (16.1–18.0) in 2018. Residents with AF had a significantly higher risk of cardiovascular mortality (adjusted hazard ratio [HR] 1.27 [1.17–1.37], P < 0.001), all-cause mortality (adjusted HR 1.14 [1.11–1.17], P < 0.001), ischaemic stroke (adjusted sub-distribution HR 1.55 [1.36–1.76], P < 0.001) and cardiovascular hospitalisation (adjusted sub-distribution HR 1.28 [1.22–1.34], P < 0.001). Conclusions Older care home residents with AF have an increased risk of adverse health outcomes, even when higher mortality rates and other confounders are accounted for. This re-iterates the need for appropriate oral anticoagulant prescription and optimal management of cardiovascular co-morbidities, irrespective of frailty status and predicted life expectancy.

Background: Treatment decisions about oral anticoagulants (OAC) for atrial fibrillation (AF) are complex in older care home residents. Aim: To explore factors associated with OAC prescription. Design and Setting: Retrospective cohort study set in care homes in Wales, United Kingdom, listed in the Care Inspectorate Wales Registry 2017/18. Method: Analysis of anonymised individual-level electronic health and administrative data on people aged ≥65 years entering a care home between 1st January 2003 and 31st December 2018, provisioned from the Secure Anonymised Information Linkage Databank. Results: Between 2003 and 2018, 14,493 people with AF aged ≥65 years became new residents in care homes in Wales and 7,057 (48.7%) were prescribed OAC (32.7% in 2003 compared to 72.7% in 2018) within six months prior to care entry. Increasing age and prescription of antiplatelet therapy were associated with lower odds of OAC prescription (adjusted odds ratio [aOR] 0.96 per one year age increase [95% confidence interval [CI] 0.95 to 0.96] and aOR 0.91 [0.84 to 0.98], respectively). Conversely, prior venous thromboembolism (aOR 4.06 [3.17 to 5.20]), advancing frailty (mild: aOR 4.61 [3.95 to 5.38]; moderate: aOR 6.69 [5.74 to 7.80]; severe: aOR 8.42 [7.16 to 9.90]) and year of care home entry from 2011 onwards (aOR 1.91 [1.76 to 2.06]) were associated with higher odds of OAC prescription. Conclusions: There has been an increase in OAC prescribing in older people newly admitted to care homes with AF. This study provides an insight into the factors influencing OAC prescribing in this population.