Coagulopathies in the Elderly

University of Alabama at BirminghamSchool of Medicine

Coagulopathies in the Elderly

• Age is not an independent risk factor for thrombotic or hemorrhagic disease, but for bleeding disorders, vitamin K deficiency and warfarin overdose are prevalent in older adults.

• Vitamin K deficiency is most commonly seen in the elderly in an acute care setting when appetite is diminished or feeding is withheld and antibiotics are being administered.

• Seniors can be exquisitely sensitive to warfarin. Older patients can develop marked prolongation of the prothrombin time not as a result of a warfarin overdose but because of the development of vitamin K deficiency. This apparent hypersensitivity disappears when the dietary intake is supplemented with oral administration of 80 to 150 micrograms of vitamin K daily.

• Bleeding complications with anticoagulant drugs appear to occur more frequently in older patients than in younger individuals. Advanced age (>75 years), intensity of anticoagulation [International Normalized Ratio (INR) > 4.0], history of cerebral vascular disease (recent or remote) and concomitant use of drugs that interfere with hemostasis (aspirin or nonsteroidal anti-inflammatory drugs) are among the most important variables in determining an individual’s risk for major bleeding with anticoagulants.

• Congenital disorders of thrombosis (Proteins C&S, antithrombin III and Factor V Leiden deficiencies) must be considered in elderly patients with recurrent thrombotic events. Some 15 –25 % of patients with these disorders will present with the first episode of thrombosis between ages 50 and 80.

• About 10% of patients who present with idiopathic deep venous thrombosis (DVT) and nearly 20% of patients with recurrent idiopathic DVT eventually develop clinically overt cancer. More than half of these patients are over 60 years of age. The majority of these cancers are adenocarcinomas and become evident within the first year after presentation with a DVT.

• It is important to search for and correct hemostatic abnormalities in patients with hemorrhagic stroke. In the elderly there is an increased frequency of vitamin K deficiency, a condition easily treated once it is recognized.

References

1. Hale PL, Owen J: Thrombotic And Hemorrhagic Disorders. In Hazzard WR, et al: Principles of Geriatric Medicine And Gerontology, 4th ed, New York, New York, 1999, McGraw Hill.
2. Sebastian JL, Tresch DD: Use of oral anticoagulants in older patients, Drugs Aging 2000 Jun; 16(6): 409-35.
3. Hussain, S: Disorders of hemostasis and thrombosis in the aged, Med ClinNorth Am 1976; 60(6): 1273-87.

Supported by a grant from the Association of American Medical Colleges and the John A. Hartford Foundation.