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LEARNING OBJECTIVES

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Learning Objectives

  • Understand the pathophysiology, diagnosis, and treatment of venous thromboembolism (VTE) in older patients.

  • Understand the role of target-specific oral anticoagulants (TSOACs) in the management of older patients with VTE.

  • Review current guidelines for the prevention of VTE in older adults.

  • Understand how aging alters hemostatic pathways to increase the risk of both thrombosis and hemorrhage.

  • Review the evaluation of older adults with hemorrhagic disorders.

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Key Clinical Points

  1. Aging is associated with an increased risk of VTE.

  2. The risk of hemorrhage also rises with age and is most commonly due to acquired bleeding disorders and disorders of platelet number or function.

  3. TSOACs are safe and effective in carefully selected older adults for the prevention and treatment of thromboembolism.

  4. A careful consideration of the net clinical benefit of anticoagulation in older adults is integral to the selection and management of oral anticoagulants in this high-risk population.

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INTRODUCTION

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This updated chapter provides some new information on this topic. Due to space constraints, we are unfortunately unable to exhaustively cite the primary literature in this field. The reader is also referred to Chapters 45, 81, and 103, which contain additional information related to thrombotic and hemorrhagic disorders in older adults.

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VENOUS THROMBOTIC DISORDERS

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Definition and Brief Summary

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Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE) are common and, in many cases, preventable causes of in-hospital death in the United States. Age and accumulation of comorbidities markedly increase the risk of VTE in older adults increasing incidence, prevalence, morbidity, and mortality versus young adults. However, the diagnosis of VTE remains underrecognized in older adults. Clinical suspicion is essential to a prompt diagnosis in older adults who may have an atypical presentation; autopsy studies demonstrate PE is frequently not suspected, nor identified, despite being the cause of death in older persons. Despite this underrecognition in seniors, the diagnostic approach remains similar across all age groups. Antithrombotic agents are the mainstay of VTE treatment given their substantial risk reductions in VTE recurrence and mortality. However, the benefit of VTE treatment may be offset in older adults by an increased risk of major bleeding complications. Balancing the risks of recurrence with hemorrhage is important to guide treatment duration.

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EPIDEMIOLOGY AND PATHOPHYSIOLOGY

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Incidence of VTE

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In the general population the annual incidence of VTE approximates 1 in 1000 persons and appears to be increasing over time. Notably, incidence rates rise exponentially with age with an approximate 7- to 10-fold increase from less than 55 years to greater than 75 years.

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Risk Factors

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One or more clinical risk factors are usually identifiable at the time of VTE diagnosis in older adults. In patients presenting with a first episode of VTE, ...

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