Osteoporosis and atrial fibrillation are both increasingly prevalent as individuals age. The National Osteoporosis Risk Assessment (NORA) study involved more than 200,000 postmenopausal women to evaluate the relationship between bone density and fracture risk. Thirty-nine percent of these ambulatory women were classified as having osteopenia and 7% had osteoporosis. Those older women with the diagnosis of osteoporosis were four times as likely to develop a fracture during the following one year follow-up, compared to those with a normal bone density. As for patients with atrial fibrillation, it’s clearly recognized that the use of warfarin, particularly in the very elderly, does reduce the risk of stroke.

I tend to base my decision on quality of life issues and perceived life expectancy, rather than chronological age. As a rough rule of thumb, if the individual has a poor quality of life with a predicted life expectancy of two years or less, I am less likely to introduce treatment such as warfarin and alendronate. Alendronate-induced esophagitis/esophageal ulcers can be a serious adverse effect. Alendronate needs to be taken first thing in the morning on an empty stomach with at least 8 ounces of water and with a patient who can sit up for 30 minutes. There are now an increasing number of patients in their 90s on warfarin for atrial fibrillation — reasons for non-use would be mainly non-compliance and poor quality life expectancy of less than two years. The pros and cons of these treatments need to be discussed openly with our elderly patients or substitute decision makers. Joel S. Hurwitz, MD

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