Oral anticoagulation challenges and therapeutic dilemmas in the very elderly: to treat and how to treat octogenarians and nonagenarians?

The proportion of very elderly patients, namely octogenarians and nonagenarians, is expected to rise substantially over the next decades. This population is more prone to age‑dependent diseases associated with higher thromboembolic and bleeding risks. The very elderly are under‑represented in oral anticoagulation (OAC) clinical trials. However, real‑world evidence is accumulating, in parallel with an increase in OAC coverage in this patient group. OAC treatment seems to be more beneficial in the oldest age spectrum. Direct oral anticoagulants (DOACs) have the dominant market share in most clinical scenarios necessitating OAC treatment, proving at least as safe and effective as conventional vitamin K antagonists. Dose adjustments due to age or renal function often need to be made in DOAC‑treated very elderly patients. When prescribing OAC in this population, an individualized, yet holistic, approach accounting for comorbidities, comedications, altered physiological function, pharmacovigilance, frailty, compliance, and risk of falls is useful. However, given the limited randomized‑level evidence on OAC treatment in the very elderly, there are still pending questions. This review will discuss recent evidence, important practical aspects, and future directions for anticoagulation treatment in atrial fibrillation, venous thromboembolism, and peripheral artery disease in octogenarians and nonagenarians.