on Aging and Health from the Ministry of Health, Labor and Welfare. Author Contributions: Conception and design: Kozaki, Tanaka. Analysis and interpretation of data: Tanaka, Nagai, Matsui. Drafting of the article: Tanaka, Matsui. Critical revision of the article for important intellectual content: Kozaki, Sudo. Final approval of the article: Sudo, Kozaki. Statistical expertise: Matsui, Nagai. Collection and assembly of data: Tanaka, Obara, Nagai, Koshiba. Sponsor’s Role: None. REFERENCES 1. Landi F, Zuccala G, Gambassi G et al. Body mass index and mortality among older people living in the community. J Am Geriatr Soc 1999;47:1072–1076. 2. Roberts SB, Rosenberg I. Nutrition and aging: changes in the regulation of energy metabolism with aging. Physiol Rev 2006;86:651–667. 3. Schwartz MW, Woods SC, Porte D Jr et al. Central nervous system con- trol of food intake. Nature 2000;404:661–671. 4. Lawton MP, Brody EM. Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist 1969;9: 179–186. 5. Meier U, Gressner AM. Endocrine regulation of energy metabolism: Review of pathobiochemical and clinical chemical aspects of leptin, ghre- lin, adiponectin, and resistin. Clin Chem 2004;50:1511–1525. 6. Bertoli S, Magni P, Krogh V et al. Is ghrelin a signal of decreased fat-free mass in elderly subjects? Eur J Endocrinol 2006;155:321–330. 7. Williams DL, Cummings DE. Regulation of ghrelin in physiologic and pathophysiologic states. J Nutr 2005;135:1320–1325. 8. Erdmann J, Lippl F, Wagenpfeil S et al. Differential association of basal and postprandial plasma ghrelin with leptin, insulin, and type 2 diabetes. Diabetes 2005;54:1371–1378. 9. Rigamonti AE, Pincelli AI, Corra B et al. Plasma ghrelin concentrations in elderly subjects: comparison with anorexic and obese patients. J Endocri- nol 2002;175:R1–R5. 10. Bouras EP, Lange SM, Scolapio JS. Rational approach to patients with unintentional weight loss. Mayo Clin Proc 2001;76:923–929. ARE GERIATRIC SYNDROMES ASSOCIATED WITH RELUCTANCE TO INITIATE ORAL ANTICOAGULATION THERAPY IN ELDERLY ADULTS WITH NONVALVULAR ATRIAL FIBRILLATION? To the Editor: Age is associated with risk of atrial fibrilla- tion (AF) and its consequences, including stroke. In turn, stroke has been associated with mortality, disability, and health-related quality of life. 1 The American Association of Chest Physicians states that anticoagulation therapy (AT) must be initiated in individuals with nonvalvular AF in moderate- and high-risk categories for the development of stroke (according to congestive heart failure, hyperten- sion, aged ≥75, diabetes mellitus, stroke, vascular disease, aged 65–74, sex (CHA 2 DS 2 VASc) score), 2,3 whereas a variety of major bleeding prediction scores, such as the hypertension, abnormal (renal/liver function), stroke, bleeding tendency, labile international normalized ratio, elderly, drugs (HAS-BLED) have been developed to aid in the decision-making process in relationship to prescribing AT. 4 Nevertheless, recent work has shown that the net clinical benefit favors the initiation of AT over the risk of major bleeding, even in individuals at high risk of bleeding. 5 Bleeding risk in elderly adults with AF is frequently overestimated, whereas thrombotic risk is underestimated. 1,6 Thus, AT is underused in this context. It is likely that age-related factors such as functional status, falls, and cognitive impairment influence the decision to anticoagu- late these individuals, although an association between the presence of geriatric syndromes (GSs) and the reluc- tance to initiate AT in elderly adults with nonvalvular Table 1. Multivariate Logistic Regression of the Absence of Oral Anticoagulation Therapy Characteristic Univariate Analyses, n = 137 Model 1, n = 136 Model 2, n = 129 Model 3, n = 128 Model 4, n = 128 Odds Ratio (95% Confidence Interval) Age 1.03 (0.97–1.08) 1.02 (0.96–1.08) — 1.03 (0.96–1.11) 1.04 (0.96–1.12) Female 0.70 (0.35–1.37) 0.61 (0.29–1.27) — 0.55 (0.21–1.42) 0.58 (0.22–1.55) Lives alone 0.67 (0.20–2.22) 0.82 (0.24–2.82) — 1.03 (0.23–4.65) 0.94 (0.20–4.35) Education, years 0.96 (0.90–1.02) 0.94 (0.88–1.01) — 0.95 (0.88–1.48) 0.97 (0.89–1.06) Hearing impairment 1.66 (0.84–3.27) — 1.57 (0.66–3.73) — — Visual impairment 2.09 (0.97–4.53) — 2.45 (0.89–6.78) 2.84 (0.99–8.16) — ≥3 falls/years 2.37 (1.01–5.53) a — 1.61 (0.53–4.86) — — IADLs disability 0.64 (0.26–1.56) — 0.81 (0.26–2.56) — — ADLs disability 0.49 (0.25–0.97) a — 1.43 (0.58–3.55) — — Depressive symptoms 5.12 (2.19–11.99) b — 4.59 (1.73–12.12) a 4.94 (1.81–13.52) a 5.14 (1.84–14.34) a Cognitive impairment 7.97 (3.62–17.53) b — 7.32 (2.98–17.99) b 6.79 (2.73–16.87) b 6.27 (2.54–15.46) b CHA 2 DS 2 VASc stroke risk score 1.03 (0.06–16.80) — — — 1.02 (0.04–22.71) HAS-BLED 2.58 (1.27–5.23) a — — — 2.52 (1.03–6.16) a Model 1 included age, sex, living situation, and educational level; Model 2 included hearing impairment, visual impairment, falls, instrumental activities of daily living (IADLs) and activities of daily living (ADLs) disability, depressive symptoms, and cognitive impairment; Model 3 included age, sex, living situ- ation, educational level, visual impairment, depressive symptoms, and cognitive impairment; Model 4 included depressive symptoms and cognitive impair- ment and was adjusted for age; sex; living situation; educational level; congestive heart failure, hypertension, aged ≥75, diabetes mellitus, stroke, vascular disease, aged 65–74, sex (CHA 2 DS 2 VASc) stroke risk score; and hypertension, abnormal (renal/liver function), stroke, bleeding tendency, labile interna- tional normalized ratio, elderly, drugs (HAS-BLED) major bleeding risk score. Depressive symptoms = Geriatric Depression Scale (GDS) >5; Cognitive impairment = Mini-Mental State Examination (MMSE) ≤ 23. P < a .05, b .001. 2236 LETTERS TO THE EDITOR DECEMBER 2013–VOL. 61, NO. 12 JAGS