Changes between health sectors and contact with multiple professionals are indisputable conditions for many frail elderly patients in anticoagulant therapy. This constitutes a risk factor. We aimed to describe the characteristics of patients receiving district-nursing assistance for their anticoagulant therapy in two Danish municipalities, with a specific focus on the complexity related to the number of professionals involved, number of hospital admissions, polypharmacy and co-morbidity.

We performed a descriptive cohort study of patients receiving district-nursing assistance for their oral anticoagulant therapy. Data were retrieved from municipal patient records and validated by district nurses.

The cohort included 467 patients; 44.8% were men, 54.2% were women; their mean age was 81.1years. Four out of five lived in their own home, the remaining lived in nursing homes or comparable facilities. During the inclusion period, 46.7% had no hospital admissions, whereas 10.1% had three or more admissions. Besides anticoagulant therapy, 96,6% of the patients received more than three medications. We found an increased mean age among mentally impaired individuals with more than three additional medications and for whom the indications for anticoagulant therapy was stated as unknown, compared to the total sample.

Danish patients in anticoagulant therapy who receive district-nursing assistance related to the therapy are characterized by physical and mental frailty, polypharmacy, multiple readmissions, multiple sector shifts, and multiple health professionals involved in single patient pathways.