To Anticoagulate or not to Anticoagulate? A Common Dilemma for the Provider: Physicians’ Opinion Poll Based on a Case Study of an Older Long-term Care Facility Resident With Dementia and Atrial Fibrillation

doi:10.1016/j.jamda.2005.08.002

Journal of the American Medical Directors Association

Volume 7, Issue 1, January 2006, Pages 23-28

https://doi.org/10.1016/j.jamda.2005.08.002 Get rights and content

Objective

Anticoagulation therapy is an acceptable strategy for the prevention of thromboembolic events in the presence of atrial fibrillation. However, this strategy is controversial in older subjects particularly in the presence of dementia. We conducted an opinion poll regarding the decision to anticoagulate or not among physicians in practice and in various levels of training (residents and fellows) that was based on a specific, yet not unusual, case scenario in the nursing home.

Setting

A university teaching hospital in the Bronx, NY.

Methods

A survey questionnaire was distributed to physicians to solicit opinions on the decision to anticoagulate based on an actual case from a LTCF and the results were analyzed.

Results

One hundred seven completed surveys were returned from 49 residents, 20 fellows, and 38 attending physicians. The majority (85%) felt that long-term anticoagulation therapy was not indicated in the case patient. However, most (88%) felt they would provide an antiplatelet agent, with the choice being 78% aspirin, 20% clopridogel, and 2% aspirin-dipyridamole. The most cited reasons for not providing anticoagulation were risk of falls (98%), dementia (40%), and short life expectancy (32%). However, 92% of respondents felt that the patient was a candidate for short-term anticoagulation therapy. Interestingly, the choices (yes, no, uncertain) to the questions were similar for all physicians irrespective of their level of training or years in practice (or faculty) after training.

Conclusions

Although long-term anticoagulation for thromboembolic events in atrial fibrillation is considered beneficial, recent reports suggest that warfarin is underused in older adults, especially in the long-term care setting. Our physician poll, based on a specific case scenario, is consistent with this opinion as reflected by both trainees and practicing physicians. While there are absolute and relative contraindications to the use of long-term warfarin, decisions should be individualized and based on risks, benefits, and quality of life of the resident.

Section snippets

Survey Case

An 87-year-old white female with known Alzheimer’s disease and AF, plus a past history of surgery for left hip fracture, was admitted to a LTCF following discharge from the hospital. Her echocardiogram revealed normal left ventricle (LV) size and function, with abnormal diastolic filling considered consistent with her age. Before her last hospitalization, she resided in the dementia unit of an assisted living facility. While in that facility, she used to ambulate using a walker with assistance.

Participants

One hundred seven surveys were completed and returned. Of these, 49 surveys were from residents in internal medicine, 20 were from fellows in specialties of medicine (including geriatric medicine), and 38 were from attending physicians in internal medicine.

Answers to Question 1

Thirteen percent of the respondents felt that the case study was a candidate for long-term anticoagulation therapy, 85% felt the patient was not a candidate for long-term anticoagulation, and 2% were uncertain. We determined no significant

Discussion

As the woman’s case scenario developed, concerns were raised as to the whether or not we should initiate warfarin therapy for long-term thromboembolic prophylaxis for AF. Our discussions with her son (her surrogate) raised several additional concerns. Because of this, we decided to conduct an opinion poll, based on this woman’s specific case history, to determine the general consensus of physicians at our medical center regarding anticoagulation individualized to this resident. One hundred

Conclusion

The literature suggests that long-term anticoagulation for thromboembolic prophylaxis in AF may be beneficial. However, recent reports suggest that warfarin is underused for this indication particularly in older adults, and even more so in the long-term care setting. Our physician poll, based on a specific case scenario, is consistent with this opinion at both the trainee and practicing physician levels. While absolute and relative contraindications to the use of long-term warfarin exist, each

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Furthermore, older adults are more likely to have severe functional deficits from a stroke affecting their daily living and placing them at higher risk for falls. Anticoagulation therapy is the main preventive method for thromboembolic stroke; however, increased bleeding risk, frequent falls, and medication interactions are major considerations in older patients.5 In the ED, treatment of AF in older patients with a rapid ventricular rate is similar to other patients.
Impact of anticoagulation in patients with dementia and atrial fibrillation. Results of the CardioCHUVI-FA registry
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El envejecimiento de la población se asocia con una prevalencia creciente de fibrilación auricular (FA) y demencia. Con este estudio se pretende analizar el impacto de la anticoagulación oral en pacientes ancianos con FA y demencia de grado moderado-grave.
Estudio retrospectivo unicéntrico que analiza a pacientes de edad ≥ 85 años con diagnóstico de FA entre 2013 y 2018. El impacto de la anticoagulación en la mortalidad, las embolias y las hemorragias se evaluó mediante un análisis multivariado de Cox. En los pacientes con demencia, dicho análisis se complementó con un propensity score matching en función de que se les prescribiera tratamiento anticoagulante o no.
De los 3.549 pacientes de 85 o más años con FA, 221 presentaban demencia de grado moderado-grave (6,1%), de los que 88 (60,2%) fueron anticoagulados. Durante un seguimiento de 2,8 ± 1,7 años, la anticoagulación se asoció con menor riesgo embólico y mayor riesgo hemorrágico tanto en pacientes con demencia (HR_embolias = 0,36; IC95%, 0,15-0,84; HR_hemorragias = 2,44; IC95%, 1,04-5,71) como sin demencia (HR_embolias = 0,58; IC95%, 0,45-0,74; HR_hemorragias = 1,55; IC95%, 1,21-1,98). Sin embargo, la anticoagulación únicamente se asoció con menor mortalidad en los pacientes sin demencia (HR = 0,63; IC95%, 0,53-0,75), no en pacientes con demencia (HR ajustada = 1,04; IC95%, 0,63-1,72; p = 0,541; HR después de propensity score matching = 0,91; IC95%, 0,45-1,83; p = 0,785).
En pacientes de 85 o más años con demencia moderada-grave y FA, la anticoagulación oral se asoció de manera significativa con menor riesgo de embolias y mayor riesgo hemorrágico, sin encontrarse diferencias en cuanto a mortalidad total.
Population aging is associated with an increased prevalence of atrial fibrillation (AF) and dementia. This study aimed to analyze the impact of oral anticoagulation in elderly patients with AF and moderate-severe dementia.
We conducted a single-center retrospective study analyzing patients aged ≥ 85 years with a diagnosis of AF between 2013 and 2018. The impact of anticoagulation on mortality, embolisms, and bleeding events was assessed by multivariate Cox analysis. In patients with dementia, this analysis was complemented by propensity score matching, depending on whether the patients were prescribed anticoagulant treatment or not.
Of the 3549 patients aged ≥ 85 years with AF, 221 had moderate-severe dementia (6.1%), of whom 88 (60.2%) were anticoagulated. During a follow-up of 2.8 ± 1.7 years, anticoagulation was associated with lower embolic risk and higher bleeding risk both in patients with dementia (hazard ratio [HR]_embolisms, 0.36; 95%CI, 0,15-0.84; HR_bleeding, 2.44; 95%CI, 1.04-5.71) and in those without dementia (HR_embolisms, 5.58; 95%CI, 0.45-0.74; HR_bleeding, 1.55, 95%CI, 1.21-1.98). However, anticoagulation was associated with lower mortality only in patients without dementia (HR, 0.63; 95%CI, 0.53-0.75) and not in those with dementia (adjusted HR, 1.04; 95%CI, 0.63-1.72; P = .541; HR after propensity score matching 0.91, 95%CI, 0.45-1.83; P = .785).
In patients aged ≥ 85 years with moderate-severe dementia and AF, oral anticoagulation was significantly associated with a lower embolic risk and a higher bleeding risk, with no differences in total mortality.
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Previous studies comparing physician’s views on prescribing demonstrate mixed results. Some have demonstrated that choices are similar, irrespective of specialty, level of training or years in practice [52], but that specialist physicians are more likely to initiate or discontinue certain medications with moderate-strong agreement [76–78]. In this study, respondents from ANZ had a greater number of geriatricians and formal training in palliative care, and more experience in treating people with dementia and advanced frailty.
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Stroke in the elderly
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Although the risk of serious hemorrhage associated with anticoagulation may be higher in elderly patients, several studies have shown that there remains a net clinical benefit of anticoagulation over antiplatelet therapy for many elderly and very elderly patients with AF (Singer et al., 2009; van Walraven et al., 2009; Marinigh et al., 2010; Ng et al., 2016). Risk of falls is an oft-cited reason for withholding anticoagulation in elderly patients with AF; however, this concern may be unfounded for most elderly patients with risk of falls (Man-Son-Hing and Laupacis, 2003; Dharmarajan et al., 2006). Available data suggest that the benefits of anticoagulation outweigh the risk of serious bleeding associated with falls in persons at high risk for stroke from AF (Man-Son-Hing et al., 1999; Gage et al., 2005).
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Persistence of warfarin therapy for residents in long-term care who have atrial fibrillation
2013, Clinical Therapeutics
Among long-term care (LTC) residents with atrial fibrillation (AF), the use of warfarin to prevent stroke has been shown to be suboptimal. For those who begin warfarin prophylaxis in LTC, persistence on this therapy has not been reported.
This study was conducted to estimate persistence on warfarin among LTC residents with AF.
A retrospective analysis was conducted by using data from an LTC database. Pharmacy dispensing data were used to track warfarin use in residents with a diagnosis of AF who were newly started on warfarin therapy. The main outcome measure was persistence of warfarin over the first year of therapy. Survival analysis included Kaplan-Meier plots and a multivariate Cox proportional hazards model to test the association of resident characteristics and conditions with warfarin discontinuation.
A total of 148 residents new to warfarin therapy met all study inclusion criteria. Median age was 84 years; 69% were female. Median time to therapy discontinuation was 197 days (95% CI, 137–249) across all study residents. By 90 days after the initiation of therapy, 37% (95% CI, 28–47) of study residents had discontinued warfarin; by 1 year, 65% (54%–76%) had discontinued warfarin therapy. The multivariate Cox regression analysis found that the following factors were independently associated with discontinuation of warfarin therapy: age 65 to 74 years (hazard ratio [HR] = 3.01 [95% CI, 1.04–8.73]), female sex (HR = 0.45 [95% CI, 0.24–0.87]), Hispanic race/ethnicity (HR = 2.86 [95% CI, 1.30–6.26]), Midwest region (HR = 2.13 [95% CI, 1.02–4.48]), and Alzheimer disease or dementia (HR = 1.97 [95% CI, 1.05–3.68]).
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: This study was internally funded as part of the Geriatric Medicine Fellowship program.

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Original studyTo Anticoagulate or not to Anticoagulate? A Common Dilemma for the Provider: Physicians’ Opinion Poll Based on a Case Study of an Older Long-term Care Facility Resident With Dementia and Atrial Fibrillation

Objective

Setting

Methods

Results

Conclusions

Section snippets

Survey Case

Participants

Answers to Question 1

Discussion

Conclusion

Chest

Mayo Clin Proc

Am J Cardiol

Am J Med

Chest

Int J Cardiol

Atrial fibrillation and stroke prevention with warfarin in the long term care setting

Arch Intern Med

Clinical practice guidelines. The use of oral anticoagulants (warfarin) in older people

J Am Geriatr Soc

Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillationAnalysis of pooled data from five randomized controlled trials

Arch Intern Med

J Am Coll Cardiol

Management of newly detected atrial fibrillationA clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians

Ann Intern Med

Prevalence and quality of warfarin use for patients with atrial fibrillation in the long term care setting

Arch Intern Med

Stroke prophylaxis in institutionalized elderly patients with atrial fibrillation

J Am Geriatr Soc

Anticoagulant-related bleeding in older persons with atrial fibrillation

Arch Intern Med

National trends in antiarrhythmic and antithrombotic medication use in atrial fibrillation

Arch Intern Med

Original study
To Anticoagulate or not to Anticoagulate? A Common Dilemma for the Provider: Physicians’ Opinion Poll Based on a Case Study of an Older Long-term Care Facility Resident With Dementia and Atrial Fibrillation