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
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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2019, MaturitasCitation Excerpt :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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2019, Handbook of Clinical NeurologyCitation Excerpt :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).
Persistence of warfarin therapy for residents in long-term care who have atrial fibrillation
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This study was internally funded as part of the Geriatric Medicine Fellowship program.