Nearly a third of nursing home residents with atrial fibrillation and advanced dementia received an anticoagulant drug in the last six months of life, a cross-sectional study showed.
Among factors increasing odds of anticoagulation were higher risks for both thromboembolic strokes and bleeding, according to Gregory M. Ouellet, MD, MHS, of Yale University in New Haven, Connecticut, and colleagues.
“These findings underscore the fact that, while practice guidelines contain a well-defined threshold for starting anticoagulation for AFib, there is no clear standard for stopping it,” Ouellet and co-authors wrote in research letter in JAMA Internal Medicine.
“Clinicians are instead asked to engage in shared decision-making with patients and their families,” they added. “Data about the benefits and harms of therapy are essential to that process. For patients with dementia, little such evidence is available, although the magnitudes of benefits and harms are likely to change substantially as the disease progresses.”
The group used Medicare data to identify 15,217 nursing home residents with atrial fibrillation and advanced dementia (mean age 87.5 years and approximately 68% women). During their last six months of life — all patients died between January 2014 and December 2017 — 33.1% received an anticoagulant.
Included patients had a CHA2DS2VASC thromboembolic risk score ≥2 (higher scores indicate higher risk, with a maximum score of 9). All patients had advanced dementia based on cognitive scores and complete dependence for all activities of daily life. The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) score, which predicts annual bleeding risk in people with atrial fibrillation who are anticoagulated, was also included in the analysis (age ≥75 years 2 points; anemia 3 points; renal disease 3 points; prior bleeding 1 point, and hypertension 1 point)
In multivariable logistic regression, greater odds of anticoagulant use were seen with:
- CHA2DS2VASC vascular risk score >7, OR 1.38 (95% CI 1.23-1.54).
- ATRIA score >7, OR 1.25 (95% CI 1.13-1.39).
- Nursing home length of stay of at least 1 year, OR 2.68 (95% CI 2.48- 2.89).
- Not having Medicaid, OR 1.59 (95% CI 1.45-1.69).
- Weight loss, OR 1.09 (95% CI 1.01-1.18).
- Pressure ulcers, OR 1.37 (95% CI 1.27-1.48).
- Difficulty swallowing, OR 1.12 (95% CI 1.02-1.22).
“These findings highlight the lack of a rational strategy for managing anticoagulation in those with limited life expectancy owing to age or illness,” wrote Anna L. Parks, MD, and Kenneth E. Covinsky, MD, MPH, both of the University of California, San Francisco, in an accompanying editor’s note. “Guidelines suggest periodic reevaluation of anticoagulation to reassess stroke and bleeding risks. However, there is a dearth of information on how to implement this because seriously ill, frail patients are understudied in both clinical trials and observational research.”
“Traditionally, the net clinical benefit of anticoagulation is driven by difference between ischemic stroke reduction and intracranial hemorrhage risk,” they added. “A more patient-centered framework would expand this narrow definition of net clinical benefit. Consideration of the competing risk of death from other causes, such as dementia or cancer, decreases the net clinical benefit of anticoagulation and should be incorporated.”
Overall, anticoagulation has clear benefits of ischemic stroke reduction and other conditions, as well as clear harms. This is reflected in the proportion of people not anticoagulated after discharge for ischemic stroke with high risk for recurrence (i.e., atrial fibrillation) — 44% in a 2017 study that also found a one-year death rate of 42.5% for those who were not receiving oral anticoagulation at discharge versus 19.1% of those who were.
In the current study, association with lesser odds of anticoagulation was seen with:
- Age 80-89 years, OR 0.82 (95% CI 0.74-0.92); ≥90 OR 0.59 (95% CI 0.52-0.66).
- Female sex, OR 0.88 (95% CI 0.81-0.95).
- Requiring restraints, OR 0.79 (95% CI 0.66-0.95).
- Being enrolled in hospice, OR 0.76 (95% CI 0.70-0.83).
“Balancing the tradeoffs required for anticoagulation will remain challenging in patients with limited life expectancy,” Parks and Covinsky wrote. “Our goal should be a framework that combines quantitative information with patients’ values to guide clinicians and patients toward individualized and informed decisions.”
The study is limited by its cross-sectional design and includes only persons with atrial fibrillation and advanced dementia in the nursing home setting, Ouellet and colleagues noted. “Nonetheless, our work points to the need for high-quality data to inform decision-making about anticoagulation in this population,” they wrote.
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Nearly a third of nursing home residents with atrial fibrillation and advanced dementia received an anticoagulant drug in the last six months of life, a cross-sectional study showed.
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Among factors increasing odds of anticoagulation were higher risks for both thromboembolic strokes and bleeding.
Paul Smyth, MD, Contributing Writer, BreakingMED™
Support for data from the Centers for Medicare and Medicaid Services was provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center.
Ouellet reported receiving grants from the National Institutes of Health during the conduct of the study.
Parks and Covinsky reported receiving grants from the National Institute on Aging.
Cat ID: 913
Topic ID: 74,913,282,494,730,913,130,255,925
