麻豆传媒

A third of elderly people with severe dementia and atrial fibrillation received an anticoagulant drug during the last 6 months of their life, an analysis of Medicare patients showed.

Nursing home length of stay and not having Medicaid were more strongly associated with anticoagulant use compared with stroke risk ( score), reported Gregory Ouellet, MD, MHS, of Yale University in New Haven, Connecticut, and co-authors.

Greater bleeding risk ( score) was also associated with greater odds of anticoagulant use, they noted in a research letter.

"Anticoagulants are often continued in patients with atrial fibrillation even when they have advanced dementia, profound cognitive and functional impairments, and limited life expectancy," Ouellet said.

"We were surprised that patients with markers of very high short-term mortality -- for example, difficulty swallowing and weight loss -- were more likely to be receiving anticoagulants," he told 麻豆传媒.

"This is counterintuitive since the potential benefits of these medications are the lowest in this group," Ouellet continued. "This may be explained by a lack of clear guidelines for clinicians about when to continue and when to stop anticoagulants in this population."

Risks and benefits of therapeutic anticoagulation in severe dementia and other life-limiting illnesses have not been well studied, observed Anna Parks, MD, and Kenneth Covinsky, MD, MPH, both of the University of California San Francisco, in an .

"In real-world practice, many patients with severe dementia have limited life expectancy and would choose to focus on quality of life," they wrote.

"However, avoiding the potential morbidity of stroke may still be within patients' and families' goals at the end of life," they pointed out. "Others might argue that for those with limited prognosis, drugs for chronic conditions that do not directly target symptoms, such as dyspnea or pain, increase the risk of adverse events without clear benefit."

In their study, Ouellet and co-authors used Medicare data to evaluate 15,217 nursing home residents with atrial fibrillation and advanced dementia who had at least moderate stroke risk (CHA₂DS₂-VASc score of 2 or more) and who died from 2014 through 2017. People not enrolled in fee-for-service Medicare and those with claims for venous thromboembolism and valvular heart disease 2 years before death were excluded.

Mean age was about 88, and 68% were women. Greater odds of anticoagulant use were tied to:

• Nursing home length of stay of at least 1 year: OR 2.68
• Not having Medicaid: OR 1.59
• CHA₂DS₂-VASc score above 7: OR 1.38
• Pressure ulcers: OR 1.37
• ATRIA score above 7: OR 1.25
• Difficulty swallowing: OR 1.12
• Weight loss: OR 1.09

Lesser odds of anticoagulant use were associated with advanced age (over 80 or 90), female sex, and those who required restraints or who were enrolled in hospice.

Traditionally, the net clinical benefit of anticoagulation has been driven by the difference between ischemic stroke reduction and intracranial hemorrhage risk, Parks and Covinsky noted. "A more patient-centered framework would expand this narrow definition of net clinical benefit," they wrote.

Factoring in competing risk of death from other causes like dementia "decreases the net clinical benefit of anticoagulation and should be incorporated," they suggested. "Clinicians already report considering geriatric syndromes such as disability and cognitive impairment during risk assessment for anticoagulation, so these should be formally integrated, given their impact on quality of life."

Bleeding events should not be limited to intracranial hemorrhage "because extracranial and so-called nuisance bleeding are common and highly bothersome to patients and can diminish quality of life and well-being," Parks and Covinsky added. "Studies of decision-making aids and dose reduction or deprescribing clinical trials using this expanded net benefit definition should be performed in this population."

The research was limited by its cross-sectional design and reflected data only about patients in nursing homes with atrial fibrillation and advanced dementia, Ouellet and co-authors noted. Still, it highlights the need for better evidence to inform anticoagulation decisions in this population, they said.

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