Unnecessary care? 1 in 3 patients with advanced dementia and AFib still given anticoagulants
Nearly 20% of patients with dementia also have atrial fibrillation (AFib), a combination that typically results in anticoagulants being prescribed to reduce the risk of stroke.
When the patient has advanced dementia and is in the final months of their life, however, should they still be given anticoagulants? The team behind a new analysis in JAMA Internal Medicine evaluated that very topic.
“As dementia progresses, function is gradually but irretrievably lost, so that the potential benefits of preventing a stroke become increasingly attenuated,” wrote lead author Gregory M. Ouellet, MD, a specialist in the department of internal medicine at Yale School of Medicine, and colleagues. “In advanced dementia, patients develop profound cognitive deficits; require help with basic self-care activities, including eating; and have a very limited life expectancy. Our objective was to determine how often anticoagulation is continued among nursing home residents in this final stage of life and to examine clinical associations of its use.”
Reviewing Medicare data from 2014 to 2017, the team found that 33.1% of nursing home residents with advanced dementia and AFib were taking anticoagulants in the last six months of their lives. Patients with higher CHA2DS2VASC stroke risk scores, longer nursing home stays, significant weight loss had a higher likelihood of still being on anticoagulants. Patients on Medicaid, meanwhile, were less likely to still be on anticoagulants.
“These findings underscore the fact that, while practice guidelines contain a well-defined threshold for starting anticoagulation for AF, there is no clear standard for stopping it,” the authors wrote. “Clinicians are instead asked to engage in shared decision-making with patients and their families. 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.”
In a separate commentary, also published in JAMA Internal Medicine, the authors observed that this analysis underscores “the lack of a rational strategy for managing anticoagulation in those with limited life expectancy owing to age or illness.”
“In real-world practice, many patients with severe dementia have limited life expectancy and would choose to focus on quality of life,” wrote authors Anna L. Parks, MD, and Kenneth E. Covinsky, MD, both of the University of California, San Francisco. “However, avoiding the potential morbidity of stroke may still be within patients’ and families’ goals at the end of life. 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.”
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.