Anticoagulation in advanced dementia needs a “rational strategy”

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A new study shows that one-third of nursing home residents with atrial fibrillation (FA) and advanced dementia remained in anticoagulation for the last 6 months of life, has highlighted the need for more information on the net clinical benefit of this treatment in this population.

The authors, led by Gregory M. Ouellet, MD, MHS, Yale School of Medicine, New Haven, Connecticut, point out that as dementia progresses, function is gradually but irretrievably lost, so the potential benefits of ‘anticoagulation to prevent stroke are attenuated more and more.

They used Medicare data to identify residents of nursing homes age 65 and older with advanced dementia and AF with at least moderate stroke risk and who died between 2014 and 2017.

They found that among 15,217 such patients (mean age 87 years), 33.1% received an anticoagulant in the last 6 months of life.

They report their findings in a research letter published online May 10 a JAMA Internal Medicine.

With the exception of hospice use, most indicators of high short-term mortality, such as difficulty swallowing, weight loss, and pressure ulcers, were associated with higher probabilities of use of hospice. anticoagulants. And counterintuitively, an increased risk of bleeding was also associated with higher probabilities of anticoagulant use.

“These findings highlight the lack of a rational strategy for managing anticoagulation in those with limited life expectancy due to age or disease,” the authors say.

They explain that while practice guidelines contain a well-defined threshold for initiating anticoagulation of AF, there is no clear standard for stopping it. Clinicians are asked to participate in decision-making shared with patients and their families.

Data on the benefits and harms of therapy are essential to this process, they say, but for patients with dementia there is little evidence available, although the magnitude of the benefits and harms is likely to change substantially as the disease progresses.

“Our work points to the need for high-quality data to inform anticoagulation decision-making in this population,” they conclude.

In an accompaniment Editor’s note, Anna L. Parks, MD, and Kenneth E. Covinsky, MD, MPH, University of California, San Francisco, write that in real-world practice, many patients with severe dementia have limited life expectancy and would choose to focus in the quality of life.

However, preventing the potential morbidity of stroke may still be within the goals of patients and families at the end of life. Others might argue that, for those with a limited prognosis, medications for chronic conditions that do not directly address symptoms (such as dyspnea or pain) increase the risk of adverse events without clear benefits, they write. But it lacks a rational strategy for managing anticoagulation in those with limited life expectancy due to age or disease.

They suggest that a more patient-centered framework is needed in this population to extend the traditional net clinical benefit of anticoagulation based on the difference between ischemic stroke reduction i intracranial hemorrhage risk.

“Consideration of the competitive risk of death from other causes, such as dementia or cancer, decreases the net clinical benefit of anticoagulation and should be incorporated,” Parks and Covinsky state. And the risks of bleeding should include so-called “annoying bleeding,” which is common and highly annoying for patients and which can decrease quality of life and well-being, they add.

They call for studies on aid for decision-making and clinical trials of dose reduction or description using this expanded definition of net benefit in this population.

“Our goal should be a framework that combines quantitative information with patient values ​​to guide physicians and patients toward individualized and informed decisions,” they conclude.

JAMA Int Med. Published online May 10, 2021. Summary, Editorial

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