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Editorial: Elderly With A-Fib and Dementia Still Given Blood Thinners

In a disturbing article about our elderly living in nursing homes, a third of older patients with A-Fib and severe dementia were still given anticoagulants during the last 6 months of their lives. This is according to analysis of patients Medicare data.

According to study authors, Dr. Gregory Ouellet of Yale University and his colleagues, “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…This is counterintuitive since the potential benefits of these medications are the lowest in this group.”

“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,” Dr. Ouellet and colleagues wrote in their article.

Dr. Ouellet unexpectedly found that greater bleeding risk (their ATRIA score) was also associated with greater odds of anticoagulant use. The greater their risk of bleeding, the more likely these elderly A-Fib patients were to be on anticoagulants.

Improper use of anticoagulants can cause intracranial hemorrhage, bruising and excessive bleeding.

Nursing home length of stay was more strongly associated with anticoagulant use instead of the patients’ stroke risk (CHA2DS2-VASc score).

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.

That Makes No Sense! Is This the Way We Treat Our Elderly?

I was astounded to read this analysis found the greater their risk of bleeding, the more likely these elderly A-Fib patients were to be on anticoagulants. This improper use of anticoagulants can cause intracranial hemorrhage, bruising and excessive bleeding.

Nursing home patients with greater risk of bleeding should not be prescribed anticoagulants, but they were.

What this finding says is that many the nursing homes weren’t all that concerned about actual stroke risk when prescribing anticoagulants.

The most important treatment for elderly patients with severe dementia and limited life expectance is, as much as possible, to help their quality of life, to let them die in peace and as much comfort as possible.

Bleeding and Bruising are Unnecessary Suffering for our Elderly

What’s the point of giving these elderly patients drugs that don’t directly target symptoms such as pain? Besides the added risk of intracranial bleeding, the elderly are prone to other bleeding (extracranial and so-called nuisance bleeding and bruising) which diminish their well-being and quality of life.

Why increase the risk of adverse events without any clear benefit?

Many Nursing Homes Are Well Run, Others Aren’t

It’s notorious how so many nursing homes in the U.S. are poorly run. The staff working there are some of the lowest paid in the US.

There is little federal oversite and inspection. Many of these nursing homes are For-Profit Organizations and have little incentive to properly care for our elderly.

Sometimes Nursing Homes are the Only Option

My mother-in-law recently passed away at age 100 after living several years in an assisted living dementia unit. Though she had lost her short-term memory, she had wonderful care there along with support from family members (5 generations). In particular, her son and daughter-in-law were absolute saints in making sure she was well taken care of.

No one wants to put their elderly relative in a nursing home. But eventually that can become the only valid option. A good nursing home can be a great help, not only to the elderly but to their family as well.

What Can You Do?

Imagine you visit a nursery home to see your elderly relative who is suffering from A-Fib and dementia. You find them covered with bruises. How does this make you feel? What should you do?

It’s Up to You to Monitor the Nursing Home. Don’t expect the government to do It. You can’t assume the nursing home is treating your elderly relative properly. You have to visit and inspect as reasonably often as possible. You have to stay on top of them. If you are too busy, ask family members (teenagers, grandchildren) to help out. Or hire someone you trust.

Keep in Contact with the Director and Staff―Know Them Personally. Do you have the phone number of the Director? Are you monitoring your relative’s prescriptions and who is medicating them?

Do you know by name the main people who take care of your relative? Don’t hesitate to tip them generously. Remember, they aren’t paid much. If the nursing home prohibits their employees from taking tips, you have to be creative (e.g., send the staff edible goodies to share).

Know Your Regulators/Legislators. Do you know the agency responsible for monitoring your relative’s nursing home? Get a specific name and phone number so you can get your complaint heard. And follow up on it.

If your nursing home is run by a for-profit corporation, get the name and phone number of the CEO. It is possible to lose a license to run a Nursing Home, (though this rarely happens).

Often a word from your state representative or local official can get the attention of your nursing home administrator. Some officials really want to know if  our elders aren’t being treated properly.

Make a Difference for Your Elderly Loved Ones

Getting old in the US can be a horrible experience. As a country, we don’t care enough about our elderly. Make the Difference for your elderly loved ones.

Resources for this article

• George, Judy. Blood Thinners Continue at End of Life, Despite Risks—No clear guideline for stopping anticoagulants in patients with advanced dementia. MedPage Today, May 10, 2021. https://www.medpagetoday.com/neurology/dementia/92501

• Ouellet, G. et al. Anticoagulant use for atrial fibrillation among persons with advanced dementia at the end of life. JAMA Intern Med 2021. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2779424 doi:10.1001/jamainternmed.2021.1819

• Ouellet, Gregory M.; et al. Anticoagulant Use for Atrial Fibrillation Among Persons With Advanced Dementia at the End of Life. Research letter. JAMA Internal Medicine , Volume 181 (8) – Aug 10, 2021. https://www.deepdyve.com/lp/american-medical-association/anticoagulant-use-for-atrial-fibrillation-among-persons-with-advanced-qHPxqZdxjV?key=JAMA

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