Atrial fib: anticoag use when advanced dementia

 In an interesting data-mining study, 1/3 of nursing home patients with advanced dementia and atrial fibrillation received anticoagulation in the last 6 months of their lives (see afib anticoag in advanced dementia jamaintmed2021 in dropbox, or doi:10.1001/jamainternmed.2021.1819 ) 

 

Details: 

-- 15,217 nursing home residents with atrial fibrillation (AF) and advanced dementia were assessed 

-- data from Medicare to identify nursing home resident 65 years or older with advanced dementia and AF with at least a moderate stroke risk, CHA₂DS₂VASC score at least 2, and who died between January 1, 2014 and December 31, 2017. Data analyzed from October 1 to December 30, 2020 

    -- advanced dementia was defined as a diagnosis of Alzheimer’s or other dementia, Cognitive Performance Score of 5 or 6, and dependence in all activities of daily living on 2 Minimum Data Set assessments within the last 6 months of life. This was cross-referenced with the Chronic Condition Warehouse flag indicating atrial fibrillation 

        -- those with venous thromboembolism and vascular heart disease in the 2 years prior to death were excluded 

-- mean age 88, 68% women 

-- falls in 32%, weight loss  36%, pressure ulcer 35%, difficulty swallowing 21%, restraints used 4%, hospice 29% 

-- CHA₂DS₂VASC score: <4 in 15%, 5-6 in 40%, >7 in 44% 

    -- CHA₂DS₂VASC is based on age 65-74 (1 point); age >74 (2 points); previous stroke or TIA (2 points); heart failure/hypertension/diabetes/vascular disease (PAD, prior MI, aortic plaque), female (1 point each), with maximum of 9 points

-- ATRIA (Anticoagulation and risk Factors in Atrial Fibrillation) bleeding risk score: < 3 in 18%, 4 to 6 in 35%, greater than 7 in 46% 

    -- the ATRIA is based on age >74 (2 points), anemia (3 points), eGFR <30 or dialysis (3 points), prior hemorrhage (1 point), hypertension history (1 point), with maximum of 10 points

        -- bleeding history was determined by using inpatient billing codes from 2 years prior to death 

-- the CHA₂DS₂VASC and the ATRIA scores provide insight into the likelihood of cardiovascular events and bleeding risk 

Results: 

-- 33% (5033 individuals) were on anticoagulation in the last 6 months of life 

-- in multi-multivariable logical regression, the following were found to be statistically associated with anticoagulant use: 

    -- CHA₂DS₂VASC score >7: OR 1.38 (1.23-1.54) 

    -- ATRIA score >7: OR 1.25 (1.13-1.39) 

    -- nursing home length of stay of at least one year: OR 2.68 (2.48-2.89) 

    -- not having Medicaid, OR 1.59 (1.45-1.69) 

    -- weight loss: OR 1.09 (1.01-1.18) 

    -- pressure ulcers: OR 1.37 (1.27-1.48) 

    -- trouble swallowing: OR 1.12 (1.02-1.22) 

 

-- Lower odds of being on anticoagulants, by multivariable logistical regression: 

    -- age 80- 89: OR 0.82 (0.74-0.92) 

    -- age >89: OR 0.59 (0.52-0.66) 

    -- female sex: OR 0.88 (0.81-0.95) 

    -- requiring restraints: OR 0.79 (0.66-0.83) 

    -- enrolled in hospice: OR 0.76 (0.70-0.83) 

 

Commentary: 

-- overall, atrial fibrillation increases with age, being around 10% of those at least 80 years old; and atrial fibrillation is responsible for about 20% of all ischemic strokes (perhaps more so in those with dementia) 

    -- a Swedish study found that 16% of people with dementia have atrial fibrillation; treatment with warfarin led to a 24% lower risk of ischemic stroke (see Treatment of Atrial Fibrillation in Patients with Dementia: A Cohort Study from the Swedish Dementia Registry - IOS Press ). This was an observational study and those chosen to be on anticoagulants may well have been a healthier population where decreasing ischemic stroke may have been in much more important goal. Mortality was also lower in this study (also a selection bias??) 

-- by age criteria alone, almost all nursing home residents would meet criteria for anticoagulation by their CHA₂DS₂VASC scores 

-- but, the overall clinical benefit of using anticoagulants likely decreases as the dementia worsens, but the risk of bleeding may increase (increased risk falls, etc.), and the life expectancy overall decreases 

-- this study confirmed that a high proportion of this group of nursing home residents with advanced dementia in the last 6 months of their lives were continued on anticoagulation 

-- interestingly, the strongest predictors of being on continued anticoagulation were being in the nursing home >1 year and not being on Medicaid (a high CHA₂DS₂VASC or ATRIA score were much less significant) 

    --were those in the nursing home longer not re-evaluated so rigorously?

    --were those not on Medicaid treated differently? were the reimbursement rates different so they were taken off meds and, in the case of warfarin, need for lab testing? were there discriminatory practices based on finances? race/ethnicity?

-- this study highlights the issue in many guidelines (including the AF ones), which have pretty clear suggestions as to when to start a test or intervention (anticoagulation here) but some nonspecific suggestion as to when to stop, often with the comment that clinicians should engage in “shared decision making” on when to stop. But, we need real data to have such shared decision making....

 

Limitations: 

--limited granular data to see if there was more of a differentiation between those on anticoagulants or not. Were those on continued anticoagulation fundamentally different and ??might have had more benefit from the anticoagulation. was the anticipation 6 months prior to their death that they would have lived longer and perhaps had more benefit from anticoagulation? 

--as an observational study finding lots of people at the end of their lives were on anticoagulation, we are not able to draw definitive conclusions (were there unmeasured confounders that led to these results?? is it actually wrong to continue anticoagulation?) 

--this study was in nursing home residents, who might have been different from those in the community, limiting generalizability of the results 

--this study only dealt with people with “advance dementia”. What about those with lesser dementia and being on anticoagulation? 

 

So, the reason I assess the study is a general one:  

--I think that overall in a busy primary care practice, patients often have an accretion of medications over time (i.e., new medications are added and older medications are simply continued if the problem is no longer an active one). And, I really understand this issue, since older people in particular typically have many medical problems that are being evaluated, and spending time reviewing problems that are stable may not be doable in the context of relatively brief primary care visits

    -- for example, many patients on PPIs remain on them forever (studies have shown that those who are started on PPIs are rarely stepped down to less aggressive anti-acid treatments, whereas those on these lesser treatments may never need to be stepped up to PPIs) 

--this study should not be interpreted to mean that we should necessarily stop anticoagulants in people with advanced dementia in the nursing home. It really only finds that a lot of people are still treated with them 

    -- but, the study does raise the issue that many medications may not be necessary in patients at the end of their lives, and may be associated with more harms (e.g. it may make sense to decrease anti-diabetic medications in those who are 93 years old and have an A1c of 7.2, since a potential harm from their decreased eating because of fatigue/feeling pooorly/food insecurity etc may well outweigh the benefit of that level of diabetic control, despite its perhaps making us feel better about our treatment effects).   

    -- the real overarching issue is that we really need good data to make informed decisions. Does harm exceed benefit in keeping patients on anticoagulants who have advanced dementia and AF? What level of age/comorbidities/dementia level does the benefit outweigh the risks? Or at what age/comorbidities/other factors should we not have the same blood sugar or blood pressure goals? 

And, good data really only comes from good studies…. 

geoff

 

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