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

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

They used Medicare data to identify nursing home residents 65 years or older with advanced dementia and AF who had at least moderate stroke risk and who died between 2014 and 2017.

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

They report their findings in a research letter published online May 10 in 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 greater odds of anticoagulant use. And counterintuitively, greater bleeding risk was also associated with greater odds of anticoagulant use.

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

They explain that while practice guidelines contain a well-defined threshold for starting anticoagulation for AF, there is no clear standard for stopping it. 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, they say, but for patients with dementia there is little such evidence available, although the magnitudes of benefits and harms are likely to change substantially as the disease progresses.

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

In an accompanying 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 on quality of life.

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, they write. But there is a lack of a rational strategy for managing anticoagulation in those with limited life expectancy owing to age or illness.

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

“Consideration of the competing 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 bleeding risks should include so-called “nuisance bleeding,” which is common and highly bothersome to patients and can diminish quality of life and well-being, they add.

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

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

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

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