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Anticoagulation in Atrial Fibrillation: What Decides? Patient Status, Provider Opinion, or Both?
11. Torn M, Bollen WLEM, van der Meer FJM, et al. Risks of oral anticoagulant therapy with increasing age. Arch Intern Med 2005;165:1527–1532. 12. Gage BF, Birman-Deych E, Kerzner R, et al. Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall. Am J Med 2005;118:612– 617. 13. Gage BF, Birman-Deych E, Radford MJ, et al. Risk of osteoporotic fracture in elderly patients taking warfarin. Arch Intern Med 2006;166:241–246. 14. Quilliam BJ, Lapane KL, Eaton CB, Mor V. Effect of antiplatelet and anticoagulant agents on risk of hospitalization for bleeding among a population of elderly nursing home stroke survivors. Stroke 2001;32: 2299 –2304. 15. Man-Son-Hing M, Laupacis A. Anticoagulant-related bleeding in older persons with atrial fibrillation: Physicians fears often unfounded. Arch Intern Med 2003;163:1580 –1586. 16. Bootman JL, Harrison Dl, Cox E. The health care cost of drug-related morbidity and mortality in nursing facilities. Arch Intern Med 1997;157: 2089 –2096. 17. Desbiens NA. Deciding on anticoagulating the oldest old with atrial fibrillation: Insights from cost-effectiveness analysis. J Am Geriatr Soc 2002;50:863– 869.
DOI: 10.1016/j.jamda.2006.03.005
The difficulties were well brought out by a recent case study of a high-risk 83-year-old nursing home resident with atrial fibrillation and numerous comorbidities, on numerous medications from different physicians.4 Interestingly, our findings were also somewhat similar to those noticed in a survey nearly a decade ago when only a small number (12%) of providers opted to initiate anticoagulation for a frail long-term care resident with atrial fibrillation in the presence of comorbidities.5 At that time, the thought process and guidelines for anticoagulation in atrial fibrillation were less stringent than today! The findings indicate that physicians continue to think similarly today because of difficulties perceived in the frail elderly regarding risks of anticoagulation, coupled with difficulties in maintaining clotting parameters in a therapeutic range.4 We encourage providers across the country to respond and comment and to revisit their own opinions regarding anticoagulation therapy in such a setting. T.S. Dharmarajan, MD Anna S. Lebelt, MD Edward P. Norkus, PhD New York Medical College Our Lady of Mercy Medical Center Bronx, NY
Anticoagulation in Atrial Fibrillation: What Decides? Patient Status, Provider Opinion, or Both? To the Editor: We are pleased with the responses that our survey on anticoagulation for atrial fibrillation in the nursing home resident in a specific setting1 has elicited. Another recent response from a researcher commented on our survey in a teaching intuition and “welcomed future extensions of the study to different facilities with a variety of demographic characteristics as well as to NH clinicians rather than the physician community.”2 Dr Cheng brings up a number of points that are consistent with and in agreement with the overall conclusions made in our article, that long-term anticoagulation therapy for thromboembolic events in atrial fibrillation may be a beneficial option in some but not all cases, whether in long-term care facilities or elsewhere.3 Both we and Dr Cheng agree that absolute and relative contraindications for long-term warfarin use exist and that the ultimate “decisions should be individualized and based on risks, benefits, and quality of life of the resident.”1 We believe that our article, Dr Cheng’s letter, and the references cited by both of us provide a sound basis for discussions regarding the difficulties involved with decision making on anticoagulation therapy, particularly in older residents in nursing homes. Issues of coexisting disease, cognitive and functional status of the patient, prior experiences with anticoagulation, life expectancy, and quality of life play important roles in deciding the course of action. The approach always should focus on the individual resident’s requirements while considering guidelines, but the provider has the ultimate decision-making responsibility; hence we agree for the need for more studies on this subject as recently suggested.2 Further, we concur with Dr Cheng, that guidelines hardly consider the comorbid status and potential for drug interactions particularly applicable to the nursing home resident. LETTERS TO THE EDITOR
REFERENCES 1. Dharmarajan TS, Varma S, Akkaladevi S, Lebelt AS, Norkus EP. To anticoagulate or not to anticoagulate? A common dilemma for the providers: Physicians’ opinion poll based on a case study of an older long-term care facility resident with dementia and atrial fibrillation. J Am Med Dir Assoc 2006;7:23–28. 2. Messinger-Rapport BA. The nursing home physician’s point of view on warfarin use. J Am Med Dir Assoc 2006;7:133–134. 3. Cheng H. Why health care providers don’t prescribe warfarin to a frail nursing home resident with atrial fibrillation. J Am Med Dir Assoc 2006, accompanying letter. 4. Warhaftig ML. Anticoagulation in a high risk nursing home resident. Annals of Long Term Care 2005;23:36 – 42. 5. Monette J, Gurwitz JH, Rochson PA, Avorn J. Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: Results of a survey of long-term care practitioners. J Am Geriatr Soc 1997;45:1060 – 1065.
DOI: 10.1016/j.jamda.2006.03.007
Effects of Group-Home Care on Behavioral Symptoms, Quality of Life, and Psychotropic Drug Use in Patients With Frontotemporal Dementia To the Editor: Patients with frontotemporal dementia (FTD), a relatively rare neurodegenerative dementia,1 present with various behavioral and psychological symptoms, including disinhibition, stereotypy, aggression, impulsivity, indifference, and aphasia. Therefore, FTD care is very difficult and distressing for caregivers. Several recent trials showed that the efficacy of atypical antipsychotic drugs and selective serotonin reuptake inhibitors reduced the behavioral and psychological symptoms LETTERS TO THE EDITOR 335
DOI: 10.1016/j.jamda.2006.03.005
The difficulties were well brought out by a recent case study of a high-risk 83-year-old nursing home resident with atrial fibrillation and numerous comorbidities, on numerous medications from different physicians.4 Interestingly, our findings were also somewhat similar to those noticed in a survey nearly a decade ago when only a small number (12%) of providers opted to initiate anticoagulation for a frail long-term care resident with atrial fibrillation in the presence of comorbidities.5 At that time, the thought process and guidelines for anticoagulation in atrial fibrillation were less stringent than today! The findings indicate that physicians continue to think similarly today because of difficulties perceived in the frail elderly regarding risks of anticoagulation, coupled with difficulties in maintaining clotting parameters in a therapeutic range.4 We encourage providers across the country to respond and comment and to revisit their own opinions regarding anticoagulation therapy in such a setting. T.S. Dharmarajan, MD Anna S. Lebelt, MD Edward P. Norkus, PhD New York Medical College Our Lady of Mercy Medical Center Bronx, NY
Anticoagulation in Atrial Fibrillation: What Decides? Patient Status, Provider Opinion, or Both? To the Editor: We are pleased with the responses that our survey on anticoagulation for atrial fibrillation in the nursing home resident in a specific setting1 has elicited. Another recent response from a researcher commented on our survey in a teaching intuition and “welcomed future extensions of the study to different facilities with a variety of demographic characteristics as well as to NH clinicians rather than the physician community.”2 Dr Cheng brings up a number of points that are consistent with and in agreement with the overall conclusions made in our article, that long-term anticoagulation therapy for thromboembolic events in atrial fibrillation may be a beneficial option in some but not all cases, whether in long-term care facilities or elsewhere.3 Both we and Dr Cheng agree that absolute and relative contraindications for long-term warfarin use exist and that the ultimate “decisions should be individualized and based on risks, benefits, and quality of life of the resident.”1 We believe that our article, Dr Cheng’s letter, and the references cited by both of us provide a sound basis for discussions regarding the difficulties involved with decision making on anticoagulation therapy, particularly in older residents in nursing homes. Issues of coexisting disease, cognitive and functional status of the patient, prior experiences with anticoagulation, life expectancy, and quality of life play important roles in deciding the course of action. The approach always should focus on the individual resident’s requirements while considering guidelines, but the provider has the ultimate decision-making responsibility; hence we agree for the need for more studies on this subject as recently suggested.2 Further, we concur with Dr Cheng, that guidelines hardly consider the comorbid status and potential for drug interactions particularly applicable to the nursing home resident. LETTERS TO THE EDITOR
REFERENCES 1. Dharmarajan TS, Varma S, Akkaladevi S, Lebelt AS, Norkus EP. To anticoagulate or not to anticoagulate? A common dilemma for the providers: Physicians’ opinion poll based on a case study of an older long-term care facility resident with dementia and atrial fibrillation. J Am Med Dir Assoc 2006;7:23–28. 2. Messinger-Rapport BA. The nursing home physician’s point of view on warfarin use. J Am Med Dir Assoc 2006;7:133–134. 3. Cheng H. Why health care providers don’t prescribe warfarin to a frail nursing home resident with atrial fibrillation. J Am Med Dir Assoc 2006, accompanying letter. 4. Warhaftig ML. Anticoagulation in a high risk nursing home resident. Annals of Long Term Care 2005;23:36 – 42. 5. Monette J, Gurwitz JH, Rochson PA, Avorn J. Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: Results of a survey of long-term care practitioners. J Am Geriatr Soc 1997;45:1060 – 1065.
DOI: 10.1016/j.jamda.2006.03.007
Effects of Group-Home Care on Behavioral Symptoms, Quality of Life, and Psychotropic Drug Use in Patients With Frontotemporal Dementia To the Editor: Patients with frontotemporal dementia (FTD), a relatively rare neurodegenerative dementia,1 present with various behavioral and psychological symptoms, including disinhibition, stereotypy, aggression, impulsivity, indifference, and aphasia. Therefore, FTD care is very difficult and distressing for caregivers. Several recent trials showed that the efficacy of atypical antipsychotic drugs and selective serotonin reuptake inhibitors reduced the behavioral and psychological symptoms LETTERS TO THE EDITOR 335