To anticoagulate or not to anticoagulate? A common dilemma for the provider: Physicians' opinion poll based on a case study of an older long-term care facility resident with dementia and atrial fibrillation

Objective: Anticoagulation therapy is an acceptable strategy for the prevention of thromboembolic events in the presence of atrial fibrillation. However, this strategy is controversial in older subjects particularly in the presence of dementia. We conducted an opinion poll regarding the decision to anticoagulate or not among physicians in practice and in various levels of training (residents and fellows) that was based on a specific, yet not unusual, case scenario in the nursing home. Setting: A university teaching hospital in the Bronx, NY. Methods: A survey questionnaire was distributed to physicians to solicit opinions on the decision to anticoagulate based on an actual case from a LTCF and the results were analyzed. Results: One hundred seven completed surveys were returned from 49 residents, 20 fellows, and 38 attending physicians. The majority (85%) felt that long-term anticoagulation therapy was not indicated in the case patient. However, most (88%) felt they would provide an antiplatelet agent, with the choice being 78% aspirin, 20% clopridogel, and 2% aspirin-dipyridamole. The most cited reasons for not providing anticoagulation were risk of falls (98%), dementia (40%), and short life expectancy (32%). However, 92% of respondents felt that the patient was a candidate for short-term anticoagulation therapy. Interestingly, the choices (yes, no, uncertain) to the questions were similar for all physicians irrespective of their level of training or years in practice (or faculty) after training. Conclusions: Although long-term anticoagulation for thromboembolic events in atrial fibrillation is considered beneficial, recent reports suggest that warfarin is underused in older adults, especially in the long-term care setting. Our physician poll, based on a specific case scenario, is consistent with this opinion as reflected by both trainees and practicing physicians. While there are absolute and relative contraindications to the use of long-term warfarin, decisions should be individualized and based on risks, benefits, and quality of life of the resident.