Thrombotic Risk and Immobility in Residents of Long-Term Care Facilities

Background: Hospitalized patients and residents of long-term care (LTC) facilities account for about 60% of all cases of venous thromboembolism (VTE), as incidence is correlated with increasing age, immobility, and underlying medical conditions. The primary aim of the study was to develop an evidence-based VTE risk stratification tool and definition of immobility for residents in LTC facilities. Methods: Using the Delphi process, a panel of vascular thrombotic and geriatric experts reviewed and ranked statements of VTE risk and immobility derived from randomized controlled trials, meta-analyses, cohort trials, case-control trials, and case series to arrive at consensus for the importance of each statement. Rating was conducted before and during an on-site meeting following discussion. Statements rated high and very high were used to develop a VTE risk stratification and immobility tool. Results: A total of 1165 publications related to VTE risk were identified from which 137 (12%) pertained to subjects with a median age of 60 years or older; 42 (31%) met study criteria. Eight (29.6%) of 79 publications pertaining to immobility met study criteria. There were 4 studies related to VTE risk and 1 to immobility that were rated as high quality. VTE risk factors were age older than 60 years, active cancer, acute infectious disease, catheter in a central vein, chronic obstructive pulmonary disease, dehydration, history of VTE, having a first-degree relative with VTE, heart failure, hypercoagulable state, immobility, inflammatory bowel disease, obesity, rheumatoid arthritis and treatment with erythroid stimulating agents to a hemoglobin value greater than 12 g/dL, aromatase inhibitor, hormone replacement therapy, megestrol acetate, or selective estrogen receptor modulators. Immobility was defined as the presence of at least 1 of the following: being bedridden or bedridden except for bathroom privileges, unable to walk at least 10 feet, recent reduction in ability to walk at least 10 feet for at least 72 hours, and having a lower limb cast. Conclusions: A risk stratification tool for VTE and immobility was developed to assist clinicians in caring for residents of LTC facilities. A prospective trial is needed to validate the tool. (J Am Med Dir Assoc 2010; 11: 211-221)