Eliquis questions

MissOldMom

My mom,who recently fell, is in physical therapy and occupational rehab hospital right now. She is scheduled to probably be released in a few weeks, and she may or may not be walking on her own by then. I had reported the fall to her heart doctor because she also is on again off again in A-fib and has been for a very long time. They are able to manage it well enough with amiodarone 200 mg twice a day. That is a very high dose and we know that. However, the middle of the road medicine really wouldn’t keep her out of A-fib, and she refuses to get a pacemaker. She has expressed to us that she does not want to be kept alive just to be alive. She has made that very clear and has a do not resuscitate order and all of that. Because of reporting the fall to her heart doctor, they have said they cannot support giving her Eliquis anymore because if she falls again and hits her head, she could have a brain bleed. I do understand that. But the Eliquis is part of what keeps her from being a high risk of stroke or blood clot. I don’t understand the reasoning of taking her off of something that’s actually helping her because of something that may or may not happen in the future. That seems beyond proactive to me, it seems actually negligent. I’m trying to get a second opinion from a different doctor, but I just wanted to see if anybody else had had a similar situation where their parent was removed from Eliquis because of a possible future fall, not because of the fall that just happened. Something in the future that may or may not happen doesn’t seem like a good enough reason to me to remove from actually helping her in another way. TIA

easy23

My husband had a partial amputation of his foot. He is temporarily in a wheelchair. He recently saw his cardiologist for a fib. The cardiologist discussed the possibility of taking him off Eliquis if he risks falling once he is walking again.

harshedbuzz

@MissOldMom

I am so sorry you find yourself in this place where you feel she isn't getting the treatment you'd prefer for her.

Even if the reason mom is in a subacute setting for rehab for a reason unrelated to the recent fall, the risk/benefit balance between Eliquis vs no Eliquis shifts as the dementia progresses. It sounds like that's where she is now.

At some point, it's not "Something in the future that may or may not happen"— PWD do fall in the later stages and despite putting appropriate safety measures in place, you can't beat gravity. Even those PWD who use wheelchairs and Broda chairs exclusively fall out of them. Bedbound patients roll out of bed onto the floor. Federal regulations that prevent the use of restraints mean you can't belt her in and probably can't use rails on a hospital bed.

It might be helpful to talk about what this looks like with her doctors (PCP, neurology and/or cardiology) or perhaps a social worker. What would a stroke or heart attack caused by a stroke or heart attack be like for her to experience? What would a brain bleed be like for her to experience? What would be her QOL if she did survive it? If she didn't survive in either scenario, what would her final days/moments be like?

Again, I am sorry you are dealing with this heartbreaking scenario.
HB

MissOldMom

https://alzconnected.org/discussion/comment/249420#Comment_249420

thank you for responding. Do you agree or disagree with what the Dr has said? I’m just curious why something that hasn’t happened yet would cause the decision by a Dr. Any insight is much appreciated.

MissOldMom

Thank you for commenting. I had not thought of it that way and this is something for me to consider more for sure. I appreciate the insight.

easy23

https://alzconnected.org/discussion/comment/249422#Comment_249422

I’m not sure if I agree or disagree with his suggestion. I haven’t decided what to do yet. I look forward to reading other replies!

SDianeL

what stage is your Mom and what is her age? Once the elderly and dementia patients fall it usually means they are a fall risk and it will happen again. As HB said there is no way to fully prevent falls. Someone on this forum posted that if you need to make tough decisions to play the scenarios all the way out, with the understanding that the disease is progressive.. Bleeding vs heart attack or stroke. Sorry you are having to make this difficult decision. 💜

MissOldMom

https://alzconnected.org/discussion/comment/249470#Comment_249470

Thank you for your reply. She is in stage 4 for sure. She shows some beginnings of stage 5. With her using her walker for every single time she gets up I guess I didn’t think this could happen as easily. And we do feel that she would have fallen a long time ago without it. Even with it, she fell (it was 3 in the morning and we actually found it on camera recorded and it looks like she simply lost her balance or her knee gave out). So more than likely she’ll need some in-home nursing even though they will send PT about 3 times a week once she’s out and back with us. While we realize this is a progressive disease, I think it was just a shock to us all that not only will she more than likely fall again but that her Eliquis is going to be stopped. What do we do about the risk of stroke and blood clot now? It almost seems like they are taking away one help (reduce risk of blood clots and stroke) to serve another (if she falls and hits her head then a brain bleed would be less likely) and it’s confusing.

harshedbuzz

@MissOldMom Circling back to your question, I did a lit search and found that some experts do see the balance between aggressive treatment of Afib with blood thinners vs fall risk resulting in brain bleeds differently than your doctor. This should be a decision decided by patient (of POA) and doctor together.

Anticoagulant use in older persons at risk for falls: therapeutic dilemmas—a clinical review - PMC

Fall risk and anticoagulation for atrial fibrillation in the elderly: A delicate balance | Cleveland Clinic Journal of Medicine

Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review - PubMed

That said, s/he may parse the situation in the context of the Hippocratic Oath's "do no harm"; death from a brain bleed caused by aggressive use of blood thinners as an avoidable death caused a prescription they wrote vs nature taking its course. It's also possible that the clinician's reluctance to prescribe is informed by their knowledge of end-stage dementia.

Having some knowledge of one death from Afib and watching several people die in the later stages of dementia, I would perhaps see aggressive treatment of any potentially terminal illness in a PWD, especially not someone with AO (in their 60s, say) or in midstages+, as denying them an exit ramp from what can be a horrific experience. My BIL died in his sleep from complications of Afib. He was an ER doc who had a mechanical fall that resulted in a brain bleed that ended his career; he had also elected not to have an internal defibrillator (because it removes the possibility of dying peacefully in one's sleep) or pacemaker (to avoid his wife or kids having to decide to deactivate it). BIL had a gentler passing than my friend's mom or either of my aunts who died from dementia complications. Dad was peaceful in the last week of his life, but the 18 months prior were very difficult for him and for us as a family.

If your mom is living alone, it may be time to reconsider that. Especially if you decide to continue with Eliquis. A transfer from rehab to an AL or MCF would be more easily done than doing so from her home at a later date.

When mom and I went over her Advanced Directive 2 years ago, I had her read this book to help her understand the consequences of certain medical interventions. I think it's valuable for all families to read.

Hard Choices for Loving People: CPR, Feeding Tubes, Palliative Care, Comfort Measures, and the Patient with a Serious Illness, 6th Ed.: Hank Dunn: 9780997261202: Amazon.com: Books

HB

JulietteBee

I think if you look at both options as prophylactic or preventative, you will see that no one option is better than the another. It boils down to preference.

Eliquis does nothing to stop Afib. It is used to minimize the risk of her heart pumping out clots while it is in an arrhythmia.

Deprescribing the Eliquis is suggested as a way to minimize the risk of a brain bleed should she have another fall.

Neither event has happened! They are both hypothetical. Prescribing AND deprescribing are what you could call loss prevention methods.

Her cardiologist is now saying that HE believes she has a higher likelihood of falling, than she has of throwing a clot & suffering a stroke. I disagree wholeheartedly.

My mom is 83. She has Afib. She is on Eliquis. As a nurse, there is zero likelihood that I would allow her doctor to take her off Eliquis.

There are lifestyle modifications I can make to ensure she does not fall. There are no accommodations I can make to prevent her from throwing a clot during one of her Afib episodes.

I hope this helps. 🙏🏽

harshedbuzz

@JulietteBee said

There are lifestyle modifications I can make to ensure she does not fall. There are no accommodations I can make to prevent her from throwing a clot during one of her Afib episodes.

With all due respect to your education and lived work experience, I cannot agree with this statement. Families can take a lot of steps to make the environment safer for their LO, but short of strapping mom onto your person with a gait belt 24/7 odds of a fall will increase with the progression of the disease.

I have dealt with falling with both of my parents— a dad with dementia and a mom with vision issues and osteoporosis.

With mom it's been pretty straight forward. We had an OT tour the house and make suggestions to support aging-in-place safely when my parents moved locally. With mom, a big part of her falls were due to weakness in core, hips and legs; 6 months of PT helped. The other big problem is her vision; she has AMD and is newly blind in one eye. Another piece for her was distraction; she's an ADHDer from way back, so she sometimes needs to be prompted to pay attention to where she's moving in space. We also did a purge of her closet to get rid of shoes that don't support safety; gone are mules, heels higher than 1 1/2" and things she bought too big because she really, really wanted them for some reason.

With dad, falls were sometimes a function of impaired spatial reasoning where he misjudged distance or misinterpreted what he saw and tripped. This was worsened by the shuffling gait of the late stages that caused his feet to catch on the floors or sidewalks. More than once he pulled mom down with him as she assisted him out of a car or on the street. Some PWD have postural issues or Pisa Syndrome that throws off their center of gravity which can also increase fall risk. We dodged that with dad. Sometimes his falls were related to drops in BP; in the late stage his body didn't regulate BP or body temperature effectively. And in the latest stage, sometimes his legs would just crumble under him with no warning. He took me down with him a few times assisting out of a chair to his walker.

FWIW, the top article I posted looks at absolute risks and does land on the Afib treatment side which is why I shared it.

HB

JulietteBee

@harshedbuzz

I can opt for mom to use a wheelchair when her gait or balance becomes unsteady.

There is NOTHING, short of giving her a blood thinner, that can prevent her from pumping out a fist full of clots EACH time she goes in an arrhythmia.

Based on medical history, my mom, and the OP's mom, have a higher likelihood of experiencing repeated Afib episodes than they have of having repeated falls.

My mom has never fallen & the OP's mom apparently has had 1 fall…ijs

SDianeL

my husband was in stage 6-7 in MC and was a fall risk, had fallen a few times and went into a wheelchair. One evening, he fell face forward out of the wheelchair with a nurse nearby. It happened so fast that the nurse could do nothing to stop it. He had to be transported to the ER and receive 5 stitches to his head. After that trauma, he became bedridden & incontinent. There is no way to totally prevent falls for dementia patients. Many fall while being walked beside a caregiver, taking the caregiver down with them. Had my husband been on blood thinners at that time I would have considered the doctor's recommendation and would have taken him off it. It may sound cold but I would have rather he died from a heart attack or stroke than suffer with dementia any longer and I realize the stroke might not have killed him. These decisions are so difficult. Each caregiver has to weigh what is best for their LO and be able to live with those decisions. Praying for your strength.

harshedbuzz

@JulietteBee

I was not trying to convince the original poster to accept the doctor's opinion but rather explain why the decision may have been made so she can be a stronger advocate for her mom in this situation. FWIW, my mom takes a blood thinner for her TAVR despite her fall risk.

A wheelchair's a great option unless she reaches forward to get something she dropped (mom nearly fell out of one back in December trying "not to be a bother"), slides forward out of it (I saw dad do this twice in those vinyl covered chairs in his MCF, or forgets she is supposed to remain in the wheelchair. When my aunt was in a SNF after breaking her hip, the family was required to provide a private duty sitter 24/7 because aunt would forget she wasn't supposed to get out of bed without assistance. I say this not to be combative, but to caution you that the best caregivers on the planet sometimes have a LO who falls. Sometimes with devastating consequences. If it does happen to you at some point, don't beat yourself up.

HB

ValerieRN

I don't understand why the MD would take her off of Eliquis just because she fell. Yes it is a risk, but so are blood clots from AFib. I think that MD has not read recent lit? My mom is on Eliquis for AFib, has fallen and hit her head a few times and they never took her off. When it happened she got a CT head to check for a bleed and that was it. If you aren't comfortable with her being off of it, I would encourage you to have a more in depth conversation with the doctor. If he still insists and you want her to be on it, then go to a different doctor.

Quilting brings calm

=She has expressed to us that she does not want to be kept alive just to be alive. She has made that very clear and has a do not resuscitate order and all of that. =

I think you have to take your own comment above into consideration and not overtreat her.

The fall she has to have been serious to send her to rehab for several weeks, and maybe still not walking on her own then. As opposed to bring checked out at the ER and sent home. This wasn’t a minor stumble. Once she has fallen this badly. a fall serious enough to warrant rehab, brain bleed, or a broken hip is very likely to happen again and that is what her heart doctor decided. He decided that this was more likely to happen than a stroke. Especially if her Afib is controlled by the medication you mention. The slightly greater risk of stroke in an Afib patient is due to uncontrolled Afib.

FYI. I have Afib. I take a low dose aspirin every day, not a blood thinner. I was on metroprolol to slow my heart rate because afib episodes caused my heart rate to jump. It slowed my heart rate too much. The doctor took me off that medication and did a cardiac ablation. No Afib episodes since then. Ask the heart doctor about a low dose aspirin.