A significant literature exists describing the most appropriate way to support older people presenting to Emergency Departments with minor head injuries who are prescribed oral anticoagulants (OAC).
The rationale behind much of the guidance is early identification of intracranial bleeding which can facilitate early neurosurgical intervention and improved outcomes.
Over the past decade, a growing number of older people living in care facilities in the UK have been prescribed oral anticoagulants in line with best practice guidance, most commonly in those who have atrial fibrillation.
In the past five years, since the development of direct oral anticoagulants (DOACs), it has become more straightforward to provide anticoagulation to older people and in particular to those for whom regular monitoring of International Normalised Ratio (INR) would be difficult.
As the numbers of people who will potentially benefit from the use of OAC has increased, the numbers of older people living with advanced frailty and in particular dementia has also risen.
It is generally accepted within the neurosurgical community that intervention for traumatic brain injury in those living with moderate to severe forms of dementia has a poor outcome.
Amongst doctors and other prescribers there is much discussion as to when anticoagulation should be discontinued for those at risk of falls.
NICE guidance dictates that anyone who has experienced a head injury when treated with an OAC should receive CT scanning within eight hours and in the presence of a normal scan, consideration should be given to repeated scanning to detect delayed intracranial haemorrhage (the latter rarely happening for care home residents in the UK)
Because of variation of governance arrangements and practice across residential and nursing homes in the United Kingdom, older people who experience unwitnessed falls are considered until proven otherwise to have potentially injured their heads (and, this, often despite the individual denying such an injury – the diagnosis of dementia influencing carers’ balance of probability and decision making).
Consequently, significant numbers of very frail and older people are transferred to local Emergency Departments following either trivial head injuries or when a head injury is only suspected but not witnessed.
For the majority of patients experiencing minor head injuries who do not have any other associated symptoms – loss of consciousness, headache, vomiting and so on, the likelihood of significant intracranial injury is small and, for those who only have a possibility of such an injury, the risk is even smaller.
For the small subset of individuals living with dementia and advanced frailty in care homes, even with the presence of a minor or major intracranial injury, the neurosurgical options are limited and most often a conservative or palliative approach to care is taken.
Some clinicians, because of this possibility restrict the use of OAC’s in those considered to be at higher risk of falls, although the numbers needed to treat or harm are difficult to establish owing to the highly individualised nature of each person’s situation and lack of research in this group of people. With this approach there is the potential to deprive certain individuals of the benefits of anticoagulants, leading to a higher incidence of strokes.
Even with a national increase in the numbers of care home residents receiving advance care plans outlining their or their family’s wishes for future care – often, avoidance of hospital attendance or admission if at all possible, the scenarios described above of OAC – possible fall – transfer to ED are common as the fear of complaint or variance with NICE guidance over-rides other concerns.
I propose a national discussion about the ways in which we support older people living in care homes who may benefit from treatment with OAC and a pragmatic, person-centred, advanced care planning approach taken which will allow individuals to benefit from treatment with anticoagulants yet avoid the risk of unnecessary hospital transfer.
Such guidance, which would need to be highly individualised for each resident and would involve considerations such as whether, in the absence of any obvious harm (assessed either by an appropriately trained senior carer, nurse or paramedic) the individual could remain at the care home without transfer to hospital.
This change to practice would inevitably improve access to OAC for those who might benefit and reduce the impact of unnecessary and often distressing hospital transfers for those in whom a best interests or personal decision has been taken to remain at their home.
An excerpt from such a document would be the following:
‘Mr AB who has advanced significant frailty and Alzheimer’s Dementia will not be transferred to hospital without appropriate discussion with his family or GP. In situations of uncertainty, as in the case of a fall with or without head injury, out-of-hours GPs and paramedic practitioners can participate in relevant decision making discussion with family members and care home staff.’
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Advance Care Plan – ACP; a document outlining an individual’s wishes in relation to their future care. You can read more here.
Atrial Fibrillation – AF; a random, chaotic form of cardiac activity which increases the risk of stroke. People at particularly high risk are those who have had a previous stroke, have raised blood pressure, diabetes or who smoke.
CT – Computerised Tomography; sensitive x-ray scanners that can detect the presence of bleeding, routinely found in ED departments and a standard part of the assessment of people with head injuries or strokes.
DOAC – Direct Oral Anticoagulant; this represents the way in which blood clotting is altered in the body, through a direct effect on clotting agents in the blood. Warfarin, works indirectly though reducing levels of Vitamin K which in turn affect the same clotting agents.
ED – Emergency Departments; this is the current name for A&E departments; it is an aspiration to move-away from the concept of ‘accident’.
INR – International Normalised Ratio; a measurement of blood’s ability to clot when treated with Warfarin, compared to a standard clotting time.
NICE – National Institute for Clinical Excellent; a UK body advising on evidence based treatments in health and social care. You can find the specific guidance here.
OAC – Oral Anticoagulant; a drug that reduces the likelihood of blood clotting, examples are the traditional Warfarin, and newer drugs Apixaban, Rivaroxaban and Edoxaban.