MEDizzy - A 79-year-old woman with Alzheimer’s dementia had recovered

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Geriatric Medicine 2

A 79-year-old woman with Alzheimer’s dementia had recovered from a delirium caused by pain from osteoporotic wedge fractures of the third and fourth lumbar vertebrae. She was extremely variable in her mobility, needed prompting to eat and drink, was unpredictable with her continence, and needed assistance with personal care. She lacked the capacity to determine her own care needs, was considered unsafe to continue living alone with care four times a day, and was waiting for a care home placement. On the fourth week of her hospital stay, despite receiving thromboprophylaxis with low molecular weight heparin (LMWH), she developed a left ileofemoral deep vein thrombosis. Systemic examination and laboratory investigations excluded secondary causes of osteoporosis and overt malignancy. What is the most appropriate maintenance treatment for her deep vein thrombosis?

ExplanationGraduated, knee high, elastic compression stockings (30–40mmHg) worn for 2 years after first episode of proximal deep vein thrombosis (DVT) reduces the frequency of post-phlebitic syndrome. They should probably also be recommended after ileo-femoral deep vein thrombosis. Dabigatran etexilate is recommended, by NICE, as a possible treatment to reduce the risk of VTE in adults who have surgery to replace their hip or knee joint. It is not recommended for treatment of venous thromboembolic disease. This patient has had an ileo-femoral DVT unrelated to a major reversible risk factor and so should have at least 6 months treatment with warfarin and, as her risk, of further VTE, will remain high (variable mobility and an ileo-femoral DVT occurring whilst receiving thromboprophylaxis) she should be considered for life-long anticoagulation, with periodic reassessment of the risks and benefits of continued anticoagulation. Therapeutic sub-cutaneous low molecular weight heparin might be recommended in patients where warfarin is contraindicated and in cancer patients. Provided there are no problems getting this patient to take her medication, she will be supervised in the care home and there are no other reasons specified to suggest that warfarin is contraindicated. Long-term treatment with heparin runs a risk of osteopenia.