Deep vein thrombosis in older hospitalised inpatients

Introduction Incidence of DVT in the elderly hospitalised medical inpatient NICE guidance Evidence for their effectiveness of GCS in elderly patients The problems associated with GCS in geriatric patients Clinical audit Summary References

Introduction

It is recommended that patients 18 years and above admitted into hospital receive a risk assessment for venous thromboembolism (VTE) and possible prophylaxis. However, there is no robust evidence on the incidence of deep vein thrombosis (DVT) in elderly patients, or clear evidence of benefits for the use of graduated compression stockings (GCS) in this age group.

Incidence of DVT in the elderly hospitalised medical inpatient

DVT is a serious condition and can be fatal, but may be preventable.^3,4 However, the incidence in the elderly is unclear as there are few studies elaborating the risk of DVT in older adults.⁴ There are studies showing that DVT is common in patients in different age groups with acute medical conditions.^3,5,6The single most important risk factor is age and immobility⁷ as documented in almost all the National Guidelines.^4,8,9 Clinically apparent DVT confirmed on investigation is even less common,¹ but DVTs may not be recognised and may still cause important complications. Pulmonary embolism (PE) is an important cause of preventable death in medical wards.⁹ The risks of DVT and PE are higher in older people as often cardiac systolic or diastolic function is compromised.¹⁰

In CLOTS 1 and 2 trials in stroke, asymptomatic DVT occurred in 133 (10·5%) patients but GCS was ineffective in preventing VTE and caused complications.¹¹ A similar result, 7% was the incidence of asymptomatic DVT in a study conducted in France.¹²

NICE guidance

NICE clinical guideline suggests all patients 18 years and older admitted to hospital with acute medical illness are at increased risk of VTE if they have had or are expected to have significantly reduced mobility for three days or more or are expected to have ongoing reduced mobility. The following conditions regarded as increase risks for DVT:

Active cancer or cancer treatment
Age over 60 years
Critical care admission
Dehydration
Known thrombophilia
Obesity (body mass index [BMI] over 30 kg/m2)
One or more significant medical comorbidities (for example: heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions).
Personal history or first-degree relative with a history of VTE
Use of hormone replacement therapy
Use of oestrogen-containing contraceptive therapy
Varicose veins with phlebitis

Those who considered having DVT prophylaxis should assessed for risk of bleeding before offering pharmacological VTE prophylaxis. Clinical judgement and balance should take place if the risk of VTE outweighs the risk of bleeding.

Should clinical status changed, reassessment is important within 24 hours. This to ensure that the methods of VTE prophylaxis being used are suitable and ensure that VTE prophylaxis is being used correctly. Any adverse events have to manage appropriately.

Mechanical VTE prophylaxis offered on based on clinical opinion taking into account clinical condition, surgical procedure and patient preference. This is particularly important in medical patients in whom pharmacological VTE prophylaxis is contraindicated. The options are:

Anti-embolism gradual compression stockings (thigh or knee length)
Foot impulse devices
Intermittent pneumatic compression devices (thigh or knee length)

Mechanical VTE prophylaxis used with caution and may be contraindicated in:

Suspected or proven peripheral arterial disease
Peripheral arterial bypass grafting
Peripheral neuropathy or other causes of sensory impairment
Any local conditions in which stockings may cause damage, for example fragile €˜tissue paper’ skin, dermatitis, gangrenes or recent skin graft
Known allergy to material of manufacture
Cardiac failure with severe leg oedema or pulmonary oedema
Unusual leg size or shape
Major limb deformity prevents correct fit.
Over venous ulcers or wounds

In addition to pharmacological intervention in form of low molecular weight heparin there are requirements to apply mechanical DVT prophylaxis that include measurement of leg and applying correct size of stocking.

Anti-embolism stockings should be fitted and patients shown how to use them by staff trained in their use. Re-assessment and measure post operatively or further legs swelling and offer correct size is recommended.

The aim is to produce a calf pressure of 14€“15mmHg by GCS. A patient needs to be encouraged to wear their anti-embolism stockings day and night until they no longer have significantly reduced mobility. Patient has to shown how to remove anti-embolism stockings daily for hygiene purposes and to inspect skin condition. In patients with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin two or three times per day, particularly over the heels and bony prominences.

It is advisable to discontinue the use of anti-embolism stockings if there is marking, blistering or discolouration of the skin, particularly over the heels and bony prominences, or if the patient experiences pain or discomfort. If suitable, offer a foot impulse or intermittent pneumatic compression device as an alternative.

Finally, monitor the use of anti-embolism stockings and offer assistance if they are not being worn correctly.

GCS are thought to reduce the risk of DVT by:

Compressing the leg and thus reducing the cross sectional area of the veins which in turn reduces stasis by increasing the blood flow velocity. Blood flow Increase by providing greater compression around the ankle than more proximally.
Augmenting the effect of the calf muscle pump.
Improving the function of venous valves and reduction of venous pooling.
Altering levels of clotting factors.

Evidence for their effectiveness of GCS in elderly patients

There are a few systematic reviews of randomised trials evaluating GCS that have concluded the value of GCS in peri-operative patients.^13,14 In 1994, a systematic review of GCS was published (11 trials, n=1752) which demonstrated that their use is associated with a 68% (95% CI 53 – 73%) reduction in the risk of DVT after surgery. A more recent systematic review showed a 62% (95% CI 52 – 70%) reduction in the risk of DVT in 2582 patients randomised in 18 trials (Roderick personal communication). The latter review also demonstrated a 53% (95% CI 3 €“ 83%) reduction in PE amongst 1466 patients entered into 12 trials.

Risk of DVT is high in patient with acute respiratory problems,¹⁵ renal failure¹⁰or severe infections.⁴ This is because of the higher rate of dehydration and hypovolaemia. However, only a small number of trials performed in studying the effectiveness of GCS in medical patients and generally the inclusion criteria were narrow.¹⁶

In 1993,¹⁷ a trial revealed effectiveness of preventing DVT by applying GCS in patient admitted in cardiology wards. There were fewer DVT in the treatment group by six in comparison to the control arm. The trial was a small study, enrolling 80 patients above 70 years old admitted with myocardial infarction and as expected the patient will also receive doses of antiplatelet or anticoagulation medication. This study excluded from meta-analysis study due to issues surrounding its methodology.¹⁶

GCS have also been also evaluated in stroke patients.¹¹ This RCT in addition to CLOTS trials collaboration revealed GCS are not clinically effective at reducing the risk of proximal DVT after stroke and are associated with some adverse effects.

Apart from these two medical conditions (myocardial infarction and stroke), there is no evidence of the benefit or harm of GCS in elderly hospitalised patients.

The problems associated with GCS in geriatric patients

GCS use is not without risks and complications. Itching and discomfort are main two reasons for variability in compliance.¹⁸ In the CLOTS trials, skin breaks, ulcers, blisters, and skin necrosis were significantly more common in patients allocated to GCS than in those allocated to avoid their use (64 [5%] vs 16 [1%]; odds ratio 4·18, 95% CI 2·40€”7·27).

Patients with severe peripheral vascular disease and/or peripheral neuropathy, their use can cause skin necrosis and occasionally this has necessitated amputation.^19,20,21 Elderly patients are more likely than surgical patients to have diabetes and peripheral vascular disease. Furthermore, incontinent of urine and /or faeces is an additional issue in many old adult,²² which can lead to soiling of the stockings, greater discomfort and more problems with the underlying skin. If stockings are ineffective the nursing staff’s time applying and monitoring them might be put to better effect.

In the UK GCS vary in cost, from £4 to £7 for one pair of full length stockings. A patient needs a pair per week allowing for regular washing. In addition there are staff costs relating to training in their use and, the regular application and removal of stockings in poorly mobile patients. Therefore, the financial implications of routine use of GCS are important to consider in order ensuring optimum application.ii.

Clinical audit

In view of all of the above considerations, a retrospective audit was performed at Southend Hospital NHS Trust.²³ Notes from 100 consecutive patients admitted to geriatric medicine wards were identified to assess concordance with the recommendation in applying GCS and assess any additional benefit of GCS and possible complications. 64 of them were eligible to apply GCS with no contra-indication to apply CGS, however it is only applied on 13 of them. The stocking had no additional benefit along with low molecular weight heparin. This audit presented in an audit meeting and from the discussion it is been concluded that there is no consensus agreement among physicians, especially between geriatricians on the usefulness of GCS.

Summary

In view of limited studies in this field, we recommend that further research is urgently needed to clarify the following questions:

What is the incidence of asymptomatic and symptomatic DVT in elderly medical inpatients?
What is the outcome of this if asymptomatic patients remain untreated?
Are GCS stockings effective at preventing DVT and PE in elderly medical patients, or do the complications outweigh the benefits?
Does VTE prophylaxis with anticoagulants reduce risk or cause harm from complications?
Should older people in hospital for acute medical condition have any prophylaxis if risk is low or complications high? Or should doctors treat this group asextremely high risk, as the current practice in orthopaedic cases, with a longer course of treatment after discharge?

A trial of combined mechanical and pharmacological VTE prophylaxis may be required whereas if risk similar or lower, a trial of no treatment versus pharmacological VTE prophylaxis alone and versus mechanical VTE prophylaxis alone may be more appropriate.

Amin K, Guyler P

References

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First published in 2013. Deep Vein Thrombosis” GM 43:23-27

deep vein thrombosis (dvt)