Is it Time to Tailor the Dose of Aspirin for Primary Prevention of Cardiovascular Events and Cancer?
[Or…Why I changed my aspirin dosing schedule]
Henry I. Bussey, Pharm.D., FCCP
I just read one of the most complex and confusing studies that I’ve ever read. This well-written article was complex and confusing because of the amount of data presented and the number of endpoints, dosing regimens, and patient subgroups addressed. The data, however, are important and, I believe, should be practice-changing. After reading the article twice and discussing it with a hematologist on the ClotCare Editorial Board, I made a substantial change in my aspirin dosing schedule; and I believe that there is a good chance that most others taking aspirin for primary prevention are taking a dose that may be ineffective and/or harmful.
If you would like to review the article for yourself, it is available at https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31307-2/fulltext
Here are some of the key points that I got from this paper that analyzed individual patient data for 117,279 patients who were enrolled in trials of aspirin for primary prevention:
In the primary prevention of cardiovascular events:
- Low-dose aspirin (75 to 100 mg daily) is effective only in individuals who weigh less than 70 Kg (Hazard Ratio, HR = 0.77) with no benefit in those who weigh 70 kg or more (HR = 0.95). Furthermore, for those who weigh 70 Kg or more, there is a trend for low-dose aspirin to increase cardiovascular events if the individual has diabetes, smokes, or is at least 70 years old.
- Low-dose aspirin may be harmful in those who weigh less than 50 Kg. (including an increased risk of sudden death).
- Enteric coated or sustained release aspirin products may be less effective.
- Alternate day dosing may be less effective.
- High-dose aspirin (300 – 325 mg or 500 mg or more) is effective in those who weigh more than 70 Kg (where low-dose is ineffective), but high-dose may be harmful in those who weigh less than 60 Kg.
- Twice a day dosing may be desirable based on (1) the impressive reduction in cardiovascular events (HR = 0.74) among patients weighing less than 70 kg. in the ESPS-2 secondary stroke prevention trial that used a regimen of 25 mg of aspirin twice a day and (2) the theory that systemic availability of aspirin may be necessary to inhibit the 10-15% of new platelets that are released daily. Patients who weighed 70 Kg or more in the ESPS-2 did not exhibit a reduction in cardiovascular events with this regimen which led the authors of the current paper to suggest that 50 – 100 mg twice a day might be effective in heavier individuals. Whether such a twice daily regimen would carry any bleeding risk in those weighing 90 kg or more is uncertain.
In the primary prevention of cancer:
- Low-dose aspirin did not alter the rate of cancer in those who weighed 70 Kg or more.
- Low-dose aspirin in those weighing less than 70 Kg increased cancer rates during the first 3 years of follow-up and this effect was especially evident in those with diabetes (HR = 1.32) and those over 70 years of age (HR = 1.35).
- High-dose aspirin seemed to have a similar impact on cancer rates as that seen with low-dose aspirin.
- Aspirin (regardless of dose or patient age) appeared to reduce the incidence of colorectal cancer at 20 years of follow-up in patients who weighed more than 50 kg and less than 80 Kg. No clear benefit was seen outside of that weight range.
- Women younger than 50 years of age who had diabetes and were taking aspirin had an especially high rate of cancer (HR = 4.35) due in part to a high rate of breast cancer (HR = 2.60).
The risk of major or significant bleeding with aspirin:
- Low-dose aspirin increases major bleeding up to a body weight of 90 Kg, above which bleeding risk disappears.
- High-dose aspirin carried an increased risk of major bleeding that not only persisted but increased at weights above 90 Kg.
Rothwell PM, Cook NR, Gaziano JM, et al. Effects of aspirin on risks of vascular events and cancer according to bodyweight and dose: Analysis of individual patient data from randomized trials. The Lancet 2018; 392:387-399. http://dx.di.org/10.1016/S0140-6736(18)31133-4
Editor’s note: As far back as the mid-1970s, some believed that the anticoagulant effect of warfarin reduced the ability of cancer cells to seed (metastasize) to new locations. At about the same time, interest started to grow in the ability of the body’s immune system to limit and eradicate cancer. In the article reviewed below by guest authors Drs. Hawkins and Hornsby, the suggestion is put forth that it is the effect of warfarin on the immune system that may explain how warfarin may prevent the development of cancer. Should this potential anti-cancer effect of warfarin (see table below) be considered when selecting an agent for long-term anticoagulation?
Table: The Incident Rate Ratio (IRR) of Cancer in Warfarin Users Compared to Non-Users
All Warfarin Users (n=92,942)
IRR (95% Confidence Interval)
|Warfarin Users with A. Fib (n=33,313)
IRR (95% Confidence Interval)
|All Types||0.84 (0.82 – 0.86)||0.62 (0.33 – 0.46)|
|Lung||0.80 (0.75 – 0.86)||0.39 (0.33 – 0.46)|
|Prostate||0.69 (0.65 – 0.72)||0.60 (0.55 – 0.66)|
|Breast (female)||0.90 (0.82 – 1.00)||0.72 (0.59 – 0.87)|
|Colon||0.99 (0.93 – 1.06)||0.71 (0.63 – 0.81)|
Note: The over-all incidence of cancer was 9.4% in warfarin users vs. 10.6% in warfarin non-users. The IRR values were adjusted for age and gender.
Review – “Association of Warfarin Use With Lower Overall Cancer Incidence Among Patients Older Than 50 Years”
Zuri Hawkins, PharmD* and Lori Hornsby, PharmD, BCPS**
There is conflicting evidence regarding the antitumor benefits of warfarin and whether there is an association between its use and lower cancer incidence. Several studies have found lower rates of certain cancers such as small cell lung cancer and urogenital cancers while other studies have failed to find an association.1-5 The exact mechanism by which warfarin may provide antitumor benefits is not completely understood. The authors of a recent cohort trial published in JAMA Internal Medicine cite the inhibition of warfarin on AXL receptor tyrosine kinase-dependent tumorigenesis and enhancement of antitumor immune response as the potential mechanism.6 The continued uncertainty of warfarin’s benefit on cancer incidence led the Norwegian researchers to examine this association further in a large, unselected population-based cohort.
Haaland et al. utilized the Norwegian National Registry to identify a study cohort (n = 1,256,725) of individuals born in Norway from January 1, 1924 to December 31, 1954 who were living in Norway during the study period. The Norwegian Prescription Database and the Cancer Registry of Norway, both with a 99% national coverage of cancer diagnoses and prescription use, were utilized to determine cancer diagnoses and warfarin use. The cohort was divided into 2 groups (warfarin users vs. nonusers). Warfarin users were defined as individuals who were on warfarin for at least 6 months and at least 2 years before any cancer diagnosis. All others were considered nonusers. The study period lasted 7 years (January 1, 2006 through December 31, 2012). Within the cohort 92,942 (7.4%) were determined to be warfarin users, with a mean duration of use of 4.7 years. There were a total of 132,687 (10.6%) individuals found to have a cancer diagnosis.
Of the warfarin users, 8754 (9.4%) were diagnosed with cancer as compared to 123,933 (10.6%) in the non-users. The incidence ratio rate (IRR) was reduced in favor of warfarin users as compared to non-users for all cancer sites (IRR, 0.84; 95% CI, 0.82-0.86) as well as prevalent organ-specific sites (lung, 0.80 [95% CI, 0.75-0.86]; prostate, 0.69 [95% CI, 0.65-0.72]; and breast, 0.90 [95% CI, 0.82-1.00]). The IRR was not statistically significant for colon cancer (IRR, 0.99; 95% CI, 0.93-1.06). In patients receiving warfarin for stroke prophylaxis in atrial fibrillation or atrial flutter, as opposed to thromboembolic disease which has a known association with cancer, the IRRs were even lower for all cancer sites (IRR, 0.62; 95% CI, 0.59-0.65), as well as prevalent sites (lung, 0.39 [95% CI, 0.33-0.46]; prostate, 0.60 [95% CI, 0.55-0.66]; breast, 0.72 [95% CI, 0.59-0.87]) and significant for colon cancer, 0.71 [95% CI, 0.63-0.81].
Overall, the study concluded warfarin use has potential cancer benefits across a number of cancer sites in patients over 50 years of age. Strengths of the study include the large population size and availability of databases that encompass 99% of the study population. While limiting the potential for misclassification bias, this cannot be ruled out due to the cohort design of the study. The inability to account for potential confounders such as life-style and genetic factors are also potential limitations. Lastly, cancer diagnoses prior to the study period were unavailable resulting in some incidence of cancer diagnosis being reoccurrences.
Data from this trial displays a potential positive association between warfarin use and cancer prevention. While the findings of the study leaves clinicians with additional considerations regarding warfarin use in at risk populations especially those with atrial fibrillation or atrial flutter, over newer oral anticoagulants with benefits such as standardized dosing, clinicians should interpret the results of these findings with caution based the limitations of the trial. Further studies assessing the use of warfarin in cancer prevention are warranted.
- Zacharski L, Henderson W, Rickles F, Forman W, et al. Effect of warfarin anticoagulation on survival in carcinoma of the lung, colon, head and neck, and prostate: Final report of VA cooperative study #75. Cancer 1984;53:2046-52.
- Akl E, Kamath G, Kim Y, Yosuico V, et al. Oral anticoagulation may prolong survival of a subgroup of patients with cancer: a Cochrane Systematic Review. J Exp Cancer Res 2007;26:175-84.
- Schulman S, Lindmarker P. Incidence of cancer after prophylaxis with warfarin against recurrent venous thromboembolism. NEJM 2000;342:1953-8.
- Kinnunen PT, Murtola TJ, Talala K, Taari K, Tammela TLJ, Auvinen A. Warfarin use and prostate cancer risk in the Finnish Randomized Study of Screening for Prostate Cancer. Scand J Urol. 2016;50(6):413-419.
- Tagalakis V, Tamim H, Blostein M, Collet J, Hanley JA, Kahn SR. Use of warfarin and risk of urogenital cancer: a population based, nested case-control study. Lancet Oncol. 2007;8: 395–402.
- Haaland GS, Falk RS, Straume O, Lorens JB. Association of Warfarin Use With Lower Overall Cancer Incidence Among Patients Older Than 50 Years. JAMA Intern Med. 2017 Dec 1;177(12):1774-1780.
Zuri Hawkins, PharmD is a PGY2 Ambulatory Care Resident at Piedmont Columbus Regional, Midtown Campus in Columbus, Georgia.
Lori Hornsby, PharmD, BCPS is an Associate Clinical Professor with Auburn University Harrison School of Pharmacy in Auburn, Alabama and Ambulatory Pharmacist at Piedmont Columbus Regional, Midtown Campus in Columbus, Georgia.
Henry I. Bussey, Pharm.D.
The Anticoaguation Forum has provided ClotCare with the following announcement.
Join World Experts at the Anticoagulation Forum Boot Camp | April 23-24, 2018 | The Intercontinental, Austin
This compact 2-day meeting provides a comprehensive curriculum that covers the essential aspects of anticoagulation, disease state, and drug management. Engaging discussion around quality improvement, new agents and special situations will benefit all practitioners and daily ‘chalk talks’ will allow for attendee participation to shape the topics. Our Austin Boot Camp features more than 4 hours of content focusing on Transitions of Care, including highlights of innovative programs, patient case studies and ideas for practice improvement in all aspects of patient transition. Approximately 11.25 contact hours of education credit will be offered for Physicians, Nurses and Pharmacists.
Registration is $399. See the full schedule, faculty listing and register at: www.acforumbootcamp.org.
Is the Watchman device better than no therapy?
Is FDA approval and use of the Watchman device misguided?
These are two questions that cardiologist John Mandrola, MD addressed in writing for Medscape.com in November, 2017. The Watchman device, which was recently approved by the FDA, was developed to block off the left atrial appendage – or “LAA” – (a sack-like structure that is off to the side of the left atrium chamber of the heart). The idea behind the Watchman device is that in patients with atrial fibrillation (AF), the risk of stroke is based on the “fact” that most clots develop in the LAA before they are pumped out to the brain. Adequate anticoagulation is usually very effective at preventing such clots, but some patients are not good candidates for anticoagulant therapy because of the associated bleeding risk. The Watchman device is designed for such patients to close off the LAA and, thereby, prevent clots from forming in the LAA. Such an approach may prevent clot-induced strokes while avoiding the need for anticoagulation. The FDA initially declined to approve the device until the results of a 2nd study became available. In a Medscape posting (www.medscape.com/viewarticle/888355), Dr. Mandrola outlined seven reasons why he remains skeptical about the value of this new device. The following comments are meant to summarize his assessments, but the reader is encouraged to review the entire article at the medscape link above.
Point 1: The additional data did not change the direction of trends in that, at 5 years, ischemic (clot-based) stroke rates were still higher with the device and the apparent lower hemorrhagic (bleeding-based) stroke rate with the device may be due, in part, to an unusually high hemorrhagic stroke rate with warfarin. The hemorrhagic stroke rate with warfarin was approximately twice as high as what had been reported in several earlier AF studies with warfarin. Dr. Mandrola also questioned inclusion of cardiovascular and unexplained death as a valid endpoint in the trials.
Point 2: The new data do not change the net benefit calculation in that all the available data indicate a 6% major procedural complication rate. This means that LAAC patients start off with a 6% chance of being harmed by the procedure and that risk has to be balanced against the possible benefit of therapy that may be “non-inferior” to warfarin. By far, the most common procedural complication was serious pericardial effusion, but major bleed, ischemic stroke, and device embolization also occurred as procedure-related events.
Point 3: The LAA is not the only source of AF-related clots from the heart, especially in those who are not good candidates for anticogulation. Dr Mandrola points out that the idea that about 90% of AF-related clots come from the LAA has not been proven and that more recent data indicate that the sickest AF patients have higher rates of clots forming outside of the LAA. It is precisely these “sicker” AF patients who are more likely to be candidates for a LAAC device due to being less likely to tolerate anticoagulation.
Point 4: Use of antiplatelet agents and anticoagulants remains a concern. Because the LAAC device is a foreign body inside the heart, usual therapy includes a period of warfarin therapy followed by antiplatelet therapy. As Dr. Mandrola points out, the bleeding risk with aspirin in AF patients has been reported to be as high as that seen with warfarin, and in one study, almost 60% of LAAC device patients remained on anticoagulation or dual antiplatelet therapy at about one year after the procedure.
Point 5: “Stroke is a systemic disease”. AF produces structural changes in the heart and blood components that lead to increased clotting risk. Insertion of a LAAC device does nothing to reverse or correct these factors that increase the risk of clots.
Points 6 & 7: I chose to combine these last two issues because they both are related to statistical methods. The first point Dr. Mandrola makes is that the authors used Bayesian statistical methods which he indicates are based on “evidence or beliefs about something”. My “take” on his discussion is that the analysis following the 2nd study may have been biased by the authors’ beliefs or views of the data from the first study. The second point, is that the non-inferiority limits were set so wide that it is possible that outcomes with the Watchman device could have been almost 5 fold worse than the warfarin outcomes and still the analysis would have met the non-inferiority limits.
So, what’s the “bottom line”? Dr. Mandrola concludes that “… we have no RCT-level evidence that LAAC is better than no therapy.” (and) “… to stretch the available evidence from Watchman vs. warfarin and conclude that it is worth exposing anticoagulation-ineligible patients to an invasive, unproven preventive procedure is misguided.”
Cynthia’s Story and a Limited Discussion of the Literature
Henry I. Bussey, Pharm.D., FCCP
Cynthia, who lives in Florida, contacted ClotCare.org out of a desire to share her story and to let others know how her surgeon changed his practices after her experience. Following her story is a short over-view on whether arthroscopic surgery warrants anticoagulant prophylaxis and, if so, what form of prophylaxis should be used.
Cynthia’s story (with limited edits) starts here:
I am 61 years old female and was in good health. In 2016, during my Zumba class I twisted my left knee and both felt and heard a crunch! I had had an ACL (anterior cruciate ligament) repair done on that knee many years before so I figured it was another ACL injury. I lived with the swelling and pain for several months and then finally decided to see an orthopedic doctor who had done my husband’s knee replacement. The xray confirmed a pretty severe tear in my meniscus and the doctor recommended arthroscopic surgery to remove the torn area of the meniscus. The doctor put me on a baby aspirin three times a day. At a week after the surgery I started feeling like I was coming down with the flu and had fatigue, chills and a low grade fever. I did not notice any unusual swelling but I did have foot cramping which felt like my toes were bending backwards. The third day of my “flu” my husband had to leave to visit his folks out of state. I remember him standing by the bed asking if he should stay because I wasn’t feeling well, I told him to go since his dad was ill. My daughter and her husband were living with us at the time so at least I wasn’t by myself. That was Saturday, a little over a week after the surgery. That night my daughter checked in on me and asked if she needed to take me to the ER and I told her no I was fine, though I was feeling worse. At around 2:30 am I rolled over and felt a sharp pain on my right side. When I breathed in I also felt it. I Googled my symptoms and didn’t see anything that suggested a blood clot. The only thing I saw was the possibility of it being shingles! So there I was wide awake thinking I was coming down with shingles. I got up and took myself to the ER not waking my daughter. I thought it was going to be a quick visit just to get a shingles shot, but when I mentioned to the ER physician I just had knee surgery his face turned white and they immediately took blood for a d-dimer test which came back positive. The CT scan showed a very large embolism blocking the whole right lung and a smaller one in the lower left lung. I was hospitalized for six days, and have been back in the hospital six times since then with tachycardia and blood pressure problems. I’m fairly stable now but do not feel quite the same as before, and look and feel much more tired. Depression is also a battle. I lost my job and my life has forever changed. Doctors are amazed I survived the attack and without any obvious heart damage, but now I feel I will be spending the rest of my life trying to figure out why. To anyone contemplating minor knee surgery, make sure you are on a better clot prevention regimen than baby aspirin. My surgeon changed his protocol based on what happened to me and now uses low molecular weight heparin (such as enoxaparin) or warfarin (brand name Coumadin) and compression stockings for patients getting minor knee surgery.
Comment on Cynthia’s story: In retrospect, because she had pain and swelling for an extended period of time before going to her doctor, it is possible that she may have developed a blood clot prior to the surgery. An injury as mild as a sprained ankle can increase the risk of developing a blood clot and the swelling may result from – or increase the risk of having – a blood clot. After surgery, her foot cramping, fatigue, chills, low grade fever, and a sharp pain upon breathing in are consistent with the signs and symptoms of a deep vein thrombosis (DVT) leading to blood clots in both lungs (bilateral pulmonary emboli or “PE”). I suspect that she also had an increase in heart rate and breathing rate which are also signs of a PE. Having a PE is a life-threatening event that should be treated as a medical emergency. If she had been more aware of the risk and the signs and symptoms of DVT and PE, perhaps she might have sought medical attention earlier and received treatment before the condition progressed as much. Her subsequent hospital admissions for tachycardia (fast heart rate) and “blood pressure problems” raise concerns about a related possible complication. With large or multiple PEs, damage to the lungs may result in an increase in the blood pressure in the lungs which, in turn, can overload the right side of the heart and lead to chronic lung and heart conditions. Hopefully that is not true in Cynthia’s case.
Discussion of DVT and PE prevention in arthroscopic knee surgery: There is an old country western song that says when you look down into the ole swimmin’ hole, what you see depends on where you stand, how you look, and what you want to see. Those words apply perfectly to the issue of using anti-clotting drugs to prevent DVT and PE in arthroscopic knee surgery. Cynthia and her surgeon apparently now are convinced that patients undergoing arthroscopic knee surgery require more aggressive anti-clotting therapy than aspirin. But the 2012 Chest guidelines recommend no such therapy – not even aspirin – for patients like Cynthia (see http://journal.chestnet.org/article/S0012-3692(12)60126-3/pdf ). Those who favor anticoagulation focus on the potential for blood clotting events to occur, and the fact that they may be fatal or life-altering, in patients who are usually relatively young and healthy. Imagine the emotional and psychological impact if Cynthia’s family had found her dead the next morning from a fatal PE. So what about those who advocate for not using any prophylaxis? Those individuals will point to the relatively low incidence of DVT & PE with such surgery, the fact that most DVTs are limited and can be treated, and the fact that anticoagulation carries a substantial risk of hemorrhage. Hemorrhage can be life-threatening and/or it can lead to other complications such as infection and repeat surgery.
As one expert in this area (Dr. Joe Caprini) once said, clinicians make treatment decisions based on data, experience, and emotion; but the most influential of these is emotion. The above comments illustrate how experience and emotion can factor in to treatment decisions, but what do the data show?
In 2008, what I believe is the largest and best randomized study of DVT and PE prophylaxis in arthroscopic knee surgery was published and is summarized in a ClotCare posting at http://www.clotcare.com/vtekneearthoscopy.aspx With more than 1,300 low risk, young patients randomized to a low molecular weight heparin (LMWH) for 7 days or graduated compression stockings (GCS) following arthroscopic knee surgery, the incidence of DVT & PE was reduced from 3.2% with GCS to 0.9% with LMWH. The difference was even greater (5.1% with GCS vs. 1.7% with LMWH) in the approximately 50% of patients who had the meniscectomy (removal of the meniscus). Major bleeding and clinically relevant bleeding was increased from 0.3% in the GCS group to 0.9% in the LMWH group. A third arm of the study included LMWH for 14 days but that arm was stopped early because of safety reasons. The main conclusions from this study was that 7 days of LMWH was beneficial in young, low risk patients and especially in those whose surgery involved meniscectomy. Many clinicians would argue that the need for LMWH is likely even greater in older patients and/or those with additional clotting risks (such as those with a prior DVT or PE); but those patients were excluded from this study. In the face of the above data, what is the argument not to use LMWH? Besides the financial cost of such therapy for all patients, the incidence of the most feared clot (PE) was low and not different (0.3% in each group) while the risk of major and clinically relevant bleeding was increased three fold with LMWH (0.3% vs 0.9%). Furthermore, the difference in DVT and PE between the two groups was due to symptomatic, distal DVT. In general, distal (below the knee) DVT carries a low risk of PE and, if symptomatic, then the condition is more likely to be identified and treated. If we can identify and treat the majority of individuals who develop a symptomatic distal DVT, then it becomes harder to justify exposing all patients to the expense and bleeding risk of LMWH therapy.
More recently (2014), there have been 2 reviews and one meta analysis on the question of DVT & PE prophylaxis in arthroscopic knee surgery (https://www.ncbi.nlm.nih.gov/pubmed/24190733 and https://www.ncbi.nlm.nih.gov/pubmed/24581264). One review concluded that there is no consensus on how to prevent blood clots in these patients and suggested that each patient needs to be managed on a case by case basis. The review and meta-analysis focused on proximal (above the knee) DVTs which are known to carry a substantially higher risk of PE than distal DVT. Key findings from that analysis were (1) that proximal DVT rate is low regardless of whether LMWH is used (4 in 2,184 patients, 0.18%) or not (29 in 1,814 patients, 1.60%), (2) that LMWH reduces the incidence of proximal DVT from 1.60% to 0.18%, and that LMWH reduces the percent of all DVTs that are proximal (29 of 136, 21.3% vs. 4 of 36, 11.1%). These values are consistent with the study discussed above and at the ClotCare link listed. So the question is more or less then same – does the limited benefit seen in approximately 2% to 3% of patients justify exposing all patients to the cost and risks of LMWH? I believe it is fair to say that the decision is a judgement call which reasonably should be influenced by the type of surgery being performed, the age of the patient (since clotting risk increases with age over 50), and other risk factors the patient may have.
But all of the above has been about LMWH… what about aspirin as was used in Cynthia’s case? Although the Chest guidelines cited above provide a “soft” recommendation for aspirin use in some orthopedic surgeries, the data, in my opinion, are not convincing and many clinicians are reluctant to embrace aspirin for this indication. But what about in arthroscopic surgery in particular? I was able to find only one study that had examined this question (see
https://www.ncbi.nlm.nih.gov/pubmed/26630467). This study described results in 66 such patients who received 325 mg of aspirin daily for 14 days vs. 104 patients who received no prophylaxis. Patients were examined for clots by ultrasound at 10 to 14 days post operatively. No DVTs were found in either group. It is difficult to know what to make of these findings. It certainly is difficult to conclude that aspirin is beneficial when the outcomes were the same as with no prophylaxis. Perhaps the study, with 170 patients was too small to identify any DVTs or perhaps some other measures or surgery technique at this single site reduced the DVT risk. It is also feasible that the ultrasound testing missed finding clots that were there. Ultrasound is less reliable for clots below the knee and, in fact, in some settings ultrasonographers are taught not to even perform the test below the knee.
So what’s the bottom line? It seems reasonable to me to consider the risk of the specific surgery being performed, any additional bleeding or clotting risks the patient may have, and have the patient and clinician(s) make an informed, individualized judgement. In addition, as in Cynthia’s case, it would seem wise to be sure that the patient is aware of not only the risks of DT &PE, but also the signs and symptoms of DVT and PE, and what to do should the signs and/or symptoms develop. In Cynthia’s cases, she ended up doing the right thing (going to the ER) for the wrong reason (she thought she had shingles, based on her “Google diagnosis”).
How Is Caregiving for a Loved One Who Has Had a Stroke?
Diane Shares Her Story of Caring for Her Husband, Bob
The “MyTherapy” blog invited ClotCare to share the following post in support of World Stroke Day, which is October 27th.
For patients at risk of stroke who do not adhere to their therapy, I often will try to impress upon them how devastating a stroke can be to their life and lifestyle. But I frequently do not address how a stroke may affect their loved one; Diane’s story (pasted below), however, illuminates this issue.
Each year, over three-quarters of a million people have a stroke in America. The impact of a stroke affects the life not only of the individual concerned, but those of friends, family, and loved ones, who often take on the role of caregiver. The responsibilities this sudden change entails are emotionally and physically demanding, and support can be difficult to find. As World Stroke Day 2017 arrives this weekend, Diane from The Pink House on the Corner shares with us her story of caregiving for her husband, Bob, whom she chose to bring home following his stroke.
A guest post by Diane
In 2010, my husband, Bob, suffered a massive stroke post-surgery. After a two-month hospitalization, he was transferred to an Acute Rehab Center where he was pronounced, as the doctor put it, “nursing home material”. Bob was 52 years old — not “nursing home material.” It was true that Bob could not walk, talk, swallow, could not stand, and had to be transferred from hospital bed to wheelchair with a Hoyer Lift. Still, I was adamant to take him home. In my mind, nursing homes were for the old, sick, dying, and Bob was none of these.
The doctor, against my wishes, proceeded with the admission process to a nursing home. Imagine my surprise when a representative from a nursing home showed up at the hospital, armed with a glossy brochure and a sales pitch about the facility that was so great, they even tried to provide 3 “units” of therapy a day. Though, of course, that depended on staffing.
A “unit” of therapy turned out to be 15 minutes. That would mean Bob would get 15 minutes of physio therapy (PT), 15 minutes of occupational therapy (OT), and 15 minutes of speech therapy (ST) each day (maybe). When I refused, I was told they didn’t need my permission — it was out of my control.
Of course, I argued. With the doctor, the case manager, all the way up to the director of the hospital, without luck. My fear was that Bob would not last long in a nursing home with a patient/nurse ratio of 8 to 1. He would not recover with 3 “units” of therapy (maybe) per day. I could give him better care at home.
Then a “miracle” happened. The nursing home wanted $3,000.00 before Bob could be admitted. I told them I didn’t have the money. Sometimes it pays to be poor. Bob was discharged, in my care, on New Year’s Eve 2010.
The realities of caregiving
I had no idea what I was getting myself into.
Me: who never changed a baby’s diaper.
Me: now the sole caregiver of a 6’3″ man who was incontinent, could not walk or stand, had a feeding tube inserted in his stomach, had aphasia and could say only three words: “no,” “radio,” and “window.”
Me: with expectations that there was “help” out there for at-home caregivers.
I did contact every agency that I could find, only to be told that Bob did not qualify for programs. He was too young, because he was under 65. He was too old, because he was over 21. We were “too rich,” as Bob’s social security disability (SSD) check was $200.00 over the income limit. I did manage to get a wheelchair ramp for the house, provided by one charity. I did get him wheelchair transport through the county bus system. I did find a financial aid program through a not-for-profit hospital that paid his co-pays for outpatient rehab. I did get help for the first month through Bob’s insurance.
We had a nursing assistant (CNA), for changing and bathing, and a nurse to teach me how to manage his meds, his feeding tube, and how to work the nightly feeding pump. But after four weeks, insurance ran out and I was on my own. I was not prepared that much of caregiving involves bodily fluids: adult diapers, urinary incontinence, daily laundry – all of which was overwhelming. I remember, that first week sitting on the back porch late one night behind a heap of urine soaked bedsheets, crying and wondering if I was really able to pull this off.
No one told me about condom catheters – I found this out a year or more later. These helped both Bob’s comfort and my cleaning up after him. No one explained that the feeding tube was not “permanent” and should be changed out every 8 weeks – this I discovered on my own, much later, and if I had known this it would have saved us countless trips to the ER for a clogged tube, and countless hours on my own unclogging the tube.
God bless the nurse who told me it was not necessary to have a daily bowel movement. The hospital had discharged Bob on a daily laxative, which meant constant diarrhoea. This nurse taught me “bowel movement management,” giving laxatives only when necessary.
The emotional strain
One of the hardest and most heart-breaking tasks was trying to keep his therapy going – I would take him to PT, ST, OT three times a week, pushing him there in his wheelchair, and though he showed improvement (being able to walk holding onto the parallel bar), the therapy was ended for “no functional improvement.” So, I had a railing installed in our hallway where Bob could practice walking, with me pushing the wheelchair behind him, and holding him up with a gait belt. I developed our own speech therapy and we practiced daily. I did this after the speech therapist insisted on using pictures for him to point at and teaching him gestures. Bob was good at repeating things and I used his ability; I would say a sentence, and he repeat it. I did his range of motion to keep his paralyzed arm and leg from freezing up. I bugged his primary care doctor every six months for a new script for outpatient therapy where they have special equipment, things we didn’t have at home. Each and every time, it was like starting from “square one,” and the insurance would stop after 8 weeks for “no functional improvement,” which never failed to shock me.
Another shock was the way people treated Bob post-stroke. “Baby talking” to him as if he were a child or an idiot. Talking over his head, to me, as if he wasn’t in the room. Shouting at him – as if he couldn’t hear. The friends and family who fled – as if stroke is contagious. Bob was still the same person just trapped in a disabled body. I wanted people to treat him with respect. Speak to him normally. Include him in conversations. Have patience as it sometimes took him time to respond. To listen. Visit. Make a phone call. Only a few did. I am grateful for those few.
There were other battles too, fighting for adequate pain medication, fighting for medical equipment and supplies, including a power wheelchair – the doctor insisting that Bob couldn’t manage it, and me arguing to at least let him try. That doctor, finally, ordered a powerchair, on the condition that it had an attendant control so that I could “drive” it. The first time I attempted to “drive” it, I plowed Bob straight into a wall. When Bob took control, he zoomed around the room.
I learned over the years to stick to my guns, follow my gut, and fight for my man.
The ups and downs of caregiving
Caregiving is hard. Frustration, anxiety, stress all build up. You find yourself crying, screaming, angry (Why us? Why me?). There is no time to take care of yourself, to sort out all these emotions. So you take a deep breath. Tough it out. Ignore that cold that doesn’t go away. Or that suspicious looking mole. Cut your own hair. Hope for the best and concentrate on caring for the one you love.
Then there’s grief. Grief over the loss of the man he once was and would never be again. Grief over a relationship that has changed from equal partners to caregiver/patient.
Blogging was one way I was able to vent/rant about the frustrations and anxieties of caregiving. I started my blog shortly after Bob came home. It was the one thing I could do for myself, steal 15 minutes a couple of times a week. I began blogging to keep my “hand” in writing (my profession) and to keep our family and friends informed, but strangely it turned into something else. I didn’t realize there is a whole “stroke community” out there, where I “met” stroke survivors and caregivers around the world and appreciated their support, their stories, and just knowing that we were not alone on this journey.
Caregiver burnout is real. There were many days when I felt I just could not “take it” any longer. Nights crying on that back porch then wiping away the tears and returning to my duties, putting on a smile for Bob’s sake.
All that said, I wouldn’t change a thing (well, except for the stroke part). I am glad I was able to care for Bob at home.
I cherish memories of quiet nights, watching a movie, holding Bob’s hand. Memories of “hand dancing” to a song on the radio. The nightly I love yous called to each other across the room. The way he would sing while doing his therapy exercises. The triumphs, like the first (and only) time he was able to stand up with a hemi-walker. Every new muscle movement he regained.
I deeply admire his courage and strength and motivation to never give up, never stop trying. To accept the things he could not change with a shrug and an “oh well.” Near the end of his life, though he was still not able walk or swallow, he could “tool around” (his words) in his powerchair and speak entire sentences. I’m sure he would’ve never accomplished those things in a nursing home.
Bob was able to spend his last five years in the comfort of his own home, with his two beloved cats, our dog, and with me by his side. For that, I will always be grateful.
Bob passed away on May 28th, 2015. We would like to thank Diane for contributing this guest post.
Henry I. Bussey, Pharm.D.,
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[Figure from WTD website… for more information check out http://www.worldthrombosisday.org/]