Mrs. L, a 90-year-old woman living with moderate Alzheimer's dementia presented to the emergency department (ED) for a fall at home. She had a mildly swollen left leg that was attributed to dependent edema and was discharged after 1 day. After discharge, she developed functional decline, requiring more assistance from her daughter because her increasingly swollen and painful left leg caused significant discomfort. As the immobility extended into the third week, the leg had doubled in size with unbearable pain. She turned delirious, agitated and aggressive toward her family. Furthermore, she refused her meals and could not sleep. It was unlike her to turn aggressive toward her family; hence they decided to bring her back to the ED. Basic blood investigations and x-rays of the left lower limb were unremarkable. Doppler ultrasound of the left lower limb revealed extensive proximal deep vein thrombosis (DVT) extending from the external iliac vein and common femoral vein to the popliteal vein. Computed tomography (CT) of the abdomen and pelvis revealed compression of the left common iliac vein by an osteophyte from the L5 vertebral body (Figure 1), with no other abnormalities to account for the cause of DVT. The working diagnosis was osteophytic May-Thurner syndrome (MTS) 1 complicated by extensive left lower limb proximal DVT, and low-molecular-weight heparin (LMWH) was started. Due to her hyperactive delirium, Mrs. L was selectively admitted to the Dementia Ward, where an interprofessional approach centered around the Hospital Elder Life Program (HELP) 2 and Person-Centered Care (PCC) 3 model aims to relieve neuropsychiatric symptoms without chemical/physical restraints. Medication reconciliation led to de-prescribing of anticholinergic drugs like diphenhydramine. Mrs. L was seen by physical and occupational therapists from day one for exercises and daytime activities that she enjoys. Nurses sat her out of bed for meals with her preferred foods, and a dietician prescribed oral nutritional supplements. Standard treatment options for extensive above knee DVT include lifelong anticoagulation, or endovascular thrombectomy followed by anticoagulation for 3 months. The decision-making process for a frail person with multiple comorbidities is often complex and person-centered, integrating input from the interprofessional team, older person and family. Moreover, the decision needs to consider the caregiver arrangement, fall-risk assessment, side effects and pharmacokinetics of medications, procedural complications, and the person's wishes. Jonsen's Four-Box Ethical Approach 4 is a useful tool for complex medical decisions that appraises medical indications, patient preference, quality of life and contextual factors. Mechanical thrombectomy with stenting and inferior vena cava (IVC) filter insertion would effectively mitigate the risk of fatal pulmonary embolism (PE), which was high since the thrombus was extensive, spanning nearly the whole length of her thigh. Thrombectomy would promptly relieve the swelling and pain, enabling Mrs. L to mobilize earlier, and reduce the need for stronger analgesia and prolonged bed rest. Getting Mrs. L out of bed and mobilizing her at the earliest opportunity would reduce her risk of immobility-associated complications like functional decline, delirium, constipation, urinary retention, and worsening sarcopenia 5. By contrast, long-term anticoagulation carried significant risks for Mrs. L due to her history of recurrent falls, such as serious injuries, medication non-adherence and increased pill burden. After a discussion with Mrs. L and her daughter, who is her healthcare surrogate, on Mrs. L's values, goals and preferences, the decision was made for endovascular intervention. Mechanical thrombectomy of the left lower limb DVT from the iliocaval confluence to the left popliteal vein, balloon venoplasty and left iliocaval stenting (Figure 2) was successfully performed. An 11 cm clot was removed uneventfully (Figure 2). Venography confirmed severe thrombosis at the left iliocaval junction (Figure 3), and satisfactory effacement of the left common iliac vein outflow narrowing after stenting (Figure 3). In addition, an infrarenal inferior vena cava (IVC) filter was inserted through the right internal jugular vein to prevent caudal migration of thrombus resulting in PE. Mrs. L tolerated the procedure well. Doppler ultrasound 1 day after the procedure showed markedly reduced clot burden in the left proximal deep venous system. After mechanical thrombectomy and stenting, pain and swelling rapidly resolved over 3 days. Mrs. L was able to ambulate using a walking frame with minimal assistance from the physical therapist on post-operative day one. She was transferred to a step-down care facility to continue rehabilitation. In clinic 3 months after her discharge, her left leg was no longer swollen, and she had resumed her evening walks with her daughter. Repeat Doppler ultrasound showed that the proximal deep venous system of the left leg remained patent. This complex case demonstrates how the 5 M's 6 can facilitate person-centered care for an older adult with clinical dilemma. Age and procedural risks should not be the sole considerations for deciding whether to proceed with an invasive intervention. Despite the risks associated with frailty and aging, physicians should consider how an intervention can improve the person's mobility/function, mind/mood, and avoid complications associated with multicomplexity like delirium, deconditioning, polypharmacy, and incontinence, while improving the person's and caregiver's quality of life. Additionally, long-term analgesia/medications may have adverse effects. Furthermore, by considering the patient's values, goals, and preferences, we can align our treatment with what matters most to the person. Mrs. L's May-Thurner syndrome—an anatomical variant with a prevalence of 22%–32% and accounting for 2%–3% of lower extremity DVT—predisposed her to develop DVT 1. Pain and swelling from DVT may have precipitated the fall. After the fall, the fear of falling and pain subsequently triggered a vicious cycle of immobility, functional decline, and extension of the DVT 1. During her stay in the Dementia Ward, HELP 2 shortened the duration of delirium. The PCC 3 model managed her neuropsychiatric symptoms without physical/chemical restraints. With prompt thrombectomy for the extensive DVT, pain control was adequate with simple analgesia, and she was walking with the physical therapist immediately after the procedure. Furthermore, her appetite and sleep improved after thrombectomy. Her family members were pleased to see the rapid improvement in her well-being and resolution of delirium and function. The standard of care for MTS-related DVT involves endovascular procedures (such as catheter-directed thrombolysis, angioplasty and stenting) which is associated with 50%–75% reduced risk of life-threatening PE 7. Anticoagulation alone is inadequate for the treatment of DVT 8. In the ATTRACT trial, the number needed to treat (NNT) was 7 for thrombolysis followed by anticoagulation, versus the NNT of 45 for patients who only received anticoagulation 8. Notably, older adults aged 85 years and older were excluded from similar trials due to concerns of bleeding from thrombolytic therapy. Nonetheless, older adults have a heightened risk of developing post-thrombotic syndrome, a long-term complication of DVT, with leg pain, swelling, discoloration and ulceration 9. Several factors contributed to Mrs. L's successful clinical outcome. Thrombectomy eliminates the risk of fatal PE while avoiding the bleeding risks associated with thrombolysis 10, and stenting relieves osteophytic compression to re-establish venous outflow, which prevents chronic venous stasis and post-thrombotic syndrome. Meanwhile, IVC filter insertion proximally prevents PE and was removed after 3 months. To further improve her function, Mrs. L was transferred to a community hospital for rehabilitation for 4 weeks. Prior to discharge, she was able to ambulate with a walking frame with minimal supervision. Moreover, she had fully recovered from delirium, and her appetite had improved. Delighted, her daughter remarked, “She is walking tall again.” All authors contributed significantly. L.Y.T. and S.S.H.K. wrote the first draft. L.Y.T., S.S.H.K., H.S., and S.C.L. interpreted the data. All authors critically reviewed and commented on the manuscript. The authors have nothing to report. The authors declare no conflicts of interest.
Tee et al. (Thu,) studied this question.