My 86 year old mother was diagnosed with Vascular Dementia. At the age of 32, she experienced a stroke, recovered with some residuals. In the past years she has lost her balance and fallen. She has had 2-3 TIAs throughout the years, which have led her to placing her in a NCF. In addition, she has AF, being treated for HBP, and diabetes. Recently it was discovered that she had a blood clot behind the left knee which is weak due to her previous stroke. The blood clot was discovered with a doppler. Two weeks after that report, I asked if another doppler would be conducted and I was told the NCF physician indicated that they had increased her anticoagulant, eliquis, and would wait 3 months before conducting another doppler exam to determine whether the clot had dissolved. I believe that because of her medical history, a doppler should be done. Am I wrong to assume this? Does this have anything to do with Medicare and/or Medicaid? Should I call the ombudsman to assist with this?
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Regarding blood thinners if she is not on Warfarin she will not need INR monitoring. That testing is not done with Eliquis. PT/INR testing is not required on those new types of anticoagulants.
If on warfarin foods one must avoid foods high in Vitamin K (green leafy vegetables). If someone on warfarin regularly eats green leafy vegetables then they are advised to stay on that diet as this is considered their baseline.
If not on warfarin the list provided of foods and meds that can affect clotting times just posted does not apply here.
Clot dissolution takes months. I would expect she will be on some sort of anticoagulant the rest of her life due to her history of a fib and now a blood clot.
There is no reason she needs to be seen more than once per month.
The U of M Hospital used to have the best list of medicines and foods that affect anticoagulants, but I haven't been able to locate it for months. I suspect it's been removed, unfortunately.
I did find a list, not as thorough as the U of M list, but thorough enough:
https://my.clevelandclinic.org/health/drugs/16182-warfarin-a-blood-thinning-drug-what-you-need-to-know-
The following is ust what the list offers, but clearly states that it's not a complete list. These meds enhance the effect, i.e., contribute to the anticoagulation effect:
Amiodarone (Cordarone®
Pacerone®)Co-trimoxazole (Bactrim®, Septra®)
Ciprofloxacin (Cipro®)
Clarithromycin (Biaxin®)
Erythromycin Multiple brands
Fluconazole (Diflucan®)
Itraconazole (Sporanox®)\
Ketoconazole (Nizoral®)
Lovastatin (Mevacor®)
Metronidazole (Flagyl®)
This is an even better list:
https://www.medicinenet.com/anticoagulants_drug_class_of_blood_thinners/article.htm#list_of_brand_and_generic_names_and_preparations_oral_injection_tablet_pill_powder
The pharmacists in the Anticoagulation Clinic explained that some levels of Vitamin K foods can be tolerable, IF the amount is consistent, but if someone suddenly eats huge amounts of celery, e.g., that's going to affect the PT/INR values.
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Let us know what the doc tells you. And keeping you in our thoughts.
As to only a once a month visit, that seems unusual to me, unless this is a facility is in a very rural area. My area is heavily metropolitan, with a lot of rehab and nursing facilities, so there's probably some competition with doctors to become a treating facility doctor.
I do recall having seen one doctor more than a few times on different days during the weeks in one of the rehab facilities we used several times. This was her PRIMARY practice though, and that probably makes a difference.
I'm learning more and more about clots and plan to keep this information in my own medical files in case I'm ever in this situation.
One reason for a doppler to be repeated so "soon" after the first doppler study would be if your Mom leg is displaying symptoms of another blood clot; symptoms that indicate that the current blood clot is NOT dissolving/descreasing in size, but INCREASING in size; or symptoms that indicate the blood clot is disrupting circulation in the lower leg and foot.
Communication is very important when dealing with your health or the health of a loved one. Ask the doctor the same question that you asked us, "Why are you waiting 3 months before performing a second (follow-up) doppler exam?"
Alva, the issue of increased risk of bleeding, vs. an already existing clot, but presumably no monitoring at all was probably the biggest concern I had. I kept viewing two trains on the same track coming at each other in opposite directions and no signal monitoring at all to deflect a crash.
Max, the doctor should have the courtesy to address your concerns. You can go to the DON (Director of Nursing) or the Administrator and make it clear (gently) that you need to have a discussion with the treating doctor about these issues so you can understand his/her position.
And you do have the right to request a different doctor. I did that once but I can't remember if it was when my mother or my father was in rehab.
And indeed, as a general rule, if ever you want to know why a doctor has done or hasn't done something - ask that doctor!
Quite honestly, get an ultrasound and it is there? Then what? Don't and something happens? Kick yourself down the street. But still there? What could you do about that?
There are only a few things that can be done. Sometimes they put in a little screen so that the clots in a lower extremity won't travel to lung or brain. But that ALONE in a person with this history and age is a risk.
For all of the above reasons my only advice would be to speak with the doctor. Ask the doctor to PLEASE give you 5" of his or her time. And ask the doctor. I honestly wouldn't have any other recourse myself.
I wish you the very best of luck and your Mom, and I hope you will update us. There is a lot here that isn't good. You know that. But the real question is what to do about it. Remember, no constrictive devices, watch for signs of bleeding. Exercise WITH HELP ONLY now if she is able to ambulate. NO rubbing of the extremities, ie lotions and things. I am so sorry.
My oncologist had an expression "Medicine is anything but an exact science, but people want ANSWERS so we give them answers". He said he could tell me that outright because I was a nurse. But basically he was saying "You have cancer; now I am going to guess the best way to treat it. I will either be right or wrong." We don't want to hear that. But sometimes it is the only truth.
First, I assume NCF means Nursing Care Facility? I couldn't find it as any other appropriate acronym. If so, the medical care won't be as tailored or intense as a private physician would provide, so I think you're wise to question the decision to wait 3 months before performing another Doppler ultrasound.
Second, I've seen good facility doctors and bad ones. Our first experience was at a rehab facility with doctors who definitely weren't top notch; in fact, we identified one who was skimming Medicare, I reported him, and Medicare initiated an investigation.
OTOH, at another facility in a town with 2 major top notch hospitals, the care was outstanding.
Third, I'm concerned about the increase in Eliquis; I assume no blood draws are taken to monitor your mother's coagulation levels? This is why the pharmacists at the Anticoagulation Clinic of a local hospital recommended against these medicines as a substitute for Warfarin/Coumadin.
With those 2 drugs, blood draws were regularly performed to monitor coagulation levels. At that time, this wasn't the practice with the Eliquis or similar drugs. So there was NO WAY of knowing if the individual was segueing into an overly anticoagulated state.
This actually happened to my father, b/c a PCP prescribed a drug that enhanced anticoagulation, notwithstanding the fact that he knew my father was taking Coumadin. Dad began hemorrhaging, we ended up in the hospital.
Fourth, I can't medically opine on whether or not another Doppler should be done sooner; I'll leave that to the medical people here. But if it was my father, I'd be contacting one of our private team and raising the issue, requesting that if necessary, he/she contact the facility and share his/her concern that testing needs to be done more frequently.
And it could be that blood draws could monitor the level of anticoagulation as a result of an increase in Eliquis; I'm not familiar enough with their application outside of Warfarin/Coumadin use to offer any insight on how blood draws might be useful with the newer drugs.
Fifth, I would do this: Watch for opinions from AlvaDeer and PamZimmint, and other medical pros who post here (and I apologize I can't recall their names right now). They'll give you more insightful advice than I can.
But I do believe your concern is justified, and I'm glad you're reaching out for advice. And b\c of your mother's medical history, and age, I'm creating a thread to draw attention to your request for the med pros to respond.