When should apixaban (Eliquis) and metoprolol be discontinued in a patient in their late 80s with dementia, a DNR order, who remains active and ambulatory?

When to Discontinue Eliquis and Metoprolol in Late 80s+ Patients with Dementia and DNR Status

In an active, ambulatory patient in their late 80s with dementia and DNR status, discontinuation of Eliquis (apixaban) and metoprolol should be strongly considered when the patient develops severe or end-stage dementia (dependence in most basic activities of daily living), has limited life expectancy, or when the risks of bleeding and falls outweigh the long-term benefits of stroke prevention and rate control.

Framework for Decision-Making

For Eliquis (Apixaban)

The decision to continue or discontinue anticoagulation requires weighing stroke prevention benefits against bleeding risks in the context of limited life expectancy and quality of life priorities.

Consider discontinuation when:

• Severe/end-stage dementia develops - defined as dependence in most basic activities of daily living or inability to respond meaningfully to environment 1
• Limited life expectancy (typically <1 year) where time-to-benefit exceeds expected survival 2
• High fall risk - particularly relevant given dementia and advanced age 3, 4
• Bleeding complications occur - even minor bleeding events should prompt reassessment 3
• Patient/family goals shift toward comfort - especially if enrolled in hospice 5

Key evidence considerations:

Recent research shows that anticoagulants are frequently continued until death in nursing home residents with dementia, with increases in anticoagulant use even in the final year of life 5. However, prospective studies in palliative populations demonstrate that deprescribing anticoagulants does not increase clinical thrombosis and may reduce bleeding while facilitating home death 2. In the last months of life, clinically relevant bleeding occurs in up to 1 in 10 patients on anticoagulation 2.

The 2019 AGS Beers Criteria specifically cautions about rivaroxaban use in adults ≥75 years, and similar concerns apply to apixaban given shared bleeding risks 4. Additionally, frailty and dementia are documented rationales for inappropriate dosing and consideration of discontinuation 3.

For Metoprolol

Beta-blocker continuation depends on the specific indication and whether symptomatic benefit persists.

Consider discontinuation when:

• Used solely for rate control in atrial fibrillation and patient is asymptomatic with adequate rate control, particularly if anticoagulation is being discontinued
• No clear symptomatic benefit from rate or blood pressure control
• Side effects emerge - bradycardia, hypotension, dizziness, falls, or confusion 1
• Patient has severe dementia with limited life expectancy where preventive cardiovascular benefits are unlikely to be realized

Continue metoprolol if:

• History of myocardial infarction (secondary prevention benefit may persist) 6
• Symptomatic heart failure with reduced ejection fraction
• Symptomatic arrhythmias requiring rate control
• Symptomatic angina

Practical Deprescribing Approach

When discontinuing Eliquis:

• No tapering required - simply stop the medication 7
• Monitor for signs of thrombosis in first 2-4 weeks if concern exists
• Document rationale clearly in medical record
• Discuss decision with patient (if capable) and family/substitute decision-maker 1

When discontinuing metoprolol:

• Gradual taper recommended to avoid rebound tachycardia or hypertension
• Reduce dose by 50% every 1-2 weeks until discontinued
• Monitor heart rate and blood pressure during taper
• Can discontinue more rapidly if no cardiac history beyond rate control

Common Pitfalls to Avoid

1. Continuing medications by inertia - The default should not be continuation simply because the patient has been on these medications long-term 5, 2

2. Ignoring fall risk - Advanced age (≥80 years), dementia, and anticoagulation create a dangerous triad for intracranial hemorrhage 3, 4

3. Failing to reassess goals of care - DNR status often signals a shift toward comfort-focused care that should prompt medication review 1, 8

4. Overlooking drug interactions - If metoprolol is continued with apixaban, be aware that diltiazem (if added) significantly increases bleeding risk compared to metoprolol alone 9

5. Not involving family/caregivers - Shared decision-making is essential, particularly regarding fall prevention and quality of life priorities 1

Special Considerations for This Population

The combination of late 80s age, dementia, and DNR status suggests:

• Life expectancy likely <2-3 years
• Time-to-benefit for stroke prevention (typically 1-2 years) may exceed survival
• Fall risk is substantially elevated with dementia
• Medication adherence may be compromised
• Goals likely favor quality of life over longevity

However, the patient's current functional status (active, ambulatory, participates in activities) argues for individualized assessment rather than automatic discontinuation. This functional preservation may indicate earlier-stage dementia where benefits still outweigh risks.

Monitoring After Discontinuation

• Assess for new neurological symptoms (stroke/TIA) in first month after stopping Eliquis
• Monitor heart rate if metoprolol discontinued
• Reassess fall frequency and bleeding events
• Document improved quality of life or adverse outcomes to inform future decisions

The strongest evidence supports deprescribing both medications when dementia progresses to severe stage, life expectancy becomes limited (<6-12 months), or when patient/family goals clearly prioritize comfort over stroke prevention 1, 5, 2.