What are the best management strategies for a 97-year-old female with a history of unwitnessed falls, complex medical conditions, and multiple medications, including anticoagulation therapy?

Management of Recurrent Falls in a 97-Year-Old on Anticoagulation

Continue anticoagulation with Eliquis while implementing an aggressive multifactorial fall prevention program, as the mortality benefit of anticoagulation for atrial fibrillation outweighs bleeding risk from falls, and discontinue or taper trazodone immediately given its significant contribution to fall risk through sedation and anticholinergic effects. 1, 2, 3

Immediate Medication Management

Discontinue High-Risk Sedating Medications

• Trazodone 100 mg must be discontinued or rapidly tapered, as it causes sedation and performance impairment that persists into the next day, directly increasing fall risk even when patients don't feel subjectively drowsy. 2
• The anticholinergic effects of trazodone (dry mouth, urinary retention, constipation) compound fall risk in older adults through multiple mechanisms. 2
• Do not use the common practice of switching trazodone to nighttime only—sedative effects persist beyond sleep hours. 2
• Consider non-pharmacologic sleep interventions or safer alternatives if insomnia management is essential. 2

Review Escitalopram Continuation

• Monitor for serotonin syndrome given the recent trazodone/escitalopram combination (agitation, tremor, clonus, diaphoresis). [@case documentation@]
• Escitalopram alone carries lower fall risk than trazodone but still requires monitoring for sedation and orthostasis. 2
• Consider whether depression/anxiety treatment justifies continued SSRI use versus fall risk in this 97-year-old. 2

Anticoagulation Decision

• Continue Eliquis without interruption—patients on anticoagulation with recurrent falls do not have increased rates of bleeding injury compared to non-anticoagulated fallers (12.8% vs 12.7%, p=0.97). 4
• However, mortality is significantly higher IF bleeding occurs while anticoagulated (21.5% vs 6.9%, p<0.01), making fall prevention paramount. 4
• The type and quality of anticoagulation does not affect fall risk itself but does affect survival after falls—apixaban (Eliquis) shows the best survival rates post-fall compared to warfarin. 3
• Daily bleeding surveillance is mandatory: check gums, stool, bruising, and any new neurologic symptoms. [1, @case documentation@]

Multifactorial Fall Risk Assessment & Interventions

Individual-Level Strategies (Highest Priority)

Gait and Balance Training:

• Implement supervised balance training at least 3 days per week through physical therapy, focusing on gait, balance, and strength components. 5, 6
• This is the single most effective intervention for fall reduction in community-dwelling older adults. 6
• Continue current PT/OT but intensify balance-specific exercises. [@case documentation@]

Medication Review:

• Beyond trazodone, evaluate metoprolol for excessive bradycardia or hypotension contributing to falls. 6
• Assess irbesartan dosing—antihypertensives are high-risk medications for falls. 6
• Perform orthostatic vital signs at each visit: measure BP/HR supine, sitting, and standing. 6, 5
• Document any drop >20 mmHg systolic or >10 mmHg diastolic. 6

Vitamin D Supplementation:

• Provide 800 IU vitamin D daily for at least 12 months—this reduces fall risk in older adults at high risk. 5, 6
• Continue supplementation given age, recent falls, and fracture history. 5

Environmental Modifications

Immediate SNF Environment:

• Ensure non-slip footwear with low heels and hard soles (not just non-slip socks). 5, 6
• Bedside commode must be available and positioned correctly. 6
• Bed rails properly positioned and functioning. 6
• Call light within reach at all times with frequent nursing reminders (not just PRN). [6, @case documentation@]
• Consider bed/chair alarms given two unwitnessed falls. 5

Discharge Planning:

• Home safety evaluation is mandatory before discharge to independent/assisted living. 6, 5
• Assess lighting, remove loose rugs, install grab bars, evaluate stairs. 2, 5
• Arrange outpatient PT continuation post-discharge. 6

Monitoring Protocol

Neuro Checks:

• Continue 72-hour neuro checks as initiated, monitoring for delayed intracranial hemorrhage given anticoagulation. [@case documentation@, 1]
• PERRLA, orientation, focal deficits, headache, confusion must be documented every shift. 6

Fall Risk Reassessment:

• Use standardized gait assessment ("get up and go test") before any discharge decision. 6
• Patient must demonstrate ability to rise from bed, turn, and steadily ambulate. 6
• If unable to perform safely, discharge is contraindicated. 6

Recurrence Risk:

• This patient has 4.7% risk of hospital readmission for recurrent fall within 6 months (median 57 days). 4
• Highest risk period is first 2 months post-fall. 4

Special Considerations for This Patient

Cognitive Impairment

• Mild cognitive impairment increases fall risk and may impair recall of fall circumstances. [@case documentation@]
• Ensure hearing aids are worn during all therapy sessions and provider visits to maximize comprehension. [@case documentation@]
• Simplified, repeated safety instructions are necessary. 6

Atrial Fibrillation Management

• Higher CHA₂DS₂-VASc scores (this patient scores ≥6) correlate with increased fall risk independent of anticoagulation. 3
• Irregularly irregular rhythm may contribute to decreased cardiac output during position changes. [@case documentation@]
• Maintain rate control with metoprolol but monitor for excessive bradycardia. [@case documentation@]

Rib Fracture & Pain

• Right 11th rib fracture may limit mobility and respiratory effort, indirectly increasing fall risk. [@case documentation@]
• Continue lidocaine patches and acetaminophen—avoid opioids which dramatically increase fall risk. [@case documentation@, 6]
• Encourage pulmonary hygiene to prevent pneumonia which would further impair mobility. [@case documentation@]

Common Pitfalls to Avoid

• Do not discontinue anticoagulation due to falls alone—the stroke risk from untreated AFib far exceeds bleeding risk from falls in most patients. 4, 3
• Do not add benzodiazepines for anxiety/insomnia—these are contraindicated in fall-risk patients. [@case documentation@, 2]
• Do not rely solely on patient recall of fall circumstances—unwitnessed falls require systematic risk factor evaluation regardless of patient report. 6, 7
• Do not discharge without documented safe ambulation—"participating in therapy" is insufficient; specific gait testing is required. 6
• Do not use vitamin D supplementation as monotherapy—it must be combined with exercise and environmental modifications. 6, 5

Implementation Strategy

Week 1:

• Discontinue/taper trazodone immediately. 2
• Initiate vitamin D 800 IU daily. 5
• Intensify PT to 3+ days/week with balance focus. 5
• Complete orthostatic vital signs. 6
• Environmental safety audit of room. 6

Weeks 2-4:

• Monitor for trazodone withdrawal effects and sleep pattern changes. 2
• Continue daily bleeding surveillance. 1
• Weekly gait reassessment. 6
• Arrange home safety evaluation if discharge anticipated. 5

Months 2-6:

• Continue balance training through outpatient PT. 5
• Monitor for recurrent falls (highest risk period). 4
• Maintain vitamin D supplementation. 5
• Regular medication review every 1-2 months. 2, 5