How do you balance anticoagulation (blood thinner) therapy risk with fall risk in an elderly patient with atrial fibrillation (irregular heartbeat) and a high risk of falls?

Anticoagulation Should Be Continued in Elderly Patients with Atrial Fibrillation Despite Fall Risk

The benefits of stroke prevention with oral anticoagulation far outweigh the bleeding risks from falls in elderly patients with atrial fibrillation, and fall risk alone should not be a reason to withhold anticoagulation. 1

The Critical Evidence on Falls and Anticoagulation

A patient would need to fall 295 times per year before the risk of subdural hemorrhage from falls outweighs the stroke prevention benefit of anticoagulation. 1 This landmark calculation demonstrates that even patients at high risk of falls derive substantial net benefit from anticoagulation. A more recent Markov decision analysis found that patients would need to fall over 45 times per year (for rivaroxaban) or 458 times per year (for apixaban) for the quality-adjusted life-years to be lower than aspirin therapy. 2

The absolute numbers make this clear:

• Approximately 25% of all strokes in patients aged 80 and above are attributable to atrial fibrillation 3
• Oral anticoagulation reduces stroke risk by 60-65% compared to no treatment 3
• The annual stroke risk without anticoagulation typically exceeds 2.5% per year in elderly patients with AF 3

Age Is Not a Contraindication

Age per se is not a contraindication to anticoagulation in high-risk atrial fibrillation patients, as the stroke prevention benefit exceeds bleeding risk in the vast majority of cases. 1, 3 While elderly patients (≥75 years) have approximately twice the bleeding risk during anticoagulation compared to younger patients, anticoagulation remains warranted when ischemic stroke risk exceeds bleeding risk—a threshold easily met in most elderly AF patients. 1, 4

Practical Management Algorithm

Step 1: Assess Stroke Risk

Calculate the CHA₂DS₂-VASc score. Patients with a score ≥2 have an annual stroke risk exceeding 2.5% per year and should receive oral anticoagulation. 3 This includes virtually all elderly patients with AF.

Step 2: Address Modifiable Fall Risk Factors

Before initiating anticoagulation, implement fall prevention strategies rather than withholding therapy: 1

• Provide walking aids and appropriate footwear 1
• Conduct home review to remove trip hazards 1
• Perform neurological assessment if falls are unexplained 1
• Optimize vision and treat orthostatic hypotension 5

Step 3: Optimize Modifiable Bleeding Risk Factors

Control hypertension aggressively, targeting blood pressure <140/90 mmHg, ideally <130/80 mmHg. 6 Poorly controlled hypertension is the most important modifiable risk factor for bleeding complications during anticoagulation. 6

Avoid concomitant antiplatelet therapy (aspirin or NSAIDs) unless there is a compelling indication, as these medications increase bleeding risk without additional stroke benefit in AF. 1, 7

Step 4: Select the Appropriate Anticoagulant

Direct oral anticoagulants (DOACs) are preferred over warfarin due to their favorable safety profile, including lower rates of intracranial hemorrhage. 5, 2

For apixaban (preferred DOAC in elderly patients):

• Standard dose: 5 mg twice daily 8
• Reduced dose: 2.5 mg twice daily if ≥2 of the following: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 6, 8

For warfarin (if DOAC not suitable):

• Target INR 2.0-3.0 for most patients 9
• Some experts recommend target INR 2.0 (range 1.6-2.5) for primary prevention in patients >75 years to minimize bleeding risk, though this remains controversial 1

Step 5: Monitor Appropriately

• Assess renal function at least annually, as renal impairment increases bleeding risk 3
• Verify appropriate dosing at each visit 3
• Review for signs of bleeding: unusual bruising, prolonged bleeding, blood in urine or stool, severe headache 6

Common Pitfalls to Avoid

Do not withhold anticoagulation based solely on fall history or fall risk. 1, 10 The propensity to fall is not an important factor in determining optimal antithrombotic therapy for elderly patients with AF. 10

Do not reduce DOAC doses off-label (i.e., outside FDA-approved criteria) in an attempt to reduce bleeding risk, as this results in reduced efficacy with limited reduction in bleeding risk. 5

Do not add aspirin to anticoagulation therapy without a specific indication (such as recent coronary stenting), as it only increases bleeding without additional stroke benefit. 6

Do not discontinue anticoagulation after a fall unless there is active severe bleeding or documented intracranial hemorrhage. 11 Studies show that 91% of patients admitted on anticoagulation who experience an in-hospital fall are appropriately discharged on anticoagulation. 11

When to Consider Withholding Anticoagulation

Anticoagulation should only be withheld in specific circumstances: 1, 5

• Active severe bleeding
• Severe frailty with limited life expectancy (<1 year)
• Documented intolerance or allergy
• Inability to ensure medication adherence (no available caregiver in patients with cognitive impairment) 1
• Multiple cerebral microbleeds on imaging suggesting very high intracranial hemorrhage risk 5

In patients with cognitive impairment or dementia, anticoagulation should only be withheld if there is no available caregiver who can guarantee medication adherence. 1