From the Guidelines
The evaluation and management of falls in geriatric patients requires a comprehensive approach, with special considerations for those on anticoagulants (blood thinners), and should prioritize a thorough fall risk assessment, immediate evaluation for injuries, and interventions to minimize fall risk and prevent future falls, as recommended by recent guidelines 1.
Key Considerations
- For all geriatric patients who fall, immediate assessment should include vital signs, neurological examination, and evaluation for injuries, particularly head trauma, with a lower threshold for neuroimaging even with minor head trauma if the patient is on anticoagulants 1.
- A thorough fall risk assessment should be conducted, including:
- Medication review (especially sedatives, antihypertensives, and psychotropics) 1.
- Vision testing.
- Gait and balance evaluation.
- Orthostatic blood pressure measurements.
- Home safety assessment.
- Interventions should include:
- Exercise programs focusing on strength and balance (such as tai chi) 1.
- Medication adjustments to minimize fall risk.
- Vitamin D supplementation (800-1000 IU daily) if deficient.
- Home modifications (removing tripping hazards, installing grab bars).
- Proper footwear.
Anticoagulant Considerations
- For patients on anticoagulants like warfarin, DOACs (apixaban, rivaroxaban, dabigatran, edoxaban), or antiplatelets, the risk-benefit ratio should be regularly reassessed 1.
- After a fall with significant injury, anticoagulation might need temporary interruption, though this decision requires careful consideration of thrombotic risk 1.
Prevention Strategies
- Prevention strategies should be intensified for these high-risk patients, including more frequent follow-up, consideration of assistive devices, and education about fall prevention and anticoagulant adherence 1.
- The multidisciplinary approach may include physical therapy, occupational therapy, and home health services to comprehensively address fall risk factors 1.
From the FDA Drug Label
Patients 60 years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of warfarin Warfarin sodium tablets are contraindicated in any unsupervised patient with senility. Caution should be observed with administration of warfarin sodium to elderly patients in any situation or physical condition where added risk of hemorrhage is present.
The evaluation and management of fall in geriatric patients with warfarin (a blood thinner) should involve caution due to the increased risk of hemorrhage.
- Key considerations for geriatric patients on warfarin include:
- Greater than expected PT/INR response to warfarin
- Increased risk of hemorrhage in situations where added risk is present
- Need for lower initiation and maintenance doses of warfarin For geriatric patients without blood thinners, the FDA drug label does not provide direct information on the evaluation and management of falls. 2
From the Research
Evaluation and Management of Fall in Geriatric Patients
- Geriatric patients are at a high risk of falls, with one in three older adults falling each year, resulting in approximately 2.5 million falls among older adults treated in emergency departments 3.
- The biggest risk factor for falling is a history of falls, and other risk factors include frailty, sedative and anticholinergic drugs, polypharmacy, and various medical conditions 3.
Management of Fall Risk in Geriatric Patients
- Current recommendations suggest that all patients age 65 years and older should be asked about falls each year, and patients can be screened for fall risk using questionnaires and the Timed Up & Go test 3.
- Care should focus on correcting reversible home environmental factors, minimizing the use of sedating drugs, addressing vision conditions, recommending physical exercise, and managing postural hypotension, foot conditions, and footwear 3.
- Vitamin D and calcium supplementation should also be considered to reduce the risk of falls 3.
Anticoagulation Therapy in Geriatric Patients with Fall Risk
- For patients needing anticoagulation for medical reasons, an assessment must balance fall risk versus the risk of discontinuing anticoagulation, such as sustaining an embolic stroke from atrial fibrillation 3.
- Clinicians often face a dilemma when patients with persistent atrial fibrillation are at risk of falling, as falls can lead to serious injuries in anticoagulated individuals, including intracranial hemorrhages 4.
- The use of anticoagulation therapy in elderly patients who fall frequently is a therapeutic dilemma, and the decision to continue or discontinue anticoagulation should be made on a case-by-case basis, considering the individual patient's risk factors and medical conditions 4.
Reversal of Anticoagulation Therapy
- In patients on warfarin, vitamin K can be used to reverse excessive anticoagulation, aiming to rapidly lower the international normalized ratio (INR) into a safe range to reduce the risk of major bleeding 5.
- For patients on direct oral anticoagulants (DOACs), specific reversal agents such as idarucizumab and andexanet alfa are available, while prothrombin complex concentrates may be used in the absence of licensed reversal agents 6.
- Vitamin K and fresh frozen plasma should not be used to reverse DOACs, and the choice of reversal strategy depends on the individual patient's situation and the specific anticoagulant used 6.