Minor Head Injury on a Direct Oral Anticoagulant in an Older Adult Living Alone

The risk is not zero, but it is low in a GCS 15 patient with a negative CT on a direct oral anticoagulant.

• Observation: observe for at least 24 hours in a setting where neurologic checks are reliable. She lives alone, which makes home observation unsafe regardless of the imaging result.
• Repeat imaging: obtain a repeat noncontrast head CT before discharge or sooner if symptoms change (worsening headache, vomiting, drowsiness, focal deficit, new confusion). Some protocols repeat at 24 hours; practice varies, and the decision should be individualized.
• Weigh the risks: delayed intracranial hemorrhage is uncommon with a normal initial CT and normal exam, but the consequence is severe in an anticoagulated older adult. The risk of hospital-acquired delirium and deconditioning from prolonged admission is also real. A 24-hour observation with a clear neurologic check protocol balances these.
• Do not discharge her alone from the emergency department on the basis of a single negative scan. Arrange a safe disposition and explicit return precautions.

Document the shared decision-making with the patient and daughter.

Balance stroke risk against bleeding risk, and recognize that the bleed risk is high but modifiable while the stroke risk is not.

• No intracranial hemorrhage on imaging: for minor TBI, anticoagulation is generally resumed after 24–48 hours once repeat imaging is stable and there is no clinical deterioration. A longer hold increases stroke risk without clear benefit.
• If delayed hemorrhage appears, hold and involve neurosurgery and cardiology; reversal may be considered in selected cases.
• CHA2DS2-VASc 5 means substantial stroke risk; the annual stroke risk is high enough that prolonged interruption is harmful.
• HAS-BLED 4 is a flag to modify bleeding risk factors - falls, blood pressure, medication review, alcohol - not a reason to withhold anticoagulation indefinitely. Address the falls: vision, gait and balance, home hazards, orthostatic blood pressure, and sedating medications.
• Verify dose appropriateness: apixaban 5 mg BID is correct only if at least two of age ≥80, weight ≤60 kg, or creatinine ≥1.5 mg/dL apply; otherwise 2.5 mg BID. Check renal function.
• Shared decision-making with the patient and daughter, documented.

Discharge home alone is a plan, not a default; it must be built.

• Home safety: occupational therapy home evaluation, grab bars, lighting, removal of throw rugs, and a clear plan for stairs. Physical therapy for balance and gait, with a cane fitting and a falls-prevention program.
• Medication safety: pill organizer or blister packaging, pharmacy synchronization, and a caregiver or pharmacist check. Missed apixaban doses are a stroke risk; double doses are a bleeding risk. Simplify the regimen where possible.
• Cognition: MoCA 22/30 with missed medications suggests she may not reliably manage a high-risk anticoagulant alone. Engage the daughter and consider daily check-ins, a medical alert device, or a home health aide. Assess decision-making capacity for medication management specifically.
• Follow-up: primary care within a week, neurology or cardiology as appropriate, and a repeat cognitive assessment once any post-injury delirium resolves.
• Red flags in writing: worsening headache, vomiting, drowsiness, weakness, or confusion - return immediately.
• Advance care planning: discuss goals and health care proxy while she can participate.

The daughter's concern is a clinical asset; include her in the plan rather than dismissing it.