Falls and anticoagulation in the very old
An 88-year-old woman with hypertension, permanent atrial fibrillation, and moderate Alzheimer dementia lives alone in a second-floor walk-up. Her CHA2DS2-VASc score is 5; she takes apixaban 5 mg twice daily. Over 8 months she has had three unwitnessed falls, one causing a forehead laceration requiring staples and a CT scan that showed no intracranial hemorrhage. She has no syncope, no chest pain, and no focal deficits. Orthostatic vitals: supine 142/78, standing at 1 minute 118/64 with no symptoms. She weighs 52 kg, creatinine 1.1 mg/dL (eGFR about 50). She uses a cane inconsistently, has throw rugs, and takes zolpidem 5 mg nightly plus oxybutynin for urgency. She wants to stay home and her daughter asks whether the blood thinner should be stopped.
1. How should the risk of continued anticoagulation be weighed against the risk of stroke, and what does the evidence say about stopping apixaban in this patient?
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Framing the trade-off. With CHA2DS2-VASc 5, untreated stroke risk is roughly 6–7% per year, and atrial fibrillation–related strokes are typically large and disabling. Apixaban reduces stroke by about two-thirds; serious bleeding on apixaban in this age group is on the order of 2–3% per year, and most falls do not cause intracranial hemorrhage. The number of falls needed to offset the stroke benefit is very large (commonly cited as hundreds per year), so stopping anticoagulation to prevent fall-related bleeding is usually the wrong trade.
What actually changes management. The falls are likely multifactorial and partly iatrogenic: nightly zolpidem (sedative, fall risk, Beers-listed), oxybutynin (anticholinergic, worsens cognition and contributes to falls), orthostatic drop of 24 mmHg systolic, throw rugs, and inconsistent cane use. Address these rather than the anticoagulant.
Dose check. Apixaban dose reduction requires two of three: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL. She meets only age and weight (creatinine 1.1), so 5 mg twice daily is the correct dose; reducing to 2.5 mg would under-treat her.
Plan. Deprescribe zolpidem (taper, sleep hygiene), switch oxybutynin to a non-anticholinergic or behavioral approach, home safety evaluation and physical therapy for gait/balance, review antihypertensives if orthostasis persists, and continue apixaban with counseling on fall precautions and head-injury red flags. Document a shared decision with the daughter.
2. The daughter asks what would happen if the apixaban were stopped. How would you counsel her, and what alternatives exist if bleeding concern remains high?
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Counseling. Explain that the medicine prevents the most disabling kind of stroke; most falls cause bruises or cuts, not brain bleeds, and her mother's CT after a head strike was clean. Stopping would leave her unprotected against a stroke that could take away her independence far more surely than a fall. Emphasize that the plan is to reduce falls (sedatives, rugs, therapy, blood pressure) rather than remove stroke protection.
If concern persists, options short of stopping:
- Optimize fall prevention aggressively (medication review, vision, footwear, home modification, PT).
- Confirm no interacting drugs (NSAIDs, antiplatelets) and no excessive alcohol.
- Reassess periodically; if she develops truly refractory falls with recurrent head injury despite intervention, revisit goals with the patient and family.
- Left atrial appendage occlusion is a consideration only in patients with a genuine contraindication to long-term anticoagulation, not simply fall risk.
Bottom line. Continue apixaban at the full dose, treat the modifiable fall contributors, and revisit only if bleeding risk becomes unmanageable despite those measures.