Falls, Frailty, and a Blood Thinner: Deprescribing Without Abandoning Benefit
84-year-old woman with hypertension, mild cognitive impairment, and atrial fibrillation has had three falls in the past six months. She lives alone with a walker. Medications: apixaban 5 mg twice daily, amlodipine 10 mg, sertraline 50 mg, zolpidem 5 mg at bedtime, oxybutynin 5 mg twice daily, donepezil 10 mg, and calcium with vitamin D. BP is 142/70 mmHg supine and 104/62 mmHg after standing 1 minute. Weight 48 kg, creatinine 1.1 mg/dL. CHA2DS2-VASc score is 5 and HAS-BLED score is 3. Her daughter asks whether the blood thinner should be stopped because "she falls all the time," and whether the bladder pill is helping.
1. Is her apixaban dose correct? Show the calculation and the rule you are applying.
Read the worked answer
No - she is being overdosed and should be reduced to 2.5 mg twice daily.
Apixaban dose reduction for atrial fibrillation requires at least two of three criteria:
- Age ≥80 years - met (84)
- Weight ≤60 kg - met (48 kg)
- Serum creatinine ≥1.5 mg/dL - not met (1.1 mg/dL)
Two of three criteria are satisfied, so the reduced dose of 2.5 mg twice daily is correct. Her creatinine clearance by Cockcroft-Gault is approximately 34 mL/min, which does not by itself mandate a further reduction; the labeled criteria, not the eGFR alone, drive the dose.
Why it matters: 5 mg twice daily in an 84-year-old, 48-kg woman doubles the bleeding risk without added stroke prevention. Equally, the error should not be corrected in the opposite direction - some clinicians under-dose patients who meet no criteria - so the checklist should be documented explicitly. Reassess the dose whenever weight or renal function changes.
2. Which medications would you stop or change, in what order, and what is the expected benefit for her falls?
Read the worked answer
Target the drugs with the strongest fall and cognition signal first.
- Stop zolpidem. Sedative-hypnotics are a leading reversible cause of falls, fractures, and delirium in older adults, and the benefit for chronic insomnia is minimal. Taper rather than stop abruptly, and replace with sleep hygiene and stimulus control.
- Stop oxybutynin. This directly answers the daughter's question: an anticholinergic bladder agent in a patient with mild cognitive impairment is likely contributing to confusion and falls rather than helping. If urgency persists, try behavioral therapy, timed voiding, or a beta-3 agonist, which is less anticholinergic.
- Reduce amlodipine, given a 38 mmHg orthostatic drop; aim for a standing systolic above 110 mmHg and recheck after 1–2 weeks. Orthostatic hypotension is a modifiable fall risk.
- Reassess sertraline for hyponatremia and falls, but do not stop it abruptly if she has active depression - treat the depression.
- Continue donepezil unless bradycardia, syncope, or GI side effects emerge; it may modestly reduce fall risk by improving attention.
Add physical therapy for gait and balance, a home safety review, vision check, and bone density assessment with osteoporosis treatment if indicated. Deprescribing is expected to reduce falls more than any single new intervention.
3. How do you answer the daughter's question about stopping the anticoagulant, and what would you say about the alternative of leaving atrial fibrillation untreated?
Read the worked answer
Recommend continuing anticoagulation at the correct reduced dose, and explain the arithmetic plainly.
Her CHA2DS2-VASc of 5 predicts a substantial annual stroke risk, and atrial fibrillation-related strokes are disproportionately severe - large, disabling, and frequently fatal. Anticoagulation reduces that risk by roughly two-thirds. The bleeding risk from falls is real but is often overestimated: a classic estimate is that a patient would need to fall on the order of 300 times per year before the intracranial hemorrhage risk of anticoagulation outweighed the stroke benefit. Three falls in six months does not approach that threshold.
What actually lowers her risk: fixing the modifiable contributors - stopping zolpidem and oxybutynin, correcting orthostatic hypotension, physical therapy, home safety, vision correction, and bone health. Stopping apixaban removes protection while leaving the falls untouched.
Frame the conversation around goals: she values independence and living alone; a disabling stroke is the event most likely to end that. Ask what she understands and prefers, document the discussion, and revisit if she develops frequent head trauma, falls become recurrent despite intervention, or she enters a comfort-focused phase of care.