Discharge Teaching for a 78-Year-Old on a New Anticoagulant with Low Health Literacy
Mrs. L, age 78, is discharged tomorrow after admission for a fall without injury. New this stay: apixaban 5 mg BID for atrial fibrillation. Comorbidities: hypertension, type 2 diabetes (A1c 8.9%), osteoarthritis, depression. She takes 11 scheduled medications, including oxycodone 5 mg q6h PRN, zolpidem 5 mg nightly, and glyburide 5 mg BID. She lives alone in a two-story home; bedroom and laundry are upstairs. MoCA 22/30 (below her estimated premorbid level), REALM-SF 4/7. She says she will "read the papers later." She drove herself to the ED and has no consistent ride to lab or clinic appointments.
1. You have one teaching session before discharge. How do you prioritize and deliver it?
Read the worked answer
Teach the one thing that can kill her in the next 72 hours, then the one thing most likely to bring her back.
Priority 1 - apixaban/bleeding:
- Why: a new anticoagulant in a patient who falls, lives alone, and cannot read the instructions reliably.
- Content: take it twice daily, never skip or double; what bleeding looks like (black stools, blood in urine, unusual bruising, headache, confusion); when to call 911 versus the clinic; she must tell every clinician and dentist.
- Method: teach-back ("Tell me in your own words when you take this and what you'd do if you missed a dose"), pictures/photographs of pills, a pill card with times of day rather than drug names only. Do not hand her a pamphlet as the primary intervention.
Priority 2 - hypoglycemia and sedatives:
- Glyburide plus declining intake plus age is a hypoglycemia setup; zolpidem plus oxycodone plus stairs is a hip fracture setup. Flag both to the discharging prescriber for deprescribing review rather than teaching her to compensate for them.
Delivery adaptations for REALM-SF 4/7 and MoCA 22:
- 3–5 minute chunks, one concept at a time, minimal numeracy demands.
- Include her daughter or a neighbor with permission; ask who helps with medications.
- Repeat the key message at least twice; confirm with teach-back at the end and again by phone at 48–72 hours.
2. The patient's daughter asks, "Shouldn't she just stop the blood thinner since she falls?" How do you counsel her?
Read the worked answer
Answer the question actually asked, with numbers framed as risk, then convert anxiety into an action plan.
Counseling:
- Untreated atrial fibrillation carries a high annual stroke risk in someone with her risk profile (age, hypertension, diabetes, vascular disease - likely CHA2DS2-VASc in the 5–6 range), and anticoagulation substantially reduces that risk. Most falls do not cause serious bleeding; most afib-related strokes are disabling.
- The modifiable variable is not the anticoagulant - it is the fall risk. Stopping the drug trades a feared, visible event (a bruise or a fall) for an invisible, catastrophic one (a stroke).
- Note that apixaban has a comparatively favorable major-bleeding profile among anticoagulants - reinforcement, not a reason to switch casually.
Action plan (give her something to do):
- Deprescribe: ask the prescriber to re-review zolpidem, oxycodone, and glyburide - the highest-yield fall and hypoglycemia interventions available today.
- Home safety: night lights, bedside commode or first-floor sleeping arrangement, remove throw rugs, handrails on both sides of stairs, closed-toe shoes.
- Physiology: orthostatic BP check before discharge, PT for strength and balance, vision check.
- Contingency: medical alert device; a written card listing apixaban and the reversal agent question for EMS.
Document the conversation and that she verbalized understanding of the bleeding precautions.
3. What post-discharge plan do you build so this does not unravel in the first two weeks?
Read the worked answer
Assume the discharge will fail by default and engineer the failure points out.
The predictable failure points and matched interventions:
| Risk | Intervention |
|---|---|
| No transport | Volunteer/paratransit enrollment before discharge, or home-lab draw; confirm the appointment is booked, not "call Monday" |
| Renal function on a new DOAC | BMP within 7–14 days (dose depends on renal function and age/weight); CBC if bleeding concern |
| Medication confusion (11 meds, BID dosing) | Pharmacy synchronization to a single pickup, 7-day pill organizer filled, blister packs if available |
| Low literacy | Picture-based pill card; teach-back repeated by phone at 48–72 hours; daughter on the call |
| Hypoglycemia | Glucose meter and strips in hand before she leaves; written threshold of what number means "call someone" |
| Social isolation | Home health nursing or PT referral; Area Agency on Aging / meal support if intake is poor |
| Driving | Explicit, documented conversation - sedation, hypoglycemia risk, and post-fall evaluation; provide the recommendation in writing |
Metrics to monitor: 72-hour follow-up call completed, 14-day ED revisit, medication reconciliation at first visit, and documentation that deprescribing was addressed. Close the loop by sending the discharge summary to the PCP and pharmacy with the specific open questions named.