Falls, Bruising, and the Decision to Keep Anticoagulation

Recommendation: continue anticoagulation; treat the falls, not the prescription.

Reasoning:

• At CHA2DS2-VASc 5, her untreated annual stroke risk is roughly 6-7% per year, and anticoagulation reduces that by about two-thirds. That is a large absolute benefit - on the order of one stroke prevented per 30-40 patient-years.
• The fear driving her question is fall-related intracranial hemorrhage. Modeling studies put the threshold at roughly 300 falls per year before the bleed risk from falls outweighs the stroke benefit of warfarin-type therapy. Two falls in four months is nowhere near that.
• The key reframe: falls are a marker of frailty and of reversible problems - orthostasis, sedatives, poor lighting. They are a reason to intensify fall prevention, not to withdraw a therapy with a much larger expected benefit.
• Exceptions worth naming: hospice/limited life expectancy, or a patient whose stroke risk is genuinely low. Neither applies.

Say plainly: "Stopping the thinner would not make you safer overall - it would trade a small bleeding risk for a much larger stroke risk." Then pivot to the plan that lowers both risks.

Dose check - 5 mg BID is correct. Apixaban is reduced to 2.5 mg BID only when at least two of three criteria are met: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL. She is 74, weighs 62 kg, and has creatinine 1.1 - she meets none. Dose-reducing without criteria would under-treat her.

Modifiable bleeding risks:

• Stop naproxen. NSAIDs plus an anticoagulant plus anemia is the highest-yield single intervention here.
• Work up the anemia: ferritin 12 with falling hemoglobin means iron deficiency until proven otherwise - check stool for occult blood, replace iron, and consider whether GI evaluation is warranted; add a PPI if there is any GI bleeding history.
• Limit alcohol; review over-the-counter supplements (fish oil, high-dose vitamin E, NSAID-containing cold remedies).

Modifiable fall risks:

• Deprescribe or reduce hydrochlorothiazide and terazosin - the classic orthostatic combination; the terazosin has no strong indication in this history.
• Recheck orthostatic vitals after the change; review vision, footwear, night lighting, home hazards, and refer to physical therapy for gait and balance training.
• Avoid benzodiazepines, Z-drugs, and antihistamines for sleep.

Repeat CBC after these changes and document the shared decision.

She gets a noncontrast head CT before anyone discusses discharge.

Reasoning:

• A patient on a direct oral anticoagulant with head trauma is a different risk category from an anticoagulant-naive patient. The validated decision rules (Canadian CT Head, New Orleans) were derived and validated in general populations and are not safely applied to anticoagulated patients.
• Intracranial hemorrhage after a fall can present with a lucid interval of hours. A normal exam in the emergency department, and even a negative initial scan, does not close the case.
• Practical sequence: noncontrast CT now; if negative, observe for at least 6-24 hours with serial neurologic checks and clear return precautions (worsening headache, vomiting, drowsiness, weakness, unequal pupils). Many centers admit or arrange a repeat scan at 6-12 hours, particularly with any anticoagulant on board, age >65, or a fall from standing or higher.
• Do not reverse anticoagulation for a negative scan. Reversal agents (andexanet alfa or four-factor PCC) are reserved for confirmed or strongly suspected major bleeding.
• Close the loop on the cause of the fall: reassess orthostatics, medications, and whether the earlier deprescribing actually happened.