Anticoagulants and Fall Risk: Prevention and Monitoring Guide

Older adults on anticoagulants often face a tough question: should we keep a blood‑thinner on board when the patient is prone to falling? The answer isn’t a simple yes or no - it’s a balance of stroke protection, bleeding danger, and how well we can lower the chance of a tumble.

Why Fall Risk Gets a Bad Rap in Anticoagulation Decisions

Falls risk is a measure of how likely a person is to experience a ground‑level accident, often rising sharply after age 65. In nursing homes, more than half of residents fall each year; in the broader community, 30‑40 % experience at least one fall. Historically, clinicians have hesitated to prescribe anticoagulants because a stumble could trigger a bleed, especially intracranial hemorrhage (ICH). However, recent data show that the absolute ICH risk from falls while anticoagulated is only 0.2‑0.5 % per year, far lower than the 1.5‑3 % annual stroke risk in patients with CHA₂DS₂‑VASc scores ≥2.

Crunching the Numbers: Stroke vs. Bleeding Scores

The first step is to quantify both risks. The CHA₂DS₂‑VASc score assigns points for congestive heart failure, hypertension, age, diabetes, stroke history, vascular disease, and sex predicts stroke in atrial fibrillation (AF). Men with a score of 2 or more, women with 3 or more, are considered moderate‑to‑high risk - meaning anticoagulation is usually recommended.

On the bleeding side, the HAS‑BLED score adds points for hypertension, abnormal renal/liver function, stroke, bleeding history, labile INR, elderly age, and drugs/alcohol use helps flag patients who might bleed. A score ≥3 signals the need for careful monitoring, not an automatic stop.

What the Evidence Says About Keeping Anticoagulation

Multiple studies published after 2020 converge on the same message: the net clinical benefit of anticoagulation outweighs the added bleed risk, even in high‑fall‑risk cohorts. A 2023 European Geriatric Medicine review calculated that a patient would need to fall about 295 times in a year for fall‑related bleeding to surpass the stroke‑prevention benefit of warfarin. Similar analyses for DOACs show an even wider safety margin, with a 30‑50 % lower ICH rate compared to warfarin.

One pragmatic trial (PMC10447288) focused on seniors with non‑valvular AF and CHA₂DS₂‑VASc ≥2. Anticoagulated participants experienced a 60‑70 % reduction in stroke, while major bleeding rose only modestly. Importantly, mortality related to bleeding was higher, but the absolute number of deaths prevented by avoiding stroke was still larger.

Guideline bodies-American College of Cardiology, American College of Physicians, and the Society of Hospital Medicine-now advise against withholding anticoagulation solely because of fall risk, unless there is active bleeding, a bleeding disorder, or uncontrolled hypertension (>180 mmHg systolic).

Choosing the Right Anticoagulant for a Fall‑Prone Patient

When the decision is to treat, the choice of agent matters. Direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, edoxaban, and dabigatran have become first‑line for most non‑valvular AF patients without severe renal impairment (creatinine clearance <15‑30 mL/min, depending on the drug). Their predictable pharmacokinetics and lower ICH risk make them attractive for those who might tumble.

For most elderly fallers, apixaban often emerges as the safest choice because it has the lowest bleeding rates among the DOACs, even in patients with moderate renal dysfunction.

Step‑by‑Step Fall‑Risk Assessment and Mitigation

Before locking in an anticoagulant, run a thorough falls assessment. The AMDA guideline breaks it into four phases: recognition, assessment, treatment, and monitoring.

1. Medication review: Identify sedatives, antihypertensives, and psychotropics that increase dizziness. Deprescribe when possible.
2. Gait and balance testing: Use the Timed Up‑and‑Go (TUG) test; >13‑second times suggest high fall risk.
3. Vision check: Ensure appropriate glasses and treat cataracts or macular degeneration.
4. Orthostatic hypotension screen: Measure blood pressure lying, then after standing for 3 minutes; a drop >20 mmHg systolic signals a problem.
5. Home safety audit: Remove loose rugs, install grab bars, improve lighting, and consider wearable fall detectors.

These steps usually take 30‑60 minutes the first time and can be repeated every 6‑12 months, or after any major health change.

Ongoing Monitoring and Shared Decision‑Making

Even after starting therapy, keep the conversation open. Re‑evaluate CHA₂DS₂‑VASc and HAS‑BLED scores annually, especially if kidney function declines or new medications are added. For DOACs, check renal labs every 6‑12 months; adjust dose if clearance drops.

When a patient does fall, act quickly: assess for head injury, obtain a CT if neurological signs appear, and consider reversal agents if bleeding is suspected. Document the event, review the falls assessment, and tweak the mitigation plan before deciding to stop the anticoagulant.

For patients at the very end of life with life expectancy under 1 year, the benefit‑to‑risk balance may tip toward stopping therapy. In those cases, discuss goals of care, quality‑of‑life priorities, and involve palliative‑care specialists.

Key Takeaways for Clinicians

• Fall risk alone is NOT a contraindication for anticoagulation when stroke risk is moderate‑to‑high.
• Use CHA₂DS₂‑VASc to justify therapy and HAS‑BLED to guide monitoring, not to withhold treatment.
• Prefer DOACs-especially apixaban-for their lower intracranial bleed rate in the elderly.
• Implement a structured, multifactorial falls assessment before and after starting therapy.
• Reassess regularly; involve the patient and caregivers in shared decisions.

Frequently Asked Questions