Anticoagulation decisions in the frail older adult who falls

What it is

An older patient with atrial fibrillation has a CHA2DS2-VASc score that calls for anticoagulation, and also falls. The question is whether the falling changes the decision. It usually does not, and the commonest error in practice is to withhold anticoagulation because of it.

Causes and risk

• About one in three community-dwelling adults aged 65 and over falls at least once a year, so this is the ordinary case, not the exception.
• Anticoagulation is withheld from many of these patients, and the driver is an over-estimation of bleeding risk rather than a measured one.
• Frailty itself is not a contraindication. The net clinical benefit still favours oral anticoagulation in frail older adults, although the margin narrows as frailty deepens.

How it presents

The exam presents it as a consultation: an older woman with chronic atrial fibrillation, brought by a relative, who has fallen and whose family asks whether the blood thinner should stop. What is being tested is whether you weigh the stroke you prevent against the bleed you fear, rather than reacting to the fall.