Anticoagulation in elderly patients who fall frequently: a therapeutic dilemma

There is general agreement that patients with persistent atrial fibrillation, who are at risk of having a stroke, need to be anticoagulated. However, clinicians often are in a difficult dilemma when these patients also are at increased risk of falling. Falls can lead to serious injuries in anticoagulated individuals, including intracranial hemorrhages. This case study describes an 88-year-old patient with a history of falling. She received multiple injuries following a fall, including a subdural hematoma. Warfarin was among the patient's many medications. Upon admission to the hospital this patient had a supratherapeutic INR that most likely contributed to her injuries. A question facing the medical team was should she continue to receive warfarin to prevent stroke after discharge from the hospital? Much controversy exists over whether older patients receiving anticoagulation therapy are at increased risk of major hemorrhagic complications. This article discusses the relationship between anticoagulation, falling, and the risks of hemorrhagic events. It also discusses opinions on when to restart anticoagulation following resolution of the subdural hematoma. In addition, the patient was taking multiple medications that are known to contribute to falls in older people. Recommendations for lowering this patient's fall risks are presented.