Prescribing dilemma: balancing risk and benefit when prescribing anticoagulation in an older patient with falls risk

This case example explores how uncertainty can arise when interpreting clinical guidelines to prescribe anticoagulation for older patients who are at risk of falls. 

A list of the skills required to manage such situations, mapped to the Royal Pharmaceutical Society’s ‘Competency framework for all prescribers’, can be found at the end of this article.

Case presentation

Mrs A is an 82-year-old female with non-valvular atrial fibrillation (NVAF), hypertension, osteoarthritis, early Parkinsonism (i.e. a tremor and occasional freezing) and mild renal impairment (i.e. estimated CrCl 45mL/min), and she has had one fall in the past year. She lives independently and uses a walking stick indoors. 

Her GP asked the pharmacist to review her because she is an older adult with multiple long-term conditions and a recent fall. Therefore, she requires a detailed evaluation of the risks and benefits of anticoagulation. Mrs A was referred to the pharmacist–prescriber for review to discuss stroke prevention and bleeding risk.

The dilemma

According to National Institute for Health and Care Excellence (NICE) guidance, anticoagulation is indicated for stroke prevention in atrial fibrillation (AF), where stroke risk is sufficiently high^​1​. However, Mrs A has an increased falls risk, which raises concerns about potentially serious bleeding — especially intracranial haemorrhage — if she falls while anticoagulated. In such situations, the prescribing clinician must consider and weigh the benefits of stroke prevention against the risk of bleeding in a patient with ageing, comorbidity and falls risk while aligning the decision with the patient’s preferences.

If anticoagulation is withheld solely owing to a ‘falls risk’, Mrs A remains at substantially increased risk of ischaemic stroke, which may lead to disabling or fatal outcomes. 

However, if anticoagulation is initiated without appropriate risk mitigation, there is a possibility of serious bleed following a fall, which would then impact quality of life for the patient. The pharmacist’s decision-making process can be seen in Box 1 and the Table below^​1,2​.

Consultation

A discussion was held with Mrs A regarding the absolute and relative risks of stroke versus bleeding, emphasising evidence that in many older people the stroke prevention benefit outweighs bleeding risk (e.g., older persons with AF and falls risk still derive net benefit from anticoagulation)^​4​.

Mrs A agreed to commence anticoagulation with apixaban. It was chosen for Mrs A because evidence shows it provides effective stroke prevention with a lower risk of serious bleeding compared to other anticoagulants. The results of a large meta-analysis, published in 2014, revealed that apixaban reduced major and intracranial bleeding more than warfarin while maintaining similar or better protection against stroke^​2​. NICE guidance, published in 2021, also highlights apixaban as the DOAC most likely to minimise major bleeding in people with AF^​1​. Considering Mrs A’s age, the moderate kidney impairment and a history of falls, apixaban offers the best balance between preventing stroke and reducing the risk of bleeding, in line with current national recommendations and safe prescribing practice.

A referral to a falls clinic and physiotherapy was made to address gait/balance. Occupational therapy was employed to conduct a home safety assessment to address environmental fall hazards (e.g. loose rugs, poor lighting, etc).

A structured medication review was arranged to identify medications or other drugs that may increase risk of falls.

Safety netting is an important element of the consultation process. Mrs A was provided with written information explaining how anticoagulation works and the signs of adverse effects to look out for, including unexplained bruising or bleeding, black or tarry stools, vomiting blood, sudden severe headache or dizziness, and any symptoms suggestive of stroke. These were explained as new facial drooping, weakness or numbness in the arm or leg — particularly on one side — slurred speech, difficulty finding words, sudden visual changes, or loss of balance or coordination. She was advised to contact her GP practice or NHS 111 without delay if any of these occurred.

The patient was also told to seek emergency help via 999 if she experienced a fall with a head injury or developed acute neurological symptoms (e.g. slurred speech, sudden facial drooping, sudden loss of vision). To support her ongoing understanding and engagement with treatment, she was also directed to reliable patient resources, including NHS information on anticoagulants and Anticoagulation UK. 

Monitoring

In discussion with Mrs A, a monitoring plan was agreed: weekly telephone contact for the first month, then monthly clinic review for next three months, checking renal function, signs of bleeding, adherence and falls occurrence.

The following monitoring plan was developed in line with guidance and product literature:

• Noting baseline renal function (eGFR/CrCl), repeating at three months and, when stabilised, annually or more frequently if there are indications of kidney decline; 
• Bleeding signs: bruising, haematuria, gastrointestinal bleeding, intracranial bleed symptoms (i.e. headache, vomiting, focal neurology);
• Falls frequency: checking whether falls continue and any subsequent injuries that led to hospitalisations etc;
• Adherence to DOAC and any notable side-effects that may impact compliance;
• Re-assessment of bleeding risk and stroke risk at annual review or sooner if significant changes were reported or identified^​5–7​.

What was the outcome?

After one month, Mrs A reported no falls, no bleeds and indicated good tolerance and adherence to the DOAC.

After three months, she sustained one minor bruise after a minor fall; however, she had no major bleeding events or hospital admissions. She reported improved confidence with walking and felt involved in her care plan. The multidisciplinary interventions (e.g. falls clinic, physiotherapy, occupational therapy (OT)) have helped in the improvement of her mobility.

Follow-up

The follow-up plan included ongoing reviews every three months, with an annual full review. 

At six months, anticoagulation was re-evaluated to ensure it remains appropriate if new bleeding risks arise (e.g. new intracranial bleed, major surgery, life expectancy change).

Reflective practice

If I were to do anything differently, I would introduce the falls risk discussion at the point of AF diagnosis or referral, rather than as an add-on later. Embedding this earlier would allow falls-prevention strategies to begin before anticoagulation is initiated, helping to optimise the overall risk–benefit balance from the outset.

On reflection, this case also highlighted how dynamic anticoagulation decisions can be, particularly in older adults with multimorbidity. Several hypothetical scenarios could have shifted the balance. For example, a markedly limited life expectancy may have reduced the net benefit of anticoagulation, prompting a different conversation about priorities of care. Alternatively, if the patient had sustained recurrent injurious falls despite interventions, the bleeding risk might have outweighed advantages, potentially favouring deprescribing. These possibilities emphasise that anticoagulation decisions are not static and must be revisited regularly as circumstances evolve.

Importantly, the non-pharmacological interventions — such as physiotherapy, OT assessment and home safety review — were crucial in improving this patient’s risk–benefit equation. These measures cannot easily be quantified using scoring tools; instead, they require nuanced, individualised assessment, considering lifestyle, home environment, social support, comorbidities, functional ability and medication burden. This reinforces the need for a flexible, holistic approach that adapts to changes in a patient’s condition, goals and living situation over time.