Use of Anticoagulation in Elderly Patients with Atrial Fibrillation Who Are at Risk for Falls

Candice L Garwood, PharmD BCPS; Tia L Corbett, PharmD


The Annals of Pharmacotherapy. 2008;42(4):523-532. 

In This Article


There is an apparent underuse of warfarin in elderly patients with AF, as there is inconsistency in opinion among clinicians about who should receive anticoagulation. The risks of warfarin are highly emphasized, while its use is low in the oldest patients who stand to gain the greatest absolute benefit from warfarin's effect. The risk of falling is cited commonly as a contraindication to a patient receiving warfarin. However, it has been suggested that warfarin's benefits outweigh its risks, even in patients who do fall. Therefore, the propensity to fall should not be considered an absolute contraindication to its use. Alternative antithrombotic strategies, such as aspirin and low-dose warfarin, have little if any benefit in high-risk elderly patients. Ultimately, a patient's underlying stroke risk should be the predominant factor that determines appropriate anticoagulation therapy in AF. Utilization of a risk stratification scheme, such as CHADS2 score, can assist the clinician in a more systematic approach to anticoagulation decision-making.

While falls should not dictate anticoagulant choice, assessment for falls and management of fall risk should be an important part of anticoagulation management. Minimizing fall risk through environmental modifications, treatment of disease states that contribute to fall risk, and reduction of use of medications known to be related to falls should be a priority. Vigilant warfarin monitoring in an anticoagulation clinic may lessen the risk of bleeding by maximizing the time that the INR is within the therapeutic range. Finally, education is a critical element to optimize anticoagulation and minimize bleeding in the elderly and should be a routine part of every anticoagulation visit.

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