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Falling Down the Slippery Slope of Anticoagulation in Older Adults (>80): More Than Meets the Eye

Vatche Melkonian, Mackenzie Mayhew, Rachele J Solomon, Adilia Ortega, Shari Selesky, Bradley Rogers Pharm, Brenda Shaver, Candace Pineda, Chauniqua Kiffin, Ibrahim IJabbour, Sara Hennessy, Juan D Arenas, Eddy H Carrillo, Andrew A Rosenthal and Tjasa Hranjec*

Background: Although fall risk increases with age, many patients remain anticoagulated (AC) indefinitely, regardless of mental or physical frailty. We hypothesized that in patients >80 years, risk of anticoagulation outweighs its benefits.

Methods: Retrospective chart review was conducted to identify older patients (>80), who have fallen from standing/ sitting, at a single level-one trauma center. Patients on and off AC were compared for demographics, injury patterns, length of stay, and long-and short-term outcomes. Data was analyzed using univariate and multivariate (MV) analyses.

Results: A total of 465 patients with mean age 87.7±0.2 (range of 80-105) were evaluated over a 10-month period, following a fall. Nearly 65% of the patients (n=300) were receiving some type of anticoagulation: aspirin and warfarin were the most frequently used. Most injuries were minor: painful extremity hematomas, lacerations, or fractures. Although 76% (n=364) of the patients were admitted from home, 30% were discharged to a skilled nursing facility. Extremity fractures were less common in AC patients; however, AC patients were more likely to bleed after a serious injury, require ICU admission and transfusion. Incidence of intracranial hemorrhage was similar between the two groups, although head injuries were more common in AC patients. The most severe (in-hospital) outcomes were seen in AC patients: five required tracheostomies and five died (p=0.0955). Short- (<90-day) and long-term (two-year) mortality was equivalent between the two groups; long-term, 35% of all patients died following a fall. MV analysis revealed that chronic medical conditions, rather than anticoagulants correlated with two-year mortality.

Conclusion: A fall from standing may foreshadow patient’s worsening physical or mental condition regardless of the cause of fall or anticoagulation status. In discharged patients, AC does not seem to contribute directly to patient demise. Instead, fall should become a marker of disease severity and patient frailty.