Why falling doesn’t mean you should stop blood thinners
Many doctors and families assume that if an older adult is prone to falls, they shouldn’t take blood thinners. It sounds logical: more falls + thinner blood = more bleeding. But this thinking is outdated-and dangerous. The truth is, fall risk alone should never be a reason to avoid anticoagulants if you’re at risk for stroke. Stopping these medications because of falls puts you at far greater risk of a disabling or deadly stroke than the chance of bleeding from a tumble.
Consider this: if you have atrial fibrillation (AFib) and a CHA₂DS₂-VASc score of 3, your chance of having a stroke in one year is about 3.2%. That’s more than 1 in 30. Now, if you’re on a blood thinner like apixaban or rivaroxaban, your stroke risk drops by 60-70%. Meanwhile, the risk of a serious brain bleed from a fall while on these drugs? Just 0.2% to 0.5% per year. You’d have to fall nearly 300 times in a year for the bleeding risk to outweigh the stroke prevention benefit. Most people don’t fall even 10 times a year.
How doctors measure your stroke and bleeding risk
Not everyone with AFib needs a blood thinner. Doctors use two key tools to decide:
- CHA₂DS₂-VASc score - This tells you your stroke risk. Points are added for things like age over 75, high blood pressure, diabetes, heart failure, and prior stroke. A score of 2 or higher in men (or 3 or higher in women) means you’re at moderate to high risk-and anticoagulation is strongly recommended, no matter how often you fall.
- HAS-BLED score - This estimates bleeding risk. Points come from high blood pressure, kidney or liver problems, past bleeding, old age (over 65), and using drugs like aspirin or NSAIDs. A score of 3 or more means you need closer monitoring, but it doesn’t mean you can’t take anticoagulants.
These scores aren’t guesses. They’re backed by data from hundreds of thousands of patients. If your CHA₂DS₂-VASc score says you need a blood thinner, and your HAS-BLED score is high, your doctor should focus on reducing your bleeding risks-not skipping the medicine.
Why DOACs are the best choice for people who fall
There are two main types of blood thinners: warfarin and DOACs (direct oral anticoagulants). Warfarin has been around for decades, but DOACs like apixaban, rivaroxaban, dabigatran, and edoxaban are now the first choice for most people-especially those at risk of falling.
Here’s why:
- DOACs lower your risk of brain bleeds by 30-50% compared to warfarin.
- They don’t need regular blood tests like INR checks.
- They have fewer food and drug interactions.
- They work faster and wear off faster, which helps if you have a fall and need emergency care.
According to 2022 data, about 80% of new prescriptions for AFib in the U.S. are for DOACs. That’s because doctors know they’re safer for older, fall-prone patients. If you’re still on warfarin and you fall often, ask your doctor if switching to a DOAC is right for you.
What you should do to prevent falls-without stopping your medicine
Instead of cutting your blood thinner, fix what’s making you fall. Most falls aren’t random. They’re caused by things you can change.
Start with a full falls assessment. This isn’t a quick chat-it’s a 30- to 60-minute review that includes:
- Medication review - Are you taking sedatives, sleep aids, blood pressure pills, or antidepressants that make you dizzy? Some can be reduced or stopped safely.
- Gait and balance test - The Timed Up and Go test measures how long it takes you to stand up from a chair, walk 3 meters, turn, walk back, and sit down. If it takes more than 12 seconds, you’re at higher risk. Physical therapy can help.
- Eye check - Poor vision is a top cause of falls. Make sure your glasses are up to date and you’re getting regular eye exams.
- Home safety - Remove throw rugs, install grab bars in the bathroom, add nightlights, and clear clutter from hallways.
- Orthostatic hypotension check - Does your blood pressure drop when you stand? This causes dizziness and is common in older adults. Your doctor can adjust meds or recommend compression stockings.
Studies show that when these steps are taken, fall rates drop by 30-50%. You don’t need to live in fear. You need a plan.
When anticoagulants really should be stopped
There are only a few real reasons to avoid or stop blood thinners:
- You’re actively bleeding (like a stomach ulcer or internal hemorrhage).
- You have a known bleeding disorder like hemophilia.
- Your blood pressure is uncontrolled-above 180/110 mmHg.
- You’re in the final months of life and the benefit of stroke prevention is unlikely to matter.
That’s it. If you’re just worried about falling, that’s not a medical reason to stop. In fact, stopping your blood thinner when you have AFib and a high stroke risk can be more harmful than the fall itself.
What patients say-and what doctors get wrong
Many older adults turn down anticoagulants because they’re scared of bleeding. One 78-year-old man, Mr. H, chose not to take a blood thinner after his doctor warned him about falls. He had a CHA₂DS₂-VASc score of 3. A year later, he had a stroke that left him unable to speak or walk.
On the other hand, Mrs. L, 82, had the same score and fell twice last year. But her doctor helped her do a falls assessment. She stopped a sedative, got a walker, had her home modified, and started balance exercises. She’s still on apixaban-and hasn’t fallen since.
The problem? About half of primary care doctors still believe fall risk alone means you shouldn’t take blood thinners. That’s not what the guidelines say. The American College of Physicians, the American Heart Association, and the Society of Hospital Medicine all agree: don’t stop anticoagulants just because someone falls.
What to ask your doctor
If you’re on a blood thinner or being considered for one, ask these questions:
- What’s my CHA₂DS₂-VASc score? Am I at high risk for stroke?
- What’s my HAS-BLED score? What’s making my bleeding risk higher?
- Am I on a DOAC or warfarin? Would switching help me?
- Can we do a full falls assessment? What can we change to make me safer?
- Are any of my medications making me dizzy or weak?
- What should I do if I fall? Do I need to come in?
These questions shift the conversation from fear to action. You’re not choosing between bleeding and stroke-you’re choosing safety and life.
Final thought: Safety isn’t about avoiding risk-it’s about managing it
Life after 70 isn’t about avoiding all danger. It’s about knowing what matters most. For most people with AFib, preventing a stroke is more important than avoiding every possible fall. With the right blood thinner, the right home setup, and the right care team, you can live longer, stronger, and safer.
You don’t need to stop your medicine to stay safe. You need a smarter plan. And that plan starts with asking the right questions-and refusing to let fear make the decision for you.
Should I stop my blood thinner if I fall often?
No. Falling often is not a medical reason to stop anticoagulants. The risk of stroke from untreated atrial fibrillation is much higher than the risk of a serious bleed from a fall. Guidelines from the American College of Physicians and other major societies say you should not discontinue blood thinners solely because of fall risk. Instead, focus on preventing falls through medication review, balance training, and home safety changes.
Are DOACs safer than warfarin if I fall?
Yes. DOACs (like apixaban, rivaroxaban, and dabigatran) reduce the risk of brain bleeding by 30-50% compared to warfarin. They also don’t require frequent blood tests and have fewer interactions with food and other drugs. For people at risk of falling, DOACs are now the first-line recommendation for atrial fibrillation, unless there’s severe kidney disease or a mechanical heart valve.
Can I reduce my DOAC dose to lower bleeding risk?
No. Reducing the dose of a DOAC below the recommended level doesn’t significantly lower bleeding risk-it just makes the drug less effective at preventing stroke. Studies show this practice offers no safety benefit and increases the chance of stroke. Always take your DOAC exactly as prescribed.
What’s the most important thing I can do to prevent falls?
Start with a comprehensive falls assessment. This includes reviewing your medications for dizziness-causing drugs, testing your balance with a Timed Up and Go test, checking your vision, removing home hazards like rugs and poor lighting, and treating low blood pressure when standing. Working with a physical therapist or geriatric care team can cut your fall risk by up to 50%.
When should I consider stopping anticoagulants?
Only in rare cases: if you’re actively bleeding, have a severe bleeding disorder, have uncontrolled high blood pressure (over 180/110), or are in the final months of life where stroke prevention is unlikely to benefit you. For most older adults-even those who fall frequently-staying on anticoagulants is the safer choice.
Andrew Forthmuller
November 13, 2025 AT 10:48Charles Lewis
November 14, 2025 AT 07:37It is profoundly concerning that the prevailing clinical narrative among primary care practitioners continues to conflate fall risk with contraindication for anticoagulation, despite overwhelming evidence to the contrary. The CHA₂DS₂-VASc and HAS-BLED scores were developed precisely to provide an evidence-based, quantitative framework for decision-making-not as heuristic tools to be overridden by anecdotal fear. When a patient presents with a CHA₂DS₂-VASc score of 3 or higher, the statistical imperative to initiate DOAC therapy is unequivocal; the annual stroke risk without intervention exceeds 3%, whereas the risk of intracranial hemorrhage on DOACs remains below 0.5%. To withhold therapy on the basis of fall frequency alone is not merely suboptimal-it is a violation of the standard of care as defined by the AHA, ACC, and ESC. The focus must shift from avoidance to mitigation: medication reconciliation, balance training, home hazard remediation, and orthostatic evaluation are not adjuncts-they are the core of safe anticoagulation in the elderly.
Furthermore, the persistent underutilization of DOACs in favor of warfarin, particularly in patients with polypharmacy or cognitive decline, reflects a troubling lag in clinical adoption. DOACs’ predictable pharmacokinetics, lack of dietary restrictions, and significantly lower risk of intracranial hemorrhage render them not only preferable but ethically mandatory in this population. The notion that a patient who falls twice a year should forgo stroke prevention is akin to denying insulin to a diabetic because they occasionally trip over their own feet.
Renee Ruth
November 15, 2025 AT 17:15Oh please. I’ve seen this movie before. Someone gets stroke because they didn’t take blood thinners, then the internet turns it into a martyr story. But what about the 70-year-old woman who spilled her coffee, slipped on a rug, cracked her skull, and bled out in the ER while her family watched? No one talks about those stories. And yeah, DOACs are ‘safer’-but they’re still blood thinners. You think the hospital bills for a brain bleed are easier than a stroke? Try being the daughter who has to sign the DNR after your mom’s brain swells for three days. This isn’t statistics. It’s trauma. And doctors act like it’s just a math problem.
And don’t get me started on ‘falls assessments.’ My aunt got one. They told her to remove rugs. She did. Then she slipped on the linoleum because the damn thing was too slick. They gave her a walker. She hated it. So she didn’t use it. And then she fell again. And guess what? They blamed her for not following ‘the plan.’ So now she’s on a DOAC, terrified to move, and her kids are too scared to visit because they don’t want to be the ones who ‘caused’ her to fall. This isn’t empowerment. It’s guilt.
Samantha Wade
November 17, 2025 AT 09:04While the article presents compelling data, it is critical to acknowledge that the real-world application of these guidelines is frequently undermined by systemic failures in geriatric care. The assertion that DOACs are universally superior for fall-prone patients assumes consistent access to specialty care, affordable medications, and reliable pharmacy services-conditions that are not universally available. Furthermore, the emphasis on ‘doing a falls assessment’ presumes the availability of physical therapists, geriatricians, and home safety evaluators, all of whom are in critically short supply in rural and underserved communities. Without addressing these structural barriers, the recommendation to ‘keep the anticoagulant’ becomes a privileged directive rather than a clinical standard.
Moreover, the dismissal of dose reduction as ‘ineffective’ is overly simplistic. While major trials do not support lowering DOAC doses for bleeding risk reduction, there is emerging evidence that in patients with borderline renal function, low body weight, or polypharmacy, individualized dosing (e.g., apixaban 2.5 mg BID) may offer a favorable risk-benefit profile without compromising stroke prevention. To rigidly enforce fixed dosing without considering patient-specific factors risks iatrogenic harm. The goal is not merely adherence to guidelines, but precision medicine tailored to the human being in front of you-not the algorithm.
Finally, the narrative that ‘fear’ drives patient decisions ignores the legitimate cultural and generational mistrust of pharmaceutical interventions among elderly populations, particularly those who have witnessed adverse drug reactions in family members. Education must be compassionate, not condescending. Telling someone ‘you’re choosing fear’ when they’ve seen a loved one bleed out from a pill is not persuasive-it’s alienating.
Elizabeth Buján
November 18, 2025 AT 22:58ok but like… i just lost my grandma to a stroke because she stopped her blood thinner after she fell in the shower. she was so scared. she thought if she didn’t move much, she’d be safe. but she didn’t move at all. she got weaker. her legs gave out. she didn’t even know she was having a stroke until it was too late. i wish someone had told her this. not just the stats, but like… ‘you can still live, just be smarter about it.’
my mom is on apixaban now and we did all the stuff they said-grab bars, nightlights, no rugs, PT twice a week. she walks like a penguin now but she’s alive and she laughs every morning. i used to think falling meant you were broken. now i know it just means you need help. not to stop living.
also… if you’re scared of bleeding? talk to your doc. ask about the reversal agents. they exist. they work. you’re not alone in this fear. but please don’t let it steal your future.
vanessa k
November 19, 2025 AT 21:47My dad’s on rivaroxaban. Fell three times last year. Once hit his head. Went to ER. They checked him, gave him a clean bill of health, and sent him home. No brain bleed. No hospital stay. Just a bump and a bruise. Meanwhile, his CHA₂DS₂-VASc is 4. If he’d stopped the med? He’d be in a nursing home now, not sitting on the porch drinking coffee. This article is right. Fear is the real enemy.
manish kumar
November 20, 2025 AT 11:35In India, we face a different challenge: access. Many elderly patients cannot afford DOACs-they’re priced for the West. Warfarin is cheap, but requires INR checks, which are not available in rural clinics. So families are forced to choose between affordability and safety. Some stop the meds entirely because they can’t manage the monitoring. This isn’t about fear-it’s about poverty. The guidelines are perfect on paper, but they ignore the reality of healthcare inequality. Until DOACs become affordable globally, telling someone to ‘just switch’ is not just impractical-it’s cruel.
Also, in many households, falls aren’t just accidents-they’re signs of neglect. Elderly people are left alone for hours, with no one to help them stand or reach the bathroom. No amount of grab bars helps if no one is home to turn on the light. We need social care, not just medical advice. A walker won’t help if you’re too weak to lift your leg because you haven’t eaten properly in days.
Nicole M
November 21, 2025 AT 21:00Wait-so if I fall a lot but my score says I need the med, I’m supposed to just… keep taking it? And fix my house? And get PT? That sounds like a lot of work. But also… kind of doable? I think I’m gonna ask my doc about switching to apixaban. I’m tired of being scared all the time.
Arpita Shukla
November 23, 2025 AT 11:48Actually, you’re all missing the point. The real issue isn’t the medicine-it’s the fact that most people don’t even know what their CHA₂DS₂-VASc score is. Doctors don’t explain it. Patients don’t ask. And then when something bad happens, everyone’s shocked. This whole article is just a glorified PSA. The real problem is systemic ignorance. Also, DOACs aren’t magic. They can still cause GI bleeds, especially in people with H. pylori or NSAID use. And no one talks about that. And what about the elderly who can’t swallow pills? Apixaban can be crushed, but not all DOACs can. So if your mom has dysphagia? What then? You just assume she’s fine? Please. This is oversimplified. Real medicine is messy.