Falls Risk on Anticoagulants: How to Prevent Bleeding Without Skipping Stroke Protection

Every year, more than 1 in 3 adults over 65 falls. For someone on a blood thinner-like warfarin or a DOAC-that fall isn’t just a stumble. It’s a potential emergency. But here’s the truth most doctors still get wrong: fall risk alone should never stop you from taking a blood thinner if you need it. The fear of bleeding from a fall is real. But the risk of having a stroke because you skipped your medication? That’s often far worse.

Why Stopping Blood Thinners Over Fall Risk Is a Dangerous Mistake

Many clinicians, especially in nursing homes or geriatric clinics, see a patient who’s unsteady on their feet and automatically think: “Better not give them a blood thinner.” It feels safer. But it’s not. Studies show that for older adults with atrial fibrillation (AF), the annual stroke risk without treatment is 1.5% to 3%. For someone with a CHA2DS2-VASc score of 3 or higher-that’s the standard tool doctors use to measure stroke risk-that risk jumps to over 3% per year. That’s roughly 1 in 30 people having a stroke each year.

Now, compare that to the risk of a serious brain bleed from a fall while on a blood thinner. It’s only 0.2% to 0.5% per year. That’s less than 1 in 200. And here’s the kicker: you’d need to fall nearly 300 times in one year for the bleeding risk to outweigh the stroke prevention benefit of warfarin. Most people don’t fall even 10 times a year.

The American College of Physicians, the European Society of Geriatric Medicine, and the American Heart Association all agree: do not withhold anticoagulation just because someone falls. In fact, they’ve made it a formal “Things We Do for No Reason” campaign-meaning it’s a common but harmful practice that needs to stop.

DOACs Are the Smart Choice for Fall-Prone Patients

If you’re on a blood thinner and you’re at risk of falling, your best option isn’t warfarin. It’s a DOAC-direct oral anticoagulant. These include apixaban, rivaroxaban, dabigatran, and edoxaban. They’re not just easier to take (no weekly blood tests), they’re safer.

DOACs reduce the risk of intracranial hemorrhage (bleeding in the brain) by 30% to 50% compared to warfarin. That’s huge for someone who might trip down the stairs or slip in the bathroom. A brain bleed is often fatal or disabling. A stroke from AF can be, too-but DOACs cut your chance of that happening by 60% to 70%.

In the U.S., about 80% of new anticoagulant prescriptions for AF are now DOACs. Why? Because doctors are finally catching on. For patients over 75, with balance issues, or living in a care home, DOACs are the clear winner.

Don’t Use CHA2DS2-VASc Alone-Check the HAS-BLED Score Too

CHA2DS2-VASc tells you your stroke risk. HAS-BLED tells you your bleeding risk. You need both.

CHA2DS2-VASc scores: 2 or higher in men, 3 or higher in women? You’re in the moderate-to-high stroke risk group. Anticoagulation is recommended.

HAS-BLED scores: If you score 3 or higher, you have a higher bleeding risk. But that doesn’t mean don’t take a blood thinner. It means you need to be more careful. Check your blood pressure. Review your medications. Fix your home. Get your vision tested. Treat your anemia. These are fixable risks.

Many people think a high HAS-BLED score means “no anticoagulation.” That’s outdated. The guideline says: “High HAS-BLED = more monitoring, not no treatment.”

What Actually Reduces Fall Risk (And Why It Matters More Than Stopping Medication)

Instead of taking away your blood thinner, fix what’s making you fall. That’s the real solution.

Here’s what works:

• Review your meds. Sedatives, sleeping pills, antidepressants, and even some blood pressure drugs can make you dizzy. Ask your doctor: “Can any of these be stopped or lowered?”
• Test your balance. The Timed Up and Go test takes 30 seconds. You stand up from a chair, walk 3 meters, turn, walk back, and sit down. If it takes more than 12 seconds, you’re at high fall risk. Physical therapy can help.
• Fix your home. Loose rugs, poor lighting, no grab bars in the bathroom-these are easy fixes. Install nightlights. Remove clutter. Use a shower chair.
• Check your eyes. Cataracts, glaucoma, or outdated glasses? Get them fixed. Vision is a top cause of falls.
• Treat low blood pressure when standing. If you feel lightheaded when you stand up, that’s orthostatic hypotension. It’s common in older adults and easily managed with hydration, compression stockings, or adjusting meds.

A study from the American Medical Directors Association showed that when nursing homes used a full falls assessment-including all these steps-fall rates dropped by up to 40%. And patients stayed on their blood thinners safely.

What You Should Never Do

There are three dangerous myths you need to avoid:

1. “I’ll just take a lower dose of my DOAC.” Wrong. Studies show reducing DOAC doses doesn’t lower bleeding risk-it raises stroke risk. These drugs are already dosed for safety in older adults. Don’t mess with it.
2. “I’ll keep my INR lower than normal.” That’s for warfarin users. Keeping INR below 2.0 doesn’t prevent bleeds. It lets clots form. Your stroke risk goes up. Don’t do it.
3. “I’ll stop the blood thinner if I fall once.” One fall doesn’t mean you’re unsafe. It means you need a falls assessment. Don’t panic. Don’t quit.

When Might It Be Right to Skip Anticoagulation?

There are rare cases where avoiding blood thinners makes sense:

• You have active bleeding-like a stomach ulcer or recent brain bleed.
• Your blood pressure is uncontrolled-above 180/110.
• You have a severe bleeding disorder, like hemophilia.
• You’re very frail, with life expectancy under 1-2 years, and your stroke risk is low (CHA2DS2-VASc = 1 or 2).

For most people-even those with multiple falls, poor balance, or living in a care home-none of these apply. The benefit of preventing a stroke still wins.

What to Do Next

If you or a loved one is on a blood thinner and has fallen-or is afraid of falling-here’s your action plan:

1. Ask your doctor: “What’s my CHA2DS2-VASc score?” If it’s 2+ (men) or 3+ (women), you need anticoagulation.
2. Ask: “What’s my HAS-BLED score?” If it’s 3+, we’ll work on reducing modifiable risks.
3. Request a full falls assessment: meds review, balance test, home safety check, vision test.
4. Ask: “Can I switch to a DOAC?” If you’re on warfarin, DOACs are safer and easier.
5. Don’t stop your medication without a plan. Talk to your doctor. Don’t self-decide.

Final Thought: Safety Isn’t About Avoiding Risk-It’s About Managing It

You can’t eliminate every fall. But you can prevent a stroke. You can’t control aging. But you can control your environment, your meds, and your choices.

The goal isn’t to live in a bubble. It’s to live well, safely, and without fear. For most people on anticoagulants, that means staying on them-while fixing what’s making them fall.

Don’t let fear of a fall steal your future. Talk to your doctor. Get assessed. Stay protected.