NUR 616 Module 5 Case Study Example

Case Study: Stroke Prevention in Atrial Fibrillation When the Patient Is 82 and Has Fallen

[Student Name]

Southern New Hampshire University

NUR 616: Primary Care of Adults and Gerontological Patients

Module Five Case Study

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Case Study: Stroke Prevention in Atrial Fibrillation When the Patient Is 82 and Has Fallen

Atrial fibrillation raises the risk of stroke about fivefold, and the risk climbs with age. Yet older adults, who have the most to gain from anticoagulation, are the least likely to receive it, and fear of bleeding after a fall is one of the most common reasons clinicians and families give. This case study examines that fear in a woman in her eighties with atrial fibrillation and a recent fall. It argues that her stroke risk far exceeds the bleeding risk from falls, that a direct oral anticoagulant at the correct dose is the best choice and that the fall itself should be treated as a problem to prevent rather than a reason to withhold treatment.

Case Presentation

Mrs. N. is 82, a retired seamstress who lives with her daughter. At a routine visit her pulse was irregular, and an ECG showed atrial fibrillation with a ventricular rate of 92. She reports occasional fluttering in her chest but no chest pain, breathlessness or fainting. Six months ago she tripped over a loose rug in her bedroom and fell onto her hip without injury; she has not fallen since. She has hypertension, controlled on lisinopril 10 mg, and osteoarthritis. A daily 81 mg aspirin, begun long ago "for her heart" with no clear indication, is still on her list, and acetaminophen as needed. She has no history of stroke, bleeding, liver disease or alcohol use.

Examination: blood pressure 132/78 mm Hg; irregularly irregular pulse at 88; weight 58 kg. No murmur. Timed Up and Go 12 seconds. No orthostatic drop. Labs: hemoglobin 12.8 g/dL, platelets 230,000, creatinine 1.1 mg/dL with creatinine clearance by Cockcroft-Gault about 36 mL/min, normal liver tests and TSH. Echocardiogram: normal left ventricular function, mild left atrial enlargement, no significant valve disease.

Her daughter says, "If she falls again on a blood thinner, won't she bleed into her brain?"

Stroke and Bleeding Risk

Her CHA2DS2-VASc score is 4: two points for age 75 or older, one for hypertension and one for female sex. The 2023 ACC/AHA/ACCP/HRS guideline recommends oral anticoagulation for patients with an estimated annual stroke risk of 2% or more, which corresponds to a CHA2DS2-VASc score of 2 or more in men and 3 or more in women, and it notes that female sex acts as a risk modifier rather than a risk on its own (Joglar et al., 2024). She clearly qualifies.

Her HAS-BLED score is 2: one point for age over 65 and one for aspirin use. A score of 3 or more flags higher bleeding risk, and the tool's value lies less in deciding whether to anticoagulate than in identifying bleeding risks that can be changed. Her aspirin is one such modifiable factor.

What the Evidence Says About Falls

The concern about falls has been studied directly. In a decision analysis of older patients with atrial fibrillation, investigators modeled the risk of subdural hematoma from falls against the benefit of stroke prevention with warfarin. By their estimate, only someone falling roughly 295 times annually would reach the point where subdural bleeding on warfarin cancels its protection, and that fall risk was not an important factor in choosing therapy regardless of age or baseline stroke risk (Man-Son-Hing et al., 1999). One fall six months ago, caused by a rug, is nowhere near that threshold.

Since that analysis, direct oral anticoagulants have lowered the risk further. A meta-analysis of the four major trials comparing them with warfarin found a 19% reduction in stroke or systemic embolism and about half the rate of intracranial hemorrhage, with a relative risk of 0.48, although gastrointestinal bleeding was more common (Ruff et al., 2014). Intracranial bleeding is precisely the event her daughter fears, and it is the complication these drugs reduce most. That finding held in the trials' older participants as well, who made up a large share of each study, so the benefit is not confined to younger patients who rarely fall.

Choosing and Dosing the Drug

Apixaban is a reasonable choice for an older adult with reduced kidney function. Its label halves the standard twice-daily dose from 5 mg to 2.5 mg only when two of three conditions hold: the patient is at least 80, weighs no more than 60 kg or has a creatinine of 1.5 mg/dL or above. Mrs. N. is past 80 and under 60 kg, while her creatinine is lower, so two conditions hold and the halved dose is correct. Underdosing is common in practice and removes much of the protection, so the dose is checked against the criteria rather than chosen by feel. Her creatinine clearance of 36 mL/min would call for dose adjustment with some other agents, which is another reason apixaban suits her. Warfarin remains an option if cost is prohibitive for her family, but it requires monitoring and carries a higher intracranial bleeding risk. Aspirin should be stopped, since it adds bleeding risk without meaningful stroke protection in atrial fibrillation.

Plan

Start apixaban 2.5 mg twice daily and stop aspirin. Rate control: start metoprolol succinate 25 mg daily for a resting rate above 80 and symptoms, with a target resting rate below 100. Falls: remove loose rugs and add night lights, which she and her daughter agreed to do this week; refer for a home safety evaluation and physical therapy for strength and balance; review footwear and vision. Monitoring: hemoglobin and creatinine in one month and then every six months, with dose reassessment if her weight or creatinine changes. Education: take doses 12 hours apart, do not double up after a missed dose, call about tarry stools, pink or red urine or bruises she cannot explain and seek emergency care for a head injury or sudden severe headache, even without visible bleeding. Follow-up in four weeks.

Conclusion

For Mrs. N., a CHA2DS2-VASc score of 4 means a substantial annual stroke risk, while one fall on a rug adds little to her bleeding risk. A correctly reduced dose of apixaban, the removal of an unnecessary aspirin and a plan to prevent the next fall answer her daughter's question honestly: the greater danger is a stroke without treatment.

References

Joglar, J. A., Chung, M. K., Armbruster, A. L., Benjamin, E. J., Chyou, J. Y., Cronin, E. M., Deswal, A., Eckhardt, L. L., Goldberger, Z. D., Gopinathannair, R., Gorenek, B., Hess, P. L., Hlatky, M., Hogan, G., Ibeh, C., Indik, J. H., Kido, K., Kusumoto, F., Link, M. S., . . . Van Wagoner, D. R. (2024). 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 149(1), e1-e156. https://doi.org/10.1161/CIR.0000000000001193

Man-Son-Hing, M., Nichol, G., Lau, A., & Laupacis, A. (1999). Choosing antithrombotic therapy for elderly patients with atrial fibrillation who are at risk for falls. Archives of Internal Medicine, 159(7), 677-685. https://doi.org/10.1001/archinte.159.7.677

Ruff, C. T., Giugliano, R. P., Braunwald, E., Hoffman, E. B., Deenadayalu, N., Ezekowitz, M. D., Camm, A. J., Weitz, J. I., Lewis, B. S., Parkhomenko, A., Yamashita, T., & Antman, E. M. (2014). Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: A meta-analysis of randomised trials. The Lancet, 383(9921), 955-962. https://doi.org/10.1016/S0140-6736(13)62343-0