“Since Dad’s fall I want him off that blood thinner — if he bangs his head, it’ll kill him”

Falls are often cited as a reason to stop anticoagulation in older people with AF, but NICE NG196 advises not withholding anticoagulation solely because of age or risk of falls. Stroke risk is assessed with CHA2DS2-VASc and bleeding risk with ORBIT; the purpose of the bleeding score is to identify and address modifiable risk factors, not to deny treatment. Modelling studies suggest a person would need to fall very many times a year before the risk of subdural haemorrhage outweighed the stroke benefit of anticoagulation. Modifiable bleeding risks include NSAIDs and antiplatelets taken without indication, excess alcohol, uncontrolled hypertension and inappropriate dosing. DOAC doses should be checked against the criteria in the SPC (for apixaban, dose reduction depends on a combination of age, weight and serum creatinine; check the SPC/local formulary) and renal function monitored. A fall is a symptom: take a falls history, look for a cause (here, likely orthostatic hypotension after starting an alpha-blocker, worsened by nocturia and evening alcohol), measure lying and standing blood pressure, review medicines, and refer for a multifactorial falls assessment (NICE NG249, 2025). A person with capacity decides about their own treatment; relatives’ views are heard and their fears addressed, but they cannot decide for him. Bereavement and alcohol use often go together in older widowed men and deserve a gentle conversation. The communication skill is managing a three-way consultation, keeping the patient at the centre, giving numbers clearly and turning fear into concrete actions that reduce both falls and bleeding risk.