Atrial Fibrillation, Coumadin, and Falls

One of the hardest decisions in medicine is deciding whether to put your 89 year old demented, at-risk-for-falls patient (who also has atrial fibrillation), on Coumadin.  Risks of Coumadin include bleeding out with a fall.  Risks of no Coumadin include stroke or heart attack.  The CHADS2 score has helped considerably (1 point for CHF, hypertension, age > or = to 75, Diabetes, and then 2 points for previous stroke). If a patient has a score of 0-1, Coumadin is unlikely to help much.  If a patient has a score of 4-6, they should be on Coumadin with strong anticoagulation education.  For scores 2-3, things are a bit more fuzzy. In any case, when placing a patient on Coumdain, discuss risks and benefits, and let them have the final say.