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Lim Wan Chieh: Choosing Which Risk to Prioritise in Frail Older Adults

Lim Wan Chieh/LinkedIn

Mar 4, 2026, 13:11

Lim Wan Chieh: Choosing Which Risk to Prioritise in Frail Older Adults

Lim Wan Chieh, Geriatrician and Internal Medicine Specialist at Sunway Medical Centre Ipoh, shared a post on LinkedIn:

“In Geriatrics, we often live in the grey zone between ‘preventing a future catastrophe’ and ‘causing a present one’.

Consider one of the most agonizing, everyday dilemmas we face: The frail, older patient admitted for a fall-related fracture, who also has Atrial Fibrillation and is on a DOAC like Apixaban.

Do we continue anticoagulation?

The clinical debate is heavy.

The Case for Stopping: They are frail. They just fell. They often have underlying renal impairment.
The Case for Continuing: Their Hemoglobin might be stable. Their CHADS-VASc score dictates they are at incredibly high risk for a devastating ischemic stroke if we stop.

So, we document the risks. We sit with the family.

We make the best evidence-based, calculated decision we can in that moment, perhaps deciding to continue the DOAC to prevent a stroke.

But what happens when, a week later, that same patient is readmitted with a massive Upper GI Bleed requiring scopes and transfusions?

Even when the patient stabilizes, the psychological toll on the physician is immediate. The ‘ghost’ of that outcome sits on your shoulder.

The inner voice whispers, ‘I saw the renal impairment. I should have stopped it’.

This is the very definition of outcome bias: judging a past medical decision based on information we only have now, rather than the data we had then.

The harsh reality of geriatric medicine is that if we had stopped the Apixaban and the patient returned with a massive stroke, we would feel the exact same crushing guilt in the opposite direction: ‘I should have continued it’.

We desperately want to believe that if we think hard enough, we can eliminate risk.

But in frail older adults, we are often just choosing which risk to prioritise.

You can make a bad decision and get a good outcome (dumb luck).
You can make a good, evidence-based decision and still get a bad outcome (the tragic reality of human biology).

To my colleagues fighting this same battle: we have to be careful.

If we let the regret of a bad outcome dictate our future practice, we will stop anticoagulating everyone. We will stop prescribing. We will begin practicing ‘anxiety-based medicine’ rather than ‘evidence-based medicine’.

Forgive yourself for the variables you cannot control. If your process was sound, if your clinical logic was solid, and if you communicated the risk to the family… you did your job.

The rest is biology.”

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