FEATURE ARTICLE Antithrombosis Management in Community-Dwelling Elderly: Improving Safety Denise Bockwoldt, RN, MS Thrombus-related conditions are increasing in the elderly population. This article provides an overview of thrombus formation and de- scribes the various pharmacologic options for prevention. Thromboprophylaxis requires an assessment of the risks and benefits of treatment so that catastrophic bleeding does not result. A practice model, the ‘‘S.A.F.E. Triad’’ is proposed to provide a framework for addressing safety concerns, while algo- rithms assist with decision-making. (Geriatr Nurs 2010;31:28-36) B lood clots are the leading cause of death in the Western world, with more than half the population dying from a thrombus-related myocardial infarction, stroke, or pulmonary em- bolism. 1 The risk and treatment of thrombosis formation has drawn the attention of most clini- cal specialties, including orthopedics, cardiology, endocrinology, geriatrics, pulmonology, surgery, and neurology. No age group is more affected by thrombosis- linked conditions than the elderly. With the aging population growing rapidly, prevention and treat- ment of blood clots are an increasingly important role of advanced practice nurses (APNs). 2 How- ever, with this role comes the responsibility of maintaining a delicate balance of preventing thrombus without causing unsafe bleeding. Careful prescribing, patient education, and monitoring are imperative to ensure safe and effective treatment. The purpose of this article is to emphasize the essential knowledge APNs need for safe antith- rombosis management in their elderly patients. On the basis of a synthesis of the literature, a prac- tice model for thromboprophylaxis safety, called the ‘‘SAFE Triad’’ (Safe Anticoagulation For Elderly), is proposed. Basics of Thrombus Formation The terms antithrombosis, anticoagulation, and antiplatelet should not be used interchange- ably. Antithrombosis is a general term referring to the inhibition of blood clot formation, whereas anticoagulation refers to any disruption with the clot-forming protein, thrombin, and the coagula- tion cascade. Antiplatelet refers to the inhibition of platelet aggregation or activation. Depending on the clinical situation, either anticoagulant medications or antiplatelet agents, or both in combination, may be prescribed. Thrombus formation occurs in both the venous and arterial circulation. Arterial thrombi are most often associated with conditions that cause tur- bulent blood flow, whereas venous thrombi are most often associated with conditions related to stasis. 3 Three conditions that predispose formation of blood clots include 1) endothelial injury within blood vessels, 2) blood stasis, and 3) hypercoag- ulability. Activation of 2 or all 3 of the conditions creates a synergistic effect, increasing the likeli- hood of clots developing. Prevention and treatment of thrombus formation (‘‘thrombopro- phylaxis’’) is directed toward alleviating these same conditions. Endothelial Injury Endothelial injury in a blood vessel, both directly and indirectly, exposes the sticky sub- endothelium, where platelets accumulate and aggregate, creating a thrombus. 4 Examples of direct endothelial injury include atherosclerotic plaque rupture, surgery, trauma, and toxic drugs. Indirect endothelial injury can be caused by illnesses that disrupt the overall health of the endothelium, such as inflammatory conditions, sepsis, HIV, and diabetes. Blood Stasis Blood stasis creates an accumulation of plate- lets and activated clotting factors. 2 Although most often occurring in the lower extremities, stasis can develop in both the venous or arterial circulation anywhere in the body, for example, 28 Geriatric Nursing, Volume 31, Number 1