+ finding balance: preventing medication related falls through appropriate medication use chanel f....
TRANSCRIPT
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Finding Balance:Preventing Medication Related Falls Through
Appropriate Medication Use
Chanel F. Agness, PharmD, Certified Geriatric Pharmacist [email protected]
Stephanie Callinan, PharmD, Geriatric Pharmacy Resident [email protected]
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High Risk Medications in Older Adults• Review age-related changes and medication
properties that increase the risk of falls in older adults• Describe potential adverse effects of at least 2 classes
of medications associated with falls in older adults.
Medication Review Process• Assess medication-related fall risk and recommend fall
prevention strategies
Session Objectives
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High Risk Medications in Older Adults
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+How the Body Processes a Drug
A: Absorption
D: Distribution
M: Metabolism
E: Elimination
+Age Related Changes in Distribution
Decrease in total body water Monitor water soluble medications
Digoxin, lithium
Body fat increases and lean muscle mass decreases Lipophilic medications have a longer half life in older
adults Long acting benzodiazepines (Diazepam)
+Age Related Changes in Metabolism
Reduced liver size and decreased blood flow to liver
Liver metabolic enzymes function adequately even in the very old
+Age Related Changes in Elimination
Decline in kidney function
Medications that are eliminated through the kidneys can accumulate Morphine Glyburide Digoxin Many others
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High Risk Medications in Older Adults
Medication classes commonly implicated in falls: Sedative/hypnotics Antipsychotics Antidepressants Anticholinergics Cardiac medications Pain medications Anticonvulsants
Older adults are at increased risk of experiencing medication adverse events, including falls related to changes in drug processing in the body.
+Sedative/Hypnotics
• Cognitive impairment, delirium, sedation
Possible adverse events
• Non-benzodiazepine hypnotics:• Zolpidem, Eszopiclone, Zaleplon
• Benzodiazepines:• Diazepam, Clonazepam, Alprazolam, Lorazepam
Examples
+Antipsychotics
• Ataxia, impaired psychomotor function, and syncope
• Olanzapine can cause orthostatic hypotension
Possible adverse events
• Haloperidol, Olanzapine, Quetiapine, Aripiprazole
Examples
+Antidepressants
• Ataxia, impaired psychomotor function, and syncope
Possible adverse events
• Fluoxetine, Sertraline, Citalopram, Paroxetine
Examples
+Anticholinergics
• Sedation, confusion, hypotension, delirium
Possible adverse events
• Tricyclic Antidepressants:• Amitriptyline, Nortriptyline
• OTC Antihistamines:• Diphenhydramine, Chlorpheniramine, Hydroxyzine
Examples
+Cardiac Medications
• Hypotension, dizziness
Possible adverse events
• Beta blockers• Nitrates• Diuretics• Digoxin
Examples
+BPH/Urinary Retention Medications
• Orthostatic hypotension
Possible adverse events
• Terazosin, Doxazosin, Prazosin
Examples
+Pain Medications
• Dizziness, syncope, CNS depression
Possible adverse events
• Opioids:• Morphine, Hydromorphone, Fentanyl,
Oxycodone
Examples
+Anticonvulsants
• Ataxia, impaired psychomotor function, syncope
Possible adverse events
• Gabapentin, Levetiracetam, Phenytoin, Valproate
Examples
+Summary
Age related changes in drug disposition can increase older adults risk of falls
Several classes of medications increase the risk of falls and should be used cautiously in older adults.
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Medication Review Process
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• Medication Reconciliation
• Adherence
Medication Review
• “Red Flag Medications”
Assess Fall Risk • Optimize
Regimen• Education
Fall Prevention
Medication Review Process
+Medication Review Process
Fall Prevention Strategies/Education
Identify potentially inappropriate “Red flag”
medications
Up to date medication list/Adherence
+Medication Reconciliation:Up to Date Medication List/Adherence
Medicines and You: A guide for older adults. http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm
+Medication Review Process
Fall Prevention Strategies/Education
Identify potentially inappropriate “Red flag”
medications
Up to date medication list/Adherence
+AGS Beers Criteria
Classifies “potentially inappropriate” medications in older adults by:
Table 1• Organ system/Category
of Drugs
Table 2• Disease or Syndrome (by
organ)
Table 3• Specific drugs, use with
caution
AGS Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society. http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf
3I: Medication/Fall Risk Score
Tool 3I: Medication fall risk score and evaluation tools. Agency for healthcare research and quality. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html
Point Value Medicine Class Potential side effects3 (High) Analgesics/opiates,
antipsychotics, anticonvulsants, benzodiazepines, non-benzodiazepine sedatives*, hypoglycemics*
Sedation, dizziness, postural disturbances, altered gait and balance, impaired cognition
2 (Medium) Antihypertensives, cardiac drugs/antiarrhythmics, antidepressants
Induced orthostasis, confusion, poor health status
1 (Low) Diuretics Increased ambulation, induced orthostasis
Score > 6 Higher risk for fall, medication fall risk evaluation
3I: Medication/Fall Risk Score
Tool 3I: Medication fall risk score and evaluation tools. Agency for healthcare research and quality. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html
Point Value
Medicine Class Potential side effects
3 (High) Analgesics/opiates, antipsychotics, anticonvulsants, benzodiazepines, non-benzodiazepine sedatives*, hypoglycemics*
Sedation, dizziness, postural disturbances, altered gait and balance, impaired cognition
2 (Medium) Antihypertensives, cardiac drugs/antiarrhythmics, antidepressants
Induced orthostasis, confusion, poor health status
1 (Low) Diuretics Increased ambulation, induced orthostasis
Score > 6 Higher risk for fall, medication fall risk evaluation
+Medication Review Process
Fall Prevention Strategies/Education
Potentially inappropriate “Red flag” medications
Up to date medication list/Adherence
Evidence-Based Fall Prevention Strategies
Medication Review
Minimize use of high risk medications
Vitamin D Supplementation
Consumer Education
Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157.
Intervention approaches to medications implicated in falls
Medication Approach
Psychoactive medications
Carefully evaluate need and consider tapering or discontinuance as possible by 10-25% of dose per week. Goal – minimize total psychoactive load, use for shortest period of time, taper to avoid adverse withdrawal effects
Benzodiazepines/Non-benzodiazepine sedative hypnotics
First-line: sleep hygiene, behavioral interventionNonprescription: melatonin?Manage underlying causes of insominiaGoal – lowest effective dose “intermittently” or “short term” 2 to 4 weeks; taper to prevent rebound insomnia
Cooper JW, Burfield AH. Medication interventions for fall prevention in the older adult. J Am Pharm Assoc(2003). 2009;49(3):e70-82Kamel Insomnia in the elderly: Cause, approach, and treatment. Am J Med 2006 119, 463-469
Intervention approaches to medications implicated in falls
Medication ApproachAntidepressants Avoid older agents (eg. Tricyclics); use lower doses of newer
SSRIs
Opiod analgesics Acetaminophen preferred agent for mild-moderate pain (max 3grams/day)Consider topical route for localized pain (eg. topical NSAIDs) Goal – Use lowest effective dose with careful titration/monitoring to manage pain AND limit adverse effects
Antihistamines Use non-sedating agents if chronic need (eg. loratadine) Avoid older, more sedating agents (ie. diphenhydramine, chlorpheniramine)
Cooper JW, Burfield AH. Medication interventions for fall prevention in the older adult. J Am Pharm Assoc(2003). 2009;49(3):e70-82
+Vitamin D Supplementation
Cochrane Review – vitamin D supplementation reduces risk of falls in older adults with clinically low vitamin D levels1
U.S. Preventive Services Task Force (USPSTF) recommends 800 units of vitamin D daily2 Diet, Multivitamin, nutritional supplements, vitamin D supplement,
prescription agents
Include in medication review and monitor for proper adherence – risk of over treatment and under treatment
1. Gillespie L, Robertson M, GIllespie W, et al. Interventions for preventing falls in older people living in the community. Cochrane database of systematic reviews (Online). 2013;Issue 9. Art. No.: CD007146:8/25/14. 2. U.S. Preventive Services Task Force. Vitamin D and calcium supplementation to prevent fractures, topic page. http://www.uspreventiveservicestaskforce.org/uspstf/uspsvitd.html.
+Consumer Education Resources
New Drug Facts Label
Ten Medicines to Avoid
STEADI Toolkit
The New Drug Facts Label
The new over-the-counter medicine label. http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/ BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/UCM349215.pdf
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CDC’s evidence-based fall prevention toolkit for healthcare providers and consumer education
ASK patients if they’ve fallen in the past year, feel unsteady, or worry about falling.
REVIEW medications and stop, switch, or reduce the dose of prescriptions that increase fall risk.
RECOMMEND Vitamin D supplements of at least 800 IU/day with calcium.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Stopping elderly accidents, deaths, & injuries tool kit. http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/about.html.
Use medication review process and tools to evaluate fall risk
Work with team to manage underlying conditions/medications and maximize use of nonpharmacologic strategies
Use high risk medications with caution at the lowest effective dose for the shortest period of time.
Provide ongoing education to patients about safe medication use
+Helpful Websites/Resources
STEADI (Stopping elderly accidents, deaths & injuries) Toolkit for health care providers http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html
Tool 3I: Medication fall risk score and evaluation tools http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html
Beers List Pocket Card, App: iGeriatrics http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf
The new over-the-counter medicine label http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/UCM349215.pdf
Medicines and Older Adults. HealthinAging.org www.healthinaging.org
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What is one strategy or tool that you can use to prevent falls and promote safe medication use in your practice?