+ finding balance: preventing medication related falls through appropriate medication use chanel f....

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Finding Balance:Preventing Medication Related Falls Through

Appropriate Medication Use

Chanel F. Agness, PharmD, Certified Geriatric Pharmacist cagness@rx.umaryland.edu

Stephanie Callinan, PharmD, Geriatric Pharmacy Resident scallinan@rx.umarylande.edu

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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

Medications and Older Adults. www.healthinaging.org

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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?