medication management to reduce fall risk in the elderly
TRANSCRIPT
Medication Management to Reduce Fall Risk in the Elderly
Tatjana Bulat,MDMedical Director, Patient Mobility Clinical
Services,VISN 8 Patient Safety CenterAssistant Professor, Department of Internal
Medicine,USF COM, Tampa, FL
Definition
! A sudden unintentional change in position causing one to land on a lower level not due to an overwhelming external force
FALLS
! Mortality-unintentional injury-sixth leading cause of death in elderly
! Morbidity-10-15% serious injury! Fractures-hip fracture 20% mortality/yr! Soft tissue injuries, subdural hematomas,
accidental hypothermia ! Loss of confidence-fear of falling (up to 50%)! Contributing factor in up to 40% of NH
admissions! 20 billion in direct health care costs annually
Prevalence in elderly
! Community living 325/1000/yr! Hospital 1,500/1000/yr! Long-term care 1650/1000/yr
Risk factors-intrinsic
! Cognitive impairment (delirium, dementia, depression)
! previous falls, fear of falling! cardiac arrhythmias, transient ischemic attacks,
stroke! Parkinson’s disease! acute and subacute medical illness! orthostatic hypotension, dehydration,
hypoglycemia
Cont.
! Musculoskeletal conditions, problems with gait and mobility, ADL impairment
! incontinence (bowel or bladder)! Vision (both contrast sensitivity and acuity) or
auditory impairment! Sensory impairments (proprioception), vestibular
dysfunction! Foot problems, ankle dorsiflexion! Normal aging-increased postural instability and
increased sway
Extrinsic
! Use of restraints- deconditioning, pressure ulcers, functional incontinence, aspiration pneumonia, DVTs, increased agitation, etc.
! decrease number of falls but risk of serious injury the same
Extrinsic risk factors, cont.
! Environmental factors-dim lighting, glare, inappropriate footwear, uneven flooring, loose carpet, wet, slippery floor, old and unstable furniture, etc.
! Polypharmacy vs. Polymedicine- more then 4 meds
! Certain classes: benzodiazepines, diuretics,psychotropics
Medications and falls
! What is the mechanism and how strong is the association?
! RCT’s/Case series: Adjustments of meds and falls risk- overall benefit
Adverse medication effects
! POSTURAL HYPOTENSION-decrease in systolic BP >20mmHg 1 min after standing
! Tricyclic antidepressants! Antypsychotics! L-dopa! Antihypertensives! Diuretics! Nitrates
Orthostatic hypotension
! Altered systems in frail/elderly:! decreased arterial compliance ! blunted response of volume/BP regulation (lower
renin, angiotensin, aldosterone)! Decr B receptor response! Decr sympathetic response (less tachy with
dehydration)! Can reduce OH by 50% with med adjustment
(Fotherby M, Postgraduate Med J 70:878-81,1994)
Cont.
! DRUG-INDUCED PARKINSOMISM-increased muscle tone, rigidity, resting tremor, impaired postural responses to change in position
! Antipsychotics! Metoclopramide! Reserpine
Cont.
! ATAXIA-toxic effect on cerebellum, vestibulosensory, or proprioceptive control systems-increased body sway, loss of balance
! PSYCHOMOTOR SLOWING-difficult to measure clinically; lack of attention or a distraction from gait and balance problems, effect on judgment and reflexes
! Benzodiazepines! Anticonvulsants-phenytoin, carbamazepine,
phenobarbital
Cont.
! MYOPATHIES-muscle wasting, weakness! Long-term steroid use! HMG CoA reductase inhibitors! -increased osteoblast activity, use of statins
in either prior 180 days (OR 0.50) or prior 3 yrs (0.57) decreased risk of hip fracture in elderly over 65 (did not measure BMI)
Wang P.S. et al. HMG-CoA Reductase inhibitors and the risk of hip fracture in elderly patients.JAMA,283(24),3211-3216, 2002.
Medication review in falls risk
! On admission, Change in condition, Post fall! Systematic review of all high risk med’s! Review indication and efficacy, potential ADE-
evaluate potential to an individual’s fall risk; what is target Sx, is it working?
! Discontinue, change to alternative or no change! Document decision in chart
BENZODIAZEPINES
! Mechanism of association-sedation, “hangover effects”, dizziness, impaired balance, decreased neuromuscular function, decreased central processing/alertness, cognitive impairment, delirium
! 7-15% of community living elderly are prescribed a benzodiazepine
! 15.6% of nursing facility residents (CMS Oscar data, 2001)
! Increased risk of falls and hip fracture
Cont.
! All benzodiazepines- 1.48 OR! Long-acting benzos-1.32 OR (diazepam,
clonazepam,chlordiazepoxide, flurazepam)! Intermediate-acting benzos- (lorazepam,
temazepam, oxazepam), Short-acting benzos-1.44 OR (triazolam, alprazolam) (Leipzig, RM et al.JAGS 47:30-39, 1999.)
Overview of research
! Risk of fall-related fracture related to dose (too high), not elimination half life (Herings et al.,1995)
! Pharmacodynamics-lower doses and lower plasma concentrations needed to achieve sedation
! Balance/Peripheral neuromuscular dysfunction(increased EMG muscle latency)-motor coordination impaired at baseline, deteriorates to a critical level after drug administration
Benzodiazepines, cont.
! Short-acting benzodiazepines associated with higher risk of nocturnal falls in NH residents (Ray et al.,2000) but less then with longer acting agents
! Metabolism-Hepatic biotransformation-oxidation (alprazolam, diazepam) vs. conjugation (lorazepam, oxazepam)
! Nonoxidative benzodiazepines do not carry a lower risk of fall-related fracture than oxidativebenzodiazepines (Sgadari et al.,2000) except for the oldest old at high doses
Cont.
! Risk of fall related fracture highest within 15 days of new prescription; risk decreases with increase in time from fill date (Neuta et al., 1996)
! Risk of fall highest within 7 days of new prescription in nursing home residents and remain elevated after 30 days from fill date (Ray et al., 2000.)
SEDATIVE-HYPNOTIC USE
! 4.8% of nursing home residents are prescribed a sedative-hypnotic (CMS OSCAR data, 2001)
! What does the research tell us?! 1.54 OR (Leipzig, RM et al. JAGS 47:30-39,1999)
! Sleep hygiene! Fall risk - Newer agents not safer (zolpidem)
Wang PS and el. Zolpidem use and hip fractures in older people. JAGS 49:1685-1690, 2001.
ANTIDEPRESSANTS
! Mechanism of association-orthostatic hypotension, dizziness, sedation, blurred vision, decreased central processing /alertness
! Effect of antidepressants on obstructed vs. unobstracted gait in healthy seniors; RDBPC crossover study-amytriptyline, paroxetine,desipramine, placebo in random order; unobstucted & with obstacle (6cm dowel) timed 9.5m; little effect on unobstructed gait but slowing with obstacle (Draganich J.,2001)
Cont.
! 8% of community-living elderly are prescribed an antidepressant (Ray, Griffin, 1990) and 35.5% NH residents (CMS OSCAR data, 2001)
! OR 1.66-any antidepressant (Leipzig et al, 1999)! Higher doses associated with higher fall rates! Little difference in fall rates between TCAs and
SSRIs ; RR 2.0 (1.8-2.2) for TCA, 1.8 (1.6-2.0) for SSRI, 1.2 (1.0-1.4) for trazodone; RR incr with dose, persisted beyond 180 days of Rx (Thapa et al., 1998)
ANTIPSYCHOTICS
! Mechanism of association-sedation, dizziness, orthostatic hypotension, blurred vision, decreased central processing/alertness, confusion, EPS
! OR 1.51-typical (Leipzig et al, 1999)! Typical (haloperidol, fluphenazine,thioridazine)
vs. atypical antipsychotics (risperidone, olanzapine, quetiapine)-less anticholinergic, less EPS, less TD
! abstract (olanzapine vs.risperidone)-retrospective; falls 17.8% vs. 6.9% (Martin et al., 2001)
ANTIPSYCHOTICS
! Typical antipsychotics (haloperidol, etc.)-poorly tolerated in PD, CVA, Lewy body dementia
! Atypicals: risperidone often exacerbates PD, quetiapine better choice
! Clozapine improves PD! ECT often effective for mood and
psychotic symptoms
ANTIPSYCHOTICS
! Improvement of psychosis vs. worsening of motor function in schizophrenia (Factor, 1999)
! Risperidone 77% vs. worse 28%! Olanzepine 70% vs. worse 46%! Quetiapine 83%, worse 17%
ANALGESICS
! Mechanism of association-dizziness, sedation, decreased central processing/alertness, impaired judgment, decreased neuromuscular function
! Narcotics-propoxyphene, meperidine! Narcotics 0.97 OR (Leipzig, 1999)
! Non-narcotic analgesics- OR 1.09 ! NSAIDs-1.16 OR (? confounding by indication)
Chronic pain adjuvants
! Gabapentin vs. amitryptiline for diabetic neuropathy- mean age 60, n=25, DB crossover –gabapentin had sig’ly more dizziness (28% vs. 8%) and trend (NS) more sedation (48vs32), ataxia (20vs.8) and OH (24vs20) Morello CM, 1999
! Nortryptiline or desipramine
ANTIHYPERTENSIVES
! Centrally acting-clonidine, methyldopa,alphablockers-OR 1.16; mechanism of action-hypotension, sedation, decreased alertness
! Beta blockers-postural hypotension, sedation! Diuretics-OR 1.08-volume depletion, electrolyte
imbalance, urgency to rush to toilet, direct vestibular toxicity (high dose loop diuretics)
OTHER CARDIAC MEDICATIONS
! Digoxin-1.22 OR! Type 1a antiarrhythmics-1.59 OR
(quinidine, procainamide,disopyramide)! Calcium channel blockers-0.94 OR! ACE inhibitors-1.20 OR! Nitrates 1.13 OR
ANTIHYPERTENSIVES
! Measure BP as close to fall incident as possible! If significant OH, stop diuretic, remove Na
restriction in diet, review timing! If ACE inhibitor preferred, and OH/sx’s-after d/c
diuretic, less renal metabolized-fosinopril (OH enalapril 6.7%, lisinopril up to 5%, fosinopril <1% (renal excretion 93% enalapril, >95% captopril, 50% fosinopril )(Facts and Comparisons, 1987)
Anticoagulation with falls risk (Man-Son-Hing M,1999)
! Risk of embolic CVA with a.fib. 5%>65, incr’d>75, CHF,HTN, Hx CVA (8%)
! Reduced risk of CVA: warfarin 68%, ASA 21%! Risk of falling >65: 33%/yr! Subdural hematomas are rare! Persons taking warfarin must fall 295 times in 1 yr
for warfarin not to be the optimal therapy (risk of SDH outweights the benefit)
Anticoagulation with falls risk
! Did not account for adverse outcomes other then SDH (increased morbidity or mortality with injury)
! Risk of bleeding increased if ETOH use, NSAID’s, GI bleed, noncompliance with med or lab monitoring
OTHER MEDICATIONS
! Antihistamines-sedation, blurred vision, confusion, acute urinary retention with overflow incontinence, orthostasis- OTC but not necessarily safe
! H2 antagonists (cimetidine)-confusion, ataxia
! Sulfonylureas-dizziness, sedation
Clinical practice algorithm: Consensus based medication
management to reduce fall risk in the elderly
Bulat T., Castle S.C., Marasco R., Fiuzat M. ; in review
Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury in the Elderly at Risk for Falls
1. Patient entry toFall Clinic
7. Indications(see worksheet)
11." Recommend
DC/Modify orReduce Rx
" Notify PCC
10. No
8. Yes
4. Yes
6. No
2. Patient Medication Assessment:Prescription for: Benzodiazepines,
Cardiovascular agents, Antidepressants,Antipsychotics, Anticholinergics/Bladderrelaxant, Anticonvulsants, Anticoagulants
3. Presentation ofUrgent/Emergent
Medication Side Effects/Symptoms?
SUMMARY ALGORITHM
5
5." Notify PCC
Immediately" Send to ER
if needed
9. For EACH class of medications, assess:Prescribing Patterns:
" Type/Class" Dose/Frequency" Combinations" Duration" Compliance
Refer to Specific Algorithm for Main Classesof Medications.
12a.Benzo-diaze-pines
12b.Cardio-vascularagents
12d.Anti-
coagu-lants
12c.Anti-
depres-sants
12e. Bladderrelaxant/ACH
Receptorantagonist
12f.Anticonvul-sant for pain
control
12g. Anti-psychotic
y p
13a. Correctprescribing
patterns
23a." Recommend
taper to off." Educate patient
about theincreased risk offalling/hipfracture with anybenzodiazepineuse.
15a. Insomnia20a. Generalizedanxiety disorder/
depression
16a." Do not use longer than 2 weeks.
Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury in the Elderly at Risk for Falls
22a. No14a. Yes
19a. Yes
12a. Benzodiazepines(Odds Ratio 1.48)1
benzodiazepineuse.16a.
" Do not use longer than 2 weeks." Emphasize sleep hygiene measures
(eliminate naps, daily exercise, nocaffeinated beverages in afternoon, usebed only for sleep, etc.).
" Treat underlying medical problemsdisrupting sleep (like pain, shortness ofbreath, symptomatic BPH, etc.).
" Environmental modifications (room toocold/hot, noise control, etc.).
" Evaluate for prescription/over the countermedications contributing to insomnia(sympathomimetics, diuretics, etc.).
21a." Consider conversion to
buspirone.6
" Maximize theantidepressant dose.
" Educate patient about theincreased risk of falling/hip fracture with anybenzodiazepine use.
" Consider referral topsychiatry
17a." Evaluate dose/frequency (for elders onlong-acting benzodiazepines, consider switchto short-acting or alternatives--still increasedrisk for falls/hip fracture).2
18a." Encourage to taper off" Educate patient about the risk of falling/hip fracture with any benzodiazepine use." Refer to sleep lab if suspicion of sleepapnea or restless leg syndrome
13b. CorrectPrescribing
Patterns
27b." Refer to clinical
guidelines for CHF,HTN, CAD4
17b. No or Mildsymptoms from
orthostasis
20b." Stop diuretic first" Decrease salt restriction" Consider splitting the dose or changingadministration times" Decrease if not tolerated or patient atrisk for injury
Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury in the Elderly at Risk for Falls
19b. Yes
26b. No14b. Yes
12b. Cardiovascular Agents(Odds Ratios: Diuretics 1.08; Centrally acting
antihypertensives 1.16; ACE inhibitors 1.20; Nitrates1.13; Type Ia antiarrhytmics 1.59; Digoxin 1.22)3
15b. Severesymptoms due to
orthostasis
16b. No
18b." Patient Education" Behavioral Adjustments (change
position slowly, sit at the edge ofthe bed for a few minutes, etc.)
" Eliminate centrally-acting agents,use tamsulosin if needed for BPHsymptons
" Reserve use of hydralazine andnitrates for CHF patients that failedACE-I/ARB, loop diuretics for CHF/CRI patients
" Use thiazides for ISH patients thatcannot be controlled on otherpreferred agents
" For BP alone use ACE-I, B-blockersor Ca channel blockers preferably
" Elastic stockings
23b.Ensurepatientunderstandsand agreeswith plan ofcare
22b. Yes
21b. BP goal:
Normal 140/90 DM < 130/85 CRI < 125/75
25b.EDUCATION: * Recommend Home BP kit; *Data sheets for recording; * Teach how to doorthostatics, especially when dizzy; * Considergiving written instruction on med adjustment ifcertain readings (like adjusting blood sugars)
24b. No
13c. Correctprescribing for indication
(depression, chronic pain,PTSD, OCD)
22c.Recommend to d/c,educate patient aboutincreased risk of falls/injury
15c." Use SSRIs as first line therapy(although fall risk is increased, they arebetter tolerated than tricyclics or MAOinhibitors)10
" If failed SSRIs, use nortryptilinepreferably to amitryptiline (lessanticholinergic)5
Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls
14c. Yes21c. No
16c.
12c. Antidepressants(Odds Ratio 1.66)1
f
ly to amitryptiline (lessinergic)5
18c." Continue, or consider
decrease to maintenancedose
" Educate patient aboutincreased risk of falls
16c.Determine if dose is
effective (e.g. use shortform GDS, 1-10 pain
scale, etc.)
20c." Refer back to PCC
for dose increase andfollow-up
" Educate patientabout increased riskof falls
17c. Yes
19c. No
, ypb
13d. Correctprescribing for
indication
24d.# Recommend
discontinue# Notify PCC
Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls
14d. Yes
23d. No
12d. Anticoagulants
20d. Yes
15d.Any high risk condition:# concomitant NSAID use# history of GI bleed# use of ETHOH# non-adherence to
prescribed regimen# greater than weekly falls.8
22d.Continue anticoagulation
21d. No
17d.Patient Education:Refer to anticoagclinic if available
16d. Yes
19d.Considerthe ongoingrisk/benefitanalysis ofcontinuedtherapy
18d. Yes
20d. Yes
13e. Correctprescribing
30e.Recommend todiscontinue, educatepatient about increasedrisk of falls/injury
17e.# Consider GU referral
Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls
14e. Yes 29e. No
12e. Bladder RelaxantACH Receptor Antagonist
15e. Hi postvoid residual
Low flowrate (men)
16e. Yes
20e.Acceptable
Control
19e. No or PVR datanot available
21e Yes
28e.# Recommend
decrease# Monitor urgency# Falls/Gait &
Balance# Scheduled
toileting
27e. No
17e.# Consider GU referral# Consider decreasing
dose or discontinuing# Monitor urgency# Falls/Gait & Balance
24e.# Consider decreasing
dose or trial oftolterodine9
# Examine CV drugs forneed and timing ofdoses--especiallydiuretics
22e. Signs/Symptons of
orthostasis, dry mouth, poorcompliance or CHS/
Psychomotorslowing dec.
attention
26e.# Educate patient
about increasedrisk for falls
# Refer to PCC forfollow up
23e. Yes
25e. No
18e.Refer toPCC forfollow up
21e. Yes
# Scheduledtoileting
Balance
13f. Correctprescribing
26f.# Recommend change# Refer to PCC/Pain
clinic
Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls
14f. Yes
25f. No
12f. Anticonvulsantfor pain control
17f.# Consider decreasing dose# Consider topical capsaicin# Recommend non-
pharmacological adjuvanttreatment (exercise,modalities) in addition tomeds
22f.# Consider decreasing
dose# Examine CV agents--
especially diuretics# Eliminate and/or
decrease dose basedon symptom control
15f. CNSSide Effects
16f. Yes
18f.Refer to PCC forfollow up
20f. Signs/Symptoms ofOrthostasis
19f. No
21f. Yes
24f.# Educate pt about
increased risk forfalls
# Refer to PCC/Pain clinic forfollow up
23f. No
13g. Correctprescribing
30g.# Recommend change# Refer to PCC/Psych
17g.# Consider decreasing
dose# Consider atypical
agent11
# Examine CV agents-especially diuretics
Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls
29g. No
12g. Antipsychotic(Odds Ratio 1.51)1
15g.Signs/Sx
Orthostasis16g. Yes
14f. Yes
19g. No
agent11
# Examine CV agents-especially diuretics
22g.# Consider decreasing
dose or change to(another) atypical agent
18g.# Refer to PCC/
Psych for followup
Orthostasis
20g. Signs/SymptomsCNS/Psychometric slowing,
decreased attention21g. Yes
24g. EPSParkinsonian
stiffness
23g. No
26g.# Consider decreasing dose11
# Consider change to (another)atypical agent11
# Consider non-antipsychotic# Perform risk/benefit analysis
of symptom control vs. sideeffects
28g.# Educate patient about
increased risk for falls# Refer to PCC/Psych for
follow up
25g. Yes
27g. No
14. Yes
Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls
13. Risk Factors forOsteoporosis
21. No
22. Refer toPCC for AnnualAssessments
SUMMARY ALGORITHM(Continued)
15. Bone densitometry (DEXA)
18. Treat osteopenia, osteoporosis(e.g. alendronate, risedronate,raloxifene; calcitonin ifcontraindicated; estrogens withunknown effectiveness)7
# Start calcium/vitamin Dsupplementation
# Hip protectors (if falling)
14. Yes
20. Consider calcium/vitamin Dsupplementation
16.Osteopenia orOsteoporosis17. Yes
19. No
Upper Gastrointestinal Complications
Preferable•Raloxifene –SERM
•Calcitonin
Caution•Bisphosphonates(alendronate, risedronate)
! Bisphosphonates may be irritating to upper GI mucosa
Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition
Nasal/Sinus Complications
Preferable•Bisphosphonates
•Raloxifene
Caution•Calcitonin
! Potential for increased nasal irritation
Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition
NSAID Usage
Preferable•Calcitonin
•Raloxifene
Caution•Bisphosphonates
! Bisphosphonates should be used with extreme caution due to the potential for increased GI irritation
Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition
GI Motility Complications
Preferable•Calcitonin
•Raloxifene
Caution•Bisphosphonates
! Bisphosphonates may precipitate esophageal erosions
Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition
Renal Dysfunction
Preferable•Calcitonin
•Raloxifene
Caution•Bisphosphonates
!Bisphosphonates are contraindicated when creatinine clearance is less than 30-35 cc/min
Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition
Hip protectors
! Designed to absorb or re-distribute (shunt) the energy of the impact
! Hard or soft shell! Decrease hip fracture rates by 50-84% if
worn at the time of fall! Long-term adherence poor