Transcript Preventing Medication-Related Falls

Preventing MedicationRelated Falls: Helping the
Elderly Find Balance
Deepa Pattani, PharmD, RPh
Owner: PrevInteract Health
[email protected]
972-372-9775
About Me
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Deepa Pattani, PharmD, RPh with over 12
years of experience as a Pharmacist
Practiced in various aspects of
pharmaceutical care
Licensed to practice in 8 states throughout
the country
Contact info:
[email protected]
972-372-9775
Learning Objectives
After completion of this activity, one should
be able to:
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Describe the relationship of age-related changes in drug
metabolism to the risk of falling in older adults
Describe at least 2 classes of medications that are
related to falls in older adults
Identify risk factors for falling in older adults
Recommend at least 2 strategies to prevent falls in the
community setting
Introduction
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Over 700,000 hospitalizations: mostly due to head
injury or fractures.
>85% of all injury-related hospitalizations and 49% of
nursing home admissions.
Falls are the 5th leading cause of death in older
adults.
30-40% of adults > 65 will experience at least 1 fall a
year.
Serious complications: disability, fractures,
hospitalizations, loss of independence, death.
Direct medical costs are $34 billion annually.
Agenda
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Age and medication related risk factors for
falls in older adults
Role of pharmacists, nurses, case managers
and social workers in the community in
preventing falls for older adults
Age-Related Changes
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Medication disposition
depends on 4
processes: A, D, M, E.
PK changes in these 4
processes can alter
function & drug activity,
making older adults
more susceptible to
SE’s – particularly falls.
Absorption
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Changes in GI motility & gastric pH alter
absorption
No evidence in the absense of disease of fall
risk
Example: PPI use increases gastric pH:
inhibits absorption of Ca, Mg, and Fe. In the
long run can cause osteoporosis, anemia
which in turn can lead to falls.
Distribution
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Increase in total body fat, decrease in lean
muscle mass and total body water.
Example: lipophilic drug: Valium. Prolonged
exposure can increase risk of cognitive
impairment & CNS depression – increasing
fall risk.
Changes in distribution may increase drug
concentrations and duration of action.
Metabolism
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30% decrease in liver size & 40% decrease
in blood flow to the liver
Two methods of metabolism:
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First pass metabolism
Cytochrome P450 enzyme system
Metabolism (cont’d)
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First pass metabolism altered due to size and
blood flow.
Example: anti-hypertensive medications such
as Inderal or verapamil are affected –
increased bioavailability results in adverse
effects such as symptomatic hypotension
which increases fall risk
CYP450 system is not affected by age,
however it is affected by multiple medications.
Elimination
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Occurs mainly through the kidneys
Renal blood flow, tubular function, GFR all
decrease with increasing age
Results in accumulated medications and
adverse events- increasing fall risk
Example: Opiates such as Morphine &
Dilaudid when accumulated can cause
sedation, dizziness & confusion
Summary
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Age-related changes in PK may have a
significant impact on drug disposition and
may increase risk of falls in older adults
Changes in absorption have not been
clinically significant, however, changes in
distribution, metabolism and elimination do
increase medication related adverse events,
in this case: falls.
Common Causes of Falls
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Lower body weakness
Difficulty balancing or walking
Hazards in the home
Inappropriate foot wear or foot pain
Visual disturbances
Vitamin D deficiency
Medications
Medications Associated With Fall Risks
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Psychotropic medications: anti-depressants,
anti-convulsants, anti-psychotics
Cardiac medications: anti-hypertensives,
anti-arrhythmics, diuretics
Sedative/hypnotic medications
Analgesics: Opioids, NSAIDs
Psychotropics
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Anti-depressants
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Common side-effects: sedation, sleep disturbances,
orthostatic hypotension, confusion, cardiac
arrhythmias, involuntary muscle movements, and
lightheadedness.
Can also cause a decrease in bone mineral density
over time and may increase risk of fractures.
Fall risk is dose-dependent and does not decrease
with prolonged use.
Psychotropics
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Anti-convulsants
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Common side effects: dizziness, sedation,
ataxia.
Drugs such as Dilantin or Tegretol: have narrow
therapeutic ranges. Small dose changes can
result in accumulated and major changes in the
body and increase side effects.
Monitoring blood levels is crucial.
Psychotropics
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Anti-psychotics
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Common side effects: EPS (akathisia, dystonia,
pseudoparkinsonism, dyskinesia), sedation, and
orthostatic hypotension
Long term use of drugs such as Haldol, Risperdal,
Zyprexa increase risk of falls by 81%.
Recommended to use the smallest possible dose
for the shortest duration of action.
Cardiac Medications
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Associated with recurrent and injurious falls
Significantly drops orthostatic blood pressure
Common side effect: dizziness due to drop in
BP
Sedative/ Hypnotics
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Common side effects: cognitive impairment,
confusion & sedation.
Examples: Xanax, Valium, Phenobarbital
Dependence and side-effects seen with short
and long lasting agents.
Ambien: similar side effect profile
Benadryl: available OTC: SEs: dementia, poor
co-ordination, visual disturbances and
confusion.
Analgesics
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Opioids (Morphine, Dilaudid)
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Common side effects: sedation, dizziness, confusion &
respiratory depression.
● NSAIDs: availble OTC, sometimes mixed with
Benadryl poses a falls risk.
Vitamin D Deficiency
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Associated with increased fall risk among
older adults.
The US Preventive Service Task Force
recommends all older adults incorporate 400
to 600 units of Vit D daily by diet or
supplementation.
Postural Hypotension
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Definition: drop in SBP >/= 20mmHg or <
90mmHg upon standing from sitting or
sleeping positions.
Behavioral modifications that help decrease
fall risk include:
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Rising slowly
Using hand rails
Crossing legs when standing
Limiting prolonged standing
Education & Counseling
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Being educted about the different classes of drugs that
can increase fall risk and counseling patients on the
same
Awareness of side-effects can help the patient take
appropriate steps to prevent falls
Never assume counseling has been provided by
physicians or pharmacists
Always ask if a patient has had a fall in the past in your
initial assessment. Helps identify high-risk patients.
Recommend full assessment of medications by a
pharmacist.
Education & Counseling
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Always counsel patients to not drive or
operate heavy machinery when a medication
is added or discontinued.
Medication non-compliance can lead to falls;
not taking the prescribed medications can
also be a possibility.
CDC reference toolkit link in handout
Common Precautions to Prevent Falls
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Have physician assess fall risk.
Build flexibility and strength: participate in a balance
or exercise program
Discuss medications and possible interactions with
physician or pharmacist – include over the counter
drugs and supplements
Annual vision and hearing screening
Appropriate footwear
Making the home safe: get rid of floor clutter, put
grab bars/ railings in the bathroom and by stairs,
install proper lighting, secure throw rugs to the floor
and place food and other items within easy reach
Potential Problems
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Social workers/ case managers, RNs, etc
may lack time learning about all the
medications and side-effects.
Patient health insurance may limit the
physicians a person can see
Co-ordinating between physicians,
specialists, hospitals can be challenging.
Collaborating With a Pharmacist
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A valuable asset for all parties involved.
Easily accessible.
Knowing when to call a pharmacist can help save
clients hundreds or even thousands of dollars in
healthcare expenditures.
Pharmacists have easy access to physicians so
collaboration can be very beneficial
Encourage patients to inform RPh of all OTC
supplements, foods, herbals, etc. in addition to RX
meds
Summary
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Age-related changes, multiple disease states
& inappropriate medication use all contribute
to falls in an older adult
Collaboration examples to help our patients:
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Hosting brown bag sessions
Education & counseling seminars
Developing a fall prevention program
Improving compliance of medications
Using screening tools
Where to Get More Information
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References include toolkits for fall risk
assessment.
CDC website
Consulting services: PrevInteract Health