Strategies to manage medication related falls in older people
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1 Strategies to manage medication related falls in older people ALLEN R. HUANG, MDCM, FRCPC RGPEO Refresher Day, April 5, Affiliated with Affilié à
2 DISCLOSURES I have no conflict of interest to declare
3 LEARNING OBJECTIVES Understand intrinsic vs. extrinsic fall risk factors Understand modifiable fall risks Understand an approach to medication review
4 FALLS IN OLDER PEOPLE 1/3 community older people fall per year Worldwide problem (Ontario 2.1/14M older than 65-yrs) Costly: % total health care spending ($13B USD in 2013) Impacts in multiple domains physical, psychological, social
5 CULPRITS Intrinsic factors Age, sex, previous falls, balance & gait impairments,functional and ADL impairments, Parkinson s, cognitive impairment, stroke, incontinence Extrinsic factors Visual impairment, depression, low education, orthostatic hypotension, pain, wandering, dizziness, home hazards, MEDICATIONS Protective being married
6 CAN WE DO ANYTHING? Non-modifiable Age Sex previous falls Parkinson s cognitive impairment stroke low education wandering Modifiable incontinence visual impairment depression orthostatic hypotension pain dizziness home hazards balance & gait impairments functional and ADL impairments MEDICATIONS Affiliated with Affilié à
7 FALL RISK INCREASING DRUGS (FRIDs) Cardiac meds BP meds Psychotropic meds Anti-depressants Anti-psychotics Benzodiazepines Glucose control meds
8 BEWARE OF DRUGS WITH ANTI-CHOLINERGIC EFFECTS Dimenhydrinate (Gravol) Diphenhydramine (Benadryl) Tolterodine (Detrol) Pseudoephedrine (Sudaphed) Cyclobenzaprine (Flexeril) Methocarbamol (Robaxin) Procyclidine (Kemadrin) Pramipexole (Mirapex)
9 DETECTION Houston, we ve had a problem Heed the warning signs (within the last 2 weeks) New meds (prescription & others) New dose New medical condition Hospitalization
10 MEDICATION REVIEW - ARMOR APPROACH Structure / process / outcome (reduce falls) Assess for potentially inappropriate meds Review interactions, adverse reactions Minimize non-essential meds Optimize 5 rights: drug, dose, formulation, time, administration Reassess evaluate changes
11 MANAGING FRIDs Cardiac meds time to benefit & goals of therapy Beta-blockers post acute coronary syndrome Calcium channel blockers Anti-arrhythmics Digoxin Anti-anginals Heart failure meds
12 MANAGING FRIDs BP meds adjust target BP, investigate adherence Diuretics Angiotensin converting enzyme inhibitors Angiotensin receptor blockers Beta blockers Calcium channel blockers Others
13 MANAGING FRIDs Psychotropic meds risk benefit, watch for cascades Anti-depressants SSRIs not much safer Anti-psychotics atypicals not much safer REVIEW THERAPEUTIC INTENT Short half-life drugs, trial of stopping, frequent monitoring
14 MANAGING FRIDs Benzodiazepines just say NO Same goes for z drugs (zolpidem, zopiclone) Glucose control meds avoid long half-life drugs metformin can decrease Vit B12 absorption
15 MEDICATION WITHDRAWAL (DEBRIDEMENT) Short half-life meds can safely be discontinued in 1-2 days Long half-life meds flurazepam, diazepam, clonazepam, lorazepam, fluoxetine, doxepine No advantage to switch from long to equivalent short half life drug, until you reach tapering dose limitations
16 EMPOWER STUDY (TANNENBAUM ET AL) Eliminating Medications Through Patient Ownership of End Results (JAMA Intern Med 2014, 174(6):890)
17 EMPOWER STUDY
18 ENGAGE YOUR HEALTH CARE TEAM Pharmacist meds review Nurse BP, weight Physiotherapist gait & balance Occupational therapist cognition, ADLs Social worker socioeconomic factors Dietician dry mouth, swallowing complaints, appetite disturbance
19 CONCLUSIONS Aim for LESS, rather than NO falls Meds are a modifiable extrinsic fall risk factor Actively listen to your team members Patients are smarter than we think ARMOR yourself with a meds review Review medications frequently, especially after a hospital stay or Emergency Room visit
20 THANK YOU! Questions & Comments Affiliated with Affilié à
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