Pills and Spills. An Update on Medications and Falls in Older Adults. Cheryl Sadowski, Pharm.D. January 21, 2009

Transcription

1 Pills and Spills An Update on Medications and Falls in Older Adults Cheryl Sadowski, Pharm.D. January 21, 2009

2 Objectives Describe patterns of use of medications for older adults. Identify medications that are risk factors for falls. Discuss appropriate interventions to reduce medication-associated falls. Describe the contributions of health care team members in reducing medicationassociated falls.

3 Outline Definitions Epidemiology of falls Impact of falls Complications of falls Risk factors for falls Pharmacoepidemiology Physiologic changes due to aging that predispose to medication adverse effects Non-pharmacologic treatment Pharmacologic interventions Role of the team

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6 History 1970 s, 1980 s description of the problem 1980 s, 1990 s definition of fall 1980 s, 1990 s identification of risk factors 1990 s, 2000 s interventions studied

7 Definitions - Fall Canadian Falls Prevention Curriculum: Unintentionally coming to rest on the ground, floor, or other lower level with or without an injury.

8 Epidemiology Injury is an important cause of death and disability among older adults (aged 65+ years) Every day: 19 fall-related admissions Every hour: 2 fall-related ER visits ACICR 2006

9 Epidemiology 9x more fall injuries occur among those % of hip fractures are due to a fall 20% of those 65+ die within a year of the hip fracture 40% of all nursing home admissions are the result of falls

10 Epidemiology 10% of falls lead to soft tissue injuries (including hematomas, sprains, joint dislocations) 5% of falls result in fractures of the humerus, wrist, pelvis, or hip 70% of fractures are of the hip

11 Epidemiology Falls account for approximately: 25% of all injury-related deaths among older adults 76% of all injury hospitalizations among older adults 60% of all injury ED visits by older adults More older adults are hospitalized because of a fall than for motor vehicle collisions, unintentional poisonings, assaults, and all other injury types combined. CH Public Health

12 Epidemiology 1/3 of the elderly fall each year Of seniors who fall, 50% fall more than once per year 90% of falls take place in the community 60% in the home 30% in public places 10% of falls occur in health care institutions Rate of falls in institutions is 3 times higher than in the community

13 Epidemiology In hospital Overall 0.65 falls/bed/year Geriatric rehabilitation units have higher rates of falls (2.7 falls/bed/year) In long term care facilities 1.5 falls /bed/year

14 Impact of Falls Each fall costs approximately $25,000 In 2003, hospitalization costs for falls: $88,000, (this dose not include ER costs, physician payment, physiotherapy payment, home care costs, medications, or cost to the patient and family)

15 Impact of falls If hospitalized, mean length of stay = 11.6 days 1/2 of older adults hospitalized for fall related injuries are discharged to continuing care. Sattin RW, 1990, 1992.

16 How do Falls Happen?

17 Mechanism of balance There are three main systems involved with postural control: CNS musculoskeletal sensory apparatus

18 Physiological Perturbations CNS Sensory Muscular Informational Perturbations Mechanical Perturbations

19 Changes Due to Aging

20 Changes in gait and balance Increased double limb support Decreased stride length Increased step width Stooped posture Decreased arm swing Loss of normal heel-toe sequence of foot-floor contact Decreased toe-foot clearance Decreased hip rotation and knee flexion during the swing phase Decreased walking speed

21 Changes in the CNS neurons, dendrites, and branching Impaired cerebral metabolism neurotransmitters nerve conduction velocity Result: disruption of rapid mobilization of complex postural response and reduced ability to compensate for impairments in sensory input

22 Changes in Sensory Systems Vestibular Visual Auditory Peripheral joint receptors

23 Changes in Sensory Systems vestibular system shows a progressive loss of labyrinthine hair cells, vestibular ganglion cells, and nerve fibers decreased touch sensitivity, two point discrimination, vibration sense, number of dermal mechanoreceptors reduced vision (cataracts, glaucoma, macular degeneration) changes in the temporal and spatial sequencing of muscle recruitment

24 Changes in Physiology Body composition: fat, lean Cardiovascular system: beta receptors, CO Renal system: GFR, nephrons Gastrointestinal tract: H+, gastric emptying time Hepatic system: size Nervous system: blood flow to CNS Pulmonary system: cilia Endocrine system: hormonal secretions

25 Changes Pharmacokinetics What the body does to a drug Pharmacodynamics What a drug does to the body

26 Changes in Pharmacokinetics Absorption: little change due to aging Distribution: Lipid soluble agents increase E.g. Ativan, Valium Water soluble agents decrease E.g. Ethanol, Lanoxin

27 Changes in Pharmacokinetics Metabolism: Some enzymes little change E.g. Ativan, Restoril, Serax easily metabolized Some enzymes decreased E.g. Valium, Flurazepam Elimination: Renal function declines

28 Changes in Pharmacodynamics Postural sway Fewer dopamine receptors in the striatum Medications of concern: Dopamine blocking agents Antipsychotics Maxeran Sedatives

29 Changes in Pharmacodynamics Orthostasis Blunting of beta-response Changes in vasculature Medications of concern: BP meds, beta-blockers (e.g. Lopressor) Tricyclic antidepressants (e.g. Elavil) Antipsychotics Diuretics (e.g. Lasix)

30 Changes in Pharmacodynamics Visceral muscle Visual disturbances Bladder instability Medications of concern: Anticholinergics (e.g. Elavil, Cogentin, Benadryl, Gravol) Cholinergic agonists (e.g. Aricept, Exelon)

31 Changes in Pharmacodynamics Higher cognitive function Decreased central cholinergic neurons Medications of concern: Anticholinergics Stimulants (e.g. Ventolin, Ritalin)

32 Changes in Pharmacodynamics Tardive dyskinesia Decreased dopaminergic neurons Medications of concern: Dopamine blocking agents Antipsychotics Maxeran

33 Risk Factors Falls and fall-related injuries usually result from the interaction between a number of risk factors

34 Risk Factors for Adverse Drug Events 6 concurrent diagnoses Number of medications and doses / day 12 doses of medications per day 9 different medications A prior adverse drug reaction Low body weight or low BMI Age (especially if >85 years) CrCl (est) of < 50 ml/min

35 Risk Factors for Falls Biological or intrinsic Behavioural Social or economic Environmental

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37 Environmental Risk Factors 18-47% of falls related to environmental hazards Examples Stairs Throw rugs Lack of grab rails Poor lighting Surfaces (hardness, slipperiness)

38 Medication Risk Factors

39 Fall Risk Factors? Laxatives Antihypertensives Digoxin Alcohol protective

40 Type of research Epidemiological studies Cohort (meds at baseline + monitor falls over 1 yr) Cross-sectional (meds at time of study and determine falls retrospectively) Case-control (med use at time of falls is recorded with controls on the same date) Randomized controlled trials Medication given in one group with falls recorded in both intervention and control group (rarely done)

41 Limitations of the research Observational epidemiological studies Cohort medications at baseline may not be the same as the medications at the time of the fall Cross-sectional depends on accuracy of recall (medication use at the time of the study is different than at the time of the fall) Case-control probably the best design but done mostly in institutions Confounding factors often uncontrolled Indication Prescribing

42 Limitations of the research Classification of drugs can vary Data is primarily from institutions Numbers of people taking a certain medication too small to analyze Statistical associations may not reflect individual risk Dose or duration of therapy often not addressed All possible medications not included in research Few large drug studies collect falls data Reflects practice trends from 80 s and early 90 s Patient reporting vs documented falls

43 Risk Factors - Magnitude Muscle weakness (4.4) History of falls (3.0) Gait deficit (2.9) Balance deficit (2.9) Use of assistive devices (2.6) Visual deficit (2.5) Arthritis (2.4) Impaired ADL (2.3) Depression (2.2) Cognitive impairment (1.8) Age > 80 years (1.7) JAGS 2001:49:

44 Multiple Risk Factors % falling Number of risk factors Tinetti et al. NEJM 1988;319:1701-7

45 Pharmacodepidemiology Seniors account for approximately 14% of the population 25% MD visits 28-40% of prescription medications in Canada 44% of drug costs in Canada (CIHI 2005)

46 Pharmacodepidemiology Seniors have a mean number of medications used /day = 8 non-prescription products/day = 2-4 chronic medical conditions /senior = 6 80% of seniors have at least 1 chronic medical condition

47 How could medications contribute? Balance Sedation/fatigue Postural hypotension and dizziness Muscle weakness Extrapyramidal gait disturbance Visual impairment Hypoglycemia Peripheral neuropathy Vestibular dysfunction Depression Cognitive impairment

48 Medications Meta-Analyses Medication Odds Ratio (CI) Any psychotropic 1.73 ( ) Neuroleptic 1.50 ( ) Sedative/hypnotic 1.54 ( ) Antidepressant 1.66 ( ) TCA 1.51 ( ) Benzodiazepine 1.48 ( ) Leipzig RM, JAGS, 1999

49 Medications Meta-Analyses Medication as a risk factor for falls 29 studies reviewed Medications implicated: Benzodiazepines Antidepressants Antipsychotics Antiepileptic drugs Blood pressure lowering drugs Hartikainen, J Gerontol 2007

50 Tricyclic Antidepressants - Current Use Current = 1.6 ( ) Indeterminant = 1.2 ( ) Former = 0.7 ( ) Curr Indeter Form Ray, et al. Arch Intern Med 1991;151:

51 Tricyclic Antidepressants - Dose Odds Ratio US, Medicaid data trend with dose relationship with current use 0 < Standardized Doses/Day Ray et al. NEJM 1987;316:363-9.

52 SRI vs TCA Drug Adjusted OR (95% CI) SSRI C 2.4 ( ) SSRI I 1.8 ( ) 2 TCA C 2.2 ( ) 2 TCA I 1.2 ( ) 3 TCA C 1.5 ( ) 3 TCA I 1.1 ( ) Liu et al. Lancet 1998;351:

53 Serotonin Reuptake Inhibitors Treatment Adjusted Rate Ratio (95% CI) None 1.0 TCA 2.0 ( ) SRI 1.8 ( ) Trazodone 1.2 ( ) Thapa et al. NEJM 1998;339:

54 Serotonin Reuptake Inhibitors Differences in indication for each drug - highest rate of falls if indication was for behavioural symptoms of dementia. Increased risk persisted throughout therapy. Thapa et al. NEJM 1998;339:

55 How Could Serotonin Reuptake Inhibitors Cause Falls? postural sway inhibition of dopamine neurons depression itself - psychomotor impairment channeling

56 Antidepressants - Summary TCA s increase the risk of falls Risk is highest early in therapy Risk may be dose related SRI s increase the risk of falls Mechanism unclear Depression itself is a risk factor for falls

57 Benzodiazepines - Dose hip fracture significance with: long t1/2 increasing dose current use Odds Ratio >1.5 Standard daily dose Ray, et al. NEJM 1987;316:363-9.

58 Benzodiazepines - Dose Increase Odds Ratio Same Inc Dec Refill Dose Sudden dose increase (refill dose) leads to higher risk of fractures Herings et al. Arch Intern Med 1995.

59 Benzodiazepines - Current Use Odds Ratio Previous Current Relationship to current use (p<0.001) Controlled for dementia Ray et al. NEJM 1987;316:363-9.

60 Benzodiazepines - New Use New users increased risk vs. other current users RR Hip fx New Current Ray et al. JAMA 1989;262:

61 Benzodiazepines - Start Date Odds Ratio for Hospitalization for Falls < Days after starting Rx Neutel et al. Age and Ageing 1996.

62 Benzodiazepines - Schedule PRN orders found to increase falls (p=0.03) Continuous users prescribed more antidepressants, antipsychotics Falls/person/month None PRN Sch Sorock et al. Arch Intern Med 1988.

63 How Could Benzodiazepines Cause Increase postural sway Impaired reaction time Ataxia Loss of co-ordination Loss of peripheral proprioception Confusion Falls?

64 Benzodiazepines - Summary Both short and long t1/2 benzodiazepines increase risk There is a dose-response relationship PRN and scheduled regimens both increase risk. New users are at highest risk. Discontinuing the medication reverses risk

65 Neuroleptics - Dose Hip fracture Significance with: increasing dose current use Odds Ratio >1.5 Standard daily dose Ray et al. NEJM 1987;316:363-9.

66 Neuroleptics - Current Use Odds Ratio Relationship to current use (p<0.001) Controlled for dementia 0 Previous Current Ray et al. NEJM 1987;316:363-9.

67 How do neuroleptics cause falls? Sedation Confusion Extrapyramidal side effects

68 Neuroleptics - Summary There is a dose-response relationship Discontinuing the medication reverses risk We don t know yet if there is a difference in fall risk among different neuroleptics

69 Psychotropics - Multiple Medications Number of CNSactive medications associated with fall status (p=0.002) Odds Ratio or more Number CNS meds Weiner, et al. Gerontology 1998.

70 Medications Meta-Analyses Medication Odds Ratio (CI) Narcotic Use 0.97 ( ) Non-narcotic 1.09 ( ) NSAID 1.16 ( ) ASA 1.12 ( )

71 Analgesics Some studies found narcotics increased risk, while others found narcotics protective. When pain is adequately treated, the risk for falls decreases.

72 Medications Meta-Analyses Medication Odds Ratio (CI) Diuretic 1.08 ( ) Thiazide 1.06 ( ) Loop 0.90 ( ) Beta-blockers 0.93 ( ) Central antihypertensives 1.16 ( ) ACE-I 1.20 ( ) Nitrates 1.13 ( ) IA Antiarrhythmics 1.59 ( ) Digoxin 1.22 ( ) CCB 0.94 ( )

73 Antihypertensives - SHEP overall 11% fell increased falls with age 6.8% age % >80 no association between falls or fractures with therapy history of faintness, orthostatic drop associated with falls (p<0.05) Curb et al. JAGS 1993.

74 Digoxin Inpatient study - incident reports Digoxin OR = 1.91 ( ) CHF OR = 1.86 ( ) highest frequency of falls 23:00-05:00 Gales et al. Ann Pharmacother 1995.

75 Cardiac Medications - Summary Few medications show increased risk. May be confounded by disease state. Evidence does not strongly support reducing doses of cardiac medications.

76 Multiple Medications Fallers Non fallers # Rx meds 3.75 ± ± 0.25 # Doses/day 6.39 ± ± 0.46 Robbins et al. Arch Intern Med 1989.

77 Multiple Medications > 4 drugs in use home dwelling elderly injurious falls (major and minor) RR = 1.3 ( ) Koski, et al. Age and Ageing 1996.

78 Multiple Medications Rate Ratios for Falls IRR to 8 Number of medications O'Loughlin, et al. Am J Epidemiol 1993.

79 Multiple Medications Multiple medications not consistently found to be a risk. Number of medications may be an indicator of frailty. Data on number of medications is dated.

80 Anticoagulation and Falls Should patients who are at risk for falls receive warfarin? Risk of CVA vs risk of bleeding complications secondary to fall What are the fall related risks? Bruising Subdural hematoma Intracerebral hemorrhage

81 Anticoagulation and Falls ICH and SDH are extremely rare CVA is very common An elderly patient must fall 295 times in a year for warfarin to not be optimal Conclusion: Risk of bleeding complications secondary to a fall are outweighed by the benefit of stroke risk reduction

82 Intervention

83 BEEEACH Prevention Model BEEEACH - Prevention model Education Equipment Health Management Behaviour Change Environment Clothing and Footwear Activity

84 Goals of Intervention Improve linkages within the community for falls prevention Reduce risk of falls and the complications from falls with appropriate interventions Maintain the autonomy and quality of life of older persons

85 Intervention It takes a village The whole is greater than the sum of its parts. Lewis Lipsitz

86 Intervention What Doesn t If in isolation: Work Medication review no action Modification of home environment Staff education Self-management programs Advice

87 Interventions In the past intervention studies showed a 30-40% reduction in falls Recently, two reviews found interventions don t work Gates, et al. BMJ 2007 Campbell, et al Age and Ageing 2007 Challenge with reviews of interventions Data is limited Programs vary

88 Intervention - Cochrane Database of Systematic Reviews 5 studies support population health interventions (2005) 62 studies (n=21,668) showed that interventions can prevent falls (2003) Multidisciplinary, mutifactorial, health/enviornmental risk factor/screening programmes in the community for both unselected people and those with a history of falls Withdrawal of psychotropic medication

89 Interventions Estimated Risk Strategy Reduction Reduction in Risk (%) Balance, gait training; strengthening exercise Reduction in home hazards post-hospitalization 19 Discontinuation of psychotropic medications 39 Multifactorial risk assessment with targeted management Community based specific balance or strength exercise programs NEJM 2003;348:42-49

90 Public Education recurrent falls are not part of normal aging falls are a frequent cause of hospitalization and death

91 Patient Education SAYGO II Keep track of falls Paying attention Taking risks Walking and balance Leg Strength Footwear Foot care Blood pressure Dizziness Medication Vision Mood Nutrition Social Life/Support Home environment

92 Health Professional Education recurrent falls are not part of normal aging falls are a frequent cause of hospitalization and death

93 Approach No falls in the last year no intervention Single fall assess for gait / balance problem (full evaluation if positive) Recurrent falls full evaluation CH Public Health

94 Approach Full evaluation history medication review vision gait / balance LES / neurological cardiovascular JAGS 2001;49:

95 Approach once patient stabilized, determine why the fall occurred develop falls protocol regionally identify risk factors contributing to falls pursue patient - specific interventions flag potential fallers within institutions refer to community programs for further fall intervention / maintenance CH Public Health

96 AGS Falls Prevention Guidelines Assessment of all older adults? Assessment of anyone with history of falls Multifactorial interventions including: - Exercise - Environmental modifications - Medication review - Assistive devices - Behavioral and educational programs

97 Community Programs START Medical Program Exercise programs Rehab Outreach Home Care Community programs for the cognitively impaired population

98 Intervention Medications are not the greatest risk factor for falls. However Medication use is potentially the most modifiable risk factor for falls Tinetti, 1995 Lawlor DA, et al. BMJ 2003;327:

99 Acute care settings: Assessment Presence of co-morbidities and complex cases Impaired / decreased mobility Impaired mental status (agitation / confusion) Pain management Continuing care Wandering / impulsive behaviour Psychotropic medications Incontinence / need for assisted toileting

100 Assessment Annual medical check-ups On admission ask for fall history or risk factors Medication reviews for those with complex regimens Review if other preventive strategies are in place: Sleeping habits Vision checks Healthy lifestyle: nutrition and exercise Appropriate chronic disease management

101 Assessment: MDS (Minimum Data Set) in Continuing Care History of falls Cognition Osteoporosis Pain Fatigue Medications Impaired gait & balance Visual & auditory deficit Orthostatic hypotension Incontinence Restraint use

102 Assessment Post-fall Addition of new medications Change in medication dosages Adverse effects such as: dizziness, confusion, incontinence, memory problems Pain management Cardiovascular symptoms: lightheadedness, arrhythmia, low blood pressure

103 Vitamin D Vitamin D deficiency in the elderly Associated with muscle weakness, postural sway RCTs have shown that Vitamin D supplementation reduces falls 23%-53% Bischoff-Ferrari, JAMA 2004

104 Vitamin D Evidence has been debated Challenges: Serum levels (lack of standardization) Dose range Duration of supplementation Currently recommended at units daily for older adults

105 Medication Interventions Drug interactions 8/35 interventions at 1 year, 77% were no long falling falls are a multidisciplinary issue and [we] recommend a team approach for successful management. Wolf-Klein, et al. Arch Phys Med Rehabil 1988.

106 Medication Interventions Comprehensive, structured individual assessment Team review of psychotropic drug use 149 recommendations (68 residents) 45% acceptance 19% fewer recurrent fallers 31% fewer injurious falls Ray, et al. JAMA 1997;278:

107 Medication Interventions Comprehensive post-fall assessment 93% required some treatment or intervention 31.2 % had medication problems Diuretic change most common intervention Rubenstein, et al. Ann Intern Med 1990.

108 Medication Interventions Focus on 8 risk factors Medications benzodiazepines 4 medications Rate of falls: 35% vs 47% (p=0.04) Tinetti, et al. NEJM 1994:331:821-7.

109 Medication Interventions Recommendations to discontinue, reduce the use of target medications Results: 30 vs 16 patients who fell (p=0.05) Cost savings = $308,000 / year AJHP 2003;60:

110 Medication Interventions - Summary Changing or reducing medications can decrease the rate of falls. These studies do not tell us how well managed the underlying medical conditions were after the intervention.

111 Medication Interventions - Summary Target highest risk patients Encourage optimal treatment of medical conditions Encourage treatment/prevention of osteoporosis Education: team, patient

112 Other Medication Related Interventions Drop in BP education New, severe pain in high risk patient falls safety assessment by OT/PT Gait and Balance tests

113 Resources Home Safety Checklist provided by the Centers for Disease Control and Prevention: ToolKit/DesktopPDF/English/booklet_Eng_des ktop.pdf Tool kit for the management of falls in older adults, including patient handouts: alls.shtml

114 Resources

115 Summary he impact of falls is significant. any falls can be prevented. lderly have risk factors for falling, but falls are not inevitable est practice in fall and injury prevention includes identification of fall risk and implementation of targeted individualized strategies.

116 Acknowledgments ACICR Barb Farrell Sandra Leung

117 Contact Information Cheryl Sadowski Phone: (780)

118 Questions