Falls most commonly seen in RACFs are due to tripping, slipping and stumbling (21.6%). Falling down stairs is relatively uncommon in

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1 This Presentation Medications and Falls Dr Peter Tenni M Pharm (Curtin), PhD (UTAS) AACPA Director, CPS A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level Outline Falls, the causes and impact on society Medicines of concern Suggested changes to medicines How a pharmacist can help What You can Do 1 2 Impact on Society Leading cause of death for those over 65 Each year 1 in 3 in the community fall 1 in 2 residential care residents fall For 20 30% this leads to loss of mobility, independence and risk of premature death The main serious injury is a hip fracture Numbers will double by 2026 Falls in RACFs Falls most commonly seen in RACFs are due to tripping, slipping and stumbling (21.6%). Falling down stairs is relatively uncommon in RACFs (0.7% of all falls). Falls are associated with a number of factors, such as environmental obstacles, dementia, delirium, incontinence and medications. 3 4

2 Falls in RACFs RACFs: Consistently Reported The bedside is the most common place for falls to occur, while the bathroom is frequently mentioned. A high percentage of falls are associated with elimination and toileting. The incidence of falls occurs across all age groups, but there is an increasing prevalence of fll falls in older people. A high percentage of falls are unwitnessed. Risk Factors for Falls in Aged Care 60% of falls are multifactorial Intrinsic or personal factors Health status and co morbidities; i Balance, gait and mobility; Dizziness; Blood pressure; Medicines Extrinsic or environmental factors Surroundings 5 6 Causes of Falls in Older Patients Presenting to the Emergency Department Most of these are symptoms there are a range of diseases that cause these 7 Reference: Bell A, Talbert-Stern J, Hennessy A. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. MJA 2000;173: Available from 8

3 Other Medical Conditions Some may not be evident or diagnosed at the time of a fall but consider: Osteoporosis Diabetes Depression Parkinson s disease Dementia TIAs/stroke Vision impairment Incontinence Personal consequences of falls Injury Fear of falling or injury Avoiding activity Social isolation Use of Risk Assessment Tools Client characteristics i and conditions i Fall history Mobility impairment Incontinence Medicines Sensory deficits Age 9 Australian Commission on Safety and Quality in Health Care. Falls prevention guidelines Available from:

4 13 14 Medicines of Concern Medicines i that t affect or cause: Agitation Affect balance Blurred vision Confusion Dizziness Drowsiness Gait problems Syncope (lightheadedness or fainting) Urgency 15 Medications that Cause Predisposing Symptoms Agitation Blurred Vision Antidepressants Eye drops Caffeine Anticholinergics Any medicine with Antipsychotics py anticholinergiceffects i t Stimulants Balance Anticonvulsants Benzodiazepines Antipsychotics Prochlorperazine Confusion Benzodiazepines (BZDs) Narcotics Psychotropics Any medicine with anticholinergic effects 16

5 Medications that Cause Predisposing Symptoms Dizziness i and Syncope hypotension Blood pressure medicines Diuretics Any medicine with anticholinergic effects Gait abnormalities Antidepressants Antipsychotics Metoclopramide Blood pressure medicines Vasodilators Urgency Diuretics 17 Drowsiness and sedation Psychotropics Benzodiazepines 40 70% increased Hypnotics risk Anticonvulsants Any medicine with anticholinergic effects Other Medicines of Concern Corticosteroids Bone weakness Anticoagulants Risk of haemorrhage Lithium Tremor, vertigo 18 Evidence Related to Medications and Falls 19 Evidence Relating to Medications and Falls Strong Evidence for Increased Falls: 4 or more medicines (of any sort) Psychotropics (benzodiazepines, antidepressants, antipsychotics) i Weaker Evidence Blood pressure and anticonvulsant medicines Lack of Evidence doesn t mean that medications aren t a cause... 20

6 Can Medication be Changed? Benzodiazepines Drowsiness is the most common adverse effect of benzodiazepines. This is often accompanied by ataxia or incoordination. A single dose of a benzodiazepine has an effect on balance andcan increase the risk of falls. This risk is further increased with regular use and as the dose increases. Thus, the lowest risk for falls is associated with a short acting benzodiazepine, prescribed PRN, at the lowest possible dose and introduced with caution. * Short acting benzodiazepines: Temazepam, Alprazolam. * Intermediate acting benzodiazepines: Lorazepam, Oxazepam. *Long acting benzodiazepines: Clonazepam, Diazepam, Nitrazepam, Flunitrazepam. 21 Can Medication be Changed? Antidepressants Antidepressants are the psychotropic agent most commonly associated with falls. Tricyclic Antidepressants (TCAs) are associated with a higher risk than Selective Serotonin Reuptake Inhibitors (SSRIs) Specifically, ca TCAs contribute to an increased ceasedrisk of falling by causing hypotension, blurred vision, motor impairment and constipation. A change in antidepressant may sometimes alter risk of falling 22 Can Medication be Changed? Antipsychotics A number of studies haveshown an association between the use of psychotropics and falls, restlessness, wandering and urinary incontinence. Use of antipsychotics in dementia may increase the rate of cognitive decline, decrease inhibitions and increase wandering. Specifically, antipsychotics predispose to falls by causing hypotension, sedation, anticholinergenic effects and extrapyramidal symptoms. Minimising use of antipsychotics can reduce risk of falls 23 Can Medication be Changed? Antihypertensives Beta blockers, calcium channel blockers, ACEIs, AIIRAs, alpha adrenoreceptor blockers can all aggravate or cause postural hypotension. Lipid soluble beta blockers can cause confusion and sleep disturbances. ACEIs and alpha blockers can cause profound first dose hypotension. Bloodpressure targets can bereviewed for many residents 24

7 Can Medication be Changed? Diuretics Diuretics All diuretics can cause volume depletion or electrolyte imbalance, thus contributing to instability. The need for potent (loop) diuretics can be reviewed in many cases 25 Can Medication be Changed? Others Antiemetics maycause ataxiaandextrapyramidaladverseand adverse effects. Antiparkinsonian drugs frequently cause postural hypotension. NSAIDs may cause confusion and dizziness. Antiepileptics may cause unsteadiness and inco ordination. Corticosteroids t id may cause mobility problems through h muscle wastage and, with prolonged use, may cause osteoporosis Alcohol isa predisposing factorforfor fallsin itself and compounds the risk of falls when taken concurrently with other agents which act on the central nervous system Alternatives to many of these medications are possible and should be explored if the medication is involved in a fall or the patient t is at high h risk ik 26 What Medicines can be Changed? Medications that predispose to falls Is the medicine necessary? Does a different medicine need to be given? Is a shorter acting medicine an option? Medicines to reduce the incidence and consequences of falls Vitamin D Ot Osteoporosis Management Vitamin D and Falls/Fractures 27 28

8 Vitamin D has other Effects Vitamin D and Falls Potential Mechanisms Muscle Effects Deficiency leads to myopathy (muscle pain, paraesthesiae, arthralgias) Variable effects of replacement on muscle strength (better in patients who were deficient initially) Neurological Effects Deficiency associated with increased cerebrovascular events and depression Replacement associated with increased walking speed and acceleration capacity Vitamin D and Falls Falls and Fractures Vitamin D deficiency present in 40 50% of non fallers and 70% of fallers (institutionalised elderly) ~20% reduction in falls (per year) with at least 800IU daily (with sufficient calcium intake) as long as appropriate levels (>60nmol/L) are achieved. Remember it reduces risk, it doesn t remove it completely 31 32

9 Summary of Recommendations (relating to medications) Summary of Recommendations (relating to medications) Falls assessment What you can do? With a plan for residents at high risk Prevention Physical aids Mobility aids, Hip protectors Review after a fall What was the cause? Could drugs be involved? Medication review following a fall if you believe drugs may be involved 35 Medications and Falls Dr Peter Tenni M Pharm (Curtin), PhD (UTAS) AACPA Director, CPS 36