A Step Forward: Promoting Independence through Falls Prevention

Transcription

1 A Step Forward: Promoting Independence through Falls Prevention 2014 Geriatric Update Meharry Consortium Geriatric Education Center

2 A Step Forward: Promoting Independence through Falls Prevention Moderator: Ronald De Vera Barredo, PT, DPT, EdD, GCS Professor and Chair, Department of Physical Therapy Tennessee State University Michelle Valentine Moseley, PharmD, BCPS Clinical Pharmacy Specialist, Geriatrics, Dept. of Veterans Affairs Tennessee Valley Healthcare System Assistant Professor, Lipscomb University College of Pharmacy Elena Wong Espiritu, OTD, OTR/L Assistant Professor, School of Occupational Therapy Belmont University

3 Objectives Describe the multifactorial causes of falls among older adults Identify tools geriatric health practitioners could use to evaluate a patient's fall risk Outline strategies that will mitigate fall risk Identify drugs that increase fall risk in geriatric patients

4 No Disclosures Ronald De Vera Barredo, PT, DPT, EdD, GCS Michelle Valentine Moseley, PharmD, BCPS Elena Wong Espiritu, OTD, OTR/L

5 Falls in Older Adults: The Role of Medication Management Michelle Moseley, PharmD, BCPS Clinical Pharmacy Specialist in Geriatrics, VA TVHS Assistant Professor, Lipscomb University College of Pharmacy

6 Learning Objectives Identify drugs that increase fall risk in geriatric patients Outline strategies that will mitigate fall risk

7 Why Do Older Adults Fall? Major causes Accident & environment related Gait and balance disorders or weakness Drop attack Confusion Postural hypotension Visual disorder Syncope Other unspecified causes: arthritis, acute illness, drugs, alcohol, pain, epilepsy, and falling from bed Rubenstein LZ, Josephson KR. Clin Geriatr Med 2002;18:

8 Efficacious Components of a Fall Prevention Program Medication adjustment Exercise and physical activity Medical assessment and management Adaptation or modification of home environment 2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons.

9 Medications and Falls Strongest risk factors Polypharmacy Psychotropic medications Potentially inappropriate prescribing Beers List Screening Tool of Older Persons Prescriptions (STOPP) criteria Examples of Psychotropic Medication Classes Antipsychotics Serotonin reuptake inhibitors Tricyclic antidepressants Benzodiazepines Hypnosedatives Huang AR, et al. Drugs Aging 2012; 29: van der Hooft CS, et al. Br J Clin Pharmacol 2008; 66: JAGS 2012;60(4): Gallagher P, et al. Int J Clin Pharmacol Ther. 2008;46(2):72 83.

10 Medication Effects That May Potentiate Fall Risk Confusion, delirium, impaired cognition Dizziness, drowsiness, sedation Hypotension, arrhythmias Hypoglycemia, hyperglycemia Dehydration, electrolyte disturbances Constipation, frequency of urination Muscle weakness, ataxia

11 Examples Of Medication Classes Associated With These Effects Alpha blockers Analgesics Antibiotics Anticonvulsants Antidepressants Antihistamines Antimuscarinics Antipsychotics Benzodiazepines Cardiovascular medications Diabetes medications Diuretics Histamine 2 blockers Hypnosedatives Laxatives Steroids Tinetti ME, et al. JAMA Intern Med. 2014;174(4): Rafiq M, et al. Journal of Clinical Epidemiology 2014;67(8):

12 Mitigating Fall Risk: Less Is More Recommendations Minimize the number of medications Discontinue psychotropics, or at least reduce the dose 2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons. Accessed 5/30/14.

13 Good Palliative Geriatric Practice Algorithm Garfinkel D, Mangin D. Arch Intern Med 2010;170(18):

14 Case Study: Mr. Wilson A 76 year old man who was referred to your outpatient falls evaluation clinic by his PCP. He has fallen three times in the last three weeks. Past Medical History: Type 2 diabetes, BPH, hypertension, hyperlipidemia, depression and osteoarthritis Medication list: Metformin 1000mg twice daily Furosemide 20mg every morning Amlodipine 10mg daily Lisinopril 20mg daily Glipizide 10mg twice daily Terazosin 5mg at bedtime Citalopram 10mg daily Simvastatin 20mg at bedtime Hydrocodone/acetaminophen 7.5/325mg every 6 hours as needed Aspirin EC 81mg daily OTC Docusate 100mg daily OTC Tylenol PM at bedtime as needed

15 Case Scenarios A. Fell in the bathroom B. Fell when he got up at night to go to the bathroom C. The room was spinning just before he fell D. He felt sweaty and shaky when he fell E. His thigh muscles felt extremely weak and sore

16 Summary Medication use is one of the most modifiable risk factors for falls in geriatric patients Direct and indirect effects of many commonly prescribed medications may increase fall risk in older adults Utilize tools such as the Good Palliative Geriatric Practice algorithm in conjunction with patient preferences, disease specific guidelines, and drug utilization review criteria to reduce medication burden and fall risk

17 Elena Wong Espiritu, OTD, OTR/L Belmont University School of Occupational Therapy

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19 Environmental Intrinsic Behavioral FALL

20 Perceived vs. Physiological Fall Risk Older Adults LOW physiological fall risk HIGH physiological fall risk LOW perceived fall risk HIGH perceived fall risk LOW perceived fall risk HIGH perceived fall risk (vigorous) (anxious) (stoic) (aware) Based on Delbaere et al., 2010

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22 safety/falls/steadi/index.html

23 Type Single Multiple Multifactorial* Definition one intervention combination of interventions, same for all people combination of interventions based on individualized assessment * Recommended by AGS/BGS guideline

24 Moderate/high challenge to balance At least 2 hours/week Ongoing basis (Sherrington et al., 2011) Tai Chi: Moving for Better Balance Otago Exercise Programme Exercise Medical management Medication adjustment Environmental modification Education Stepping On Matter of Balance

25 education SELF- MANAGEMENT skill development Self-Management Attitudes Client Behaviors Skills information sharing SUPPORT create situations

26 SYMPTOM MONITORING PROBLEM SOLVING DECISION MAKING ACTION PLANNING LOCATING & USING RESOURCES COMMUNICATION

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30 recommendations/prevention_of_falls_summary_of_recommendations September 20 Management.pdf Retrieved