Prevention of Medication-Related Falls Through Appropriate Medication Use. Clay Sprouse, MEd., CPhT Piedmont Technical College

Transcription

1 Prevention of Medication-Related Falls Through Appropriate Medication Use Clay Sprouse, MEd., CPhT Piedmont Technical College

2 Disclosure I have no relevant financial or nonfinancial relationships to disclose as it relates to this presentation.

3 Objectives At the completion of this activity, the pharmacy technician will be able to: Describe the influence of age-related drug metabolism on the risk of falling Describe potential side effects of at least 2 classes with high risk medications associated with increased fall risk in older adults Identify risk factors for falling in older adults Utilize fall risk assessment tools to evaluate medication-related fall risk Explore at least 2 fall prevention strategies

4 Introduction Unintentional falls are the leading cause of fatal and nonfatal injuries in older adults CDC says older adults accounted for over 25% of all hospital ED visits related to unintentional falls 28-40% of community dwelling older adults over the age of 65 will sustain one or more falls in a year Falls are associated with serious health consequences such as fractures, disability and loss of independence

5 Introduction continued Proactive strategies such as multifactorial risk assessment partnered with a targeted intervention has shown most success in reducing falls in older adults With increased knowledge, pharmacy personnel can play an important role

6 ADME and its effects on Falls Absorption, Distribution, Metabolism, Elimination Absorption in older adults may be altered due to age-related changes in gastric ph or GI motility Older adults are also more susceptible to drug induced changes in absorption For example, PPI and antacids may inhibit the absorption of other critical medications taken in older age Changes in distribution occur as a result of a decrease in total body water and lean muscle mass Decrease in total body water results in increased concentrations of water soluble meds such as digoxin and lithium Can increase risk of falls due to effects such as dizziness and blurred vision Meds like benzodiazepines pose a fall risk related to their prolonged half-life in older adults related to an increase in body fat with age

7 ADME and its effects on Falls (continued) As adults age, decrease in liver size and blood flow can alter drug clearance As a result, medications that undergo extensive first-pass metabolism or require activation in the liver may be altered in older adults Propranolol undergoes extensive first-pass metabolism and has an increased bioavailability in older adults which could lead to increased hypertension or symptomatic hypotension, therefore falls occurring Renal blood flow, tubular function, and filtration rates all decline with increasing age Many examples of renal eliminated meds that can accumulate and predispose older adults to adverse effects associated with falls Morphine is eliminated through the renal system. If there are issues with elimination, side effects such as sedation, dizziness and confusion can increase leading to a major increase in risk of falls

8 High Fall Risk Medications Psychotropic medications encompass several classes of medications commonly used in older adults including antidepressants, anticonvulsants, antipsychotics, benzodiazepines, sedative/hypnotics and opioid analgesics One community based study had use of any psychotropic agent by older adults increased the risk of falls by 47%

9 High Fall Risk Medications First and second generation antipsychotics can cause sedation and orthostatic hypotension Long term use of antipsychotics has been shown to increase fall risk by 81% compared to short term use Sedatives/hypnotics can cause cognitive impairment, sedation and confusion. Benzos are associated with an increased fall risk after a new start and with long term use Non-benzodiazepine sedatives/hypnotics, such as zolpidem, have a similar side effect profile

10 High Fall Risk Medications Antidepressants can cause ataxia (loss of body movement), hypotension and syncope (temporary loss of consciousness) Little difference in fall and fracture risk between SSRI and tricyclic antidepressants Older adults should be monitored when first starting antidepressants, with dosage adjustments and long-term use Opioid analgesics, such as morphine, hydromorphone, fentanyl, and oxycodone can cause dizziness, syncope, and CNS depression Studies have mixed results but several have shown increased fall risk Risk increased when used with other meds that show high fall risk

11 High Fall Risk Medications Other classes have been studied and shown to increase fall risk in older adults Anticonvulsants, cardiac meds, NSAIDS Many of these meds have been associated with recurrent and injurious falls

12 Fall Risk in Older Adults Falls in community dwelling older adults is a common geriatric syndrome Absolute risk of falls in study participants ranged from 11% in older adults with no risk factors to 54% in patients with multiple risk factors Older adults are at risk of falls and risk is correlated with the number of risk factors Clinical practice guidelines recommend that all older adults over 65 be routinely screened for history of falls to identify patients that may be high risk and could benefit from intervention

13 Fall Risk in Older Adults Risk Factors include: History of falls Orthostatic hypotension Balance disturbances Decreased mobility/poor muscle strength Visual impairment Unsuitable footwear Use of psychotropic medications Limited functional status Cognitive or other neurologic impairments

14 Risk Assessment Tools AGS (American Geriatric Association) identifying PIMs (potentially inappropriate medications) The tool organizes PIMs into 3 tables: organ system/therapeutic category, drug-disease/drug-syndrome interactions, and drugs to be used with caution Tool is available as a pocket card and may be used in any practice setting to assist with evaluating appropriateness of a older adult s edicatio regimen and risk of falls

15 Risk Assessment Tools Tool 31: Medication Fall Risk Score and Evaluation Tool Developed for hospitalized patients but can easily be used in other settings 3 tier risk factor identification Point value system based on medications fall risk potential Score of 6 or higher is a high risk for falls

16 Assessment in the Community Pharmacy Older adults at high risk, particularly those with a history of recurrent falls receive targeted interventions in areas of strength and balance, home safety, vision assessment and medication management Community pharmacies are uniquely qualified and positioned to recommend targeted medication interventions and provide education to prevent medication-related falls in community dwelling older adults

17 Assessment in the Community Pharmacy Medication regimen review Minimize use of psychotropic medications and other high risk medications Interventions to prevent postural hypotension Vitamin D supplementation Education of fall prevention

18 Minimize Use of High Risk Management Patient specific medication review Several studies that included medication reviews as part of a multifactorial intervention showed a significant reduction in falls Reducing psychotropic use demonstrated multiple health benefits including fewer falls, improved functional status and less cognitive decline Pharmacists and pharmacy technicians can make recommendations to reduce or eliminate use of psychotropic and other inappropriate medications (implementation of nonpharmacologic strategies or opting for medications with fewer adverse effects)

19 Vitamin D Supplementation Older adults are at increased risk of vitamin D deficiency which is associated with increased fall risk According to US Preventative Services Task force recommends 400 to 600 units of vita i D i to older adults diets Multivitamin or vitamin D supplement is recommended Instructions on use and varieties available

20 Education and Counseling Encourage all older adults to participate in fall prevention programs Group programs and individualized counseling should be considered as part of an effective fall prevention strategy Healthinaging.org provides materials geared towards the health of older adults cdc.gov has the STEADI (Stopping Elderly Accidents, Deaths & Injuries) Toolkit CDC has developed a series of brochures and posters geared towards involving older adults and preventing falls National Institute of Aging has information on fall prevention

21 Summary Age-related changes, co-morbid conditions and inappropriate medication use increases the risk of falls in older adults Pharmacy personnel collaborating with the healthcare team can help ensure appropriate medication use Conducting medication reviews for high risk older adults Screening and appropriate counseling on high risk meds may reduce risk in vulnerable adults Pharmacies that serve large geriatric population may be successful in developing fall prevention programs

22 Class Assessment Which of the following classes is associated with the highest risk of falls in older adults? A. Antipsychotics B. Anti-hypertensives C. Diuretics D. NSAIDS Benzodiazepines can cause which of the following adverse effects that can increase risk of falls in older adults? A. Sedation B. Cognitive Impairment C. Delirium D. All of the Above

23 Class Assessment Medications that undergo extensive - metabolism or require activation in the liver may be altered in older adults. Side effects of analgesic opioids can include all of the following except: A. Syncope B. Dizziness C. Central Nervous System Depression D. All of the Above

24 Class Assessment True/False: Co ditio of a patie t s shoes could determine risk for a fall. True/False: Patients with a fall history will likely not suffer from any other falls.

25 Class Assessment Several studies that included as part of a multifactorial intervention showed a significant reduction in falls. The Centers for Disease Control provides a free toolkit to assist healthcare providers and patients in the prevention of accidents and falls called STEADI. STEADI stands for.