Workshop 4: Preventing Falls through Medication Vigilance

Transcription

1 Workshop 4: Preventing Falls through Medication Vigilance Nancy L. Losben, R.Ph., CCP, FASCP, CG Chief Quality Officer Omnicare, Inc. & Diane C. Vaughn, RN, C-DONA/LTC, LNHA VP, Clinical Services Benedictine Health System Goals Describe how medication risk awareness is involved with the HATCh model Identify the effect falls have on the elderly Describe common pharmacologic issues and meds that contribute to falls 1

2 Holistic Approach to Transformation Change Model (HATCh) Six Competency Domains Care Practices Competency 1.1Demostrate an Understanding of risks that lead to falls 1. Identify Medications that May Contribute to Falls and Fall Risk 2

3 Competency-Based Education (CBE) a cluster of related knowledge, skills, and attitudes that affects a major part of one s job (a role or responsibility), that correlates with performance on the job, that can be measured against wellaccepted standards, and that can be improved via training and development. Training focuses on learning desired outcomes Design makes statements of observable and measurable behavior Staff must have the necessary knowledge, skill and attitude to attain the highest level of performance. Competency Based Education 3

4 Background 2 nd most common adverse event Occur in 30-60% of the older adults / year 10-20% result in serious injury, hospitalizations, and / or death 10% of ER and 6% of hospitalizations >65 YO Falls are the leading cause of injuries in older adults Medications 32,000 Seniors Suffer Hip Fractures Caused By Medications 20% Will Die Within 5 Years On average, individuals 65 to 69 years old take nearly 14 prescriptions per year, individuals aged 80 to 84 take an average of 18 prescriptions per year 4 medications is considered a falls risk 4

5 Falls Risk Factors Weakness Unsteadiness Confused State Sleep Quality Medications Medications and Falls Common Pharmacologic Mechanisms: Orthostatic hypotension Dizziness Decreased postural reflexes Extrapyramidal symptoms Myorelaxant effects Visual impairment Impaired cognition / CNS effects 5

6 AHCA/NCAL Webinars Preventing Falls through Medication Vigilance Nancy L. Losben, R.Ph., CCP, FASCP, CG Chief Quality Officer Omnicare, Inc. Objectives To recognize the medication regimen as a risk for safety and falls. To identify the timeframe when a resident is at his/her highest risk to fall after a change in in the medication regimen. To enhance and coordinate safety and quality improvement activities. 12 6

7 Centers for Disease Control and Prevention 5% of adults 65 and older live in nursing homes but 20% of deaths from falls (1,800 yearly) Up to 20% of falls cause serious injuries Reasons for falls in LTF facilities: frailty, chronic conditions, gait disturbances, memory problems, ADL decline, medications Fall risk is significantly elevated during the 3 days following any drug that affects the central nervous system 13 Any one of these medication related problems (MRP) can increase the risk for falling Drowsiness Dizziness Low blood pressure Low heart rate Parkinson s effect Ataxia/gait disturbance Vision disturbance Low blood sugar Urinary urgency 14 7

8 Adverse Consequences Some adverse consequences occur quickly or abruptly, while others are more insidious and develop over time. Adverse consequences may become evident at any time after the medication is initiated, e.g., when there is a change in dose or after another medication has been added. When reviewing medications used for a resident, it is important to be aware of the medication s recognized safety profile, tolerability, dosing, and potential medication interactions. Although a resident may have an unanticipated reaction to a medication that is not always preventable, many ADRs can be anticipated, minimized, or prevented. In theory, any medication, or a lack of one, can be the underlying cause of a fall. But do you know which medications are most likely to increase the risk of falling? 16 8

9 Medication Categories Recognized as Risks for Falling Opioid analgesics Anticonvulsants Antidepressants Anti-Parkinson s Anxiolytics Antipsychotics Antihistamines Antiarrhythmic Appetite stimulant Barbiturates Diuretics Hypoglycemics; insulin Medications to treat continence 17 Medications associated with Injury with a Fall Anticoagulants Anti-seizure medications Chemotherapy Laxatives Psychopharmacologics Sedatives/hypnotics 9

10 Diuretics Hypotension Urinary urgency Incontinence Dehydration Electrolyte imbalance Temporal effect Onset Peak 19 Cardiovascular Drugs Hypotension Low heart rate Lethargy Delirium Syncope, dizziness Bleeding Immediate release Vs. Sustained release 20 10

11 Antipsychotics Routine, seldom PRN Lowest Possible Dose Recent Dose Increase or Reduction Extrapyramidal Side Effects Blurred Vision Lethargy Somnolescence Is it efficacious? 21 Anxiolytics Routine vs. PRN orders Short acting benzodiazepines preferred Lowest possible dose Recent dose increase or reduction Lethargy Efficacy 22 11

12 Hypnotics Routine Vs. PRN Short Acting Benzodiazepines or newer nonbenzodiazepines Given while in bed Used no more than 10 consecutive days or manufacturer s suggested direction Morning functionality/hangovers Falls out of bed 23 Antidepressants Tricyclic's Highly anticholinergic Blurred Vision Confusion Changes in heart rate Restlessness, sleeplessness Drug Interactions SSRI s and SSNRI s have a better safety profile 24 12

13 Muscle Relaxants and Antiparkinson Drugs Muscle weakness Central nervous system effects Behavioral symptoms Temporal relationship to administration and ADL performance 25 Laxatives Cathartics/bowel urgency Electrolyte imbalance Tolerance, Impaction Toileting plan Opioid therapy and anticholinergics can cause constipation 26 13

14 Pain Medications Opioids Risk vs. Benefit Drowsiness/dizziness Vs. Relief Constipation Vs. Mobility Non-steroidal anti-inflammatory drugs GI effects Confusion, other CNS effects 27 Anticholinergic Medications Medications that could affect function, level of consciousness, gait, balance, visual acuity, or cognitive ability, Causing symptoms such as dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium, excitability, memory loss, unsteadiness, dizziness, or hallucinations. 14

15 Anticholinergic Effect Blind as a bat. Mad as a hatter, red as a beet, hot as Hades, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone." 29 Anticholinergic Drugs often antihistamines, antidepressants, over active bladder medications examples Generic Brand Name Generic Brand Name Amantadine Symmetrel Hydroxyzine Vistaril Clozapine Clozaril Meclizine Antivert Cyclobenzaprine Flexeril Ranitidine Zantac Diphenoxylate/ atropine Lomotil Olanzapine Zyprexa Diphenhydramine Benadryl Oxybutynin Oxytrol Desipramine Norpraminl Paxoxetine Paxil Furosemide Lasix Tolterodine Detrol 15

16 Syncope Diuretics Calcium channel blockers ACE inhibitors Nitrates Antipsychotics Antihistamines Anti-Parkinson's medications Opioids Alcohol Managing Medication- Related Syncope The first 72 hours following modification of any of these medications is the timeframe of highest risk to fall Alert care staff to any affected resident with a change in their medication regimen to a higher risk of fall Focus on residents who are usually independent in ADL s Remind residents to rise slowly Temporarily use a gait belt Monitor blood pressure daily Observe and document the resident s response to the medication Report findings to the physician and and pharmacist 16

17 Sometimes, adding a medication to a resident s medication regimen can help to reduce falls and minimize injuries. Unmanaged Pain as a Risk for Falls Residents in pain will likely avoid painful stimulus by sitting and lying down Increases the risk of fall as a result of deconditioning Residents in pain will also attempt to change position to find a more comfortable state 17

18 Managing Pain Classification Acute Recent onset Chronic nociceptive- somatic, visceral neuropathic mixed/unspecified psychologically mediated Chronic Malignant Chronic Non-malignant Identify Underlying Conditions that May Cause Pain PAIN Heart Angina Neurological Heart Attack Herpes Zoster Thrombosis Spinal and nerve injury Peripheral vascular disease Dental Pain Skin Wounds Ulcers Incisions infections Neurological Diabetic Neuropathy Herpes Zoster Spinal and nerve injury 36 Musculoskeletal Arthritis Fracture Osteoporosis Back problems Amputation Cancer GI Pain WALA 18

19 Treating Pain to Achieve Mobility and Strength Principles for Analgesics Choice of Drug Appropriate for patient's type of pain What has worked in the past Appropriate for patient s severity of pain At level appropriate to assessed pain Use combinations of drugs Not necessarily combined drugs Ongoing evaluation Benefit Risks 38 WALA 19

20 Principles for Analgesics Administration Adequate doses Titrate to individual needs Patient response Drug itself Onset Peak effect Duration Around the clock 39 WALA Principles for Analgesics Administration Address breakthrough pain Same drug if possible Monitor benefit Consider risk for ADRs Address early Advise resident Oral route whenever possible Or other non-invasive Review and evaluate 40 WALA 20

21 Vitamin D Can reduce falls by reducing osteoporosis and preventing sarcopenia (loss of muscle mass) Benefits of Vitamin D are distinct from its effect on bone. Controversial Evaluating Falls at Care Conference Previous fall, initial fall Circumstances, use incident report with Vital Signs for analysis Medication Regimen as a risk 4 or more drugs, new drug Drug therapy class Temporal relationship to fall Chemical restraints Review behavior monitoring sheets Blood sugars, blood pressures, pulses Lab tests: glucose, electrolytes, hydration, hemoglobin/hematocrit 42 21

22 Reducing the Risk Approaches Eliminate unnecessary drugs Find lowest effective doses of medications through dose reduction Monitor efficacy and resident responses to medications Monitor labs 43 Evaluation of Falls at Quality Improvement Meetings Interdisciplinary- Don t forget to include: Rehab Services Dietitian Pharmacist Environmental Services Bring List of those who have Fallen Crosswalk to Psychotropic Drug list Crosswalk to changes in condition Crosswalk to those who experienced infection Crosswalk it to those who had changes in their medication regimen 44 22

23 Evaluation of Falls with Injury Crosswalk it to residents on anticoagulants Crosswalk it to residents with a diagnosis of osteoporosis Crosswalk it to residents treated for seizures Crosswalk it to residents who use hypnotics Crosswalk it to resident with a history of impaction and/or laxative use Summary A fall may be the result of an adverse drug reaction of any medication or combination of medications A resident is most likely to fall within the first 3 days of a change in the medication regimen Planning to minimize falls during QA/PI meetings requires comparison of data from multiple sources

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