Medicine Related Falls Risk Assessment Tool (MrFRAT) User Guide for Age Related Residential Care Facility Staff in Hawke s Bay (Revised edition November 2015)
The Medicine Related Falls Risk Assessment tool (MrFRAT) in Appendix 1 is designed to help identify patients at risk of falls due to their current medicine regimen. The tool was developed using an evidence based assessment of the risk medicine classes have of causing falls. Instructions for use Who The Age Related Residential Care (ARRC) registered nurse is responsible for completing the Medicine Related Falls Risk Assessment Tool. A score 4 indicates that a medicine review may be beneficial to review those medicines which place the patient at a falls risk. The medicine review can be carried out by the resident s general practitioner or a clinical pharmacist facilitator working in the resident s general practice. When It is recommended that this tool is completed: a) As part of admission, during development of the long term care plan (first 3 weeks) b) As part of Post Falls Assessment It may also be of value to review: c) Annually as part of a multidisciplinary review d) Six monthly with care plan review e) As a communication tool with the general practitioner regarding specific medicines How For each regular medicine the resident is charted, decide if the medicine belongs to one of the following medicine classes: (for more information on medicines belonging to each class see Appendix 2). Hypnosedative (antipsychotics, benzodiazepine, zopiclone, sedating antihistamines) Antidepressant (all classes) Anticholinergic agent Antihypertensive (diuretics and alpha blockers only) Antiepileptic Digoxin
Medicines If the medicine belongs to one of the above classes, it is then assigned a score as indicated on the MrFRAT. Hypnosedatives and antidepressants are given a score of 2 per medicine, anticholinergic agents are given a score of 1 per medicine, and the other medicine classes have a score of 1 per classification (not medicine). Score each medicine only once; even it is part of two classes of medicine. If a medicine can be categorised within two medicine classes, use the highest score. An example is clonazepam which is a benzodiazepine prescribed for the management of epilepsy. Clonazepam is given a score of 2 as a hypnosedative, rather than a score of 1 as an antiepileptic agent. Only medicines prescribed on the regular medicine chart should be counted when completing the MrFRAT. As required medicines should not be included; however if a medicine is charted PRN but administered daily, then it should be included in the MrFRAT calculation, and the use of this medicine discussed with the general practitioner regarding it being charted as a daily medicine, or daily administration ceasing. Appendix 2 provides a list of common medicines for each medicine classes within the Medicine Related Falls Risk Assessment Tool. Long term medicines Next, count up the total number of medicines that are charted regularly; six or more daily regular orally administered medicines trigger a score of 2. Only orally administered medicines contribute to this score; the following are not included: Inhalers or nebulisers Topical creams or ointments Injections Eye and ear drops Nasal drops and sprays Exception Daily insulin does contribute towards the count for long term medicines due to the risk of hypoglycaemia and it therefore included in the count for 6 or more long term medicines. NOTE: Some preparations contain more than one medicine. Examples include: cilazapril + hydrochlorothiazide tablets docusate sodium + sennoside B tablets (Laxsol) paracetamol + codeine tablets When adding up the total number of oral daily medicines a resident is taking these combined products should be given a count of 1 for each medicine ingredient; therefore cilazapril + hydrochlorothiazide tablets count as 2 long term medicines even though it is administered as one tablet.
Only daily long term medicines contribute to this score; the following do not: monthly cholecalciferol (vitamin D) weekly folic acid weekly bisphosphonate, such as, alendronate or risedronate; or monthly etidronate The following supplements or complementary medicines should not contribute to this score. Examples: Cranberry capsules B complex tablets Multivitamins Kiwi crush Fish oil Magnesium Folic acid daily Exception: Daily St John s Wort supplement is counted as a long term oral medicine, due to the risk of interactions with other medicines and its action as an antidepressant. Gender If the resident is female this triggers a score of 1. Research has found a higher rate of falling and risk of fracture in females (>65 years) compare to males 1. Total up all the scores: medicine classes, number of medicines, and gender. 1 Chang V.C and Do M.T. Risk Factors for falls among seniors. Implications of Gender. Am J Epidemiol 2015; 181(7): 521-531
Example Patient AB, 86 years, female, prescribed the following: Quetiapine 25mg nocte Zopiclone 7.5mg nocte Inhibace Plus (cilazapril 5mg and hydrochlorothiazide 12.5mg) once daily Spironolactone 12.5mg once daily Citalopram 20mg daily Aspirin 100mg once daily Levetiracetam 500mg twice daily Symbicort Turbuhaler 200/6 Two puffs twice daily Cholecalciferol 1.25mg once a month Medicine Medicine Class Score Quetiapine 25mg nocte Antipsychotic hypnosedative 2 Zopiclone 7.5mg nocte Hypnosedative 2 Inhibace Plus Hydrochlorothiazide 12.5mg Cilazapril 5mg Antihypertensive diuretic Antihypertensive ACE inhibitor 1 No score for ACE inhibitor Spironolactone 12.5mg Antihypertensive 0 (antihypertensive category already counted ) Citalopram 20mg daily Antidepressant 2 Aspirin 100mg daily Antiplatelet 0 Levetiracetam 500mg bd Antiepileptic 1 6 medicines Quetiapine Zopiclone Cilazapril Hydrochlorothiazide Spironolactone Citalopram Aspirin Levetiracetam TOTAL = 8 Female 1 Total 11 2
Outcome based on risk score The action taken following the completion of MrFRAT is based on the risk score and/or whether the patient is currently taken vitamin D. Risk score 4 If the risk score is 4 the patient is considered at elevated risk of a fall due to the current medicine regimen. If the score is 4 a medicine review is recommended; please communicate to general practitioner as per the usual facility process. Risk score <4 but no vitamin D charted Complete vitamin D screening tool. Additional comments Space is provided on the MrFRAT sheet for the recording of additional comments. Information to be recorded here is anything that may be of assistance to the general practitioner or clinical pharmacist who is reviewing the medicines following a completed MrFRAT. Helpful information may include: Listing medicines not considered in MrFRAT but that may contribute to falls, such as opioids Listing other antihypertensive agents prescribed in addition to diuretics and/or alpha blockers If hypotensive If the resident has a prosthetic joint Medical conditions which may contribute to falls, for example rheumatoid arthritis, Parkinson s Disease Co-existing alcohol issues Recent cognitive decline
Additional resources RANZCP Practice Guideline: The Use of Antipsychotics in Residential Aged Care Royal Australian and New Zealand College of Psychiatrists. 2008. URL: http://www.bpac.org.nz/a4d/ranzcpguide.asp Helpful information within the above Guideline on: 1. Identifying the target problem/s: What is the aim of an intervention? 2. Formulating the target problem/s: Why is the challenging behaviour or symptom occurring? 3. Non-pharmacological management of the target problem/s: What interventions are worth trying Antipsychotics in dementia: Best Practice Guide URL: http://www.bpac.org.nz/a4d/resources/docs/bpac_a4d_best_practice_guide.pdf Helpful information includes: 1. Differential features of the 3Ds; Delirium; Depression and Dementia 2. Assessment of patients with BPSD a. Differential Diagnosis b. Contributing factors or triggers c. Identify problems d. Formulating the problem 3. Medicines that could precipitate or worsen BPSD 4. Factors that may contribute to or worsen BPSD Medicines Care Guides for Residential Aged Care Ministry of Health, New Zealand URL: https://www.health.govt.nz/system/files/documents/publications/medicines-care-guides-for-residentialaged-care-may11.pdf Helpful information includes: Strategies to Reduce the Use of Antipsychotic Medicines Registered Nurse Care Guides for residential aged care Waitemata District Health Board URL: http://www.waitematadhb.govt.nz/healthprofessionals/racipcareguides.aspx Helpful information on dementia, falls, syncope and collapse. Care giver guides available on Delirium, depression and dementia and Falls, fractures and incidents. Reducing Harm From Falls Programme Health Quality and Safety Commission URL: http://www.hqsc.govt.nz/our-programmes/reducing-harm-from-falls/
Appendix 1: MrFRAT Template
Appendix 2: Common Medicines Listed below is a list of the common medicines contained within each medicine class; however, there may be others. Please refer to MIMS (New Ethicals) or New Zealand Formulary (www.nzf.org.nz) for a more comprehensive list. Hynosedatives Antihypertensives Antipsychotics Risperidone Quetiapine Olanzapine Aripiprazole Clozapine Prochlorperazine Benzodiazepines and Z-drugs Diazepam Clonazepam Lorazepam Oxazepam Nitrazepam Sedating Antihistamines Promethazine Cyclizine Antidepressants Fluoxetine Paroxetine Citalopram Escitalopram Sertraline Venlafaxine Mirtazapine Anticholinergics Oxybutynin Orphenadrine Solifenacin Diuretics Bendrofluazide Hydrochlorothiazide (Inhibace Plus, Accuretic and Losartan + hydrochlorothiazide) Indapamide Chlorthalidone Alpha Blockers Doxazosin Terazosin Anti-epileptics Phenytoin (Dilantin) Carbamazepine (Tegretol) Sodium Valproate (Epilim) Lamotrigine Haloperidol (Serenace, Haldol) Chlorpromazine (Largactil) Trifluoperazine (Stelazine) Levomepromazine (methotrimeprazine) (Nozinan) Ziprasidone Triazolam Temazepam Midazolam Zopiclone (a Z-drug) Clobazam Diphenhydramine Amitriptyline Nortriptyline Dothiepin Doxepin Imipramine Moclobemide Bupropion hydrochloride (Zyban) Benztropine Procyclidine Tolterodine Furosemide Bumetanide Spironolactone Prazosin Gabapentin (Nupentin) Levetiracetam Topiramate
Appendix 3: MrFRAT Fax Template (ISBAR format)
Acknowledgements The MrFRAT tool was developed by Clinical Pharmacists Peter McIntosh and Brendan Duck. The MrFRAT User Guide for ARRC staff and the General Practitioner Guide were developed by Clinical Pharmacist, Di Vicary. Together with the other members of the Hawke s Bay Clinical Pharmacist Facilitation team, the tool and guides were introduced across the region within primary care, increasing the focus on medicine related falls risk and individual patient medicine reviews. Additional acknowledgements: Health Hawke s Bay Hawke s Bay District Health Board All Age Related Residential Care facility clinical managers and nurses who participated in the training session related to the use of this tool and provided general feedback. Many thanks to all those involved with the development of these resources and their ongoing review. If you would like further information, please contact: Di Vicary Clinical Facilitator Medicines and Diagnostics pharmacist@healthhb.co.nz (06) 871 5663