Medicine Related Falls Risk Assessment Tool (MRFRAT) 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 1. Who The 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. 2. What This tool has been designed to be completed based on the information provided on the resident s current medicine chart. If a medication chart is unavailable information on medicines should be collected and compared from at least 2 sources, including a primary source: Primary sources include: o verbal information from the patient, patient s family/caregiver o patient held medication list, that is, yellow card o patient s own medicines as presented by the patient (noting date of supply and expiry date) Secondary sources include: o previous/current general practitioner s information o previous/current community pharmacy s information o community mental health team information o previous aged residential care facility Tertiary sources of information include: o clinical notes o transfer letters (discharge summary) o hospital pharmacy records 3. When It is recommended that this tool is completed: a) On admission
b) As part of Post Falls Assessment 4. How For each regular medicine the resident is charted, decide if the medicine belongs to one of the following medicine classes: Hypnosedative (antipsychotics, benzodiazepine, zopiclone, sedating antihistamines) Antidepressant (all classes) Anticholinergic agent (oxybutynin, benztropine, orphenadrine) Antihypertensive (diuretic, alpha blocker) Antiepileptic Digoxin 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, while 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. Only medicines prescribed on the regular medicine chart should be counted when completed the Medicine Related Falls Risk Assessment Tool. 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. Next, count up the total number of medicines that are charted regularly, six or more daily regular medicines triggers a score of two. Next score gender one if the resident is female. Total up all the scores: medicine classes, number of medicines and gender.
Example: Patient AB, 86 years, female Medicine Medicine Class Points Quetiapine 25mg nocte Antipsychotic hypnosedative 2 Zopiclone 7.5mg nocte Hypnosedative 2 Inhibace Plus Cilazapril 5mg Hydrochlorothiazide 12.5mg Antihypertensive ACE inhibitor Antihypertensive - diuretic 1 (for diuretic component, not ACE inhibitor component) Spironolactone 12.5mg Antihypertensive 0 (this category already counted above) Citalopram 20mg daily Antidepressant 2 Aspirin 100mg daily Antiplatelet 0 Levetiracetam 500mg bd Antiepileptic 1 6 medicines 2 Female 1 Total 11
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 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 within each class on the Medicine Related Falls Risk Assessment Tool (MRFRAT) 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 for a more comprehensive list www.nzf.org.nz. Antipsychotics Risperidone Quetiapine Olanzapine Aripiprazole Clozapine Benzodiazepines Diazepam Clonazepam Lorazepam Oxazepam Sedating Antihistamines Promethazine Cyclizine Antidepressants Fluoxetine Paroxetine Citalopram Escitalopram Sertraline Venlafaxine Mirtazapine Diuretics Bendrofluazide Hydrochlorothiazide (Inhibace Plus, Accuretic and Losartan + hydrochlorothiazide) Indapamide Chlorthalidone Alpha Blockers Doxazosin Terazosin Anti-epileptics Phenytoin Carbamazepine (Tegretol) Sodium Valproate (Epilim) Lamotrigine Haloperidol (Serenace, Haldol) Chlorpromazine (Largactil) Trifluoperazine (Stelazine) Levomepromazine (methotrimeprazine) (Nozinan) Ziprasidone Triazolam Temazepam Midazolam (Zopiclone) not a benzodiazepine but similar risk of falls Diphenhydramine Amitriptyline Nortriptyline Dothiepin Doxepin Imipramine Moclobemide Furosemide Bumetanide Spironolactone Prazosin Gabapentin (Nupentin) Levetiracetam Topiramate
Appendix 3: MRFRAT Fax Template (ISBAR format)