Posted on January 27, 2017 in: Professional Practice
By Lindsey Ghiringhelli, Pharm.D., BCGP, consultant pharmacist, Pharmerica
Medication regimen reviews following a fall are commonly requested for residents of nursing facilities. About half of all residents in nursing homes fall every year, but increasingly, falls are also the reason for their admission.1 According to the Centers for Disease Control, one out of five falls leads to a major injury, such as a fracture or head injury.2 More than 70,000 patients are hospitalized each year due to falls, and direct medical costs are estimated at $34 billion dollars annually (adjusted for inflation).2 Elderly patients are three times as likely to die following a low-level fall compared to those under 70 years of age.3
Medications are just a piece of a much larger picture when it comes to preventing falls or performing root-cause analysis following a fall, and the entire healthcare team should be involved in this process. Other risk factors include gait and balance impairment, neuropathy, advanced age, visual or auditory dysfunction, muscle weakness, acute illness, inflammation, pain, orthostasis, dementia, Parkinson’s Disease, incontinence, environmental hazards, poor footwear and restraints.1, 4, 5 As pharmacists, we have unique drug knowledge that helps us identify which medications are most likely to contribute to falls, especially in the elderly. Reducing or eliminating these medications, whenever appropriate, can improve overall safety and quality of life for the patient.1, 5 Often times necessary medications can be switched to bedtime administration or parameters added to hold for sedation, hypotension or bradycardia. Working with the prescriber, patient and caregivers will help to weigh the risks and benefits of each medication, identify unnecessary drugs or find opportunities to use lower doses for safer medication therapy.
In beginning a medication regimen review, it is important to gather as much information about the patient and the fall(s) as possible. Consider the circumstances and timing of the fall(s), recent medication changes, lab monitoring, vitals, non-pharmacological interventions, medical history, etc. This information can be used to rule medications in or out based on pharmacokinetics and side effect profiles. Identify high-risk medications such as CNS depressants, drugs that cause dizziness, confusion, blurred vision, syncope, hypotension, orthostasis, hypoglycemia or dehydration. This would include benzodiazepines, sedative/hypnotics, antipsychotics, anticonvulsants, muscle relaxants, antidepressants, antihistamines, anticholinergics, antihypertensives, anti-diabetic agents, anti-arrhythmics, narcotics, ophthalmic products, bowel medications and others. It can sometimes seem that there are more medications with fall potential than those without, which is why a discerning eye and extensive pharmaceutical knowledge is so valuable to the healthcare team.
Additional fall risk may occur when drugs interact to increase serum concentrations. For example, NSAIDs may increase serum concentrations of digoxin, CYP-2C19 inhibitors such as omeprazole can increase concentrations of citalopram and carvedilol, and calcium channel blockers (both dihydropyridines and non-DHPs) can increase serum phenytoin and subsequent risk of toxicities. 6 Renal and hepatic dosing guidelines, body weight, chronic conditions and fluid balance changes can also indicate a need to use lower doses. If multiple medication changes are warranted or tapering is needed, recommend a step-wise approach to give the patient time to adjust and the prescriber time to evaluate for any potential consequences of the change. Tools to aid in the medication review process include the Updated Beer’s Criteria7 and Screening Tool of Older Person’s Prescriptions (STOPP).8 These resources provide detailed definitions for potentially inappropriate drugs and specific conditions which predispose the elderly to adverse drug events.
This review process is useful for evaluating medication-related risk following a fall, but the ultimate goal is to prevent future falls and injuries. Elderly patients who have fallen are two to three times more likely to fall again.2 Though you may have ruled out certain high-risk medications as contributing to one particular fall, consider adding closer monitoring, utilizing non-pharmacological therapies, reducing doses or discontinuing these medications, since they may still contribute to a future fall. Talk to your patients, care providers and prescribers about the risks associated with these medications and be a team player to help reduce or discontinue any potentially inappropriate medications and to advocate for safe and appropriate medication use.