Medications and Fall Risk in

the Elderly

Kyle Campbell, PharmD

Vice President, Pharmacy and Quality Measurement

May 24, 2016

National Nursing Home Quality Care Collaborative in Florida

Objectives

• Identify the impact of falls in the elderly

• Understand medication-related fall risk

• Describe physiological changes that altermedication effects in the elderly

• Recognize medication side effects

• Identify drug/drug classes to consider infall assessment

• Describe medication alternatives and fall-prevention strategies

2

Clinical Relevance

• About 50–75 percent of nursing home residents

fall each year1

• In long-term care (LTC) settings, 10–20 percent

of falls result in an injury2

• Falls are the leading cause of injury deaths in

the geriatric population3

• Each year, 2.5 million older adults are treated in

emergency departments (EDs) for fall injuries4

1) Willy & Osterberg, 2014

2) CDC 2015. 3) CDC 2012

4) CDC 2016

3

Modifiable and Non-Modifiable Risk Factors

Risk Factors for Falls

Age Lower

Extremity Weakness

Visual/ Auditory

Impairment

Cognitive Impairment/

Dementia

Polypharmacy (≥4 meds)

Female Gender

Comorbidities

Environment

Balance/Gait Impairment

History of Falls/Fractures

5) Van Voast Moncada, 2011

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Medications and Fall Risk

• number of Rx meds = risk for falls6

• Frailest patients most likely to be receiving

the most medications7

• 44 percent of men and 57 percent of

women age 65 and older use ≥5medications and about 12 percent of both

men and women take ≥10 per week8

6) Freeland et al., 2012

7) Haumschild et al., 2003

8) Woodruff, 2010

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Medications and Fall Risk

No risk factor is as preventable or

reversible as medication use.9

9) Leipzig et al., 1999

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Why are the Elderly More at Risk?

• Absorption: effects are variable– Decreased gastrointestinal motility

– Reduced gastric acid secretion increased pH

• Distribution: effects water and fat soluble drugs– Decreased muscle mass and total body water

– Increased body fat

• Metabolism:– Decreased liver function

• Elimination:– Decreased kidney function

10) Wooten, 2012

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Medication Side Effects Associated with Falls

• Agitation

• Arrhythmias

• Confusion

• Dizziness

• Gait / EPS

• Sedation

• Syncope

• Impaired balance

• Orthostatic

hypotension (OH)

• Increased ambulation

• Cognitive impairment

• Visual disturbances

11) Huang et al., 2012

8

Anticholinergic Effects (AE)

• Blurred vision

• Flushing

• Altered mental status

• Dry mouth, dry eyes

• Urinary retention

• Elevated body temperature

12) Ramnarine & Tarabar, 2015

9

Medications/Classes

• Central Nervous System

– Anti-Parkinson drugs

– Antidepressants*

– Antipsychotics*

– Benzodiazepines*

– Non-benzodiazepine

hypnotics

– Antihistamines

– Anticonvulsants*

– Muscle Relaxants

– Narcotic Analgesics

• Cardiovascular– Antihypertensives

– Antiarrhythmics

– Digoxin

– Nitrates

– Diuretics

• Others– Hypoglycemics

– H2-receptor blockers

– Proton pump inhibitors

– NSAIDs

– Corticosteroids

5) Van Voast Moncada, 2011

*Indicates classes most strongly associated with falls 13) Woolcott et al., 2009

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Antidepressants

• Classes: TCAs and SSRIs

• Examples: amitriptyline (Elavil®), paroxetine

(Paxil®), nortriptyline (Pamelor®)

• Effects: anticholinergic effects (AE), orthostatic

hypotension (OH), dizziness, sedation, blurred

vision, decreased alertness

• Alternatives:

– SSRIs with shorter t1/2: escitalopram (Lexapro®),

sertraline (Zoloft®)

– SNRIs: venlafaxine (Effexor®), duloxetine (Cymbalta®)14) Hanlon, 2015– Bupropion (Wellbutrin®)

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Antipsychotics

• Classes: Typical and atypical

• Examples: chlorpromazine (Thorazine®),

haloperidol (Haldol®), olanzapine (Zyprexa®)

• Effects: sedation, dizziness, orthostatic hypotension

(OH), extrapyramidal symptoms (EPS), increased

mortality in dementia patients16

• Alternatives:

– Dependent on clinical situation14

• Always use lowest dose for shortest duration possible

• Non-anticholinergic agents such as aripiprazole (Abilify®) for14) Hanlon, 2015schizophrenia or bipolar disorder only.

15) Bulat et al., 2008

16) FDA 2008

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Benzodiazepines (BZDs)

• Classes: Long-acting/short-acting

• Examples: diazepam (Valium®), clorazepate

(Tranxene®), alprazolam (Xanax®)

• Effects: sedation, cognitive impairment,

unsteady gait

• Alternatives:

– Insomnia: sleep hygiene, cognitive behavioral

therapy, melatonin17

– GAD/Anxiety: buspirone (Buspar®), SNRIs14

14) Hanlon, 2015

17) Bulat et al., 2008

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Prevention Strategies: BZDs

• Avoid combining with other high-risk

medications (e.g., opioids)18

• Close monitoring and regular medication

review necessary

–Risk increased in first 1-2 weeks of initiating

therapy and when using higher doses18

–Decrease dose or use lowest dose possible if

applicable

–Avoid abrupt discontinuation of medication; slow

taper is recommended18) Institute for Clinical

Systems Improvement, 2012

14

Non-Benzodiazepine Hypnotics

• Examples: eszopiclone (Lunesta®), zolpidem

(Ambien®), zaleplon (Sonata®)

• Effects: sedation, delirium, unsteady gait

• Alternatives:

– Sleep hygiene

• Minimize caffeine intake

• Limit frequent daytime napping

• Avoid late heavy dinner

– Cognitive behavioral therapy (CBT)

14) Hanlon, 2015

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Cardiovascular Medications

• Types: Antihypertensives

• Examples: doxazosin (Cardura®), nifedipine

(Procardia®), prazosin (Minipress®), clonidine

(Catapres®), methyldopa (Aldomet®)

• Effects: orthostatic hypotension (OH)

• Alternatives:

– Alpha blockers (selective)

• Tamsulosin (Flomax®) – Benign prostatic

hyperplasia (BPH)

– Thiazide-type diuretics• Hydrochlorothiazide 14) Hanlon, 2015

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Prevention Strategies: Cardiovascular Meds

• Alpha blockers

– Take at bedtime

• Diuretics17

– Take in a.m. to avoid nighttimeambulation

• Patient Education: OrthostaticHypotension (OH)

– Stand up slowly after sitting or lyingdown

– Get adequate hydration

– Monitor blood pressure routinely17) Bulat et al., 2008

17

Antihistamines

• Types: 1st generation antihistamines

• Examples: hydroxyzine (Atarax®),diphenhydramine (Benadryl®)

• Effects: anticholinergic effects (AE),sedation, cognitive impairment

• Alternatives:– Intranasal normal saline

– 2nd generation antihistamines• Loratadine (Claritin®), fexofenadine (Allegra®), cetirizine

(Zyrtec®)

– Intranasal steroids• Fluticasone (Flonase®)

14) Hanlon, 2015

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Skeletal Muscle Relaxants

• Examples: cyclobenzaprine (Flexeril®),

carisoprodol (Soma®), metaxalone (Skelaxin®),

baclofen (Lioresal®)

• Effects: anticholinergic effects (AE), sedation,

cognitive impairment, weakness

• Alternatives:

– Physical Therapy

– Acetaminophen (if pain is present)

14) Hanlon, 2015

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Narcotic Analgesics

• Examples: oxycodone/APAP (Percocet®),

hydromorphone (Dilaudid®)

• Effects: dizziness, confusion, sedation

• Alternatives:

– Acetaminophen alone (recommended max dose 3g/d)

– Short-acting NSAIDs: ibuprofen (Advil)

• Controversy in literature if narcotics are

associated with increased falls19

19) Leipzig, 2015

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Problems with Medication Management in

Nursing Homes

• Multiple medications

• Multiple prescribers

• Multiple prescription drug plans

• Relationships between providers

• Medication reconciliation/transitions of care

• Pressure to institute or continue medications

– Family (less aware of risks)

5) Van Voast Moscada, 2011

21

Prevention Strategies

• “Treat the whole patient…..”20

• Multidisciplinary approach

• Medication Review

20) Lee, 1998

22

S

A

L

I

• Simplify Regimens

• Adverse Drug Effects

• Indications Must be Clear

• Lists of Drugs

Prevention Strategies

• “Optimize physician-pharmacist

relationship”21

– Policy for Medication Regimen Review

(MRR)

• Process for communication

• Timing of communication

• Expected documentation on

recommendation and response

• Completed document retained

21) Levenson & Saffel, 2007

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Prevention Strategies

• Chronic diseases appropriately treated

– Screen and treat Osteoporosis

– Vitamin D

• Dose: 800 IU daily

• Improves skeletal function

• Decreased risk of falls in elderly22

– Calcium

• 1000-1200 mg/daily23

22) Murad & Elamin, 2011

23) Ross, 2010

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Resources: National Nursing Home Quality

Care Collaborative (NNHQCC) Tools

– Fall Root Cause – Restraints and Falls:Analysis Alternative• Nursing homes can use Interventions

this form to identify fall• Provides suggestedrisk factors

interventions to avoid– Fall Prevention

restraints utilizationsIntervention Care Plan and/or reduce falls• This worksheet helps

– Fall Risk Assessmentthe interdisciplinarynursing home team • Assist with identifyingdevelop a fall risk factorsmultidisciplinary plan ofcare to prevent falls

https://www.hsag.com/en/medicare-providers/states-of­

service/florida/nursing-homes/resources/mobility/

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Summary

• Falls are substantial cause of morbidity and

mortality

• Polypharmacy is a risk factor for falls

• Elderly are at greater risk of side effects

• Adverse drug events (ADEs) are not widely

recognized

• Most evidence exists for fall risk and

psychotropics13

• Medication review can minimize risk

• Preventative medications should be considered13) Woolcott et. al, 2009

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References

1. Willy, Betty, PT, and Christine Osterberg, RN. "Strategies for Reducing Falls in Long-Term Care."Annals of Long Term Care, Jan. 2014. Web. 21 Feb. 2016.

2. "Falls in Nursing Homes." Centers for Disease Control and Prevention, 30 June 2015. Web. 20Feb. 2016.

3. "10 Leading Causes of Injury Deaths by Age Group Highlighting Unintentional Injury Deaths,United States – 2012." CDC (2012): n. pag. Print.

4. "Important Facts about Falls." Centers for Disease Control and Prevention, 20 Jan. 2016. Web. 19Feb. 2016.

5. Van Voast Moncada, Lainie, MD. "Management of Falls in Older Persons: A Prescription forPrevention." American Family Physician, 1 Dec. 2011. Web. 21 Feb. 2016.

6. Freeland, Kathryn, Amy Thompson, and Yumin Zhao. "Medication Use and Associated Risk ofFalling in a Geriatric Outpatient Population." Medscape. The Annals of Pharmacotherapy, 2012.Web. 19 Feb. 2016.

7. Haumschild, M. J., Karfonta, T. L., Haumschild, M. S., & Phillips, S. E. (2003). Clinical andeconomic outcomes of a fall-focused pharmaceutical intervention program. Am J Health SystPharm, 60(10), 1029-1032.

8. Woodruff, Kathleen, CRNP. "Preventing Polypharmacy in Older Adults." Medscape. AmericanNurse Today, 2010. Web. 19 Feb. 2016.

9. Leipzig, R. M., Cumming, R. G., & Tinetti, M. E. (1999). Drugs and falls in older people: asystematic review and meta-analysis: I. psychotropic drugs. Journal of the American GeriatricsSociety, 47(1), 30-39.

10. Wooten, James M., PharmD. "Pharmacotherapy Considerations in Elderly Adults." SouthernMedical Association 105.8 (2012): 437-45. 8 Aug. 2012. Web. 19 Feb. 2016.

11. Huang, Allen R., Louise Mallet, and Christian M. Rochefort. "Medication-Related Falls in theElderly." Drugs and Aging 29.5 (2012): 359-76. Pubmed. Web. 19 Feb. 2016.

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References

12. Ramnarine, Mityanand, MD, and Asim Tarabar, MD. "Anticholinergic Toxicity Clinical Presentation." Medscape, 9 Aug. 2015. Web. 17 Feb. 2016.

13. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169(21):1952-60.

14. Hanlon, J. T. (2015). Journal of the American Geriatrics Society: Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug– Disease Interactions in the Elderly Quality Measures. Retrieved February 17, 2016, from http://onlinelibrary.wiley.com/doi/10.1111/jgs.13807/pdf

15. Bulat, T., Castle, S. C., Rutledge, M., & Quigley, P. (2008). Clinical practice algorithms: medication management to reduce fall risk in the elderly-part 4, anticoagulants, anticonvulsants, anticholinergics/bladder relaxants, and antipsychotics. J Am Acad Nurse Pract, 20(4), 181-190.

16. "Information for Healthcare Professionals: Conventional Antipsychotics." US Food and Drug Administration, 16 June 2008. Web. 19 Feb. 2016.

17. Bulat, T., Castle, S. C., Rutledge, M., & Quigley, P. (2008). Clinical practice algorithms: medication management to reduce fall risk in the elderly--Part 3, benzodiazepines, cardiovascular agents, and antidepressants. J Am Acad Nurse Pract, 20(2), 55-62.

18. Summary Of Changes Report – April 20. Prevention of Falls - Acute Care Protocol. N.p.: Institute for Clinical Systems Improvement, Apr. 2012.

19. Leipzig, Rosanne, MD. "Drugs and Falls in Older People: A Systematic Review and Meta-analysis: II. Cardiac and Analgesic Drugs." Journal of the American Geriatrics Society, 27 Apr. 2015. Web. 21 Feb. 2016.

20. Lee, R.D. (1998). Polypharmacy: A Case report and a new protocol for management. J Am Board Fam Pract, 11(2),140-44.

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References

21. Levenson SA, Saffel DA. The consultant pharmacist and the physician in the nursing home: roles,relationships, and a recipe for success. J Am Med Dir Assoc. 2007;8(1):55-64.

22. Murad, Mohammad Hassan, and Khalid B. Elamin. "The Effect of Vitamin D on Falls: A SystematicReview and Meta-Analysis." The Journal of Clinical Endocrinology & Metabolism 96.10 (2011):2997-3006. J Clin Endocrin Metab., 27 July 2011. Web. 18 Feb. 2016.

23. Ross, Catharine. "Dietary Reference Intakes for Calcium and Vitamin D." Institute of Medicine, Nov.2010. Web. 18 Feb. 2016.

24. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate MedicationUse in Older Adults. (2015). Retrieved February 11, 2016, fromhttp://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full

25. Bischoff-Ferrari, H. A., Dawson-Hughes, B., Willett, W. C., Staehelin, H. B., Bazemore, M. G., Zee,R. Y., et al. (2004). Effect of vitamin D on falls: a meta-analysis. JAMA, 291(16), 1999-2006.

26. French, D.D., Chirikos ,T.N,. Sephar, A., et al. (2005). Effect of concomitant use ofbenzodiazepines and other drugs on the risk of injury in a veterans population. Drug Saf., 28,1141­1150.

27. Kaufman, D.W., Kelly, J.P., Rosenberg, L., Anderson ,T.E,. Mitchell, A.A. (2002). Recent patterns ofmedication use in the ambulatory adult population of the United States. The Slone Survey. JAMA ,287, 337-44.

28. Riefkohl, E., Bieber, H., Burlingame, M., & Lowenthal, D. (2003). Medications and falls in theelderly: A review of the evidence and practical considerations. P&T, 28 (11).

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Special thanks to: José León-Burgos, PharmD Candidate 2016

Justyna Czerniewska, PharmD

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State Nursing Home Team Contacts

Florida NNHQCC Team

FL-NNHQCC@hsag.com

Arizona Keith Chartier, MPH

Clinical Project Manager

602.801.6906 KChartier@hsag.com

Ohio James Barnhart, BHS, LNHA

Quality Improvement Project Lead

614.307.5475

JBarnhart@hsag.com

California Jennette Silao, MBA, MPH

Associate Director

818.265.4676 JSilao@hsag.com

This material was prepared by Health Services Advisory Group, Inc., the Quality Improvement Organization for Florida under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the

U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. FL-11SOW-C.2-05202016-01

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