Preventing Medication-Related Falls: Helping the Elderly Find Balance Deepa Pattani, PharmD, RPh Owner: PrevInteract Health Deepa.Pattani@PrevInteract.com 972-372-9775

About Me Deepa Pattani, PharmD, RPh with over 12 years of experience as a Pharmacist Practiced in various aspects of pharmaceutical care Licensed to practice in 8 states throughout the country Contact info: Deepa.Pattani@PrevInteract.com 972-372-9775

Learning Objectives After completion of this activity, one should be able to: Describe the relationship of age-related changes in drug metabolism to the risk of falling in older adults Describe at least 2 classes of medications that are related to falls in older adults Identify risk factors for falling in older adults Recommend at least 2 strategies to prevent falls in the community setting

Introduction Over 700,000 hospitalizations: mostly due to head injury or fractures. >85% of all injury-related hospitalizations and 49% of nursing home admissions. Falls are the 5th leading cause of death in older adults. 30-40% of adults > 65 will experience at least 1 fall a year. Serious complications: disability, fractures, hospitalizations, loss of independence, death. Direct medical costs are $34 billion annually.

Agenda Age and medication related risk factors for falls in older adults Role of pharmacists, nurses, case managers and social workers in the community in preventing falls for older adults

Age-Related Changes Medication disposition depends on 4 processes: A, D, M, E. PK changes in these 4 processes can alter function & drug activity, making older adults more susceptible to SE’s – particularly falls.

Absorption Changes in GI motility & gastric pH alter absorption No evidence in the absense of disease of fall risk Example: PPI use increases gastric pH: inhibits absorption of Ca, Mg, and Fe. In the long run can cause osteoporosis, anemia which in turn can lead to falls.

Distribution Increase in total body fat, decrease in lean muscle mass and total body water. Example: lipophilic drug: Valium. Prolonged exposure can increase risk of cognitive impairment & CNS depression – increasing fall risk. Changes in distribution may increase drug concentrations and duration of action.

Metabolism 30% decrease in liver size & 40% decrease in blood flow to the liver Two methods of metabolism: First pass metabolism Cytochrome P450 enzyme system

Metabolism (cont’d) First pass metabolism altered due to size and blood flow. Example: anti-hypertensive medications such as Inderal or verapamil are affected – increased bioavailability results in adverse effects such as symptomatic hypotension which increases fall risk CYP450 system is not affected by age, however it is affected by multiple medications.

Elimination Occurs mainly through the kidneys Renal blood flow, tubular function, GFR all decrease with increasing age Results in accumulated medications and adverse events- increasing fall risk Example: Opiates such as Morphine & Dilaudid when accumulated can cause sedation, dizziness & confusion

Summary Age-related changes in PK may have a significant impact on drug disposition and may increase risk of falls in older adults Changes in absorption have not been clinically significant, however, changes in distribution, metabolism and elimination do increase medication related adverse events, in this case: falls.

Common Causes of Falls Lower body weakness Difficulty balancing or walking Hazards in the home Inappropriate foot wear or foot pain Visual disturbances Vitamin D deficiency Medications

Medications Associated With Fall Risks Psychotropic medications: anti-depressants, anti-convulsants, anti-psychotics Cardiac medications: anti-hypertensives, anti-arrhythmics, diuretics Sedative/hypnotic medications Analgesics: Opioids, NSAIDs

Psychotropics Anti-depressants Common side-effects: sedation, sleep disturbances, orthostatic hypotension, confusion, cardiac arrhythmias, involuntary muscle movements, and lightheadedness. Can also cause a decrease in bone mineral density over time and may increase risk of fractures. Fall risk is dose-dependent and does not decrease with prolonged use.

Psychotropics Anti-convulsants Common side effects: dizziness, sedation, ataxia. Drugs such as Dilantin or Tegretol: have narrow therapeutic ranges. Small dose changes can result in accumulated and major changes in the body and increase side effects. Monitoring blood levels is crucial.

Psychotropics Anti-psychotics Common side effects: EPS (akathisia, dystonia, pseudoparkinsonism, dyskinesia), sedation, and orthostatic hypotension Long term use of drugs such as Haldol, Risperdal, Zyprexa increase risk of falls by 81%. Recommended to use the smallest possible dose for the shortest duration of action.

Cardiac Medications Associated with recurrent and injurious falls Significantly drops orthostatic blood pressure Common side effect: dizziness due to drop in BP

Sedative/ Hypnotics Common side effects: cognitive impairment, confusion & sedation. Examples: Xanax, Valium, Phenobarbital Dependence and side-effects seen with short and long lasting agents. Ambien: similar side effect profile Benadryl: available OTC: SEs: dementia, poor co-ordination, visual disturbances and confusion.

Analgesics Opioids (Morphine, Dilaudid) Common side effects: sedation, dizziness, confusion & respiratory depression. NSAIDs: availble OTC, sometimes mixed with Benadryl poses a falls risk.

Vitamin D Deficiency Associated with increased fall risk among older adults. The US Preventive Service Task Force recommends all older adults incorporate 400 to 600 units of Vit D daily by diet or supplementation.

Postural Hypotension Definition: drop in SBP >/= 20mmHg or < 90mmHg upon standing from sitting or sleeping positions. Behavioral modifications that help decrease fall risk include: Rising slowly Using hand rails Crossing legs when standing Limiting prolonged standing

Education & Counseling Being educted about the different classes of drugs that can increase fall risk and counseling patients on the same Awareness of side-effects can help the patient take appropriate steps to prevent falls Never assume counseling has been provided by physicians or pharmacists Always ask if a patient has had a fall in the past in your initial assessment. Helps identify high-risk patients. Recommend full assessment of medications by a pharmacist.

Education & Counseling Always counsel patients to not drive or operate heavy machinery when a medication is added or discontinued. Medication non-compliance can lead to falls; not taking the prescribed medications can also be a possibility. CDC reference toolkit link in handout

Common Precautions to Prevent Falls Have physician assess fall risk. Build flexibility and strength: participate in a balance or exercise program Discuss medications and possible interactions with physician or pharmacist – include over the counter drugs and supplements Annual vision and hearing screening Appropriate footwear Making the home safe: get rid of floor clutter, put grab bars/ railings in the bathroom and by stairs, install proper lighting, secure throw rugs to the floor and place food and other items within easy reach

Potential Problems Social workers/ case managers, RNs, etc may lack time learning about all the medications and side-effects. Patient health insurance may limit the physicians a person can see Co-ordinating between physicians, specialists, hospitals can be challenging.

Collaborating With a Pharmacist A valuable asset for all parties involved. Easily accessible. Knowing when to call a pharmacist can help save clients hundreds or even thousands of dollars in healthcare expenditures. Pharmacists have easy access to physicians so collaboration can be very beneficial Encourage patients to inform RPh of all OTC supplements, foods, herbals, etc. in addition to RX meds

Summary Age-related changes, multiple disease states & inappropriate medication use all contribute to falls in an older adult Collaboration examples to help our patients: Hosting brown bag sessions Education & counseling seminars Developing a fall prevention program Improving compliance of medications Using screening tools

Where to Get More Information References include toolkits for fall risk assessment. CDC website Consulting services: PrevInteract Health