Falls risk and medication Selina Khanom : Dementia Team Pharmacist

Aim To understand how medication can be a risk factor for falls

Objectives Learn about the NSF for older people – what it is and why it is relevant Understand both why and how medicines can increase risk of falls Appreciate the importance of preventing osteoporosis in older people Learn tips on how to use medicines safely

What are NSF’s? National Service Frameworks (NSFs) are policies set by the NHS to define standards of care for major medical issues such as cancer, coronary heart disease, mental health and diabetes. NSFs are also defined for some key patient groups including children and older people. We will be looking specifically at the NSF for Older people

Role of NSF The two main roles of NSFs are: Set clear quality requirements for care based on the best available evidence of what treatments and services work most effectively for patients. Offer strategies and support to help organisations achieve these.

How are NSF’s developed? Health professionals Patients Carers Health service managers Voluntary agencies Other experts

Why is the NSF for Older People relevant? The aim of standard 6 of the NSF for Older People is to reduce the number of falls that result in serious injury and ensure effective treatment and rehabilitation for those who have fallen.

Every year over 400,000 older people in England attend A & E departments following a fall. Preventing falls in frail older people will save lives and decrease disability.

Intrinsic Risk factors Preventing falls Intrinsic Risk factors Environmental Hazards

Intrinsic risk factors Balance, gait or mobility problems including those due to degenerative joint disease and motor disorders such as stroke and parkinsons disease Visual impairment Impaired cognition or depression Postural hypotension Taking 4 or more medicines, in particular centrally sedating or blood pressure lowering

Why is medication a risk factor? Polypharmacy = When a patient is prescribed four or more drugs It is a risk factor for falls and potential harm in older people Sometimes it is medication that is necessary, but quite often it occurs over time when a medication is simply not discontinued when no longer needed

Why is medication a risk factor? Taking four or more medications significantly increases the risk for falling because There are a greater number of side effects associated with multiple medication use and the side effects are often more intense Interactions between medications can also cause side effects Medications react differently in the body as a person ages which can increase the risk for falling

How medicines can cause falls Sedation Impaired postural stability (inability to maintain posture) Hypotension (low blood pressure) Drug induced parkinsonism (Parkinson like symptoms) Visual impairment (blurred vision, dry eyes) Hypoglycaemia (low blood sugar) Vestibular damage (tinnitus, deafness) Hypothermia (low body temperature) Confusion Dehydration

How medicines can cause falls Sedation/Drowsiness Antidepressants Antipsychotics Parkinsons disease medication Impaired postural stability Hypnotics Sleep aids Benzodiazpines Postural hypotension Diuretics

How medicines can cause falls Drug induced Parkinsonism Antipsychotics Blurred vision/Dry eyes Visual Impairment Antihistamines Drugs for urinary incontinence Hypoglycaemia Beta blockers Haloperidol Antidiabetic medication Insulin Quinine

How medicines can cause falls Tinnitus, deafness Vestibular damage Water tablets Aspirin quinine, Certain antibiotics Confusion Antispychotics Sedatives Heart tablets Hypothermia Beta blockers Clonidine Antipschotics Sedative hypnotics also decrease body's ability to respond to low ambient temperature

How medicines can cause falls Dehydration Can increase the risk of falls and this might occur in older people taking diuretics (water tablets) and laxatives

Medication reviews In patients taking medicines known to contribute to falls, medication review can play an important role in falls prevention. Where a patient has fallen, medication review and subsequent prescribing changes have been shown to reduce further falls.

What is a medication review ......“Structured review of the efficacy and continuing appropriateness of a patients medication”.. A medication review may result in either modification or withdrawal from a drug. If neither are possible, close monitoring may be appropriate.

Osteoporosis Prevention Older people with osteoporosis will be at increased risk of fractures if they fall. This patient group should be advised to Ensure adequate nutrition – especially with calcium and vitamin D Perform regular weight bearing exercise Stop smoking Avoid alcohol

Osteoporosis Prevention Bisphosphonates are commonly used for the treatment and prevention of osteoporosis Taken ONCE weekly Some common examples include Generic name Brand name alendronate Fosamax ibandronate Boniva risedronate Actonel

Osteoporosis Prevention Patients prescribed a bisphosphonate may also be prescribed calcium tablets Vitamin D tablets Calcium should be taken at least half an hour after bisphosphonate

Tips for safe medication use Keep a list of all medications including prescriptions, over the counter medications, vitamins, and herbals. Keep all your medicines in the same place Ask questions about your medicines. Use only one chemist when possible. Take your medicine according to the directions.

Tips for safe medication use Talk to your doctor or pharmacist if you do not want to take your medicines or cannot take them. Tell your doctor about any changes in your health. Tell your doctor if any medicine makes you feel better or worse. Throw away medicines that are out of date. Do not share medicines with family or friends

Prescribed medication that can cause falls Parkinson's disease Pain Seizures Sleep Anxiety Nerves Aggression Schizophrenia Parkinsons Heart problems Swelling Blood pressure Urinary accidents Epilepsy Mood Depression Cramps Muscle spasms Painkillers Antihistamines

Over the counter medicines that can cause falls Painkillers (ibuprofen, naproxen) Cold and flu (pseudoephedrine, phenylepherine) Allergy tablets (chlorpheniramine, promethazine) Heartburn tablets (ranitidine, cimetidine, famotidine) Sleeping tablets (diphenhydramine e.g Nytol )

CASE STUDY 89 years old male Wife recently passed away Mr M CASE STUDY 89 years old male Wife recently passed away Dosette box contains: Bisoprolol 10mg Clopidogrel 75mg Ramipril 10mg Furosemide 40mg Mirtazepine 45mg Aspirin 75mg Simvastatin 40mg Mr M also buys Nytol from his chemist. Since his wife passed away he has difficulty sleeping at night.

Summary Falls prevention is one the aims of the NSF for Older People Polypharmacy is a risk factor for falls Medication reviews can help to reduce the risk of falls Patients at risk of osteoporosis should be on preventative medication Encourage patients to use medication safely

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