1. Medicines & Falls Jo Murray, Falls Prevention Coordinator April 2012

2. SHFT Falls Prevention Team April 2012 Aim –To explore which medicines are potential causes of falls in older people and what we can do to reduce the risk. Objectives By the end of this session delegates will: –Understand which medicines are potential causes of falls –Have a range of possible interventions to reduce risk of falls and fractures.

3. Drugs in older people Older people handle drugs less well Homeostatic changes –Decreased baroreceptors – postural hypotension –Control of body sway - ataxia e.g. benzodiazepines –Glucose and electrolyte control e.g. diuretics Decreased renal function –Renal function decreases by 10% per decade after 40! Decreased lean body mass –Increases half life of many drugs Decreased plasma albumin –Increase free fraction of protein bound drugs SHFT Falls Prevention Team April 2012

4. Low Blood Pressure on standing (postural hypotension) On standing blood pressure may fall very quickly causing dizziness. To screen for this risk factor, blood pressure should be measured when the patient is lying down and standing up as a baseline clinical observation on admission. A drop of systolic BP > 20mm Hg or diastolic >BP 10mm Hg is a risk factor. Also, an initial lying blood pressure of <90mm Hg is a risk factor SHFT Falls Prevention Team April 2012

5. When prescribing for the elderly Which drugs to avoid if possible? Should the dose be smaller? SHFT Falls Prevention Team April 2012

6. Medicines that make people fall over Anticholinergic drugs –Tricyclic antidepressants Diuretics –Hyponatraemia – e.g. Moduretic –Diuresis – rushing to the toilet Antihypertensives –Low blood pressure on standing e.g. alpha blockers Sedatives –Day time sedation e.g. benzodiazepines, antihistamines, opiates SHFT Falls Prevention Team April 2012

7. Medicines that make people fall over Diuretics –dizziness –urgency to pass urine –postural hypotension –low sodium - confusion Is it needed? Is the dose too high? Could the timings of doses be split? SHFT Falls Prevention Team April 2012

8. Medicines that make people fall over Antipsychotics –e.g. chlorpromazine, risperidone –sedation and dizziness –dose dependent reduce dose change to an alternative SHFT Falls Prevention Team April 2012

9. Medicines that make people fall over Hypnotics and anxiolytics –e.g. diazepam, temazepam –only licensed for short term use i.e. 2 to 4 weeks. –Drowsiness, next day, confusion –Nitrazepam 30 hours, temazepam 10 hours. Possibly longer in elderly avoid offer withdrawal SHFT Falls Prevention Team April 2012

10. Medicines that make people fall over Insulin and oral hypoglycaemics –dizziness due to hypoglycaemia –avoid long acting agents e.g. glibenclamide Analgesics –e.g. morphine, co-dydramol –drowsiness, hypotension- large doses switch to alternative e.g. paracetamol reduce dose SHFT Falls Prevention Team April 2012

11. Others….. NSAIDs –e.g. ibuprofen, diclofenac –dizziness and vertigo change to paracetamol * For more detailed information please read Falls Medication information sheet on intranet and in resource files SHFT Falls Prevention Team April 2012

12. Reviewing medicines Polypharmacy – is it necessary? –Does it have a purpose? –Does the patient want it? –Is it being used to treat a side effect of another medicine? –Even if “evidence based” is it likely to be useful for that patient? SHFT Falls Prevention Team April 2012

13. 4 things to consider….. Be suspicious of medicine induced falls if on lots of tablets Try and reduce benzodiazepine and sedative use. Look out for low blood pressure on standing Offer calcium and vitamin D to at risk patients SHFT Falls Prevention Team April 2012

14. Compliance issues Is the patient taking the correct medicines? –Are they taking too much? –Are they taking medicines that should have stopped? –Do they take anything OTC or borrowed? –Can they swallow the medicines? SHFT Falls Prevention Team April 2012

15. Vitamin D is a steroid vitamin, a group of fat-soluble prohormones, which encourages the absorption and metabolism of calcium and phosphorous People who are exposed to normal quantities of sunlight do not need vitamin D supplements because sunlight promotes sufficient vitamin D synthesis in the skin. Vitamin D deficiency not only causes osteomalacia but can exacerbate osteoporosis SHFT Falls Prevention Team April 2012

16. Who should be on Calcium and vitamin D? e.g. Adcal D3, Calcichew D3 forte Elderly patients with a history of falling Patients of south asian origin Elderly patients either housebound or living in residential /nursing accommodation. Patients who have a low body weight (BMI <19 kg/m2) Patients who have been taking a corticosteroid e.g. prednisolone> 7.5mg daily for 3 months or more – these patients will need bisphosphonate in addition to stop bone loss … If a fall occurs there is less likelihood to fracture SHFT Falls Prevention Team April 2012

17. Just about every old person could benefit from calcium and vitamin D! Over the age of 75 years. Female (being that females fall more than males) At risk of falling / previous falls Long term immobility No/poor contact with sunlight Poor diet (especially lacking in dietary foods) Low body mass Previous fracture Family history of hip fracture Smoker Heavy drinker Early menopause SHFT Falls Prevention Team April 2012

18. Conclusion Be suspicious of medicines as a cause of falls Refer to GP (or pharmacist) to review medicines and make changes Suggest Calcium + Vitamin D to patient and prescriber Ensure medication reviews are clearly recorded in patient notes and care plan to ensure clear audit trail SHFT Falls Prevention Team April 2012