1. Preventing Medication-Related Falls: Helping the Elderly Find Balance
Deepa Pattani, PharmD, RPh
Owner: PrevInteract Health

2. 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:

3. 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

4. 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.

5. 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

6. 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.

7. 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.

8. 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.

9. 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

10. 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.

11. 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

12. 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.

13. 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

14. 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

15. 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.

16. 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.

17. 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.

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

19. 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.

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

21. 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.

22. 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

23. 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.

24. 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

25. 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

26. 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.

27. 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

28. 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

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