"Medication Interventions for Fall Prevention in the Older Adult." J

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Fall prevention in older adults ReviewsFalls are the leading cause of injury-related deaths andthe most common cause of nonfatal injuries and hospitaltrauma admissions among older adults. The injuries andsecondary effects sustained in and after a fall can considerablyaffect elder patients’ mobility and independence long afterthey leave the hospital. More than one-third of adults age65 years or older fall every year. As the population ages, therate of occurrence of falls will increase unless strategies areimplemented to reduce the number of falls and their cumulativeadverse effects. 1–3To assess the causes of falls and compile recommendedactions that pharmacists can take to decrease patients’ risksof falling, we searched Medline and the Agency for HealthcareResearch and Quality’s website (www.ahrq.gov) using thesearch terms falls, medications and falls, fall risk factors, andAt a GlanceSynopsis: Pharmacists can identify elderly patientsat risk for falls and minimize fall risk by assessingcurrent medications both prescribed and possiblyneeded to reduce fall risk. A comprehensive fall-reductionstrategy should address physical mobility and abilityto accomplish activities of daily living, medicationmanagement, home/room safety, and environmental(community) safety. Total psychoactive drug load, particularlypsychotropic drugs, must be considered carefully,and efforts should be made to taper, discontinue,and/or replace drugs implicated in increasing fall risk.A fall risk assessment method that incorporates fallhistory and risk factors, current disease states andconditions, and medications that may increase fall riskis presented in the current work.Analysis: Efforts to correct anemia in elderly patientsmay decrease fall risk. Falls and fall-related fracturerisk can also be decreased by ensuring adequatevitamin D and calcium intake. Evidence suggests thatbuspirone intervention in place of benzodiazepinesand/or antipsychotics, careful drug withdrawal by stepwisediscontinuance with tapering of 10% to 25% ofthe dose per week, or both interventions can reducefalls by up to 70%.falls interventions and outcomes. Additional resources wereidentified from personal data in preparation for publicationconsideration by the authors and bibliographies from gatheredarticles.Causes of fallsResearch indicates that falls are caused by multiple factorsthat are both internal and external to elder patients. 1–3 The followingfour areas of risk have been identified:(1) Physical mobility and ability to accomplish activitiesof daily living (ADLs). Fall risk can be increased by thedeconditioning that can occur with normal aging (e.g., “ifyou do not use it, you lose it”) and by the loss of musclestrength that can occur with multiple conditions, such asstroke, heart failure, and osteoarthritis. The best exampleof this loss is the ability to transfer between bed and walkeror wheelchair to do ADLs of toileting, bathing, meals, andsocial interaction within the older adult’s living environment.Physical therapy aimed at maintaining and improvingmuscle strength with daily exercise is the cornerstoneof this area of risk reduction. Routine encouragement ofexercises such as partial deep knee bends and arm dipsthat use muscles that enable movement from bed or wheelchairfor transfers to the walker or tripod cane and walkingas permitted with assistance can help to “retrain” deconditionedleg and arm muscles. An elevated toilet seator plastic piece that fits on the seat and elevates the seat8 to 12 inches can help to increase the safety of transfersfor toileting. (For references and resources to address thisarea, see Appendix 1 in the electronic version of this article,available online at www.japha.org.)(2) Medication management. The need for a comprehensiveevaluation of all medications both before and especially aftereach fall is the main emphasis of this article. 1 –55(3) Home/room safety. A simple evaluation is required of theareas contacted by patients in their homes or in long-termcare facilities to ensure safe transit and support. Looserugs should be removed, and handrails to support the patientin bathrooms and walking around quarters and bedsshould be installed. Adequate lighting and floors that allowgood traction with shoes or slippers are also important tohome/room safety (online Appendix 1).(4) Environmental (community) safety. The patient andcaregiver must have a means of contact with the outsideworld. This could be achieved with a call button or radioLearning objectives■■ State the causes and risk factors for falls.■■ List medications implicated in both increasing and reducing fall risk.■■ Describe a fall risk assessment method.■■ List approaches and medication alternatives for reducing fall risk.■■ Describe how the pharmacist may offer medication assessment to assist prescribers and patients in determining whether theirprescription and nonprescription drugs may be increasing or decreasing fall risk.ACPE Activity Type: Knowledge-BasedJournal of the American Pharmacists Association www.japha.org M a y /Ju n 2009 • 49:3 • JAPhA • e71
Reviews Fall prevention in older adultsdevice that summons help when one is unable to ambulateor needs assistance. A cell phone kept on the patient is anothersimple method for letting caregivers know that helpis needed (online Appendix 1).Comprehensive strategyA comprehensive fall-reduction strategy that addresses allfour of the above areas can be effective. However, many previousefforts have been hampered by several factors:(1) Failure to consider all possible causes of falls, especiallymedications and the need for physical assistance to improvestrength and ambulation ability.(2) Failure to translate research into practice, especially whenmedications are concerned. (This article concentrates onremedying this apparent failure.)(3) Lack of coordination among interested but disparate organizationsthat support the older adult and their caregivers.(4) Minimization and trivialization of the issue, sometimesthrough media images casting older people as powerlessand pathetic (e.g, the “I’ve fallen and I can’t get up” commercials).(5) Scarcity of approaches that are culturally sensitive and appropriatefor older adults of all literacy levels. Adult daycareand senior centers, as well as assisted-living and personalcare facilities, are ideal locations for training bothpatients and caregivers to decrease fall risk. Online Appendix1 has numerous resources that document these factorsand can aide educational efforts.Numerous studies show the benefit of multifactorial fallrisk interventions and improved outcomes with comprehensivestrategy implementation, and guidelines for fall preventionhave been published. 35–43Psychoactive drug medication interventions are limited bythe lack of validation of currently available assessment instruments;most falls are caused by multiple risk factors that alsoshould be taken into account but are not covered in this review(e.g., gait assessment, strength training, environmental assessmentand changes). Online Appendix 1 lists resources thatmay be of value in fall risk-reduction educational programs.Fall risk assessment methodsFalls in the older patient clearly lead to increased healthcare use and decreased functional status. 1 A fall risk indexbased on the number of chronic disabilities has been advocated.2 Earlier studies of fall factors, incidence, and morbidityfound that those who sustained falls were more likely to be sufferingfrom dementia, were prescribed more sedating drugs,and had abnormal balance and gait compared with age- andsex-matched control patients. In addition, orthostasis, arthritides,incontinence, and strokes were more prevalent in thesepatients. 3–5 A fall risk assessment that incorporates psychotropicand other psychoactive medications has been developed(Figure 1), 6 and medications implicated in falls have beendescribed. 7 A multifactorial intervention to reduce the risk offalling among the elderly living in the community has been developed.8Basic patient assessment method for pharmacistsThe pharmacist may benefit from using a universal problem-orientedmedical record (POMR) or medication therapymanagement (MTM) method to assess and recommendchanges in the patients’ drug regimen 51 as well as physical andlaboratory assessments that may be needed to optimize drugtherapy. We developed an online 15-hour (1.5–continuing educationunit) course on physical and laboratory assessment ofthe older adult; it is available at www.rxugace.com or www.shca-ga.org.The POMR method has four steps:(1) Perform a history of patients problems, including past andcurrent diagnoses, conditions, all medications, past operations,immunizations, and adverse drug reactions, as wellas abnormal physical and lab findings that need to be addressed.Some practitioners prefer to group problems byorgan system (e.g., cardiovascular, endocrine, pulmonary,gastrointestinal, genitourinary, neuropsychiatric, dermatologic).(2) Match the medications found with the problems list; actionmay be needed if there are medications or problems that donot match or are not addressed.(3) Assess how adequately each problem is being addressedby using the SOAP method for each problem: subjective (S)or complaints of the patient; objective (O) or things thatcan be assigned numerical values such as physical findingsof the vital signs of blood pressure, pulse, respiration,and temperature and lab values; assessment (A) of S and Ofindings for each problem; and plan (P) for communicationof the assessment of each problem.(4) Communication of the problems that need to be addressedto the appropriate prescriber, patients and their caregivers,and administrators responsible for the patient is themost important step of the process.The POMR process may be thought of as a part of the MTMprocess. The American Pharmacists Association (APhA) andNational Association of Chain Drug Stores released version 2.0of an MTM service model, which can be downloaded at www.nacdsfoundation.org, and a certificate training program developedby APhA and the American Society of Consultant Pharmacistsis available at www.pharmacist.com.DefinitionsPsychotropics are defined as anxiolytics, hypnotics, antipsychotics,and antidepressants. Psychoactives or central nervoussystem (CNS)-active agents include psychotropics and theprokinetic agent metoclopramide, narcotic or opioid analgesics,antiparkinson agents, anticonvulsants, muscle relaxants,antihistamines, and centrally acting antihypertensives. 7A patient’s total psychoactive drug load is best definedas the total number of psychotropic and other psychoactivemedications given on a regular (i.e., at least weekly) basis. Asneededmedications given on a less-than-weekly basis may beconsidered relevant if their usage occurred within 1 week of afall and the drugs involved were antipsychotics or longer-actingbenzodiazepines (BZs). 7e72 • JAPhA • 49:3 • M a y /Ju n 2009www.japha.orgJournal of the American Pharmacists Association
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