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

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Fall prevention in older adults Reviewsa. Acetaminophen alone on a regular or as-needed scheduleb. Hydrocodonec. Tramadold. Fentanyl3. In place of her zolpidem, you recommend which ofthe following?a. No naps after mealsb. Activities to prevent sleep after mealsc. If zolipdem is needed, hold until 11:00 pm to midnightd. All of the above alternatives are correct.4. If the patient had been taking other psychotropicmedications such as anxiolytics and/or antipsychotics,her fall risk could be decreased by which of thefollowing?a. Abruptly stopping all psychotropic drugsb. Stepwise discontinuance of her psychotropic drugs(i.e., one drug at a time)c. Careful tapering of each psychotropic drug to avoidwithdrawal reactionsd. Alternatives b and c are correct.Answer key: 1. d; 2. a; 3. d; 4. dEvidence for medication association withfalls and fracturesA study of physical and pharmacologic “restraint” of 307nursing home patients with dementia showed that 43% to 45%of residents received medications that could be viewed as pharmacologicrestraints. Residents with physically abusive behavior,infrequent family visits, and severe cognitive impairment(i.e., lack of recall or orientation to time, place, or person) weremore likely to receive pharmacologic restraints. 9 An earlier1-year study of 33,351 Illinois nursing home residents foundthat 60% received at least one psychotropic medication duringthat year. 10 In 4,501 cases of hip fracture among ambulatorypatients 65 years of age or older, 11 BZs with a longer half-lifehave been associated with a greater risk of falls and hip fracturecompared with BZs with a shorter half-life.Self-assessment questions5. The nursing home patient with which of the followingmay be more likely to receive pharmacologic “restraints”with psychotropics?a. Physically abusive behaviorb. Infrequent family visitsc. Severe cognitive impairmentd. All of the above alternatives are correct.6. Severe cognitive impairment may involve lack of patientrecall or orientation to which of the following?a. Timeb. Placec. Persond. All of the above alternatives are correct.Answer key: 5. d; 6. dBoth long- and shorter-acting BZs markedly increase therisk of falls. Serum diazepam blood levels have been directlycorrelated with the incidence of falls. 12 Even shorter-actingBZs (e.g., triazolam, oxazepam) given more often than one totwo times per week have been associated with increased fallrisk. 13 A study of the sensitivity of elderly individuals to triazolamfound that pharmacokinetic rather than pharmacodynamicdifferences between older and younger patients explained thegreater sensitivity to the drug. Peak serum triazolam concentrationwas approximately 50% higher and triazolam clearance50% lower in the elderly versus the younger group of patients. 14Both antipsychotics and antidepressants also have been shownto increase fall risk. 15 An association between antihistamines,narcotic analgesics, anticonvulsants, metoclopramide, antihypertensives,and falls in those taking other multiple psychoactive(i.e., both with and without psychotropics) medicationsalso has been reported. 16–20 The risk of falls is doubled for eachpsychotropic added to the patient’s drug regimen, both with andwithout other psychoactive medications (e.g., antihistamines,narcotic analgesics, anticonvulsants, metoclopramide, antihypertensives).24–28Self-assessment questions7. Both long- and shorter acting BZs have been shownto increase fall risk.a. Trueb. False8. Fall risk has been shown to be increased by both singleand multiple agent use of which of the following?a. Anxiolyticsb. Antipsychoticsc. Antidepressantsd. All of the above alternatives are correct.9. Fall risk has been shown to be increased by which ofthe following?a. Single psychoactivesb. Multiple psychoactivesc. Alternative a or b is correct with or without psychotropicdrugs.d. All of the above alternatives are correct.10. Fall risk increases by roughly how much for each psychotropicadded to a patients drug regimen?a. One-halfb. Two timesc. Three timesd. Four timesAnswer key: 7. a; 8. d; 9. d; 10. bMedication interventions and fallsBeneficial changes in psychotropic medications 17 and themultidisciplinary interventions of nurses, consultant pharmacists,and attending clinicians to reduce falls, injuries, andJournal of the American Pharmacists Association www.japha.org M a y /Ju n 2009 • 49:3 • JAPhA • e75
Reviews Fall prevention in older adultscosts 18–20 are also important means of fall prevention. In onestudy, buspirone intervention in place of BZs and/or antipsychotics,careful drug withdrawal by stepwise discontinuancewith tapering of 10% to 25% of the dose per week, or both alsohave been shown to decrease falls by 70% and improve cognitioncompared with similar patients. 17 The provisions of theOmnibus Budget Reconciliation Acts of 1987 and 1990 on appropriateuse of psychotropic drugs in the United States mandateat least two to three tapering attempts of anxiolytics andantipsychotic psychotropics within the first 6 to 12 months ofplacement within a nursing facility. Effective October 1, 2008,Medicare no longer reimburses for falls occurring in acute caresettings, as a “hospital-acquired condition.” 21 The newest Centersfor Medicare & Medicaid Services (CMS) guidelines stressthe need for gradual reduction of all psychotropic medicationdoses, including buspirone, unless patient dementia or otherneuropsychiatric illness worsens during attempts at tapering.Examples of the concept of adverse effects on rapid or suddenversus gradual drug withdrawal include seizures with BZs, tardivedyskinesia or return of schizophrenia signs and symptomswith antipsychotics, and serotonin syndrome and worsening ofdepression with rapid withdrawal of antidepressants. See www.cms.hhs.gov for the latest CMS guidelines for medications.A meta-analysis of 57 studies on the contribution of psychotropicdrugs to falls in older patients concluded that a small butconsistent association exists between the use of most classesof drugs and falls. The meta-analysis did not consider or defineinappropriate polypharmacy. 22 Falls were second only to nonsteroidalanti-inflammatory drug (NSAID) adverse drug reactionsas causes for adverse drug reaction hospitalizations fromthe long-term care facility. 23 A 1966–1999 review of psychotropicsand falls suggested that all psychotropics may increase therisk of falls and that each additional agent may increase theoverall risk by a factor of 2.0 per psychotropic. 24 A communitybased6-month study of 305 male veterans (age 70–104 years)using psychoactive CNS-active medications were screenedat study entry for mobility, cognition, and depression. CNSactivemedications were categorized as BZs, other sedative–hypnotics, neuroleptics, tricyclic antidepressants, and opioidanalgesics. Patients were prospectively followed for 6 monthsto monitor falls; at the end of this time period, patients wereclassified as fallers (at least one fall) or nonfallers. The relationshipbetween CNS-active drug use and falls was examinedusing multivariable analyses. The risk of falls was significantlygreater in CNS-active medication users compared with nonusers.Adjusted odds ratio (OR) was 1.54 (95% CI 1.07–2.22)for one CNS-active drug and 2.37 (1.14–4.94) for two or moreagents. In community-dwelling elderly, use of multiple CNS-activemedications is associated with enhanced fall liability comparedwith use of one CNS-active drug. 25Inappropriate polypharmacy and multiplepsychoactive drugsMultiple psychotropic and psychoactive drugs should betaken into account when fall interventions are evaluated, andreduction in total psychotropic and psychoactive drug load mayreduce fall occurrence and recurrence. 26–28 Simply put, eachadditional psychotropic doubled the rate of falls, as suggestedby an earlier review 24 and research. 26–28 An earlier study in thispopulation indicated that those who had psychotropic drugs tapered,changed to other agents, and/or discontinued had fewerfalls and injuries and less cognitive decline over 1 year. 17 A differencewas observed in the mean Reisberg global deteriorationscale 29 in those with a diagnosis of dementia between usersof psychotropic drugs (5.8 on 7-point scale) and those taperedto nonuse of psychotropic drugs (4.7) in the groups at the beginningof the study. 17The most recent finding is that all causes of hospitalizationof the older adult from long-term care are directly proportionalto the total psychoactive drug load. 28 The recent black boxwarning relabeling of all antipsychotics states that this classof medications should not be used for long periods in patientswith dementia because of greater risk of death—more evidencethat these drugs have high risk for the older adult. Pharmacistsshould review these black box warnings on antipsychotic packageinserts and patient education materials or at the Food andDrug Administration drug safety website (www.fda.gov/medwatch/safety).Anemia and vitamin D deficiency and fallsIn community-dwelling elderly, anemia is associated witha number of health-related functional declines, such as frailty,disability, and muscle weakness. These may contribute to falls,which, in the elderly, result in serious injuries in perhaps 10%of cases. Whether anemia increased the risk of injurious falls inan elderly population was investigated using health insuranceclaims and laboratory test results data from January 1999 toApril 2004 for 47,530 individuals 65 years of age or older enrolledin more than 30 managed care plans. 45Anemia in nursing home residents appears to be underrecognized.For residents older than 70 years, the prevalence ofanemia in one study for both men (Hb
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