Identifying Fall Risk: Strategies to Prevent Falls

Identifying Fall Risk: Strategies to Prevent Falls

Teri Hecht, R.PhBoard Certified Geriatric PharmacistSeptember 18, 2020

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Learning Objectives

• Identify potential fall risk factors• Determine high risk medication that

may contribute to falls• Implement key fall interventions• When to refer to pharmacist for review• Use national fall prevention programs

to assist with patient/family education

What is the leading cause of fatal and non-fatal injury among adults 65 years of age and older?A. Motor vehicle accidentsB. SuffocationC. FallsD. Fires/burns

Huge impact on quality of life

Among people who fall, less than half talk to their healthcare provider about it.

Resources for Fall Prevention

• https://www.cdc.gov/steadi/materials.html

Additional resources available at www.cdc.gov/steadi/patient.html.

ncoa.org/healthy-aging/falls-prevention/falls-prevention-awareness-day/general-resources/infographics-handouts/

▪ 6 Steps to Prevent a Fall infographic and video▪ 6 Steps to Protect Your Loved One from a Fall▪ Winterize to Prevent Falls▪ Osteoporosis and Falls▪ Osteoarthritis and Falls▪ Myths about Falls▪ All available at no cost:

www.ncoa.org

National Council on Aging Resources and Handouts

Dizziness

/Vertigo

Cardiovascular disease

Neurological condition

Medical Conditions

Vision/hearing Impairment

Peripheral Neuropathy

Proprioception

Impaired Sensory

Muscle weakness

Gait & balance disturbance

Decreased body weight

Age related Changes

Intrinsic Risk Factors

Intrinsic Risk Factors

Demographic

Age Gender Race

Medications PersonalFactors

Environmental Hazards

High Risk Medication Ill fitting footwear Throw rugs

Polypharmacy Inappropriate walking aids

Poor Lighting

Medications Nocturnal Voiding Electrical Cords

Extrinsic Risk Factors

Medication and Fall Risk “FRID’s”

•Psychotropics

•Anti-diabetic

•Opioid analgesics

•Cardiovascular agents

•Antiepileptics

•Antidepressants

■ Anticholinergics: oxybutynin, amitriptyline, diphenhydramine.■ Antihistamines: hydroxyzine■ Medications impacting blood pressure: doxazosin■ Muscle relaxants: cyclobenzaprine, methocarbamol

30% lower risk for stroke

21% increased

risk for falls

Cardiovascular Medication Use: RISK VS BENEFIT

Mrs. Doubtfire is 81 year old female

Case Study

Mrs. Doubtfire is an outgoing 81-year-old Caucasian womanShe lives in an assisted living community. Her son reports that she was just seen in the hospital’s emergency room a week ago because she fell when she was getting out of the shower. Mrs. Doubtfire has a history of hypertension, hyperlipidemia, diabetes, CAD, and CHF.

Her Son indicates she has had “too manyfalls to count.” Mrs. Doubtfire agrees that she falls a lot, but she’spessimistic. “Old people fall, that’s just how it is,” she says.

MEDICATION LIST:Lantus 20 units subcutaneously at bedtimeLisinopril 20 mg dailyMetoprolol Succinate ER 200 mg dailySpironolactone 12.5 mg dailyFurosemide 20 mg dailyPotassium Chloride 20 mEq dailyDigoxin 125 mcg dailyFluoxetine 40 mg dailyClonazepam 1 mg qhs as needed for sleepAtorvastatin 10 mg at bedtimeAspirin 81 mg dailyVITALS: Supine – 129/53, 59; Sitting – 103/40, 60; Standing –101/51, 62.

SAFE Medication Review FrameworkA Team-based Approach Use this framework to conduct a medication review to help prevent older adult falls.

SScreen for medications that may increase fall risk.

AAssess the patient to best manage health conditions.

FFormulate the patient’s medication action plan.

EEducate the patient and caregiver about medication changes and fall prevention strategies.

2016

Formulate the patient’s medication action plan.

■ Stop medications when possible

MEDICATION LIST:Lantus 20 units subcutaneously at bedtimeLisinopril 20 mg dailyMetoprolol Succinate ER 200 mg dailySpironolactone 12.5 mg dailyFurosemide 20 mg dailyPotassium Chloride 20 mEq dailyDigoxin 125 mcg dailyFluoxetine 40 mg daily

Clonazepam 1 mg qhs as needed for sleepAtorvastatin 10 mg at bedtimeAspirin 81 mg dailyVITALS: Supine – 129/53, 59; Sitting – 103/40, 60; Standing –101/51, 62.

■ Switch to safer alternatives

Formulate the patient’s medication action plan.

MEDICATION LIST:Lantus 20 units subcutaneously at bedtimeLisinopril 20 mg dailyMetoprolol Succinate ER 200 mg dailySpironolactone 12.5 mg dailyFurosemide 20 mg dailyPotassium Chloride 20 mEq dailyDigoxin 125 mcg daily

Fluoxetine 40 mg dailyClonazepam 1 mg qhs as needed for sleepAtorvastatin 10 mg at bedtimeAspirin 81 mg daily

Formulate the patient’s medication action plan.

MEDICATION LIST:Lantus 20 units subcutaneously at bedtimeLisinopril 20 mg dailyMetoprolol Succinate ER 200 mg dailySpironolactone 12.5 mg dailyFurosemide 20 mg dailyPotassium Chloride 20 mEq dailyDigoxin 125 mcg dailyFluoxetine 40 mg dailyClonazepam 1 mg qhs as needed for sleepAtorvastatin 10 mg at bedtimeAspirin 81 mg daily

Educate the patient and/or

caregiver about medication changes and fall prevention strategies. Discuss the following:■ Reasons for medication changes■ Steps for implementing action plan ■ Other approaches to reduce fall risk ■ Importance of referrals to specialists such as PT/OT/vision check

1 Have the patient lie down for 5 minutes.2 Measure blood pressure and pulse rate.3 Have the patient stand.4 Repeat blood pressure and pulse rate measurementsafter standing 1 and 3 minutes.

MeasuringOrthostaticBlood Pressure

A drop in BP of ≥20 mm Hg, or in diastolic BP of ≥10 mm Hg, orexperiencing lightheadedness or dizziness is considered abnormal.

Who Has High Risk for Falls??

•Time frame of 1 month post hospital discharge

•Suffered a fall within past 12 months

•Diagnosed as a frail individual

•Acute illness

•Exacerbations of chronic illness

Identify and address fall risk factors

Refer as needed to specialists or community programs

Follow up with patient in 30 days

KEY STEPS FOR FALL PREVENTION

KEY FALL INTERVENTIONS

• Add Vitamin D supplementation• Modify medication• Manage hypotension• Prevent hypoglycemia • Address foot and vision problems• Enhance strength and balance• Educate patient and family• Optimize safety

Involve Your Consultant Pharmacist

• Provide a list of residents who have suffered a fall prior to each MRR

• Invite the consultant pharmacist to routine fall review meetings

• Request a medication review after a fall

• High risk resident with history of falls and complicated regimen

“Any new symptom in an older patient should be considered a drug side effect until proven otherwise”

Questions?

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[email protected]

(425) 308-0400

Sources

• www.cdc.gov/steadi• ncoa.org/healthy-aging/falls-prevention/falls-prevention-

awareness-day/general-resources/infographics-handouts/• https://www.medscape.com/viewarticle/841020• https://www.medscape.com/viewarticle/831517• https://www.youtube.com/watch?v=o54v_tuEvpw• JAMA Intern Med. 2015; 175 (3): 450-452