9/19/2014 1 Workshop 4: Preventing Falls through Medication Vigilance Nancy L. Losben, R.Ph., CCP, FASCP, CG Chief Quality Officer Omnicare, Inc. & Diane C. Vaughn, RN, C-DONA/LTC, LNHA VP, Clinical Services Benedictine Health System Goals Describe how medication risk awareness is involved with the HATCh model Identify the effect falls have on the elderly Describe common pharmacologic issues and meds that contribute to falls
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9/19/2014
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Workshop 4: Preventing Falls through Medication
Vigilance Nancy L. Losben, R.Ph., CCP, FASCP, CG
Chief Quality OfficerOmnicare, Inc.
&Diane C. Vaughn, RN, C-DONA/LTC, LNHA
VP, Clinical ServicesBenedictine Health System
Goals
� Describe how medication risk awareness is involved with the HATCh model
� Identify the effect falls have on the elderly
� Describe common pharmacologic issues and meds that contribute to falls
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Holistic Approach to Transformation Change Model
(HATCh) � Six Competency Domains
� Care Practices
� Competency 1.1Demostrate an Understanding of risks that lead to falls� 1. Identify Medications that May Contribute to Falls and
Fall Risk
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Competency-Based Education(CBE)
“… ‘a cluster of related knowledge, skills, and attitudes that affects a major part of one’s job (a role or responsibility), that correlates with performance on the job, that can be measured against well-accepted standards, and that can be improved via training and development.”
� Training focuses on learning desired outcomes
� Design makes statements of observable and measurable behavior
� Staff must have the necessary knowledge, skill and attitude to attain the highest level of performance.
Competency Based Education
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Background
� 2nd most common adverse event
� Occur in 30-60% of the older adults / year
� 10-20% result in serious injury, hospitalizations, and / or death
� 10% of ER and 6% of hospitalizations >65 YO
� Falls are the leading cause of injuries in older adults
Medications
� 32,000 Seniors Suffer Hip Fractures Caused By Medications
� 20% Will Die Within 5 Years
� On average, individuals 65 to 69 years old take nearly 14 prescriptions per year, individuals aged 80 to 84 take an average of 18 prescriptions per year
� ≥ 4 medications is considered a falls risk
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Falls Risk Factors
� Weakness
� Unsteadiness
� Confused State
� Sleep Quality
� Medications
Medications and Falls
� Common Pharmacologic Mechanisms:� Orthostatic hypotension
� Dizziness
� Decreased postural reflexes
� Extrapyramidal symptoms
� Myorelaxant effects
� Visual impairment
� Impaired cognition / CNS effects
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AHCA/NCAL Webinars
Preventing Falls through Medication Vigilance
Nancy L. Losben, R.Ph., CCP, FASCP, CG
Chief Quality Officer
Omnicare, Inc.
Objectives
� To recognize the medication regimen as a risk for safety and falls.
� To identify the timeframe when a resident is at his/her highest risk to fall after a change in in the medication regimen.
� To enhance and coordinate safety and quality improvement activities.
12Fall Prevention
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Centers for Disease Control and Prevention
5% of adults 65 and older live in nursing homes but 20% of deaths from falls (1,800 yearly) Up to 20% of falls cause serious injuries
Reasons for falls in LTF facilities: frailty, chronic conditions, gait disturbances, memory problems, ADL decline, medications
Fall risk is significantly elevated during the 3 days following any drug that affects the central nervous system
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Any one of these medication related problems (MRP) can increase the risk
for falling
� Drowsiness
� Dizziness
� Low blood pressure
� Low heart rate
� Parkinson’s effect
� Ataxia/gait disturbance
� Vision disturbance
� Low blood sugar
� Urinary urgency
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Adverse Consequences
� Some adverse consequences occur quickly or abruptly, while others are more insidious and develop over time.
� Adverse consequences may become evident at any time after the medication is initiated, e.g., when there is a change in dose or after another medication has been added.
� When reviewing medications used for a resident, it is important to be aware of the medication’s recognized safety profile, tolerability, dosing, and potential medication interactions.
� Although a resident may have an unanticipated reaction to a medication that is not always preventable, many ADRs can be anticipated, minimized, or prevented.
In theory, any medication, or a lack of one, can be the underlying cause of a fall.
� But do you know which medications are most likely to increase the risk of falling?
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Medication Categories Recognized asRisks for Falling
� Routine, seldom PRN � Lowest Possible Dose� Recent Dose Increase or Reduction� Extrapyramidal Side Effects� Blurred Vision� Lethargy � Somnolescence� Is it efficacious?
21Fall Prevention
Anxiolytics
� Routine vs. PRN orders� Short acting benzodiazepines preferred� Lowest possible dose� Recent dose increase or reduction� Lethargy� Efficacy
22Fall Prevention
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Hypnotics
� Routine Vs. PRN
� Short Acting Benzodiazepines or newer non-benzodiazepines
� Given while in bed
� Used no more than 10 consecutive days or manufacturer’s suggested direction
� Morning functionality/hangovers
� Falls out of bed
23Fall Prevention
Antidepressants
� Tricyclic's
� Highly anticholinergic
� Blurred Vision
� Confusion
� Changes in heart rate
� Restlessness, sleeplessness
� Drug Interactions
� SSRI’s and SSNRI’s have a better safety profile
24Fall Prevention
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Muscle Relaxants and Antiparkinson Drugs
� Muscle weakness
� Central nervous system effects
� Behavioral symptoms
� Temporal relationship to administration and ADL performance
25Fall Prevention
Laxatives
� Cathartics/bowel urgency
� Electrolyte imbalance
� Tolerance, Impaction
� Toileting plan
� Opioid therapy and anticholinergics can cause constipation
26Fall Prevention
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Pain Medications
� Opioids
� Risk vs. Benefit� Drowsiness/dizziness Vs. Relief
� Constipation Vs. Mobility
� Non-steroidal anti-inflammatory drugs
� GI effects
� Confusion, other CNS effects
27Fall Prevention
Anticholinergic Medications
� Medications that could affect function, level of consciousness, gait, balance, visual acuity, or cognitive ability,
� Causing symptoms such as dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium, excitability, memory loss, unsteadiness, dizziness, or hallucinations.
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Anticholinergic Effect
“Blind as a bat. Mad as a hatter, red as a beet, hot as Hades, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone."
� The first 72 hours following modification of any of these medications is the timeframe of highest risk to fall� Alert care staff to any affected resident with a change in
their medication regimen to a higher risk of fall� Focus on residents who are usually independent in ADL’s� Remind residents to rise slowly� Temporarily use a gait belt� Monitor blood pressure daily� Observe and document the resident’s response to the
medication� Report findings to the physician and and pharmacist
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Sometimes, adding a medication to a resident’smedication regimen can help to reduce falls and
minimize injuries.
Unmanaged Pain as a Risk for Falls
� Residents in pain will likely avoid painful stimulus by sitting and lying down
� Increases the risk of fall as a result of deconditioning
� Residents in pain will also attempt to change position to find a more comfortable state