1. Falls and Medications Jane R. Mort, Pharm.D. - Professor of Clinical Pharmacy - - Professor of Clinical Pharmacy - South Dakota State University - South Dakota Foundation for Medical Care -

2. Falls and Medications Objectives: Describe consequences of and risk factors for falls. Describe consequences of and risk factors for falls. Identify medications that increase the risk of falls. Identify medications that increase the risk of falls. Describe how medications increase the risk of falls. Describe how medications increase the risk of falls. Utilize a systematic approach to evaluate a resident’s fall. Utilize a systematic approach to evaluate a resident’s fall.

3. Falls Frequency 1/3 elderly in community fall 1/3 elderly in community fall 50% of nursing home residents fall 50% of nursing home residents fall

4. Falls Consequences Consequences Serious injuries – 5-10% Serious injuries – 5-10% Hip fractures Hip fractures Some lack full recovery Some lack full recovery Death Death Repeated falls Repeated falls Disability Decreased quality of life Nursing home placement Cost Death

5. Factors Leading to an Increase Risk of Falls Host factors Visual impairments Visual impairments Postural hypotension Postural hypotension Syncope Syncope Lower Extremity Dysfunction Lower Extremity Dysfunction Hypothyroidism Hypothyroidism Nocturia Nocturia

6. Factors Leading to an Increase Risk of Falls Host factors Osteoporosis Osteoporosis Dizziness Dizziness Drop Attacks Drop Attacks Confusion Confusion Gait Problems Gait Problems

7. Factors Leading to an Increase Risk of Falls Environment Poor Lighting Poor Lighting Objects on the Floor Objects on the Floor Unstable Furniture Unstable Furniture Stairs without Railings Stairs without Railings Low Beds or Toilets Low Beds or Toilets

8. Most Common Causes of Falls Nursing Home Gait, Balance, Strength – 26% Gait, Balance, Strength – 26% Dizziness – 25% Dizziness – 25% Environment – 16% Environment – 16% Community Environment – 41% Gait, Balance, Strength – 13% Drop Attacks – 13%

9. How Medications May Precipitate a Fall Postural Hypotension Postural Hypotension Muscle Coordination Problems Muscle Coordination Problems Sedation Sedation Confusion Confusion Dizziness Dizziness

10. Antidepressants Odds Ratio – 1.7 Odds Ratio – 1.7 Tricyclic Antidepressants (TCAs) vs Selective Serotonin Reuptake Inhibitors (SSRIs) Tricyclic Antidepressants (TCAs) vs Selective Serotonin Reuptake Inhibitors (SSRIs) 2.0 vs 1.8 2.0 vs 1.8 Reasons for the findings Reasons for the findings

11. Benzodiazepines Odds Ratio – 1.5 Odds Ratio – 1.5 Mechanism Mechanism Drowsiness Drowsiness Dizziness Dizziness Confusion Confusion Impaired Coordination Impaired Coordination Long versus Short Half-life Agents Long versus Short Half-life Agents

12. Antipsychotic Agents Odds ratio – 1.5 Odds ratio – 1.5 Mechanism Mechanism CNS Depressant Effects CNS Depressant Effects Movement Disorders Movement Disorders

13. Antihypertensive Agents Studies have reported conflicting results Studies have reported conflicting results Mechanism Mechanism Dizziness Dizziness Postural hypotension Postural hypotension Syncope Syncope Fatigue Fatigue Decreased Cerebral Blood Flow Decreased Cerebral Blood Flow

14. Antihypertensive Agents Diuretics Odds Ratio – 1.8 Odds Ratio – 1.8 Mechanism Mechanism Orthostatic Hypotension Orthostatic Hypotension Volume Depletion Volume Depletion Electrolyte Abnormalities Electrolyte Abnormalities Calcium Channel Blockers Odds Ratio – 1.8-2.0 Mechanism: Hypotension Fatigue Muscle Weakness Dizziness Arrhythmia

15. Cardiovascular Agents Antiarrhythmics OR – 1.6 OR – 1.6 Mechanism Mechanism Due to medications or underlying arrhythmia? Due to medications or underlying arrhythmia? Digoxin OR – 1.2 – 2.2 Mechanism Underlying disease Weakness Visual disturbances Arrhythmias

16. Pain Medications Narcotics Odds Ratio Odds Ratio Mechanism Mechanism CNS Depression CNS Depression Orthostatic Hypotension Orthostatic Hypotension Dizziness Dizziness NSAIDs Odds Ratio – Insignificant Possible Mechanisms Dizziness Confusion Mood changes GI toxicity

17. Polypharmacy Number of Medications Associated with an Increased Risk Number of Medications Associated with an Increased Risk 1 med – 1.4 1 med – 1.4 2 meds – 2.2 2 meds – 2.2 3 meds – 2.4 3 meds – 2.4 Mechanism Mechanism Additive Effect Additive Effect Compliance Problems Compliance Problems Indicates More Conditions Indicates More Conditions

18. Assessing the Role of Medications in Falls RAP Multiple falls? Multiple falls? Internal Risk Factors Internal Risk Factors Cardiovascular Cardiovascular Neuromuscular/Functional Neuromuscular/Functional Orthopedic Orthopedic Perceptual Perceptual Psychiatric or Cognitive Psychiatric or Cognitive

19. Assessing the Role of Medications in Falls RAP External Factors External Factors MEDICATIONS MEDICATIONS Prior to or after the fall? Prior to or after the fall? If prior, how close was it administered to the fall? If prior, how close was it administered to the fall? Appliances and devices Appliances and devices Environmental/Situational Hazards Environmental/Situational Hazards Vital signs Vital signs Things to do for those at risk for future falls Things to do for those at risk for future falls

20. Medications in susceptible residents may increase the risk of falls. It is important to recognize the risk associated with the use of these medications and adjust therapy as necessary to prevent a fall.