1. + Finding Balance: Preventing Medication Related Falls Through Appropriate Medication Use Chanel F. Agness, PharmD, Certified Geriatric Pharmacist cagness@rx.umaryland.edu Stephanie Callinan, PharmD, Geriatric Pharmacy Resident scallinan@rx.umarylande.edu

2. + High Risk Medications in Older Adults Review age-related changes and medication properties that increase the risk of falls in older adults Describe potential adverse effects of at least 2 classes of medications associated with falls in older adults. Medication Review Process Assess medication-related fall risk and recommend fall prevention strategies Session Objectives

3. + High Risk Medications in Older Adults

4. + How the Body Processes a Drug A: Absorption D: Distribution M: Metabolism E: Elimination

5. + Age Related Changes in Distribution Decrease in total body water Monitor water soluble medications Digoxin, lithium Body fat increases and lean muscle mass decreases Lipophilic medications have a longer half life in older adults Long acting benzodiazepines (Diazepam)

6. + Age Related Changes in Metabolism Reduced liver size and decreased blood flow to liver Liver metabolic enzymes function adequately even in the very old

7. + Age Related Changes in Elimination Decline in kidney function Medications that are eliminated through the kidneys can accumulate Morphine Glyburide Digoxin Many others

8. + High Risk Medications in Older Adults Medication classes commonly implicated in falls:  Sedative/hypnotics  Antipsychotics  Antidepressants  Anticholinergics  Cardiac medications  Pain medications  Anticonvulsants Older adults are at increased risk of experiencing medication adverse events, including falls related to changes in drug processing in the body.

9. + Sedative/Hypnotics Cognitive impairment, delirium, sedation Possible adverse events Non-benzodiazepine hypnotics: Zolpidem, Eszopiclone, Zaleplon Benzodiazepines: Diazepam, Clonazepam, Alprazolam, Lorazepam Examples

10. + Antipsychotics Ataxia, impaired psychomotor function, and syncope Olanzapine can cause orthostatic hypotension Possible adverse events Haloperidol, Olanzapine, Quetiapine, Aripiprazole Examples

11. + Antidepressants Ataxia, impaired psychomotor function, and syncope Possible adverse events Fluoxetine, Sertraline, Citalopram, Paroxetine Examples

12. + Anticholinergics Sedation, confusion, hypotension, delirium Possible adverse events Tricyclic Antidepressants: Amitriptyline, Nortriptyline OTC Antihistamines: Diphenhydramine, Chlorpheniramine, Hydroxyzine Examples

13. + Cardiac Medications Hypotension, dizziness Possible adverse events Beta blockers Nitrates Diuretics Digoxin Examples

14. + BPH/Urinary Retention Medications Orthostatic hypotension Possible adverse events Terazosin, Doxazosin, Prazosin Examples

15. + Pain Medications Dizziness, syncope, CNS depression Possible adverse events Opioids: Morphine, Hydromorphone, Fentanyl, Oxycodone Examples

16. + Anticonvulsants Ataxia, impaired psychomotor function, syncope Possible adverse events Gabapentin, Levetiracetam, Phenytoin, Valproate Examples

17. + Summary Age related changes in drug disposition can increase older adults risk of falls Several classes of medications increase the risk of falls and should be used cautiously in older adults.

18. + Medication Review Process

19. + Medication Reconciliation Adherence Medication Review “Red Flag Medications” Assess Fall Risk Optimize Regimen Education Fall Prevention Medication Review Process

20. + Fall Prevention Strategies/Education Identify potentially inappropriate “Red flag” medications Up to date medication list/Adherence

21. + Medication Reconciliation: Up to Date Medication List/Adherence Medicines and You: A guide for older adults. http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm

22. + Medication Review Process Fall Prevention Strategies/Education Identify potentially inappropriate “Red flag” medications Up to date medication list/Adherence

23. + AGS Beers Criteria Classifies “potentially inappropriate” medications in older adults by: Table 1 Organ system/Category of Drugs Table 2 Disease or Syndrome (by organ) Table 3 Specific drugs, use with caution AGS Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society. http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdfhttp://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf

24. 3I: Medication/Fall Risk Score Tool 3I: Medication fall risk score and evaluation tools. Agency for healthcare research and quality. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html Point ValueMedicine ClassPotential side effects 3 (High)Analgesics/opiates, antipsychotics, anticonvulsants, benzodiazepines, non- benzodiazepine sedatives*, hypoglycemics* Sedation, dizziness, postural disturbances, altered gait and balance, impaired cognition 2 (Medium)Antihypertensives, cardiac drugs/antiarrhythmics, antidepressants Induced orthostasis, confusion, poor health status 1 (Low)DiureticsIncreased ambulation, induced orthostasis Score > 6Higher risk for fall, medication fall risk evaluation

25. 3I: Medication/Fall Risk Score Tool 3I: Medication fall risk score and evaluation tools. Agency for healthcare research and quality. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html Point ValueMedicine ClassPotential side effects 3 (High)Analgesics/opiates, antipsychotics, anticonvulsants, benzodiazepines, non- benzodiazepine sedatives*, hypoglycemics* Sedation, dizziness, postural disturbances, altered gait and balance, impaired cognition 2 (Medium)Antihypertensives, cardiac drugs/antiarrhythmics, antidepressants Induced orthostasis, confusion, poor health status 1 (Low)DiureticsIncreased ambulation, induced orthostasis Score > 6Higher risk for fall, medication fall risk evaluation

26. + Medication Review Process Fall Prevention Strategies/Education Potentially inappropriate “Red flag” medications Up to date medication list/Adherence

27. Evidence-Based Fall Prevention Strategies Medication Review Minimize use of high risk medications Vitamin D Supplementation Consumer Education Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-157.

28. Intervention approaches to medications implicated in falls MedicationApproach Psychoactive medications Carefully evaluate need and consider tapering or discontinuance as possible by 10-25% of dose per week. Goal – minimize total psychoactive load, use for shortest period of time, taper to avoid adverse withdrawal effects Benzodiazepines/ Non-benzodiazepine sedative hypnotics First-line: sleep hygiene, behavioral intervention Nonprescription: melatonin? Manage underlying causes of insominia Goal – lowest effective dose “intermittently” or “short term” 2 to 4 weeks; taper to prevent rebound insomnia Cooper JW, Burfield AH. Medication interventions for fall prevention in the older adult. J Am Pharm Assoc(2003). 2009;49(3):e70-82 Kamel Insomnia in the elderly: Cause, approach, and treatment. Am J Med 2006 119, 463-469

29. Intervention approaches to medications implicated in falls MedicationApproach AntidepressantsAvoid older agents (eg. Tricyclics); use lower doses of newer SSRIs Opiod analgesicsAcetaminophen preferred agent for mild-moderate pain (max 3grams/day) Consider topical route for localized pain (eg. topical NSAIDs) Goal – Use lowest effective dose with careful titration/monitoring to manage pain AND limit adverse effects AntihistaminesUse non-sedating agents if chronic need (eg. loratadine) Avoid older, more sedating agents (ie. diphenhydramine, chlorpheniramine) Cooper JW, Burfield AH. Medication interventions for fall prevention in the older adult. J Am Pharm Assoc(2003). 2009;49(3):e70-82

30. + Vitamin D Supplementation Cochrane Review – vitamin D supplementation reduces risk of falls in older adults with clinically low vitamin D levels 1 U.S. Preventive Services Task Force (USPSTF) recommends 800 units of vitamin D daily 2 Diet, Multivitamin, nutritional supplements, vitamin D supplement, prescription agents Include in medication review and monitor for proper adherence – risk of over treatment and under treatment 1. Gillespie L, Robertson M, GIllespie W, et al. Interventions for preventing falls in older people living in the community. Cochrane database of systematic reviews (Online). 2013;Issue 9. Art. No.: CD007146:8/25/14. 2. U.S. Preventive Services Task Force. Vitamin D and calcium supplementation to prevent fractures, topic page. http://www.uspreventiveservicestaskforce.org/uspstf/uspsvitd.html. http://www.uspreventiveservicestaskforce.org/uspstf/uspsvitd.html

31. + Consumer Education Resources New Drug Facts Label Ten Medicines to Avoid STEADI Toolkit

32. The New Drug Facts Label The new over-the-counter medicine label. http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/ BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/UCM349215.pdfhttp://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/

33. Medications and Older Adults. www.healthinaging.orgwww.healthinaging.org

34. + CDC’s evidence-based fall prevention toolkit for healthcare providers and consumer education ASK patients if they’ve fallen in the past year, feel unsteady, or worry about falling. REVIEW medications and stop, switch, or reduce the dose of prescriptions that increase fall risk. RECOMMEND Vitamin D supplements of at least 800 IU/day with calcium. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention. Stopping elderly accidents, deaths, & injuries tool kit. http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/about.html. http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/about.html

35. Use medication review process and tools to evaluate fall risk Work with team to manage underlying conditions/medications and maximize use of nonpharmacologic strategies Use high risk medications with caution at the lowest effective dose for the shortest period of time. Provide ongoing education to patients about safe medication use

36. + Helpful Websites/Resources STEADI (Stopping elderly accidents, deaths & injuries) Toolkit for health care providers http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.htmlhttp://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html Tool 3I: Medication fall risk score and evaluation tools http://www.ahrq.gov/professionals/systems/long-term- care/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html http://www.ahrq.gov/professionals/systems/long-term- care/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html Beers List Pocket Card, App: iGeriatrics http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCar d.pdf http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCar d.pdf The new over-the-counter medicine label http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingM edicineSafely/UnderstandingOver-the-CounterMedicines/UCM349215.pdf http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingM edicineSafely/UnderstandingOver-the-CounterMedicines/UCM349215.pdf Medicines and Older Adults. HealthinAging.org www.healthinaging.orgwww.healthinaging.org

37. + What is one strategy or tool that you can use to prevent falls and promote safe medication use in your practice?