A Welsh Overview of Pharmacy and Falls Prevention Timothy Banner All Wales Consultant Pharmacist Community Healthcare Honorary Lecturer – Welsh School of Pharmacy, Cardiff University

Major risk factors History of falls Postural hypotension Alcohol Poor vision Hearing loss Mobility/gait problems Incontinence Stroke Low morale Dementia

Polypharmacy More drugs = increased risk of falls Increasing age, illness = increased risk of falls Increased risk factors = increased falls

How Medicines Can Cause Falls Sedation, drowsiness Hypoglycaemia Confusion Vestibular damage (tinnitus, deafness) Orthostatic hypotension Impaired postural stability Visual impairment (blurred vision, dry eyes) Drug induced Parkinsonism Hypothermia Dehydration

Brain (psychotropic drugs) Stopping psychotropic drugs can reduce falls (risk v benefit) Taking a psychotropic medicine can double the risk of falling ??? 2 or more psychotropic medicines Due to Drowsiness/slow reaction times Orthostatic hypotension

Heart and Circulation In older people systolic BP of 110mmHg or less is associated with increased risk of falls. Drugs which slow heart rate or reduce BP can cause falls. Stopping cardiovascular medication reduces syncope and risk of falls by 50% (risk v benefit)

Aims to address some of the problems associated with the current management of polypharmacy, particularly in the frail elderly The guideline also aims to summarise the expected effectiveness of several of the main current medicines strategies looking at: What benefit do various medicines strategies hope to achieve? How many patients per annum need to be treated with that medicine to obtain benefit for one patient? Where possible, how long is it estimated that treatment was needed in therapeutic trials to show a significant difference between being on that medicine and not being on that medicine?

Medication Assessments Without assessment patients who are at high risk for falls may receive medication that will increase that risk May be recent changes but usually medicines have been taken for a period of time without review Older people may be more “sensitive” to medicines due to pharmacokinetic changes AB in Polypharmacy clinic – 86% patients on 4+ meds Follow up with GP showed 26% had total number of medications decreased Overall reduction in falls frequency and falls related injury was 84%

Role of health care team Steps required in minimizing the risks of falls – Gather all medication information of patient – Review each medication to identify any potential meds that increase falls – Monitor efficacy and adverse reactions – Make necessary adjustments to medication in relation to disease or patient’s reaction – Resist the temptation to request/prescribe additional medication to treat side effects All Healthcare Providers need to be vigilant in medication monitoring

Questions for review? Risk/Benefit ratio? Safer drug/non-pharmacological alternative? Minimise dose v therapeutic benefit? Bone protection?

Counselling Taking medication at an inappropriate time can increase the risk of falls E.g. taking diuretics late in the day, then getting up at night to go to the toilet E.g. taking SSRIs at night, then needing night sedation

Where can/do we do this?

Community Pharmacy Accessibility Regular Contact - deliveries Advice – health campaigns Signposting MUR – Medicines Use Review DMR – Discharge Medicines Review Limited/no access to clinical records

Primary/Community Care GP practice based pharmacists Cluster pharmacists Medicines Management teams Discharge/Community resource teams Scope to conduct medication reviews with access to clinical records

Hospital Pharmacy A&E Admissions – medical/surgical Fracture clinics Rehabilitation wards Review medication with clinical records, make changes/communicate with primary care

Medication linked to increased risk of falling Opportunities for medication review should be maximised Risk v benefit discussion is key to prescribing/deprescribing Available tool to aid review NOTEARS, STOPP/START AWMSG guidance, Scottish guidance

Thank You Any Questions? timothy.banner@wales.nhs.uk