Falls and Medicines Management Dr Nick Flynn IMC 21468 Falls and Medicines Management Falls Prevention Conference 19th November 2015 Royal Marine Hotel Dun Laoghaire

Media contributor (radio/online/print) Dr Nick Flynn IMC 21468 GP Partner GP to Garda Prisoners GP in Cork Prison 2010-13 Medical Director Medical Director Media contributor (radio/online/print)

Heather House Nursing Home Blair’s Hill Nursing Home Dr Nick Flynn IMC 21468 Heather House Nursing Home HSE run Nursing Home 50 bed 24 Mental Health Needs 24 Care for the older person 2 beds are closed Blair’s Hill Nursing Home Private Nursing Home 37 beds 2 Learning Disability 5 Mental Health Needs 30 Care for the older person

Conflicts of interest: HSE – I am a GP with a GMS contract and other public contracts TEVA – educational grant Novartis – educational grant CONFLICTS OF INTEREST NO CONFLICTS OF INTEREST in relation to today’s subject matter

Objectives of todays session Understand why medications may have different effects on us as we get older. Discuss why medications may be associated with falls in older people. Suggest how we might reduce the risks of falls due to medications with “Medications reviews” and a “risk assessment tool”.

Irish people are living longer into old age! Aging Ireland (>65 years) Aging population 11.04% in 200620.28% by 2041 Increase in life expectancy Increase in dependence ratios 15.9% in 2006 36.3 by 2041 Medical consumption Greatest consumers of pharmacotherapy globally

Meet the patients! Meet Sonny: Meet Frank:

Process of aging Anatomical changes Physiological changes Skeletal changes- alterations in posture and body contours Predominance of bone resorption over bone formation- osteoporosis (25% of women and 6% of men are affected) Decrease in lean body mass Physiological changes Start to occur in the 5th decade Result in an overall reduction in homeostatic control Psychological changes Intrinsic (e.g. senile dementia) or extrinsic factors (bereavement) Loss of cognitive skills including memory Mental rigidity: Relativity inability to look at situations in different ways

Altered drug handling due to age Homeostasis Pharmacodynamics Pharmacokinetics - Absorption - Metabolism - Distribution - Elimination

Gastrointestinal absorption Physiological Change Affect on absorption Reduced saliva production ↓ Rate Delayed gastric emptying Decreased GI motility Decreased gastric transport processes ↔ (Exceptions: iron, calcium, vitamin B12).

Metabolism First pass metabolism ↓ in first pass metabolism→ ↑ in bioavailability Extraction from the blood ↓ clearance of drugs with high extraction ratios e.g. calcium antagonists Metabolic capacity ↓ ed by up to 60% → ↑ blood levels, ↑ t 1/2 Hepatic metabolism – main route of elimination of many drugs

Distribution Body composition changes Protein binding changes Increased adipose tissue Fat soluble drugs: ↑ duration of action e.g. haloperidol, diazepam. Reduced body water Water soluble drugs: ↑ serum levels e.g. theophylline, atenolol, propranolol, hydrochlorthiazide Protein binding changes Decreased albumin- acidic drugs Reductions in systemic perfusion Reduced cardiac output Increased vascular resistance Increase permeability across the blood-brain barrier

Elimination Renal function decreases Decreased size by 20% Loss of 30% of functioning glomeruli reduced glomerular filtration rate Reduced clearance will result in extended half lives and increased serum levels- accumulation and toxicity if doses are unadjusted. Serum creatinine as a marker for renal function

Pharmacodynamics Increased sensitivity to particular medicines due to: Change in receptor binding Warfarin increased β1 and β2 receptor decreased α2 receptor increased Increased sensitivity to particular medicines due to:

How medications can cause falls Sedation / Drowsiness Anti-depressants Antipsychotics Parkinson's disease medication Impaired postural stability Hypnotics Benzodiazpine Postural hypotension Diuretics Visual impairment / blurred vision / dry eye Antihistamines Drugs for urinary incontinence How medications can cause falls Drop a couple of images in here

How medications can cause falls Drug induced Parkinsonism Antipsychotics Hypoglycaemia Antidiabetic medication (Sulphonylureas) Insulin Quinine Vestibular damage Tinnitus, deafness Diuretics How medications can cause falls Drop a couple of images in here

How medications can cause falls Hypothermia Beta blockers Antipsychotics Sedative hypnotics also decrease body's ability to respond to low ambient temperature Dehydration Can increase the risk of falls and this might occur in older people taking diuretics and laxatives Confusion Antihistamines Drugs for urinary incontinence

Developing a trigger chart to predict falls risk: The risk of having a fall increases with the number of associated intrinsic risk factors. Patients with 4 or more risks factors identified are at the greatest risk of having a fall. previous fall polypharmacy i.e. 4 or more drugs psychotropic drug or other high risk drug use alcohol >1 unit/day poor mobility/ gait orthostatic hypotension balance disorders visual impairment hearing impairment cognitive impairment

Polypharmacy: William Osler (1849-1919) “One of the first duties of the physician is to educate the masses not to take (inappropriate) medicine.” “Imperative drugging – the ordering of medicine in any and every malady (i.e. polypharmacy) - is no longer regarded as the chief function of the doctor.”

Anonymous…. “Some sort of rough and ready natural law seems to be at work, balancing both the interests of the physician and the patient; the physician is expected to prescribe with only approximate accuracy and the patient is expected to comply with modest fidelity. Thus mankind has been able to survive bleeding, cupping, turpentine stupes and Panalba”

Polypharmacy: Polypharmacy is a core problem i.e. inappropriate over-prescribing in response to complex comorbidity Multi morbidity Polypharmacy AD Events More Prescribing

Kafka F. ‘A country doctor’ ‘To write a prescription is easy but to come to an understanding with the patient is hard.’

Medication review process: Level Three Full Medication review At least annually Level Two Treatment review Regularly perhaps 3/12 Level One Prescription review On re-issuing each script

Albert Schweitzer MD. ‘Your inner Physician’ ‘Each patient carries their own doctor inside themselves. They come to us not knowing that truth. We are at our best when we give the doctor that resides within each patient a chance to go to work’

Medication review guidance: Diagnosis Correct diagnosis Still valid Drug Dose Frequency Side Effects Interactions Monitoring Patient/Carer Indication Dose/schedule Aware of SFX Address Pt concerns Next review date Step One Step Two Step Three

Drug Kardexes

Anti-muscarinic drugs Benzodiazepines & Hypnotics High risk drugs TCA – drowsiness and blurred vision SSRI – less sedating / blurred vision Antidepressants Hypotension / Parkinsonism Prochlorperazine. Antipsychotics Acute confusion Especially in those with dementia Anti-muscarinic drugs Avoid long acting benzos Sedation / confusion / fall at night Benzodiazepines & Hypnotics Levodopa - confusion & sedation Dose reduction as patient ages Drugs used in Parkinson's disease

Moderate risk drugs Anti-histamines Beta-blockers Diuretics Drowsiness and possible hypotension Anti-histamines Bradycardia and hypotension Beta-blockers Dehydrations -> Hypotension. Diuretics Drowsiness, sedation and confusion Opiate analgesics

ACE inhibitors / Angiotensin II antagonists Moderate risk drugs Hypotension especially if used with diuretics ACE inhibitors / Angiotensin II antagonists Hypotension – less likely in BPH doses Alpha –blockers Dizziness Anti-arrythmics Dizziness, blurred vision and drowsiness Anti-epileptics

Low risk drugs Calcium Channel Blockers Nitrates Hypotension Bradycardia Calcium Channel Blockers Dizziness due to postural hypotension Nitrates Diarrhoea -> dehydration Hypoglycaemia Oral anti-diabetic drugs Proton Pump Inhibitors H2 agonists esp. Cimetidine Antacids

In Summary: Medications may have different effects on us as we get older. Polypharmacy is an independent risk factors for falls. Medications reviews and a risk assessment tool can decrease falls due to medications. It’s a (multi-disciplinary) team game!

Thank You.