FALL PREVENTION – MEDICATION REVIEW
Pharmacy - Kelsey Trail Health Region
Height
Scr
Weight
Place Patient
Addressograph Here
Calculated Clcr
The patient IS NOT taking the following medication. Vitamin D may DECREASE the risk of
falling:
 Vitamin D (800-2000 units daily for adults)
The patient IS taking the following medications, which may INCREASE the risk of falling:
PSYCHOTROPICS
 Sedative-hypnotics, including zopiclone, and especially benzodiazepines (BZDs)
 Neuroleptics (antipsychotics)
 Tricyclic antidepressants (TCAs)
 Selective serotonin reuptake inhibitors (SSRIs)
CARDIOVASCULAR MEDICATIONS
 Digoxin
 Antihypertensives, especially diuretics:  diuretic  ACE I  ARB  CCB  β-blocker
 Class 1A antiarrhythmics (procainamide, quinidine, and disopyramide)
OTHER MEDICATIONS
 Anticholinergics – including antihistamines, TCAs, and antipsychotics
 Anticonvulsants
 Opioid Analgesics (within first 48 hrs of initiation or dosage increase)
OTHER RISK FACTORS TO CONSIDER
 Elderly patients (65 years of age or older)
 Impaired renal function
 Four or more scheduled medications
 Anticoagulants/Antiplatelets (may increase the risk of injury from a fall)
Untreated:  osteoporosis  urinary incontinence  delirium  pain (may have an increased
risk of injury from falls)
PLEASE CONSIDER THE FOLLOWING RECOMMENDATIONS TO REDUCE THE RISK OF
FALLING:
Any PRINTED version of this document is only
accurate up to the date this document was developed.
KTHR can not guarantee the currency or accuracy of
any printed policy. KTHR accepts no responsibility for
use of this material by any person or organization not
associated with KTHR. No part of this document may
be reproduced in any form for publication without
permission of KTHR.
Pharmacist: ________________________________ Date: _________________________
Page 1
Adapted with permission from Fall Medication Regimen Review form created by:
Polly Robinson, PharmD, CGP, FASCP - August 18, 2005, St. John Medical Center, Tulsa, OK
FALL PREVENTION – MEDICATION REVIEW
VITAMIN D

Vitamin D receptors are found in muscle. Muscle weakness is a symptom of vitamin D deficiency. Some
evidence suggests that vitamin D supplementation may prevent falls by improving muscle strength 1

Vitamin D is made by sun-exposed skin and is found in some food. However, it is difficult to obtain
enough vitamin D from food, and most people don’t get much sun exposure, especially those living in
northern latitudes. 2

According to a meta-analysis by Bischoff-Ferrari et al., if 15 older adults were supplemented with vitamin
D, 1 fall could be prevented (NNT=15). Although confidence intervals of some individual studies cross
the line of no difference, the pooled estimates favour vitamin D supplementation. Vitamin D supplements
may be worth considering for elderly patients. 3

Recommendations: 400 IU for infants; 600 IU for kids; 800-2000 IU for adults. Evidence suggests the
higher adult dose is safe and may provide additional benefits. 4
PSYCHOTROPICS
- Sedative-hypnotics, including zopiclone, and especially benzodiazepines (BZDs)

BZDs impair balance centrally and peripherally. BZDs may also cause CNS depression leading to
impaired reaction times. Risk is greater at higher doses for both long- and short-half-life BZDs.

There is no clear benefit of short-acting BZDs or newer agents in reducing falls.

Risk of fall is greatest in the first 15 days of therapy or when increasing doses of BZDs.

Risk is increased with patients taking more than one BZD; therefore, combinations should be avoided.

Zopiclone - The recommended dosage in elderly is 3.75 mg, possibly increased to 7.5 mg. Zopiclone
causes increased body sway, which is a surrogate marker for fall risk. 5
- Neuroleptics (Atypical and Typical Antipsychotics)

May cause EPS, sedation, gait abnormalities, dizziness, blurred vision, cognitive impairment, and
orthostatic hypotension.

Newer antipsychotics may have improved side-effect profiles, although there is no evidence relating to
falls.
- Tricyclic antidepressants (TCAs)

Doses ≥ 50mg of amitriptyline are associated with an increased risk for falls.

Proposed mechanism of action includes orthostatic hypotension, sedation, and/or cognitive impairment
due to anticholinergic effects.
- Selective serotonin reuptake inhibitors (SSRIs)

New use of SSRIs is associated with a greater risk for falls. Recommend starting with a low dose for the
1st week, then slowly increasing to therapeutic levels.

Doses ≥ 20mg of fluoxetine have a higher risk for falls.

May induce hyponatremia, which can lead to delirium; recommend monitoring electrolytes.
CARDIOVASCULAR MEDICATIONS
- Digoxin

There is a weak association between digoxin and falls. Digoxin is renally-eliminated.
- Antihypertensives

Antihypertensives have been proposed to contribute to fall risk via postural hypotension (drop in SBP of ≥
20 mmHg, in DBP of ≥ 10 mmHg, OR to a pressure of < 90 mmHg when standing).

Diuretics have been significantly associated with falls (vertigo, orthostatic hypotension, frequent
urination). Most studies have found a non-significant relationship between other antihypertensives and
falls.

Inadequate treatment of a cardiovascular disease may also be a factor in increasing fall risk.
- Class 1A antiarrhythmics (procainamide, quinidine, and disopyramide)

The relationship between these agents and falls may be due to the adverse effects of the medication or
the disease (low blood pressure with light-headedness).
OTHER MEDICATIONS
- Anticholinergics

Anticholinergic properties include dizziness, sedation and blurred vision. Anticholinergics include
atropine, benztropine, hyoscine, scopolamine, etc.

Sedating antihistamines have strong anticholinergic properties and the half-life may be extended in
elderly patients. For example, the half-life of diphenhydramine is about 13.5 hrs in elderly patients and
about 2 to 10 hrs in younger adults. 6

Other drugs with anticholinergic properties include TCAs, neuroleptics, antispasmodics (oxybutynin), and
some antiemetics (prochlorperazine, metoclopramide, promethazine, trimethobenzamide, etc.).
- Anticonvulsants

May cause dizziness, ataxia, orthostatic hypotension, blurred vision, somnolence, and confusion, which
are greatest at the beginning of therapy or after increases in dose.
Page 2
Adapted with permission from Fall Medication Regimen Review form created by:
Polly Robinson, PharmD, CGP, FASCP - August 18, 2005, St. John Medical Center, Tulsa, OK
FALL PREVENTION – MEDICATION REVIEW
- Opioid Analgesics

Opioids, in general, do not cause falls. However, they may cause sedation, dizziness, or confusion in the
first 48 hours after initiation or a dose increase.

Patients usually develop tolerance to these side effects within 2 to 3 days of a stable dose. Therefore
frequent dosage changes or use of PRNs may increase the risk of side effects.

Pain may increase the risk of falls. Therefore, adequate pain control is important.
OTHER RISK FACTORS TO CONSIDER
Elderly patients (≥ 65 years of age) have altered pharmacokinetics and may be more “sensitive” to
medications.
Renal function impairment may result in medication accumulation and increased risk of adverse reactions.
Patients taking ≥ 4 prescription drugs, regardless of pharmacologic classification, are at an increased risk
for falls.
Anticoagulants/Antiplatelets may directly increase the risk of injury from falls due to an increased
bleeding risk.
Patients with untreated osteoporosis, urinary incontinence, delirium, pain may have an increased risk of
injury from falls.

Delirium can occur with dementia, strokes, Parkinson’s disease, infection, abnormal blood sugars, low
pulse Ox, worsening organ function (kidney failure, liver failure, heart failure, etc.)

Pain can affect an individual’s mobility, which in turn, can increase the risk of falls. Any changes in
mobility may cause a fear of falling and anxiety, which may cause a decrease in activity levels, leading to
increased muscle weakness and fall risk.
Page 3
Adapted with permission from Fall Medication Regimen Review form created by:
Polly Robinson, PharmD, CGP, FASCP - August 18, 2005, St. John Medical Center, Tulsa, OK
FALL PREVENTION – MEDICATION REVIEW
The following algorithms were developed by Bulat et al. 7,8 in an “effort to standardize prescribing practices, reduce
medication-associated fall risks, and generate clinical tools for fall clinics”. The algorithms may be used as a
starting point to assist in medication assessment relating to fall risk. In all cases, try to find a balance by weighing
the benefits of treating the disease against the risk (and implications) of falling.
Figure 1
Benzodiazepines
Zopiclone
(short-term use ≤ 2 weeks)
Insomnia






Yes


Appropriate
indication and
dose?
Do not use longer than 2 weeks
Emphasize sleep hygiene measures
(eliminate naps, daily exercise, no
caffeinated beverages in afternoon,
use bed only for sleep, etc.)
Treat underlying medical problems
disrupting sleep (like pain, shortness
of breath, symptomatic BPH, etc.)
Environmental modifications (room too
cold/hot, noise control, etc.)
Evaluate for prescription/over the
counter medications contributing to
insomnia (sympathomimetics,
diuretics, etc.)
Yes
Other accepted
indications*






Evaluate dose/frequency (for elderly on
long-acting benzodiazepines, consider
switch to short-acting or alternatives - still
increased risk for falls/hip fracture)
Key Points:
*Labeled indications for benzodiazepines in Canada:
anxiety disorders
panic disorder
insomnia
perioperative medication
seizure disorder
skeletal muscle spasticity
alcohol withdrawal
No
Recommend to taper off
Educate patient about the
increased risk of falling/hip
fracture with any
benzodiazepine use

9
Consider switching to alternative therapeutic
agents and optimizing dosing
Maximize the antidepressant dose
Educate patient about the increased risk of
falling/hip fracture with any benzodiazepine use
Consider referral to specialists for non-drug
therapy
Recommend to taper off
Educate patient about the increased risk of
falling/hip fracture with any benzodiazepine use
Suggest referral to sleep lab if suspicion of sleep
apnea or restless leg syndrome
*Also used in management of: 9
agitation
restless leg syndrome
skeletal muscle spacticity
adjunct in N/V associated with chemotherapy
or prior to surgical or diagnostic procedures
Page 4
Adapted with permission from clinical practice algorithms created by:
Bulat et al. – 2008 - Tampa Patient Safety Center, Tampa Bay, Florida / Greater Los Angeles Healthcare
System, Los Angeles, California 7,8
FALL PREVENTION – MEDICATION REVIEW
Figure 2
Cardiovascular Agents (diuretics, centrally
acting antihypertensives, ACE inhibitors,
nitrates, type Ia antiarrhythmics, digoxin)
Appropriate
indication and
dose?
Yes
Severe
symptoms due to
orthostasis?**
Yes




No

No

Refer to clinical guidelines*
for CHF, HTN, CAD
Stop diuretic first
Decrease salt restriction
Consider splitting the dose or changing administration
times (so peak effects don’t happen all at once)
If Ace-I indicated, try agent with less renal metabolism
(i.e. fosinopril) 10,11
Decrease dose if not tolerated or patient at risk for
injury
No or mild
symptoms from
orthostasis







Patient education
Behavioural adjustments (change position
slowly, sit at the edge of the bed for a few
minutes, etc.)
Eliminate centrally-acting agents, use
tamsulosin if needed for BPH symptoms
Reserve use of hydralazine and nitrates for
CHF patients that failed ACE-I/ARB; loop
diuretics for CHF/CRI patients
Use thiazides for ISH patients that cannot
be controlled on other preferred agents
For BP alone use ACE-I, B-blockers or Ca
channel blockers preferably
Elastic stockings
BP goal:
Optimal 120/80
DM <130/80
Uncomplicated
HTN: <140/90

Yes
Ensure patient
understands and
agrees with plan
of care
No
EDUCATION:

Recommend Home BP measurements

Provide data sheets for recording
Key Points:
* More information about clinical guidelines may be accessed at:
BC Heart Failure Guidelines and Flowsheet: 12
https://www.sma.sk.ca/data/1/rec_docs/56_BC_Heart_Failure_Guidelines_and_Flowsheet.pdf
CHEP Guidelines: 13
http://hypertension.ca/chep/wp-content/uploads/2010/04/FullRecommendations2010.pdf
Stable Coronary Artery Disease Guidelines (USA Reference): 14
http://www.icsi.org/coronary_artery_disease/coronary_artery_disease__stable_.html
Coronary Artery Disease Flowsheet: 15
https://www.sma.sk.ca/data/1/rec_docs/101_SK_HQC_Coronary_Artery_Disease_Flowsheet.pdf
Dyslipidemia Guidelines: 16
http://www.druginfo.usask.ca/pdf/Dyslipidemia_Guidelines_FULL.pdf
**Orthostasis definition: reduction in systolic BP of > 20 mmHg or < 10 mmHg at 1 minute after standing. The first
blood pressure should be measured after the patient has been sitting for at least 10 minutes, then again on
immediate standing, and again at 1 and 3 minutes after standing. 7
Page 5
Adapted with permission from clinical practice algorithms created by:
Bulat et al. – 2008 - Tampa Patient Safety Center, Tampa Bay, Florida / Greater Los Angeles Healthcare
System, Los Angeles, California 7,8
FALL PREVENTION – MEDICATION REVIEW
Blood Pressure Targets: 17
Optimal: <120/<80
Normal: <130/<85
No risk factors; no target organ
damage
Isolated systolic HTN (ISH)
Moderate-High Risk

If home BP
measurement
Diabetes or Renal Disease
Elderly
High normal: <140/<90
(1/2 of these people will develop HTN within 2
years!)
Consider Treatment
≥160/100
Target
<140/90
SBP >160
≥140/90
≥135/85
SBP <140
<140/90
<135/85
≥130/80
Consider treatment in all patients
with the above indications,
regardless of age. However,
proceed with caution in frail elderly
patients. 13, 18, 19
<130/80
Use a more gradual reduction to
target BP. For example, start with
an intermediate goal of <160. 19
Holding medications (for adults - in general***): 20, 21, 22, 23
Antihypertensives
Hold if SBP < 100
Rate controlling medication: beta-blockers, digoxin, etc.
Hold if heart rate < 50
***Always consult prescriber orders and drug monograph for drug specific information
Page 6
Adapted with permission from clinical practice algorithms created by:
Bulat et al. – 2008 - Tampa Patient Safety Center, Tampa Bay, Florida / Greater Los Angeles Healthcare
System, Los Angeles, California 7,8
FALL PREVENTION – MEDICATION REVIEW
Figure 3
Antidepressant

Yes




No
Recommend to stop
medication
Educate patient
about increased risk
of falls/injury
Use SSRIs as first line therapy (although fall
risk is increased, they are better tolerated
than tricyclics or MAO inhibitors)
If failed SSRIs, use nortryptiline preferably
to amitryptiline (less anticholinergic)
Yes

Appropriate
indication and
dose?
Determine if dose
is effective (eg:
use short form
GDS*, 1-10 pain
scale, etc.)

No

Recommend dose
increase and
follow-up
Educate patient
about increased
risk of falls/injury
Continue, or consider decrease to maintenance
dose
Educate patient about increased risk of falls
Key Points:
* GDS: Geriatric Depression Scale 24
http://www.stanford.edu/~yesavage/Testing.htm
Page 7
Adapted with permission from clinical practice algorithms created by:
Bulat et al. – 2008 - Tampa Patient Safety Center, Tampa Bay, Florida / Greater Los Angeles Healthcare
System, Los Angeles, California 7,8
FALL PREVENTION – MEDICATION REVIEW
Figure 4
Anticoagulants
Yes
Appropriate
indication and
dose?
Any high risk condition:

Concomitant NSAID
use?

History of GI bleed?

Use of alcohol?

Non-adherance to
prescribed regimen?

Greater than weekly
falls?

Continue anticoagulation
No


Benefit > risk

Patient education
Refer to
anticoagulation
clinic (if available)
Recommend to
stop medication
Risk > benefit
Consider the ongoing
risk/benefit analysis of
continued therapy
Key Points:
Assessing anticoagulation therapy and fall risk can be difficult. Essentially, one must weigh risk of bleeding from a
fall against the benefit of therapy. In many cases, continued anticoagulation is necessary.
For example, Man-Son-Hing et al. concluded that patients receiving anticoagulation for chronic atrial fibrillation
must fall about 295 times in 1 year for the risk of subdural hematoma (SDH) due to a fall to outweigh the benefit of
stroke prevention through anticoagulation (Bulat et al., 2008 – Part 4). 25
Expert opinion defines “greater than weekly falls” as an indicator that the patient’s risk of bleeding (while taking
anticoagulants) may potentially outweigh the benefit of treatment (Bulat et al., 2008 – Part 4). 8
The decision to modify anticoagulation in patients with atrial fibrillation must be made on a case-by-case basis
using clinical judgment.
The following information should assist in the decision to treat with anticoagulants:
CHADS2 score: 26
http://www.bcguidelines.ca/gpac/pdf/stroke_appendix_a.pdf
CHEST Guidelines: 27
http://chestjournal.chestpubs.org/content/133/6_suppl
Page 8
Adapted with permission from clinical practice algorithms created by:
Bulat et al. – 2008 - Tampa Patient Safety Center, Tampa Bay, Florida / Greater Los Angeles Healthcare
System, Los Angeles, California 7,8
FALL PREVENTION – MEDICATION REVIEW
Figure 5
Bladder Relaxants
Anticholinergics

Appropriate
indication and
dose?
Yes
High post void
residual?
Low flow rate
(men)?
No or PVR data
not available
Acceptable
control?
Yes




Consider genitourinary
(GU) referral
Consider decreasing
dose or stopping drug
Monitor urgency
Falls/gait & balance
assessment (by
specialist)
Follow-up

No



Yes
Yes


No
Recommend to stop
medication
Educate patient about
increased risk of
falls/injury


Signs/symptoms of
orthostasis, dry mouth,
poor compliance,
psychomotor slowing,
decreased attention?
Recommend decreased
dose
Monitor urgency
Falls/gait & balance
assessment (by specialist)
Scheduled toileting

No

Educate patient
about increased
risk of falls/injury
Follow-up
Consider decreasing dose
or trial of tolterodine
Examine CV drugs for
need and timing of dosesespecially diuretics
Page 9
Adapted with permission from clinical practice algorithms created by:
Bulat et al. – 2008 - Tampa Patient Safety Center, Tampa Bay, Florida / Greater Los Angeles Healthcare
System, Los Angeles, California 7,8
FALL PREVENTION – MEDICATION REVIEW
Figure 6
Anticonvulsant
for pain control
Appropriate
indication and
dose?
Yes
CNS side
effects?
No
Signs/symptoms
of orthostasis?


No
Recommend change
Refer to pain clinic

No

Yes
Yes



Educate patient
about increased risk
of falls/injury
Follow-up
Consider decreasing dose
Consider topical capsaicin
Recommend nonpharmacological adjuvant
treatment (exercise,
modalities) in addition to
meds




Consider decreasing dose
Examine CV drugs for need
and timing of doses especially diuretics
Stop drug or decrease dose
based on symptom control
Follow-up
Page 10
Adapted with permission from clinical practice algorithms created by:
Bulat et al. – 2008 - Tampa Patient Safety Center, Tampa Bay, Florida / Greater Los Angeles Healthcare
System, Los Angeles, California 7,8
FALL PREVENTION – MEDICATION REVIEW
Figure 7
Antipsychotic
Appropriate
indication and
dose?


No
Recommend change
Refer to psych
Yes

Consider decreasing
dose
Consider atypical agent
Examine CV agents especially diuretics


Yes
Signs/symptoms
of orthostasis?
No
Signs/symptoms of
CNS / psychometric
slowing, decreased
attention?
Yes


Follow-up
Consider decreasing
dose or change to
(another) atypical agent
No
EPS?
Parkinsonian
stiffness?
Yes




Consider decreasing dose
Consider change to (another)
atypical agent
Consider non-antipsychotic
Perform risk/benefit analysis of
symptom control vs. side effects
No


Educate patient
about increased
risk of falls/injury
Refer to psych for
follow-up
Page 11
Adapted with permission from clinical practice algorithms created by:
Bulat et al. – 2008 - Tampa Patient Safety Center, Tampa Bay, Florida / Greater Los Angeles Healthcare
System, Los Angeles, California 7,8
FALL PREVENTION – MEDICATION REVIEW
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