+
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
+
Session Objectives
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
+
High Risk Medications in Older Adults
+ How the Body Processes a Drug
A: Absorption
D: Distribution
M: Metabolism
E: Elimination
+
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)
+
Age Related Changes in Metabolism
Reduced liver
size and
decreased blood flow to
liver
Liver
metabolic enzymes
function adequately even
in the very old
+
Age Related Changes in Elimination
 Decline
in kidney function
 Medications
that are eliminated
through the kidneys can
accumulate
 Morphine
 Glyburide
 Digoxin
 Many
others
+
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.
+
Sedative/Hypnotics
Possible adverse events
• Cognitive impairment, delirium, sedation
Examples
• Non-benzodiazepine hypnotics:
• Zolpidem, Eszopiclone, Zaleplon
• Benzodiazepines:
• Diazepam, Clonazepam, Alprazolam, Lorazepam
+
Antipsychotics
Possible adverse events
• Ataxia, impaired psychomotor function, and
syncope
• Olanzapine can cause orthostatic hypotension
Examples
• Haloperidol, Olanzapine, Quetiapine, Aripiprazole
+
Antidepressants
Possible adverse events
• Ataxia, impaired psychomotor function, and
syncope
Examples
• Fluoxetine, Sertraline, Citalopram, Paroxetine
+
Anticholinergics
Possible adverse events
• Sedation, confusion, hypotension, delirium
Examples
• Tricyclic Antidepressants:
• Amitriptyline, Nortriptyline
• OTC Antihistamines:
• Diphenhydramine, Chlorpheniramine, Hydroxyzine
+
Cardiac Medications
Possible adverse events
• Hypotension, dizziness
Examples
• Beta blockers
• Nitrates
• Diuretics
• Digoxin
+
BPH/Urinary Retention Medications
Possible adverse events
• Orthostatic hypotension
Examples
• Terazosin, Doxazosin, Prazosin
+
Pain Medications
Possible adverse events
• Dizziness, syncope, CNS depression
Examples
• Opioids:
• Morphine, Hydromorphone, Fentanyl,
Oxycodone
+
Anticonvulsants
Possible adverse events
• Ataxia, impaired psychomotor function, syncope
Examples
• Gabapentin, Levetiracetam, Phenytoin,
Valproate
+
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.
+
Medication Review Process
+
Medication Review Process
• Medication
Reconciliation
• Adherence
Medication
Review
Assess Fall
Risk
• “Red Flag
Medications”
• Optimize
Regimen
• Education
Fall
Prevention
+
Medication Review Process
Up to date medication
list/Adherence
Identify potentially inappropriate
“Red flag” medications
Fall Prevention
Strategies/Education
+
Medication Reconciliation:
Up to Date Medication List/Adherence
Medicines and You: A guide for older adults.
http://www.fda.gov/Drugs/ResourcesForYou/ucm163959.htm
+ Medication Review Process
Up to date medication
list/Adherence
Identify potentially inappropriate
“Red flag” medications
Fall Prevention
Strategies/Education
+
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.pdf
3I: Medication/Fall Risk Score
Point Value
Medicine Class
Potential side effects
3 (High)
Analgesics/opiates,
antipsychotics,
anticonvulsants,
benzodiazepines, nonbenzodiazepine 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)
Diuretics
Increased ambulation, induced
orthostasis
Score > 6
Higher risk for fall, medication fall risk evaluation
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
3I: Medication/Fall Risk Score
Point Value Medicine Class
Potential side effects
3 (High)
Analgesics/opiates,
antipsychotics,
anticonvulsants,
benzodiazepines, nonbenzodiazepine
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)
Diuretics
Increased ambulation,
induced orthostasis
Score > 6
Higher risk for fall, medication fall risk evaluation
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
+ Medication Review Process
Up to date medication
list/Adherence
Potentially inappropriate “Red flag”
medications
Fall Prevention
Strategies/Education
Evidence-Based
Fall Prevention Strategies
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.
Consumer Education
Vitamin D
Supplementation
Minimize use of high
risk medications
Medication Review
Intervention approaches to
medications implicated in falls
Medication
Approach
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/
First-line: sleep hygiene, behavioral intervention
Non-benzodiazepine Nonprescription: melatonin?
sedative hypnotics
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
Intervention approaches to
medications implicated in falls
Medication
Approach
Antidepressants
Avoid older agents (eg. Tricyclics); use lower doses of newer
SSRIs
Opiod analgesics
Acetaminophen 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
Antihistamines
Use 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
+
Vitamin D Supplementation
 Cochrane Review –
vitamin D supplementation reduces risk
of falls in older adults with clinically low vitamin D levels1
 U.S. Preventive
Services Task Force (USPSTF) recommends
800 units of vitamin D daily2

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.
+
Consumer Education Resources
New Drug Facts Label
Ten Medicines to Avoid
STEADI Toolkit
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.pdf
Medications and Older Adults. www.healthinaging.org
+
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.
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
+
Helpful Websites/Resources

STEADI (Stopping elderly accidents, deaths & injuries) Toolkit for health care
providers http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html

Tool 3I: Medication fall risk score and evaluation tools
http://www.ahrq.gov/professionals/systems/long-termcare/resources/injuries/fallpxtoolkit/fallpxtk-tool3i.html

Beers List Pocket Card, App: iGeriatrics
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

Medicines and Older Adults. HealthinAging.org www.healthinaging.org
+
What is one strategy or tool that you
can use to prevent falls and promote
safe medication use in your practice?