Older-Adult Fall Prevention Guide for Community Pharmacists

Older-Adult Fall Prevention Guide for

Community Pharmacists

September 2019

Project Leads: Stefanie P. Ferreri, PharmD, BCACP, FAPhAand Susan J. Blalock, PhD, MPH

Older-Adult Fall Prevention Guide for

Community Pharmacists

Stefanie P. Ferreri, PharmD1

Susan J. Blalock, MPH, PhD1

Jessica M. Robinson, PharmD1

Chelsea P. Renfro, PharmD2

Jan Busby-Whitehead, MD3

1UNC Eshelman School of PharmacyUniversity of North Carolina at Chapel Hill

Chapel Hill, North Carolina

2University of Tennessee Health Science Center College of Pharmacy

Memphis, Tennessee

3UNC School of MedicineUniversity of North Carolina at Chapel Hill

Chapel Hill, North Carolina

2019

This document is in the public domain and may be used and reprinted without permissions except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of the copyright holders.

Suggested Citation:Ferreri SP, Blalock SJ, Robinson JM, Renfro CP, Busby-Whitehead, J. Older Adult Fall Prevention Guide for Community Pharmacists. UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill. August 2019.

ACKNOWLEDGEMENTS

We acknowledge and appreciate the important contributions of Tenley Brown, PharmD, Sarah Shockley, PharmD, Emma Feder, and Pooja Shah for preparing and organizing the contents of this guide.

In addition, we gratefully acknowledge the support of this guide through a grant (1U01CE002769-01) from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. We extend a special thanks to Elizabeth Burns, Yara Hadid, Robin Lee, and Sue Neurath from the Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control.

Funding Opportunity Notice: “The project described was supported by Grant Number 1U01CE002769-01 from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. General Disclaimer: “The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.”

Research Disclaimer: "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.”

3

Table of Contents

Chapter 1: Introduction …………….…………………………………….. 5Older Adult Falls: An Opportunity for PharmacistsCommunity Pharmacy Fall Prevention: Who Can Benefit?Risk Factors for Older Adult Falls

Chapter 2: Fall Prevention Process ………………………………......... 10Community Pharmacy Algorithm for Fall Risk Screening, Assessment, and Care CoordinationQuick Reference GuideFall Prevention: Pharmacists’ Patient Care ProcessCase Study

Chapter 3: Implementing Fall Prevention …………………….……… 27Key Considerations for Your PharmacyBest PracticesFrequently Asked Questions (FAQ)

Appendices …………………….…………………………………………. 35Appendix A: High-Risk Medication IndexAppendix B: Blank FormsAppendix C: Resources

Older-Adult Fall Prevention Guide for Community Pharmacists | 2019

Glossary of Key Terms

Fall Prevention Service: A three-step clinical service for community pharmacies to help decrease the risk of falling in older adults.

High-Risk Medications: Medications recognized as having significant risk of causing falls in older adults.

Medication Review: A comprehensive review to identify and assess medications that may increase an older adult’s risk of falling.

Older Adult: Adult age 65 and older.

Project Champion: Pharmacy staff member responsible for overseeing intervention training, implementation, and documentation. This role may be filled by a technician or pharmacist.

Screening: Process of asking patient Key Three STEADI questions to determine eligibility for medication review and assessment of gait, balance, and strength.

Stopping Elderly Accidents, Deaths & Injuries (STEADI): An initiative of the Centers of Disease Control and Prevention (CDC) to educate patients, family, and healthcare providers about the risk of falling and to develop ways to decrease fall-associated injury and death in older adults. More information available www.cdc.gov/steadi/index.html.

STEADI-Rx: An initiative of the CDC to educate and encourage pharmacy staff to provide fall prevention interventions in the community pharmacy setting. More information available at www.cdc.gov/steadi/steadi-rx.html.

Support Staff: Pharmacy staff responsible for implementing and documenting intervention; includes pharmacists, interns, and technicians.

4Older-Adult Fall Prevention Guide for Community Pharmacists | 2019


5

Chapter 1: Introduction

Chapter Preview:

• Older Adult Falls: An Opportunity for Pharmacists• Community Pharmacy Fall Prevention: Who Can Benefit?• Risk Factors for Older Adult Falls


Older Adult Falls: An Opportunity For Pharmacists

Falls in older adults are a growingand significant public health concern.More than one in four older adultsfalls each year1 and communitypharmacists can play a vital role toreduce the risk of falls. In the pastdecade, fall deaths have increased by30% and it is estimated that falls,both fatal and nonfatal, contribute$50 billion in annual medical costs.2

Certain medication classes affectcognition and physical function whichcontributes to fall risk. Pharmacistscan play a role in fall prevention byassessing medication regimens andproviding clinical recommendationsto help reduce the risk of falls.Managing medications has shown tohave 39% effectiveness in reducingfalls in older adults.3,4 Using geriatric-support tools such as The AmericanGeriatrics Society (AGS) BeersCriteria5, pharmacists can easilyidentify potential misuse ofmedications in older adults.Pharmacists can work with otherhealthcare providers to make animpact on both individual patients’and public health outcomes.

.

The Centers for Disease Control andPrevention (CDC) developed theStopping Elderly Accidents, Deaths,and Injuries (STEADI) initiative toprovide tools for healthcare providersto assist with fall prevention efforts.6

Community Pharmacy Fall Prevention

Community pharmacies andcommunity pharmacists have anopportunity to address this growingpublic health problem. Incollaboration with UNC EshelmanSchool of Pharmacy and UNC Schoolof Medicine at the University ofNorth Carolina at Chapel Hill, the CDChas developed STEADI-Rx.

STEADI-Rx helps pharmacists screenolder adults for fall risk in thepharmacy, offers tools to help thepharmacist perform a medicationreview to identify potentially harmfulmedications, and encourages thepharmacist to provide medicationchange recommendations to providerand patient in order to improvehealth and reduce fall risk.

Older-Adult Fall Prevention Guide for Community Pharmacists | 2019 7

Risk Factors for OlderAdult Falls

Certain chronic conditions, such asthose affecting cognition, vision,postural hypotension and gait andbalance have been associated withan increased risk of falls in olderadults. Table 1 lists symptoms thatmay lead to an increased risk forolder adults.

Home HazardsHazards in the home can increase therisk of falls. Hazards may includemissing handrails on stairs or grabbars in bathtubs, poor lighting,obstacles on the floor, slippery oruneven surfaces, and misuse ofassistive devices.

STEADI-Rx follows the JointCommission of PharmacyPractitioners (JCPP) Pharmacists’Patient Care Process. This processgoes through five steps (Collect,Assess, Plan, Implement, and Follow-Up: Monitor and Evaluate) that canbe incorporated into any clinicalservice.

Patient’s are the primary focus ofSTEADI-Rx. However, the service alsoimpacts public health stakeholderssuch as federal and stategovernments, and health plans. Thegoal of this service is to improvepatient outcomes and reduce overallhealth care costs. STEADI-Rx can leadto improved patient care andincreased interprofessionalcommunication.

Table 1: Symptoms Associated with Falls

• Muscle weakness• Unsteadiness• Dizziness• Syncope• Foot pain or structural

abnormalities• Bladder and bowel

conditions • Changes in cognitive function• Nutritional deficiencies• Sensory impairment – visual,

auditory, or temporal


Physiological Changes of AgingPhysiological changes associated withaging can negatively impact gait,balance, muscle strength, vision, andhearing in older adults, as well asimpact how the body responds totherapy. In addition to alteredabsorption, distribution, metabolism,and elimination of medications thatoccurs in older adults, they may oftenexperience enhanced sensitivity tomedications. These changes lead toincreased risk of drug-druginteractions and adverse drugreactions. Fear of falling also has anegative impact on balance in olderadults.

Medications: Older adults taking fouror more chronic medications have anincreased risk of falling. The moremedications an older adult takes, themore risk of side effects associatedwith falls such as anticholinergic andpsychoactive effects. The AmericanGeriatrics Society Beers Criteria,creates a list of medications that canbe harmful to older adults. Table 2lists medication classes that arelinked to falls. Many of thesemedications are highlyanticholinergic or have side effectssuch as sedation, dizziness, andpostural hypotension. An older adulttaking at least one medication withinthese classes is at higher risk for falls.

Postural Hypotension Postural (orthostatic) hypotension isa drop in blood pressure related tochanges in posture (i.e., moving fromlying to sitting up or from sitting tostanding). The sudden drop inpressure can cause inadequate bloodflow to the body’s organs andmuscles, leading to an increased riskof falling. Common symptomsinclude dizziness, lightheadedness,weakness, headache, blurred vision,pressure across back of shoulders orneck, and nausea. In order to detectthe presence of posturalhypotension, blood pressuremeasurements should be made whilelaying, sitting, and standing. A 20mmHg decrease in systolic bloodpressure or a 10 mmHg decrease indiastolic blood pressure within 3minutes of moving from laying tositting, or sitting to standing isindicative of postural hypotension.

Table 2: High Risk Medication Classes2,3

• Anticonvulsants• Antidepressants• Antihistamines• Antihypertensives• Antipsychotics • Benzodiazepines• Muscle relaxants• Opioids• Sedative hypnotics


References:1. Bergen G. Falls and Fall Injuries Among Adults

Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65.

2. Florence CS, Bergen G, Atherly A, Burns E, Stevens J, Drake C. Medical Costs of Fatal and Nonfatal Falls in Older Adults. J Am Geriatr Soc. 2018;66(4):693-698.

3. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146.

4. Stevens JA, Lee R. The Potential to Reduce Falls and Avert Costs by Clinically Managing Fall Risk. Am J Prev Med. 2018;55(3):290-297.

5. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 0(0).

6. Stevens JA, Phelan EA. Development of STEADI: A Fall Prevention Resource for Health Care Providers. Health Promot Pract. 2013;14(5):706-714.


10

Chapter 2: Fall Prevention Process

Chapter Preview:

• Community Pharmacy Algorithm for Fall Risk Screening, Assessment, and Care Coordination

• Quick Reference Guide• Fall Prevention: Pharmacists’ Patient Care Process• Case Study


Figure 2.1: CDC STEADI-Rx Community Pharmacy Algorithm

12

Quick Reference Guide

Step 1: Screen Patients

❑ Identify eligible patients: • Adults > 65 years of age; taking• > 4 chronic medications; or• > 1 high risk medication

❑ Ask the Three Key STEADI questions (Feels unsteady when standing or walking? Worries about falling? Fell in the past year?)

▪ If patient says YES to ANY question – PROCEED TO STEP 2▪ If patient says NO to all questions – educate patient about falls, document

answers, and share results with patient’s provider using the Provider Consult Form (Appendix B); reassess falls risk in one year or any time a patient presents with a fall.

Step 2: Assess Modifiable Risk Factors

❑ Document answers to the Three Key STEADI questions.❑ Identify medications that increase fall risk and evaluate use❑ Schedule appointment with patient and complete a medication review❑ Review medications and relevant health data

▪ Use the Community Pharmacy Falls Risk Checklist (Appendix B) and UNC High-risk Medication Recommendations (Appendix C)

❑ Identify medication therapy problems (MTP) and other modifiable risk factors❑ Ask about postural hypotension


Step 3: Coordinate Care

❑ Determine if any interventions are needed ❑ Develop and share patient-centered care plan with patient, caregiver, primary care

provider, and other relevant providers▪ Include screening results, MTPs, and recommendations▪ Medication recommendations should include medication name, strength,

dose, and frequency▪ Use the Provider Consult Form (Appendix B) for documentation and

sharing information❑ Refer to provider for an evaluation of gait, strength, and balance using the Provider

Consult Form (Appendix B)❑ Educate patient about fall prevention strategies and provide educational resources❑ Schedule follow-up and document patient-centered plan and pharmacist activities❑ Follow up with provider within 7 days if no response received

❑ Call provider’s office to verify they received the Provider Consult Form❑ Resend Provider Consult Form if provider did not receive it

❑ Follow-up with patient in 30-90 days❑ If no MTPs were identified, follow up with patient yearly (or any time a patient

presents with a fall)

Fall Prevention: Pharmacists’ Patient Care Process

To optimize STEADI-Rx delivery across pharmacies, this guide incorporates theJoint Commission of Pharmacy Practitioners (JCPP) Pharmacists’ Patient CareProcess (PPCP).1 The PPCP is a standardized process with five key actions:Collect, Assess, Plan, Implement, and Follow-up. By using the PPCP to guideimplementation of STEADI-Rx, pharmacies can ensure that they are providingcomprehensive, patient-centered fall-prevention interventions. In this guide,the STEADI-Rx process is divided into key PPCP activities:

Figure 2.2 JCPP Pharmacists’ Patient Care Process

COLLECT

ASSESS

PLAN

To provide effective fall preventioninterventions for older adults, thepharmacy must collect relevantpatient information. This includesscreening patients to identifywhether fall-related risk factors arepresent (STEADI-Rx Step 1:Screening) and collecting relevanthealth and medication informationto assess the patient.

After relevant information has beencollected, pharmacists shouldassess fall-related risk factors(STEADI-Rx Step 2: AssessModifiable Risk Factors) within thecontext of the patient’s overallhealth status and identify actual orpotential medication therapyproblems (MTPs).

A patient-centered plan should bedeveloped in consultation with thepatient, their primary care provider,and other providers (STEADI-Rx Step3: Care Coordination). It shouldinclude a plan for implementationand follow-up.


IMPLEMENT

FOLLOW-UP

The patient-centered plan shouldbe documented and implementedin a timely manner by all membersof the interdisciplinary team. Thisincludes initial patient education,as well as scheduling pharmacyfollow-up with patients andproviders.

A follow-up plan should includeworking with providers within 7 daysto resolve any actual or potentialMTPs. Follow-up with patients within30-90 days or as needed. For patientswho did not have fall-related riskfactors present, reassess patients onan annually or when presenting witha new fall.


References:

1. Joint Commission of Pharmacy Practitioners. Pharmacists’ Patient Care Process. May 29, 2014. Available at: https://jcpp.net/wp-content/uploads/2016/03/PatientCareProcess-with-supporting-organizations.pdf.

15

Identify patients eligible for screening:Adults age 65 years or older using

• ≥ 1 high-risk medication*OR

• ≥ 4 chronic medications OR

• Any time patient presents with an acute fall


STEADI Three Key Questions: 1. Feels unsteady when standing or

walking?2. Worries about falling?3. Fell in the past year? If YES Ask:

➢ How many times? ➢ Were you injured?

NO to all questions: = NOT At Risk

YES to any questions: = At Risk

Start Here

PREVENT Future Risk• Educate patient on fall prevention and refer to community exercise

or fall prevention program• Reassess yearly or any time patient presents with an acute fall

Next Page

COLLECT relevant health information

Key tips for screening:

1. Create alerts to notify pharmacy staff at point-of-dispensing or point-of-sale when a patient is eligible for screening. If an electronic alert is not available, use a bag tag (Figure 2.3).

2. Train technicians, clerks, students, and delivery drivers to screen patients.

3. Help patients understand why you are asking about their history of falls. Explain your role as a patient care champion and provide empowering education about falls prevention.

4. Reduce pharmacy burden by combining screening with provision of another service (e.g., medication therapy management)

Figure 2.3 Bag Tag Example

*High-risk medication Index – Appendix A

STEADI-Rx Fall Prevention Guide for Community Pharmacists | 2019


Key tips for collecting information:

1. Obtain information from multiple sources (e.g.,

patients, caregivers, dispensing profile, primary

care provider, or controlled substance monitoring

database).

2. Use technicians to collect active medication list

from dispensing profile or primary care provider

prior to patient appointment.

3. Schedule patients for telephone or face-to-face

appointments to conduct a medication review.

4. The Community Pharmacy Fall Risk Checklist

(Figure 2.4) is used to help pharmacy collect

relevant information related to fall risk-factors and

high-risk medication-use. It is for internal-use-only

and should not be shared with patients or other

providers.

Figure 2.4 Community Pharmacy Fall Risk Checklist

Screened At Risk (Answered YES to at

least 1 question)

Document answers to the three key questions

Next Page

Schedule patient appointment to review medications and relevant health information.

Collect information:• Past medical history• Active medication list (Rx, OTC, and herbal

medications)• Preferences and beliefs• Socioeconomic factors• Functional status

Form available in Appendix B.



Key tips for medication review

1. Focus on high-risk medication classes (Table 2.1)

when evaluating your patient’s medications.

2. The High-risk Medication Index can help identify

individual high-risk medications (Appendix A).

3. Assess each high-risk medication to identify

whether it is age-appropriate, correct indication,

effective, free of adverse effects, and whether

patients are adherent.

4. AGS Beers Criteria®1 and UNC High-Risk Medication

Recommendation Guide2 provide guidance on

potentially inappropriate medications.

5. Assess other modifiable risk factors including

symptoms of postural hypotension, presence of

home hazards, or need for balance-strengthening

exercise.

• Anticonvulsants

• Antidepressants

• Antihypertensives

• Antipsychotics

• Antispasmodics

• Benzodiazepines

• Opioids

• Sedatives/hypnotics

• Tricyclic antidepressants

Table 2.1 High-Risk Medication Classes

Assess

Next page

Review high-risk medications and evaluate the appropriateness of each medication:

▪ Indication▪ Effectiveness▪ Safety▪ Adherence

Identify any medication therapy problems (MTPs) associated with the use of high-risk medications.

Assess other modifiable risk factors:• Postural hypotension

• Symptoms of lightheadedness or dizziness from lying to standing?

ASSESS modifiable risk factors

Full list available in the High Risk Medication Index, Appendix B.



Key tips for developing recommendations:

1. Use AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults and UNC High Risk Medication Recommendation Guide (Appendix C) provide guidance for reducing, changing, or discontinuing medications.

2. Provide adequate background information to help providers understand the need for changes to therapy. See example in Figure 2.5.

3. Not all patients will need a modification to their medications. However ALL patients are eligible for a gait, balance, and strength assessment from their primary care provider.

4. It may be helpful to remind providers that gait, balance, and strength assessment is a billable assessment.

5. When determining an appropriate follow up time consider the following:1. Will follow-up frequency need to be one time or longitudinal?2. What type of follow-up is required (e.g., face-to-face, phone, electronic)3. When is follow-up needed?

Figure 2.5 Pharmacists’ Recommendation Example

“Patient has recently experienced several injurious falls and endorses symptoms of dizziness and sedation. If appropriate, please consider switching from paroxetine to citalopram, which has a better safety profile in relation to falls. I recommend paroxetine taper and washout prior to switching to citalopram. In addition, please assess gait, balance, and strength at next visit. The patient was educated about the importance of proactive falls prevention and provided with educational resources.”

Develop medication recommendations: • Include medication name, strength, dose,

frequency, and refills

Identify educational and follow-up needs of patient and/or caregivers

Coordinate Care

Coordinate care with patient, caregiver, primary care provider, other providers to develop a patient-centered care plan

Next page

PLAN to reduce risk of falls

19Older-Adult Fall Prevention Guide for Community Pharmacists | 2019 19

IMPLEMENT patient-centered plan

Schedule follow-up with patient within 30-90 days

Educate about fall prevention strategies and resources▪ Identify and remove potential home hazards ▪ Regular hearing and vision check-up▪ Exercise to improve balance and strength (i.e., Otago, Tai Chi)▪ Use https://www.cdc.gov/steadi/patient.html to find patient education materials

Implement

Share medication therapy problems and recommendations with primary care provider using Provider Consult – Medication Assessment form (Appendix B)

Share Screening and Medication Review Results

Share answers to Three Key STEADI questions and patient education with primary care provider using Provider Consult – Fall Screening form (Appendix B)

NO problems identified

Medication therapy problems identified

Next page

Recommend evaluation of gait, strength, and balance

Key tips for sharing recommendations:

1. Use the Fax Form and Provider Flyer (Appendix B) to help providers understand the fall prevention activities being conducted by the pharmacist.

2. Contact provider offices to determine if they would like to receive recommendations by fax, electronic messaging, or by phone. If they prefer phone, ask them if you can still share a copy to ensure reciprocal sharing of information.


https://www.cdc.gov/steadi/patient.html

2020STEADI-RX Community Pharmacy Older-Adult Fall Prevention | 2019

Key tips for Documentation and Follow-up:

1. A variety of fall risk measures impact primary care providers, so it’s important to share information collected, as well any interventions provided (i.e., education).

2. Provider offices may receive large quantities of daily faxes, leading to recommendations being lost or misplaced. It’s important to identify the preferred communication methods of each office to encourage successful transmission of information.

3. Create alerts in your dispensing software to notify staff at point-of-dispensing or point-of-sale whether a patient is due for follow-up. If an alert is not available in either of these systems, a paper or HIPAA-compliant electronic calendar can be a used.

Send results to patient’s provider

Document and Schedule Follow-

Up

Document patient-centered care plan, pharmacist activities, and plans for follow-up

CALL: Provider’s office to verify they received the Provider Consult Form; resend if needed

Repeat STEADI-Rx falls assessment on a yearly basis or when presenting with an acute fall.

FOLLOW UP with patient in 30-90 days: Discuss ways to improve patient receptiveness to the patient-provider care plan and address barrier(s).

Response RECEIVED from

provider

Response NOT RECEIVED from provider within 7 days

FOLLOW-UP with patient and provider



References:1. American Geriatrics Society 2019 Updated AGS

Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 0(0).

2. UNC High Risk Medication Recommendations. UNC Eshelman School of Pharmacy 2019. Available online atpharmacy.unc.edu/research/centers/cmo

Fall Risk Screening (STEADI-Rx Step 1)Before ringing up her prescriptions, the pharmacy technician screens Mrs. Booker because she istaking 4 or more medications, which increases her risk for falls. The technician uses the ThreeKey STEADI questions to screen her. Mrs. Booker states “Yes” to the question, “I have fallen inthe past year”, therefore, she has screened positive for increased risk of falling.

When asked, Mrs. Booker reports she fell the previous week but wasn’t hurt and didn’t seek medical attention. She says she was out walking with a friend. They were talking, and she wasn’t looking where she was going. She tripped over a crack in the sidewalk. This was her first fall.

Assess of Modifiable Risk Factors (STEADI-Rx Step 2)The technician alerts the pharmacist that Mrs. Booker screened positive for falls risk, who then performs a comprehensive medication review utilizing the Community Pharmacy Fall Risk Checklist (Example on next page).

Mrs. Booker takes the following medications:

• Fluoxetine 40 mg by mouth daily• Lorazepam 0.5 mg - 1 mg by mouth twice daily as needed• Levothyroxine 75 mcg by mouth daily• Hydrochlorothiazide 25 mg by mouth daily• Docusate 200 mg by mouth daily• Acetaminophen 500 mg by mouth four times daily as needed for pain

Mrs. Booker reports using lorazepam 1-2 times per week and acetaminophen 3-4 times per week. When asked about her adherence, she states that she might miss her fluoxetine once a month. She currently uses a pill box. The pharmacist also asks Mrs. Booker if she has been having any symptoms of postural hypotension (i.e., dizzy or lightheaded upon sitting up or standing). She states she has a little dizziness when getting out of bed for the last week. Her BP measures 105/67 mmHg in the pharmacy. She also states that she has not been able to sleep since she started taking her fluoxetine a couple months ago.

The pharmacist makes the following assessment:

• Fluoxetine, lorazepam, and hydrochlorothiazide are high-risk medications• Fluoxetine is a long-acting SSRI known to cause sleep disturbances• Lorazepam use is consistent with refill history; appropriate to use in older adults• History of a fall, even if by accident, increases future risk• Hydrochlorothiazide dose was increased (12.5 to 25 mg) two weeks ago, is likely cause of

postural hypotension symptoms

Case Study: Carolina Booker


Mrs. Booker is a 76-year-old woman who lives independently in her own home. She has come to the community pharmacy to pick up her medications.

Case Study

Carolina Booker

2/21/1942 00/00/0000

fluoxetine 40 mg daily (sleep disturbances)

Dr. John Paul

Hydrochlorothiazide 25 mg daily Dr. John Paul

Dr. John PaulLorazepam 0.5-1 mg twice daily, PRN; patient taking 1-2 times per week

Mrs. Booker reports falling last week but she wasn’t hurt and didn’t seek medical attention. She was out walking with a friend and tripped over a crack in the sidewalk. This was her first fall. She reports symptoms of postural hypotension, as well as that fluoxetine keeps her up at night. Lorazepam use is consistent with refill history and she does not appear to be experiencing adverse effects. Lorazepam is an appropriate benzodiazepine for her age, but will continue to monitor risk/benefit.

Case Study

Care Coordination (STEADI-Rx Step 3)The pharmacist states he can talk to her primary care provider to make a recommendation for another medication that will not cause her to stay up at night. He also recommends lowering the dose of hydrochlorothiazide to help stop dizziness in the morning. The pharmacist then reviews the STEADI patient education brochures, What To Do To Prevent Falls and Check for Safety, with the patient. The pharmacist explains to Mrs. Booker that due to her risk of falling, he is suggesting she follow-up with her primary care provider regarding an assessment of gait, strength and balance.

Before ending the interview, the pharmacist sets up an appointment to follow-up with Mrs. Booker in one month to assess medication changes, sleep, and symptoms of dizziness.

After Mrs. Booker leaves, the pharmacist uses the Fax Form and Provider Consult Form –Medication to share screening results and medication recommendations, as well as a recommendation to assess gait, strength, and balance with Mrs. Booker’s primary care provider. After the primary care provider has reviewed the pharmacist’s report, a return communication can be sent to the pharmacy for documentation. (Example on next page).


Case Study

John Paul, MD Chris Lovett, PharmD

00/00/0000

(000)000-0000

(000)000-0000 (000)000-0000

(000)000-0000

2

Case Study



Carolina Booker

2/21/1942

John Paul, MD

00/00/0000

(000)000-0000

Patient reports sleep disturbance since starting fluoxetine 40 mg daily

Consider fluoxetine taper and switch to citalopram 20 mg 1 tablet daily

to avoid sleep disturbance

Patient reports symptoms of postural hypotension, which may be caused by

Hydrochlorothiazide 25 mg daily

If appropriate, please consider reducing dose to 12.5 mg 1 tablet daily

Chris Lovett, PharmD

(000)000-0000 (000)000-0000

Lovett Pharmacy

Mon-Thur; 8am – 6pm

Case Study


27

Chapter 3: Implementing Fall Prevention

Chapter Preview:

• Key Considerations for Your Pharmacy• Best Practices• Frequently Asked Questions (FAQ)

Key Considerations for Your Pharmacy

BEFORE YOU BEGIN

Conduct Environmental Scan

For many pharmacies, older adults comprise a large portion of their patient population,making fall-prevention a great service opportunity. Fall-prevention activities can easilyintegrate into existing pharmacy services like medication therapy management. Whenplanning the scale (i.e., resource attribution) of fall prevention activities to provide, you willneed to identify what portion of your patient population will benefit and how the service willfit into your existing model. A SWOT Analysis (Table 3.1) can help identify internal andexternal factors that may impact implementation.

Identify Project Champion

Identify a project champion for pharmacy success. This person needs to be someone who willchampion the service to patients and pharmacy staff. They will supervise implementation,ensure appropriate documentation and follow-up. A technician or pharmacist isrecommended for this role.

Assess Readiness

Assess the pharmacy’s readiness to provide fall-prevention activities and determine stepsneeded to implement the service. This includes developing an action plan to optimizestrengths and opportunities, as well as to mitigate weaknesses and threats. A readinessassessment may include questions listed in Table 3.2.

Establish Support

An important step for successful implementation is to gain the support of pharmacy staff andmanagement. When presenting this as a potential service, develop an outline of the service’sgoals/purpose, as well as key steps, people, training, and resources needed. Staff may bemore willing to participate when they recognize fall- prevention as an opportunity to improvepatient outcomes and advance the role of community pharmacy in patient care. Additionalfactors that may help encourage staff participation is having access to comprehensive fall-prevention training, tools that improve workflow efficiency, and ongoing leadership support.


Table 3.1 Fall-Prevention Service SWOT Analysis

Strengths Internal factors that may support successful fall-prevention services (e.g., resources available, staff already providing other services)

Weaknesses Internal factors that may hinder successful fall-prevention services (e.g., poor workflow or documentation procedures)

Opportunities External factors that may support successful fall-prevention services (e.g., large older adult population, supportive providers, lack of similar programs in other pharmacies, existing community resources)

Threats External factors that may hinder successful fall-prevention services (e.g., nearby pharmacies with robust fall-prevention services, lack of reimbursement)


Table 3.2 Fall Prevention Readiness Assessment

• What resources are needed (e.g., personnel, tools, clinical resources)?

• What training is needed (i.e., clinical knowledge, technical skills)?

• Does the service have appropriate leadership support & staff buy-in?

• Does dispensing workflow accommodate service activities (i.e., screening, medication review, care coordination)?

• Is there sufficient capacity for this service (e.g., slack resources, other enhanced services)?

• Does the pharmacy provide other enhanced services (e.g., MTM, adherence packaging, POC testing, ABM)

• Are there methods in place to market the service to patients and/or providers?

• What are opportunities for collaboration (e.g., patient advocacy, other health care providers, community stakeholders)?

MTM – medication therapy management,, POC – point-of-care, ABM – appointment-based model formedication synchronization


GETTING STARTED

Gather Resources

Start by gathering necessary tools andresources to conduct fall-preventionactivities. Table 3.3 contains a list of usefulresources.

Develop Procedures

Develop procedures that efficientlyincorporate fall-prevention activities intoexisting pharmacy workflow. Ideally, the fall-prevention service should be technician-driven, with pharmacists participating inportions that require clinical judgement and

Table 3.3 Tools & Resources

• STEADI-Rx toolkit resources (print or electronic)

• Bag tags or point-of-sale alerts • Patient chart or folders (print or

electronic)• Binder for storing print resources• Patient appointment calendar

(print or electronic)• Clinical resources (e.g., Up To Date,

Lexicomp)• AGS Beers Criteria for Potentially

Inappropriate Medications in Older Adults®

• UNC High-Risk Medication Recommendations

and expertise. Fall-prevention should be a staff-wide initiative, with student interns, clerks,and delivery drivers providing ancillary support. There are five specific areas where thepharmacy must identify and provide support:

1. Patient Identification: Develop a system for identifying patients at highest risk for falls. Ifpossible, target patients electronically using pharmacy dispensing software. Contact yourvendor to learn how to create alerts. Alternatively, you can use filters or reports to identifyeligible patients. It is optimal to automate this process so reports do not need to be repeatedor updated.

2. Screening: Screening can be offered at any point within workflow. Pharmacies may find it convenient to combine screening with delivery of another service, such as the appointment-based model for medication synchronization. For example, monthly telephone calls are an excellent opportunity to engage patients about falls. Screening can be provided by any member of pharmacy staff. Use electronic alerts within workflow or at point-of-sale to notify staff if patient is eligible for screening. Lastly, procedures should be developed for determining how pharmacists will be alerted when patients screen positive.

3. Medication Review: In order to optimize pharmacists’ time for clinical activities, technicians should be responsible for collecting the majority of information for a high-risk medication review. Updated medication lists may be gathered from pharmacy dispensing software, primary care providers, or the electronic health record (EHR) where available. Pharmacists should confirm active medications during the interview. Patient interviews can be conducted by phone or face-to-face, with technicians managing scheduling and reminders.

4. Follow-up: Schedule patient follow-up during the patient interview, using a HIPAA-compliant electronic calendar to manage follow-up activities. Depending on the nature of issue, follow-up can be provided by either pharmacists or support staff.


5. Documentation: All fall-prevention activities should be fully documented in a patient chart and shared with patients’ primary care providers. Fall risk screening and medication review are key components of fall-risk assessment, and are quality performance measures for providers. By sharing information in a useful manner, pharmacists have an opportunity to assist providers and build sustainable models of collaboration. STEADI-Rx forms should be shared by fax or electronically, and then documented in paper or electronic patient charts. If available, we recommend documentation in the patient’s EHR or eCare plan.

Identify Staff Roles

Staff roles and responsibilities should be identified for fall prevention procedures:

1. Screening

• Who will identify eligible patients and set electronic or print alerts?

• Who will screen patients with the Key Three STEADI questions (e.g., technician, delivery driver, pharmacist)?

• Who will document patient responses?

2. Medication Review

• Who will gather patient health and medication information prior to review (e.g., technician, pharmacist)?

• Who will schedule patient appointment and make reminder call (e.g., technician, clerk, pharmacist)?

• Who will conduct medication review (e.g., any pharmacist)?

• Who will document medication review (e.g., technician, pharmacist)?

3. Care Coordination

• Who will provide care plan, recommendations, and patient education (e.g., designated pharmacist or any pharmacist)?

• Who will provide patient or prescriber follow-up (e.g., technician, delivery driver, pharmacist)?

• Who will document care coordination activities (e.g., technician, pharmacist)?

Provide Training

Clinical and technical training is necessary for successful implementation of STEADI-Rx.Onboard training should include review of clinical knowledge for pharmacists, as well ascomprehensive technical training for all support staff. Each member of staff should understandthe core clinical components of STEADI-Rx, as well as processes and procedures. In addition, allstaff may benefit from communication training (e.g., motivational interviewing) to enhanceinteractions with patients, caregivers, and providers.


A Word On Staff Roles and Enhanced Services

Community pharmacy dispensing workflow is fast-paced, leaving little time for staffdevelopment or provision of clinical services. In order to provide new services, it is necessaryfor pharmacies to build capacity through efficiency and by providing technical staff with non-traditional clinical support roles. For example, implementing services such as theAppointment-based model (ABM) for medication synchronization1 may help improvedispensing workflow while providing technician staff with the opportunity to be moreinvolved in clinical follow-up. The ABM aligns prescription refills on a 30- or 90-day schedule,reducing the number of times a patient visits the pharmacy each month. In this model,technicians conduct monthly telephone appointments with patients to assess adherence,medication changes, or recent health events. This provides a mechanism for technician-driven follow-up and collection of clinical information. Importantly, by incorporatingtechnician staff to manage the technical processes within an enhanced service, it providesstaff with the opportunity to engage with patients in meaningful ways and increase theirknowledge and skillset.

STEADI-Rx is designed to allow all pharmacy staff to join the falls prevention effort andprovide meaningful intervention on behalf of older adults. Whether by engaging techniciansto screen patients at the prescription counter, or delivery drivers to screen for home hazards,gait imbalance, or other risk factors, everyone in the pharmacy can make a difference in apatient’s life.

1 www.aphafoundation.org/appointment-based-model

Market Service

Community pharmacies have a broad audience to market fall-prevention services. Marketingdirected to patients should be individualized and help patients and caregivers understand therisks associated with falling and inappropriate medication usage, as well as how pharmacistscan help mitigate those risks. In addition to personally sharing your message with patients,use initiatives like the National Council on Aging’s Falls Prevention Awareness Day (annuallyin September) to draw upon national momentum. Provider messaging should target mutualbenefit for patients, providers, and pharmacists through improved patient outcomes andadherence to performance measures. In addition, marketing to other health care providersand community/public health stakeholders can increase your pharmacy’s referrals and canhelp create strong partnerships.


BEST PRACTICES:

Patient Communication

Conversations about aging may be difficult for older adults and caregivers. It is important forpharmacy staff to be respectful and aware of the difficult challenges faced during the processof aging. Be mindful that falls can be sensitive topic, with older adults often embarrassed toadmit that they have fallen in the past. Chronic conditions such as dementia not only worsenthe risk of falls, but make it difficult for older adults to recognize and report concerningsymptoms. They may not be able to recall previous falls or injuries. Many older adults,caregivers, and health care providers may have a false belief that falls are a natural part ofaging. While it is true that age is a risk factor, there are a variety of evidence-basedinterventions that can keep older adults strong, safe, and living independently. Part of thepharmacist’s role is to explore misconceptions through empathy and active listening.Conversations should focus on empowering the patient.

It may be helpful for pharmacy staff to participate in communications training in order toimprove the quality of patient interventions. Motivational interviewing is a technique thathelps guide health care providers in understanding how patients perceive and make sense oftheir conditions and/or experiences. The way that health care providers respond to patientsense-making has a direct impact on patient behavior and willingness to collaborate. It isessential to build rapport and gain patient trust before recommending medication or lifestylechanges.

Be mindful of how you communicate using verbal, nonverbal and written techniques:

• Verbal: Is your language easy to understand, convey empathy, and devoid of medicaljargon?

• Non-verbal: Does your expression and posture support your verbal communication; do youappear open and empathetic?

• Written: Are your materials written at the appropriate health literacy level; do you usethem as props to guide patients to the most important information?

In-Depth Motivational Interviewing Training

Bruce Berger, PhD (Auburn University) and William Villaume, PhD (Auburn University) areauthors of Motivational Interviewing for Health Care Professionals: A Sensible Approach(American Pharmacists Association, 2013). This book provides a step-wise approach to learningand understanding motivational interviewing – without the use of acronyms or other hard-to-remember comparisons. An updated version is due to be published in late 2019.

In 2018, they released comMIt Comprehensive Motivational Interviewing Training an onlinecontinuing education course with 8.0 CE contact hours through Purdue University College ofPharmacy (https://ce.pharmacy.purdue.edu/mi/introduction).

Both resources provide the psychologic and physiologic foundation for health behavior and howhealth care providers can overcome barriers to promote patient health and well-being.

CE: Pharmacists, Technicians

https://ce.pharmacy.purdue.edu/mi/introduction


Provider Communication

It may be helpful to contact primary care providers with whom you share mutual patients toidentify the most useful method for communicating and sharing information. It is importantto recognize that like us, other health care providers face their own workflow challenges. Inaddition, it may be useful to discuss whether the provider is collecting fall-relatedinformation, such as STEADI screening results, and how the pharmacy can help provideadditional information and insight. If possible, request access to the office’s EHR to limit thenumber of faxes, emails, or phone calls shared from the pharmacy. If they cannot provideyou with remote access, they may allow a member of your staff to visit the office to updatepatient information. Finally, when making medication recommendations, share acomprehensive recommendation that contains drug name, strength, dose, frequency, andnumber of refills. Table 3.4 contains tips for improving interprofessional communication withproviders.

Table 3.4 Key Tips for Interprofessional Communication

General• Develop trust with providers by sharing high-quality assessment and recommendations• Identify the a point-person in the office if the provider is not available• Determine communication method that is easiest for all office staff (i.e., not just

provider)• Use pharmacy branding (i.e., logo) on external forms to build trust and brand

recognition• Maintain open communication• Accept constructive criticism• Address miscommunication immediately

Sharing Recommendations• Determine what information is most valuable to providers (i.e., avoid ”checking the

box”)• Patient information (i.e., reported by patient or observed by pharmacist)• Clinical information (i.e., medication risks)

• Prioritize medication therapy problems (i.e., do not share everything at once)• Provide clear assessment and sufficient background information to understand the

problem• Provide clear action item(s) for provider and/or pharmacist• Offer comprehensive recommendations (i.e., drug name, strength, dose, frequency,

refills)• Provide individual pharmacist’s contact information and availability• Use legible handwriting and avoid abbreviations


Can I complete screenings and medication reviews by phone?

Yes, all activities can be conducted by phone to accommodate home-bound patients.

How many attempts to contact the patient for screenings and medication reviews should be made?

If feasible, attempt to contact the patient three (3) times. For hard-to-reach patients, ask for updated contact information at every pharmacy visit, or contact known family members to identify an active phone number.

What if a patient refuses to be screened or to complete a medication review?

Use motivational interviewing to better understand the patient’s resistance. Provide education resources about falls and fall prevention to help empower the patient.

How should I approach a patient when asking the Three Key STEADI questions?

Staff should indicate that the pharmacy is participating in an initiative to reduce older adult falls. Personalize your message to focus on ways that STEADI-RX can help the individual patient. Avoid medical jargon.

How do I know whether a medication is high-risk or not?

The High-Risk Medication Index in Appendix A includes a comprehensive list of medications linked to falls and injury.

Where can I find resources for high-risk medications?

Appendices A-B provide resources and direction for identifying and mitigating risks associated with high-risk medications. The AGS Beers Criteria for Potentially Inappropriate Medications and UNC High Risk Medication Recommendations are two useful tools for making evidence-based medication recommendations.

What if medication issues are identified that are unrelated to falls?

Utilize whatever method your pharmacy normally uses to alert prescribers of medication issues.

What if I did not identify any medication issues, should I still share responses to the Three Key STEADI questions?

Yes. Every patient who responds “YES” to any of the questions is eligible for a gait, balance, and strength assessment from prescriber. The Provider Consult – Fall Assessment form can be completed and shared with providers.

Frequently Asked Questions

Appendix A: High Risk Medication Index



Medication Drug Class A

Abilify Antipsychotics

acebutalol Antihypertensives

Aceon Antihypertensives

Accupril Antihypertensives

Actiq Opioids

Aldactazide Antihypertensives

Aldactone Antihypertensives

Aldomet Antihypertensives

alprazolam Benzodiazepines

Altace Antihypertensives

Ambien Benzodiazepines

amiloride Antihypertensives

amitriptyline Tricyclic Antidepressants

amlodipine Antihypertensives

amobarbital Sedative Hypnotics

amoxapine Tricyclic Antidepressants

Amytal Sedative Hypnotics

Anafranil Tricyclic Antidepressants

Apresoline Antihypertensives

Aptiom Anticonvulsants

aripiprazole Antipsychotics

asenapine maleate Antipsychotics

Asendin Tricyclic Antidepressants

Atacand HCT Antihypertensives

atenolol Antihypertensives

Ativan Benzodiazepines

Avalide Antihypertensives

Avapro Antihypertensives

Azor Antihypertensives

B

baclofen Antispasmodics

Banzel Anticonvulsants

belladonna alkaloids Antispasmodics

Benicar HCT Antihypertensives

Bentyl Antispasmodics

benazepril Antihypertensives

bisoprolol Antihypertensives

Blocadren Antihypertensives

brivaracetam Anticonvulsants

Briviact Anticonvulsants

bumetanide Antihypertensives

Bumex Antihypertensives

buprenorphine Opioids

bupropion Antidepressants

Buspar Antidepressants

Medication Drug Class buspirone Antidepressants

butabarbital Sedative Hypnotics

butalbital Sedative Hypnotics

Butisol Sedative Hypnotics

Butrans Opioids

Bystolic Antihypertensives

Byvalson Antihypertensives

C

Caduet Antihypertensives

Calan Antihypertensives

candesartan Antihypertensives

captopril Antihypertensives

carbamazepine Anticonvulsants

Carbatrol Anticonvulsants

Cardene Antihypertensives

Cardizem Antihypertensives

Cardura Antihypertensives

carisoprodol Antispasmodics

Cartia Antihypertensives

carvedilol Antihypertensives

Catapres Antihypertensives

Celexa Antidepressants

Celontin Anticonvulsants

Cerebryx Anticonvulsants

chlorazepate Benzodiazepines

chlordiazepoxide Benzodiazepines

chlorthiazide Antihypertensives

chlorpromazine Antipsychotics

chlorthalidone Antihypertensives

chlorzoxazone Antispasmodics

citalopram Antidepressants

clidinium-chloridazepoxide Antispasmodics

clobazam Anticonvulsants

clomipramine Tricyclic Antidepressants

clonazepam Benzodiazepines

clonidine Antihypertensives

clozapine Antipsychotics

Clozaril Antipsychotics

codeine Opioids

Coreg Antihypertensives

Corgard Antihypertensives

Cozaar Antihypertensives

cyclobenzaprine Antispasmodics

Cymbalta Antidepressants

D

Dalmane Benzodiazepines


Medication Drug Class Dantrium Antispasmodics

dantrolene Antispasmodics

darifenacin Antispasmodics

Demadex Antihypertensives

Demerol Opioids

Depakene Anticonvulsants

Depakote Anticonvulsants

desipramine Tricyclic Antidepressants

desvenlafaxine Antidepressants

Desyrel Antidepressants

Detrol Antispasmodics

diazepam Benzodiazepines

dicyclomine Antispasmodics

Dilacor Antihypertensives

Dilantin Anticonvulsants

Dilaudid Opioids

diltiazem Antihypertensives

Diltzac Antihypertensives

Diovan HCT Antihypertensives

diphenhydramine Sedative Hypnotics

Ditropan Antispasmodics

Diuril Antihypertensives

divalproex sodium Anticonvulsants

Dolophine Opioids

Donnatol Antispasmodics

Doral Benzodiazepines

doxazosin Antihypertensives

doxepin Tricyclic Antidepressants

doxylamine Sedative Hypnotics

duloxetine Antidepressants

Duragesic Opioids

Dyazide Antihypertensives

Dynacirc Antihypertensives

Dyrenium Antihypertensives

E

Effexor (Effexor XR) Antidepressants

Elavil Tricyclic Antidepressants

Enablex Antispasmodics

enalapril Antihypertensives

Entresto Antihypertensives

eplerenone Antihypertensives

eprosartan Antihypertensives

Equanil Sedative Hypnotics

escitalopram Antidepressants

Esidrix Antihypertensives

eslicarbazepine Anticonvulsants

Medication Drug Class estazolam Benzodiazepines

eszopiclone Benzodiazepines

ethosuximide Anticonvulsants

Exforge Antihypertensives

ezogabine Anticonvulsants

F

Fanapt Antipsychotics

felbamate Anticonvulsants

Felbatol Anticonvulsants

felodipine Antihypertensives

fentanyl Opioids

Fentora Opioids

fesoterodine Antispasmodics

Fetzima Antidepressants

Fioricet Sedative Hypnotics

Fiorinal sedative hypotics

flavoxate Antispasmodics

Flexeril Antispasmodics

fluoxetine Antidepressants & Antipsychotics

fluphenazine Antipsychotics

flurazepam Benzodiazepines

fluvoxamine Antidepressants

fosinopril Antihypertensives

fosphenytoin Anticonvulsants

furosemide Antihypertensives

Fycompa Anticonvulsants

G

gabapentin Anticonvulsants

Gabitril Anticonvulsants

Geodon Antipsychotics

guanabenz Antihypertensives

guanfacine Antihypertensives

H

Halcion Benzodiazepines

Haldol Antipsychotics

haloperidol Antipsychotics

hydralazine Antihypertensives

hydrochlorothiazide Antihypertensives

hydrocodone Opioids

Hydrodiuril Antihypertensives

hydromorphone Opioids

Hygroton Antihypertensives

hyoscyamine Antispasmodics

Hypovase Antihypertensives

Hytrin Antihypertensives


Medication Drug Class eslicarbazepine Anticonvulsants

Hyzaar Antihypertensives

I

iloperidone Antipsychotics

imipramine Tricyclic Antidepressants

indapamide Antihypertensives

Inderal Antihypertensives

Innopran Antihypertensives

Inspra Antihypertensives

Intuniv Antihypertensives

Invega Antipsychotics

irbesartan Antihypertensives

isocarboxazid Antidepressants

Isoptin Antihypertensives

isradipine Antihypertensives

K

Keppra Anticonvulsants

Klonopin Benzodiazepines

L

labetalol Antihypertensives

lacosamide Anticonvulsants

Lamictal Anticonvulsants

lamotrigine Anticonvulsants

Lasix Antihypertensives

Latuda Antipsychotics

Lentopres Antihypertensives

Levatol Antihypertensives

Levbid Antispasmodics

levetiracetam Anticonvulsants

Levo-Dromoran Opioids

levomilnacipran Antidepressants

levorphanol Opioids

Levsin Antispasmodics

Levsinex Antispasmodics

Lexapro Antidepressants

Librax Antispasmodics

Librax Benzodiazepines

Librium Benzodiazepines

Limbitrol Benzodiazepines

Lioresal Antispasmodics

lisinopril Antihypertensives

Loniten Antihypertensives

Lopressor Antihypertensives

lorazepam Benzodiazepines

Lorcet Opioids

Lortab Opioids

Medication Drug Class losartan Antihypertensives

Lotensin Antihypertensives

Lotrel Antihypertensives

loxapine Antipsychotics

Loxitane Antipsychotics

Lozol Antihypertensives

Ludiomil Tricyclic Antidepressants

Lunesta Benzodiazepines

lurasidone Antipsychotics

Luvox Antidepressants

Lyrica Anticonvulsants

M

maprotiline Tricyclic Antidepressants

Marplan Antidepressants

Mavik Antihypertensives

Maxzide Antihypertensives

Mellaril Antipsychotics

meperidine Opioids

meprobamate Sedative Hypnotics

metaxalone Antispasmodics

methadone Opioids

methocarbamol Antispasmodics

methsuximide Anticonvulsants

methyldopa Antihypertensives

metolazone Antihypertensives

metoprolol Antihypertensives

Micardis Antihypertensives

Microzide Antihypertensives

Midamor Antihypertensives

Miltown Sedative Hypnotics

Minipress Antihypertensives

minoxidil Antihypertensives

mirtazapine Antidepressants

Moban Antipsychotics

molindone Antipsychotics

morphine Opioids

MS Contin Opioids

Mysoline Anticonvulsants

N

nadalol Antihypertensives

Nardil Antidepressants

Navane Antipsychotics

Nebilet Antihypertensives

nebivolol Antihypertensives

nebivolol/valsartan Antihypertensives

nefazodone Antidepressants


Medication Drug Class Nembutal Sedative Hypnotics

Neurontin Anticonvulsants

nicardipine Antihypertensives

Nifedipine Antihypertensives

nimodipine Antihypertensives

Nimotop Antihypertensives

nisoldipine Antihypertensives

Norco Opioids

Norflex Antispasmodics

Normodyne Antihypertensives

Norpramine Tricyclic Antidepressants

nortriptyline Tricyclic Antidepressants

Norvasc Antihypertensives

Nucynta Opioids

O

olanzapine Antipsychotics

olmesartan Antihypertensives

Onfi Anticonvulsants

Opana Opioids

Orap Antipsychotics

Oretic Antihypertensives

orphenadrine Antispasmodics

oxazepam Benzodiazepines

oxcarbazepine Anticonvulsants

oxybutynin Antispasmodics

oxycodone Opioids

OxyContin Opioids

oxymorphone Opioids

P

paliperidone Antipsychotics

Pamelor Tricyclic Antidepressants

Paraflex Antispasmodics

Parnate Antidepressants

paroxetine Antidepressants

Paxil Antidepressants

penbutolol Antihypertensives

pentobarbital Sedative Hypnotics

pentazocine Opioids

perampanel Anticonvulsants

Percocet Opioids

perindopril Antihypertensives

Permitil Antipsychotics

perphenazine Antipsychotics

phenelzine Antidepressants

phenobarbital Anticonvulsants

phenytoin Anticonvulsants

Medication Drug Class pimozide Antipsychotics

pindolol Antihypertensives

Plendil Antihypertensives

Potiga Anticonvulsants

prazosin Antihypertensives

pregabalin Anticonvulsants

primidone Anticonvulsants

Prinivil Antihypertensives

Pristiq Antidepressants

Pro-Banthine Antispasmodics

Prolixin Antipsychotics

propantheline Antispasmodics

propranolol Antihypertensives

protriptyline Tricyclic Antidepressants

Prozac Antidepressants

Q

quazepam Benzodiazepines

quetiapine Antipsychotics

quinapril Antihypertensives

R

ramipril Antihypertensives

Raudixin Antihypertensives

Remeron Antidepressants

reserpine Antihypertensives

Restoril Benzodiazepines

Risperdal Antipsychotics

risperidone Antipsychotics

Robaxin Antispasmodics

Roxidone Opioids

rufinamide Anticonvulsants

S

Sabril Anticonvulsants

sacubitril/valsartan Antihypertensives

Sanctura Antispasmodics

Sapris Antipsychotics

Sarafem Antidepressants

secobarbital Sedative Hypnotics

Seconal Sedative Hypnotics

Sectral Antihypertensives

Serax Benzodiazepines

Seroquel Antipsychotics

Serpalan Antihypertensives

Serpasil Antihypertensives

sertraline Antidepressants

Serzone Antidepressants

Sinequan Tricyclic Antidepressants


Medication Drug Class Skelaxin Antispasmodics

solifenacin Antispasmodics

Soma Antispasmodics

Sonata Benzodiazepines

spironolactone Antihypertensives

Stelazine Antipsychotics

Sular Antihypertensives

Surmontil Tricyclic Antidepressants

Symbyax Antipsychotics

T tapentadol Opioids

Taztia Antihypertensives

Tekturna HCT Antihypertensives

Tegretol Anticonvulsants

telmisartan Antihypertensives

temazepam Benzodiazepines

Tenex Antihypertensives

Tenoretic Antihypertensives

Tenormin Antihypertensives

terazosin Antihypertensives

Thalidone Antihypertensives

thioridazine Antipsychotics

thiothixene Antipsychotics

Thorazine Antipsychotics

tiagabine Anticonvulsants

Tiazac Antihypertensives

timolol Antihypertensives

tizanidine Antispasmodics

Tofranil Tricyclic Antidepressants

tolterodine Antispasmodics

Topamax Anticonvulsants

topiramate Anticonvulsants

Toprol XL Antihypertensives

torsemide Antihypertensives

Toviaz Antispasmodics

Trancot Sedative Hypnotics

Trandate Antihypertensives

trandolapril Antihypertensives

Tranxene Benzodiazepines

tranylcypromine Antidepressants

trazodone Antidepressants

triamterene Antihypertensives

triazolam Benzodiazepines

Tribenzor Antihypertensives

Tridione Anticonvulsants

trifluoroperazine Antipsychotics

Medication Drug Class Trilafon Antipsychotics

Trileptal Anticonvulsants

trimethadione Anticonvulsants

trimipramine Tricyclic Antidepressants

trospium Antispasmodics

Tussionex Opioids

Tylenol #3 Opioids

U

Urispas Antispasmodics

V

Valium Benzodiazepines

valproate Anticonvulsants

valsartan Antihypertensives

Vasoflex Antihypertensives

Vasotec Antihypertensives

venlafaxine Antidepressants

verapamil Antihypertensives

Vesicare Antispasmodics

Vicodin Opioids

Vicoprofen Opioids

vigabatrin Anticonvulsants

Viibryd Antidepressants

vilazodone Antidepressants

Vimpat Anticonvulsants

Visken Antihypertensives

Vivactil Tricyclic Antidepressants

W Wellbutrin/Wellbutrin SR Antidepressants

Wytensin Antihypertensives

X Xanax Benzodiazepines

Z zaleplon Benzodiazepines

Zanaflex Antispasmodics

Zarotin Anticonvulsants

Zaroxolyn Antihypertensives

Zayasel Antihypertensives

Zebeta Antihypertensives

Zestril Antihypertensives

Ziac Antihypertensives

ziprasidone Antipsychotics

Zoloft Antidepressants

zolpidem Benzodiazepines

Zonegran Anticonvulsants

zonisamide Anticonvulsants

Zyprexa Antipsychotics

Appendix B: STEADI-Rx Forms


• Community Pharmacy Fall Risk Checklist• Provider Flyer• Fax Form• Provider Consult – Medication• Provider Consult – Fall Screening


43


44


45


46


47

Appendix C: Resources


Medication Recommendation Resources

UNC High Risk Medication Recommendationswww.pharmacy.unc.edu/research/centers/cmo

AGS Beers Criteria for Potentially Inappropriate Medications in Older AdultsAmerican Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 0(0). doi:10.1111/jgs.15767

Patient Education Resources

Stay Independentwww.cdc.gov/Steadi/pdf/stay_independent_brochure-a.pdf

What You Can Do About Fallswww.cdc.gov/steadi/pdf/STEADI-Brochure-WhatYouCanDo-508.pdf

Postural Hypotension: What It Is and How to Manage Itwww.cdc.gov/Steadi/pdf/postural_hypotension-a.pdf

Check for Safetywww.cdc.gov/Steadi/pdf/steadi_checkforsafety_brochures-a.pdf

Talking about Fall Prevention with Your Patientswww.cdc.gov/steadi/pdf/Talking_about_Fall_Prevention_with_Your_Patients-print.pdf

CDC STEADI Initiative

STEADI-Rxwww.cdc.gov/steadi/steadi-rx.html

STEADI: The Pharmacist’s Role in Older adult Fall Preventionwww.cdc.gov/steadi/pdf/STEADIPharmacistTrainingResources-508.pdf

Older-Adult Fall Prevention Guide for Community Pharmacists

Documents

Transcript of Older-Adult Fall Prevention Guide for Community Pharmacists