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Workshop 4: Preventing Falls through Medication

Vigilance Nancy L. Losben, R.Ph., CCP, FASCP, CG

Chief Quality OfficerOmnicare, Inc.

&Diane C. Vaughn, RN, C-DONA/LTC, LNHA

VP, Clinical ServicesBenedictine Health System

Goals

� Describe how medication risk awareness is involved with the HATCh model

� Identify the effect falls have on the elderly

� Describe common pharmacologic issues and meds that contribute to falls

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Holistic Approach to Transformation Change Model

(HATCh) � Six Competency Domains

� Care Practices

� Competency 1.1Demostrate an Understanding of risks that lead to falls� 1. Identify Medications that May Contribute to Falls and

Fall Risk

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Competency-Based Education(CBE)

“… ‘a cluster of related knowledge, skills, and attitudes that affects a major part of one’s job (a role or responsibility), that correlates with performance on the job, that can be measured against well-accepted standards, and that can be improved via training and development.”

� Training focuses on learning desired outcomes

� Design makes statements of observable and measurable behavior

� Staff must have the necessary knowledge, skill and attitude to attain the highest level of performance.

Competency Based Education

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Background

� 2nd most common adverse event

� Occur in 30-60% of the older adults / year

� 10-20% result in serious injury, hospitalizations, and / or death

� 10% of ER and 6% of hospitalizations >65 YO

� Falls are the leading cause of injuries in older adults

Medications

� 32,000 Seniors Suffer Hip Fractures Caused By Medications

� 20% Will Die Within 5 Years

� On average, individuals 65 to 69 years old take nearly 14 prescriptions per year, individuals aged 80 to 84 take an average of 18 prescriptions per year

� ≥ 4 medications is considered a falls risk

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Falls Risk Factors

� Weakness

� Unsteadiness

� Confused State

� Sleep Quality

� Medications

Medications and Falls

� Common Pharmacologic Mechanisms:� Orthostatic hypotension

� Dizziness

� Decreased postural reflexes

� Extrapyramidal symptoms

� Myorelaxant effects

� Visual impairment

� Impaired cognition / CNS effects

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AHCA/NCAL Webinars

Preventing Falls through Medication Vigilance

Nancy L. Losben, R.Ph., CCP, FASCP, CG

Chief Quality Officer

Omnicare, Inc.

Objectives

� To recognize the medication regimen as a risk for safety and falls.

� To identify the timeframe when a resident is at his/her highest risk to fall after a change in in the medication regimen.

� To enhance and coordinate safety and quality improvement activities.

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Centers for Disease Control and Prevention

5% of adults 65 and older live in nursing homes but 20% of deaths from falls (1,800 yearly) Up to 20% of falls cause serious injuries

Reasons for falls in LTF facilities: frailty, chronic conditions, gait disturbances, memory problems, ADL decline, medications

Fall risk is significantly elevated during the 3 days following any drug that affects the central nervous system

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Any one of these medication related problems (MRP) can increase the risk

for falling

� Drowsiness

� Dizziness

� Low blood pressure

� Low heart rate

� Parkinson’s effect

� Ataxia/gait disturbance

� Vision disturbance

� Low blood sugar

� Urinary urgency

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Adverse Consequences

� Some adverse consequences occur quickly or abruptly, while others are more insidious and develop over time.

� Adverse consequences may become evident at any time after the medication is initiated, e.g., when there is a change in dose or after another medication has been added.

� When reviewing medications used for a resident, it is important to be aware of the medication’s recognized safety profile, tolerability, dosing, and potential medication interactions.

� Although a resident may have an unanticipated reaction to a medication that is not always preventable, many ADRs can be anticipated, minimized, or prevented.

In theory, any medication, or a lack of one, can be the underlying cause of a fall.

� But do you know which medications are most likely to increase the risk of falling?

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Medication Categories Recognized asRisks for Falling

� Opioid analgesics� Anticonvulsants� Antidepressants� Anti-Parkinson’s� Anxiolytics� Antipsychotics� Antihistamines

� Antiarrhythmic� Appetite stimulant� Barbiturates� Diuretics� Hypoglycemics; insulin� Medications to treat continence

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Medications associated with Injury with a Fall

� Anticoagulants

� Anti-seizure medications

� Chemotherapy

� Laxatives

� Psychopharmacologics

� Sedatives/hypnotics

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Diuretics

� Hypotension� Urinary urgency� Incontinence� Dehydration� Electrolyte imbalance� Temporal effect

� Onset � Peak

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Cardiovascular Drugs

� Hypotension� Low heart rate� Lethargy� Delirium� Syncope, dizziness� Bleeding � Immediate release Vs. Sustained release

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Antipsychotics

� Routine, seldom PRN � Lowest Possible Dose� Recent Dose Increase or Reduction� Extrapyramidal Side Effects� Blurred Vision� Lethargy � Somnolescence� Is it efficacious?

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Anxiolytics

� Routine vs. PRN orders� Short acting benzodiazepines preferred� Lowest possible dose� Recent dose increase or reduction� Lethargy� Efficacy

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Hypnotics

� Routine Vs. PRN

� Short Acting Benzodiazepines or newer non-benzodiazepines

� Given while in bed

� Used no more than 10 consecutive days or manufacturer’s suggested direction

� Morning functionality/hangovers

� Falls out of bed

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Antidepressants

� Tricyclic's

� Highly anticholinergic

� Blurred Vision

� Confusion

� Changes in heart rate

� Restlessness, sleeplessness

� Drug Interactions

� SSRI’s and SSNRI’s have a better safety profile

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Muscle Relaxants and Antiparkinson Drugs

� Muscle weakness

� Central nervous system effects

� Behavioral symptoms

� Temporal relationship to administration and ADL performance

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Laxatives

� Cathartics/bowel urgency

� Electrolyte imbalance

� Tolerance, Impaction

� Toileting plan

� Opioid therapy and anticholinergics can cause constipation

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Pain Medications

� Opioids

� Risk vs. Benefit� Drowsiness/dizziness Vs. Relief

� Constipation Vs. Mobility

� Non-steroidal anti-inflammatory drugs

� GI effects

� Confusion, other CNS effects

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Anticholinergic Medications

� Medications that could affect function, level of consciousness, gait, balance, visual acuity, or cognitive ability,

� Causing symptoms such as dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium, excitability, memory loss, unsteadiness, dizziness, or hallucinations.

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Anticholinergic Effect

“Blind as a bat. Mad as a hatter, red as a beet, hot as Hades, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone."

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Anticholinergic Drugsoften antihistamines, antidepressants,

over active bladder medicationsexamples

Generic Brand Name Generic Brand Name

Amantadine Symmetrel® Hydroxyzine Vistaril®

Clozapine Clozaril® Meclizine Antivert®

Cyclobenzaprine Flexeril® Ranitidine Zantac®

Diphenoxylate/atropine

Lomotil® Olanzapine Zyprexa®

Diphenhydramine Benadryl® Oxybutynin Oxytrol®

Desipramine Norpraminl® Paxoxetine Paxil®

Furosemide Lasix® Tolterodine Detrol®

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Syncope

� Diuretics

� Calcium channel blockers

� ACE inhibitors

� Nitrates

� Antipsychotics

� Antihistamines

� Anti-Parkinson's medications

� Opioids

� Alcohol

Managing Medication- Related Syncope

� The first 72 hours following modification of any of these medications is the timeframe of highest risk to fall� Alert care staff to any affected resident with a change in

their medication regimen to a higher risk of fall� Focus on residents who are usually independent in ADL’s� Remind residents to rise slowly� Temporarily use a gait belt� Monitor blood pressure daily� Observe and document the resident’s response to the

medication� Report findings to the physician and and pharmacist

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Sometimes, adding a medication to a resident’smedication regimen can help to reduce falls and

minimize injuries.

Unmanaged Pain as a Risk for Falls

� Residents in pain will likely avoid painful stimulus by sitting and lying down

� Increases the risk of fall as a result of deconditioning

� Residents in pain will also attempt to change position to find a more comfortable state

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Managing PainClassification

� Acute

� Recent onset

� Chronic� nociceptive- somatic, visceral� neuropathic� mixed/unspecified� psychologically mediated

� Chronic Malignant

� Chronic Non-malignant

WALA36

Identify Underlying Conditions that May Cause Pain

Neurological•Herpes Zoster

• Spinal and nerve injury

PAIN

HeartAngina

Heart AttackThrombosisPeripheral vasculardisease

SkinWoundsUlcers

Incisionsinfections

MusculoskeletalArthritisFracture

OsteoporosisBack

problemsAmputation

CancerNeurological

•Diabetic Neuropathy• Herpes Zoster

• Spinal and nerve injury GI PainDental Pain

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Treating Pain to Achieve

Mobility and Strength

WALA38

Principles for Analgesics

� Choice of Drug� Appropriate for patient's type of pain

� What has worked in the past� Appropriate for patient’s severity of pain

� At level appropriate to assessed pain� Use combinations of drugs

� Not necessarily combined drugs� Ongoing evaluation

� Benefit� Risks

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WALA39

Principles for Analgesics

� Administration

� Adequate doses

� Titrate to individual needs� Patient response

� Drug itself

� Onset

� Peak effect

� Duration

� Around the clock

WALA40

Principles for Analgesics

� Administration� Address breakthrough pain

� Same drug if possible� Monitor benefit

� Consider risk for ADRs� Address early� Advise resident

� Oral route whenever possible� Or other non-invasive

� Review and evaluate

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Vitamin D

� Can reduce falls by reducing osteoporosis and preventing sarcopenia (loss of muscle mass)

� Benefits of Vitamin D are distinct from its effect on bone.

� Controversial

Evaluating Falls at Care Conference

� Previous fall, initial fall� Circumstances, use incident report with Vital Signs

for analysis� Medication Regimen as a risk

� 4 or more drugs, new drug� Drug therapy class� Temporal relationship to fall� Chemical restraints

� Review behavior monitoring sheets� Blood sugars, blood pressures, pulses� Lab tests: glucose, electrolytes, hydration,

hemoglobin/hematocritFall Prevention42

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Reducing the RiskApproaches

� Eliminate unnecessary drugs

� Find lowest effective doses of medications through dose reduction

� Monitor efficacy and resident responses to medications

� Monitor labs

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Evaluation of Falls at Quality Improvement Meetings

� Interdisciplinary- Don’t forget to include:� Rehab Services

� Dietitian

� Pharmacist

� Environmental Services

� Bring List of those who have Fallen� Crosswalk to Psychotropic Drug list

� Crosswalk to changes in condition

� Crosswalk to those who experienced infection

� Crosswalk it to those who had changes in their medication regimen

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Evaluation of Falls with Injury

� Crosswalk it to residents on anticoagulants

� Crosswalk it to residents with a diagnosis of osteoporosis

� Crosswalk it to residents treated for seizures

� Crosswalk it to residents who use hypnotics

� Crosswalk it to resident with a history of impaction and/or laxative use

Summary

A fall may be the result of an adverse drug reaction of any medication or combination of medications

A resident is most likely to fall within the first 3 days of a change in the medication regimen

Planning to minimize falls during QA/PI meetings requires comparison of data from multiple sources.

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