A Step Forward: Promoting Independence through

Falls Prevention

2014 Geriatric UpdateMeharry Consortium Geriatric Education Center

A Step Forward: Promoting Independence through

Falls Prevention

Moderator: Ronald De Vera Barredo, PT, DPT, EdD, GCSProfessor and Chair, Department of Physical Therapy

Tennessee State University

Michelle Valentine Moseley, PharmD, BCPSClinical Pharmacy Specialist, Geriatrics, Dept. of Veterans Affairs

Tennessee Valley Healthcare System Assistant Professor, Lipscomb University College of Pharmacy

Elena Wong Espiritu, OTD, OTR/LAssistant Professor, School of Occupational Therapy

Belmont University

Objectives

Describe the multifactorial causes of falls among older adults

Identify tools geriatric health practitioners could use to evaluate a patient's fall risk

Outline strategies that will mitigate fall risk

Identify drugs that increase fall risk in geriatric patients

No Disclosures

• Ronald De Vera Barredo, PT, DPT, EdD, GCS• Michelle Valentine Moseley, PharmD, BCPS• Elena Wong Espiritu, OTD, OTR/L

FallsinOlderAdults:TheRoleofMedicationManagement

Michelle Moseley, PharmD, BCPSClinical Pharmacy Specialist in Geriatrics, VA TVHS

Assistant Professor, Lipscomb University College of Pharmacy

LearningObjectives

• Identify drugs that increase fall risk in geriatric patients

• Outline strategies that will mitigate fall risk

WhyDoOlderAdultsFall?• Major causes

– Accident & environment‐related– Gait and balance disorders or weakness– Drop attack– Confusion– Postural hypotension– Visual disorder– Syncope– Other unspecified causes: arthritis, acute illness, drugs, alcohol, pain, epilepsy, and falling from bed 

Rubenstein LZ, Josephson KR. Clin Geriatr Med 2002;18:141–158.

EfficaciousComponentsofaFallPreventionProgram

Exercise and physical activity

Medical assessment 

and management

Medication adjustment

Adaptation or Adaptation or modification of home 

environment

2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons. 

MedicationsandFalls• Strongest risk factors

– Polypharmacy– Psychotropic medications

– Potentially inappropriate prescribing

• Beers List• Screening Tool of Older Persons’ Prescriptions (STOPP) criteria

Examples of Psychotropic Medication Classes• Antipsychotics• Serotonin‐reuptake inhibitors• Tricyclic antidepressants• Benzodiazepines• Hypnosedatives

Examples of Psychotropic Medication Classes• Antipsychotics• Serotonin‐reuptake inhibitors• Tricyclic antidepressants• Benzodiazepines• Hypnosedatives

Huang AR, et al. Drugs Aging 2012; 29:359–76.van der Hooft CS, et al. Br J Clin Pharmacol 2008; 66:276–82.

JAGS 2012;60(4):616‐31Gallagher P, et al. Int J Clin Pharmacol Ther. 2008;46(2):72–83.

MedicationEffectsThatMayPotentiateFallRisk

Confusion, delirium, impaired cognition

Dizziness, drowsiness, sedation

Hypotension, arrhythmias

Hypoglycemia, hyperglycemia

Dehydration, electrolyte disturbances

Constipation,  frequency of urination

Muscle weakness, ataxia

ExamplesOfMedicationClassesAssociatedWithTheseEffects

Alpha blockers BenzodiazepinesAnalgesics Cardiovascular medicationsAntibiotics Diabetes medicationsAnticonvulsants DiureticsAntidepressants Histamine‐2 blockersAntihistamines HypnosedativesAntimuscarinics LaxativesAntipsychotics Steroids

Tinetti ME, et al. JAMA Intern Med. 2014;174(4):588‐595.Rafiq M, et al. Journal of Clinical Epidemiology 2014;67(8):877‐886.

MitigatingFallRisk:LessIsMore• Recommendations

– Minimize the number of medications– Discontinue psychotropics, or at least reduce the dose

2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons . http://www.medcats.com/FALLS/frameset.htm. Accessed 5/30/14.

GoodPalliative‐GeriatricPracticeAlgorithm

Garfinkel D, Mangin D. Arch Intern Med 2010;170(18):1648‐1654

CaseStudy:Mr.Wilson

A 76 year‐old man who was referred to your outpatient falls evaluation clinic by his PCP. He has fallen three times in the last three weeks.

Past Medical History: Type 2 diabetes, BPH, hypertension, hyperlipidemia, depression and osteoarthritis

Medication list:• Metformin 1000mg twice daily• Furosemide 20mg every 

morning• Amlodipine 10mg daily• Lisinopril 20mg daily• Glipizide 10mg twice daily• Terazosin 5mg at bedtime• Citalopram 10mg daily• Simvastatin 20mg at bedtime• Hydrocodone/acetaminophen 

7.5/325mg every 6 hours as needed

• Aspirin EC 81mg daily• OTC Docusate 100mg daily • OTC Tylenol PM® at bedtime 

as needed

CaseScenarios

A. Fell in the bathroomB. Fell when he got up at night to go to the 

bathroomC. The room was spinning just before he fellD. He felt sweaty and shaky when he fellE. His thigh muscles felt extremely weak and 

sore

Summary• Medication use is one of the most modifiable risk factors for falls in geriatric patients 

• Direct and indirect effects of many commonly prescribed medications may increase fall risk in older adults

• Utilize tools such as the Good Palliative‐Geriatric Practice algorithm in conjunction with patient preferences, disease‐specific guidelines, and drug utilization review criteria to reduce medication burden and fall risk

Elena Wong Espiritu, OTD, OTR/LBelmont University

School of Occupational Therapy

FALL

Behavioral

EnvironmentalIntrinsic

Older Adults

LOW 

physiological fall risk

LOW perceived fall risk

(vigorous)

HIGH perceived fall risk

(anxious)

HIGH physiological 

fall risk

LOW perceived fall risk

(stoic)

HIGH perceived fall risk

(aware)

Based on Delbaere et al., 2010

Perceived vs. Physiological Fall Risk

http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html  

Type DefinitionSingle one interventionMultiple combination of 

interventions, same for all people 

Multifactorial* combination of interventions based on individualized assessment

* Recommended by AGS/BGS guideline

Moderate/high challenge to balance

At least 2 hours/weekOngoing basis

(Sherrington et al., 2011)

Tai Chi: Moving for Better Balance

Otago Exercise Programme

ExerciseMedical managementMedication adjustment

Environmental modificationEducation

Stepping OnMatter of Balance

Self-Management

Client

AttitudesBehaviors

Skills

education information sharing

skill development

create situations

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LF-M

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EN

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SU

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SYMPTOM MONITORING

PROBLEM SOLVING

DECISION MAKING

ACTION PLANNING

LOCATING & USING

RESOURCESCOMMUNICATION

http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_

recommendations/prevention_of_falls_summary_of_recommendations

Retrieved

September 20 http://www.coag.uvic.ca/cdsmp/documents/What_is_Self‐Management.pdf