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Kathleen Kiernan

Falls Prevention and Bone

Health – Medication

Considerations

Senior Pharmacist Midlands Regional Hospital Tullamore (MRHT), MPSI 9328

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Presentation Content 1. Introduction 2. Falls Background 3. Screening Tools for Inappropriate Prescribing 4. Assessment Tools 5. Potential Inappropriate Prescribing (PIP) 6. Polypharmacy 7. Falls risk medication(s) 8. Medication review/medicines optimisation 9. Research 10. Summary 11. References

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Introduction • Ireland has an aging population;1

– In 2008 11% of the population was aged 65 years and over, this is expected to increase to 18% within 25 years

• A FALL is “an unexpected event in which the participant comes to rest on the ground, floor, or lower level”2

• Falls are a significant, preventable cause of morbidity and mortality in the older people population1

• Falls in the older people are a common cause of morbidity & an increasing reason for presentation to hospital3

• With advancing age and frailty there is increased chance of multimorbidity and prescription of inappropriate medicines, some of which may contribute to the risk of falls3

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Introduction • Some older adults have a combination of health-related factors that increase their

risk of having a fall, such as:1 – muscle weakness – problems with balance and mobility – poor eyesight

• Around 30% of adults who are over 65 years and who are living in the community will experience at least one fall a year. This figure rises to 50% for those who are living in nursing homes or residential care2

• Not all falls will result in injury, but a significant minority do. For example, 20% of older adults will require medical attention for a fall, and 5% will experience a serious injury, such as a fracture3

• Falls can also have an adverse psychological impact, particularly on older people. A fall can sometimes result in a person losing confidence, becoming withdrawn and feeling like they have lost their independence3

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Introduction

• Falls are a common but often an overlooked source of injury and unfortunatly, in many cases, death

• The Irish Longitudinal Study on Ageing (TILDA) found that in Ireland; 2 in 5 experience a fall in a two year period with 20% requiring hospital attendance. This equates to 60,000 people per year in Ireland requiring medical attention for a fall. Risk factors for falls, such as unsteadiness, depression, fear of falling, are modifiable and can be treated and improved6

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Impact of Falls1

• In Ireland the baseline economic burden of falls and fractures was estimated at €404 million in 2008, with the costs of inpatient care, mortality, decreased quality of life and long-stay care being the main contributors to the overall cost of falls and fractures

• It is estimated that costs will escalate if current trends continue, and by 2020 the cost of falls related injuries will be €922 to €1077 million

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Falls Background8

Falls

Extrinsic Intrinsic;

- Medications

- Polypharmacy

- Potentially inappropriate prescribing

Environmental

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Screening Tools for Inappropriate Prescribing

• There are many different tools to identify potentially inappropriate prescribing in the older population

• These are not falls specific risk assessment tools.

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Assessment Tools

• Beers’ criteria and screening tool of older people’s prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria9

• FORTA; Fit fOR The Aged, is a drug classification system to identify both inappropriate medications and omission10

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Tools to Measure Exposure to Sedative/Anticholinergic Medications 18, 19, 20

• Many tools which have been developed to quantify a person’s exposure to sedative or anti-cholinergic medications specifically. 1. ‘Sedative Load Model’

2. ‘Anti-cholinergic Drug Scale’

3. ‘Drug Burden Index’ (DBI) - quantifies exposure to both sedative & anticholinergic medications.

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Potential Inappropriate Prescribing (PIP)11, 12, 13, 14

• A high prevalence of PIP has been identified in the older population • Polypharmacy has been associated with falls

– The use of fall risk medication(s) and polypharmacy affect the risk of falls

– Patients aged 50 years with polypharmacy (>4 medications) was associated with increased falls risk if the patients medications included a regular antidepressant or benzodiazepine

• Psychotropic medications; sedatives, hypnotics & benzodiazepines – linked to increased falls risk

• Cardiovascular drugs leading to hypotension, bradycardia & dizziness are also implicated

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Polypharmacy4

• Is the prescription of 4 or more medicines Independently associated with negative outcomes in frailty particularly where there is a decline in nutritional status, functional ability & cognitive capacity?

• Problematic polypharmacy is recognised as a potentially modifiable contributing factor in falls and frailty!

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Falls Risk Medication(s)10 1. Antimuscarinics/anticholinergics and those with anticholinergic

side effects, for example, amitriptyline, chlorphenamine, loperamide

2. ACE inhibitors and angiotensin receptor blockers 3. Α blockers 4. Antipsychotics 5. Benzodiazepines and Z drugs 6. Calcium channel blockers 7. Vasodilator antihypertensives used in heart failure 8. Opioids

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Medication review4

“Any systematic assessment of the pharmacotherapy of an individual patient that aims to evaluate and optimise patient medication by a change in prescription either by a recommendation or by direct change”

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Medication Reviewed 12, 15

• Data from two studies identified that patients who are admitted to hospital due to a fall or fracture did not have their falls risk increasing medication’s reviewed which would potentially lower their future risk of a fall

• Falls risk increasing medications evaluated included; cardiovascular medications, psychotropic medications; sedative or hypnotics, antipsychotics, antidepressants, benzodiazepines, antiepileptic medication, anticholinergics & anti-Parkinson medications

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Medication Reviewed 16, 17, 21, 22

• NICE & the IMSN recommended that it is essential that those who suffer a fracture have a medication review and this modifiable risk factor is addressed

• Improving patient outcomes through medicines optimisation is essential

• Multidisciplinary input is essential to ensure all the patients risk factors are managed

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Medication Review Tool23

• WIDE review; – Wholistic: Establishing patient’s priorities and goals of

care – Integrated: Linking with primary care providers – Deprescribing and dose reduction with the goal of

improving quality of life and patient outcomes – Evaluation of each medication in terms of the

potential risks and benefits to the frail patient employing tools such as STOP criteria

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Research shows 4

• Patients aged 65 years and older who have experienced a fall in the past year – addition of each medication above 4 increases their fall risk by 14%

• For each added medicine, increased physician-reported falls in the preceding 30 days by 7%

• A systemic review shows that; benzodiazepines, antidepressants, antihypertensives & antipsychotics are among the most common medicines to be prescribed to older people with polypharmacy

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Summary • Falls are a significant, preventable cause of morbidity and mortality • TILDA; 60,000 people per year in Ireland require medical attention for a

fall • Assessment tools available and evidence based; STOP/START & FORTA • PIP has been identified and polypharmacy has been associated with falls • Falls are associated with; cardiovascular medications, psychotropic

medications: sedative or hypnotics, antipsychotics, antidepressants, benzodiazepines, antiepileptic medication, anticholinergics & anti-Parkinson medications

• NICE & IMSN recommend a medication review & this modifiable risk is addressed

• WIDE review

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References 1. National Steering Group on the Prevention of Falls in Older People and the Prevention and Management of Osteoporosis throughout Life.

Strategy to Prevent Falls and Fractures in Ireland’s Ageing Population [Internet] Available from: https://www.hse.ie/eng/services/publications/olderpeople/strategy-to-prevent-falls-and-fractures-in-irelands-ageing-population.html (Last accessed 25/04/2019)

2. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. Cochrane database Syst Rev [Internet]. 2012 Jan; 9:CD007146. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22972103 (Last accessed 25/04/2019)

3. HSE, 2018, Falls, [online] Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z. Available from: https://www.hse.ie/eng/health/az/f/falls/ (Last accessed on 14/05/2019)

4. Marvin V, Ward E, et al., 2017, Deprescribing medicines in the acute setting to reduce the risk of falls, European Journal of Hospital Pharmacy, 24; 10-15

5. The Irish Times, 07/01/2017, Ageing Ireland: Living longer and cleaner brings its own problems Available from: https://www.irishtimes.com/news/health/ageing-ireland-living-longer-and-cleaner-brings-its-own-problems-1.2928267 (Last accessed 14/05/2019)

6. Kenny A, et al. The Irish longitudinal study on ageing (TILDA) Newsletter 2017; Dec. 2017, 1 Available from: https://tilda.tcd.ie/publications/reviews-newsletters/pdf/Newsletter_2017.pdf (Last accessed 25/04/2019)

7. Hamilton HJ, Gallagher PF, O’Mahony D. Inappropriate prescribing and adverse drug events in older people. BMC Geriatr [Internet]. 2009 Jan [cited 2014 Sep 16];9(1):5. Available from: http://www.biomedcentral.com/1471-2318/9/5

8. Fumio ETO, 2001, Causes of Falls in the Elderly, JMAJ, 44 (7); 299-305

9. Panel TAGS 2012 BCUE. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc [Internet]. 2012 Apr [cited 2014 Jul 10];60(4):616–31. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3571677&tool=pmcentrez&rendertype=abstract (Last accessed 14/05/2019)

10. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing [Internet]. 2014 Oct 16 [cited 2014 Oct 17];afu145 – . Available from: http://ageing.oxfordjournals.org/content/early/2014/10/16/ageing.afu145.full (Last accessed 14/05/2019)

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References 11. Kuhn-Thiel AM, Weiß C, Wehling M. Consensus validation of the FORTA (Fit fOR The Aged) List: a clinical tool for increasing the appropriateness of

pharmacotherapy in the elderly. Drugs Aging [Internet]. 2014 Feb [cited 2015 Aug 20];31(2):131–40. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3907693&tool=pmcentrez&rendertype=abstract (Last accessed 14/05/2019)

12. Bradley MC, Motterlini N, Padmanabhan S, Cahir C, Williams T, Fahey T, et al. Potentially inappropriate prescribing among older people in the United Kingdom. BMC Geriatr [Internet]. 2014 Jan [cited 2014 Sep 13];14(1):72. Available from: http://www.biomedcentral.com/1471-2318/14/72 (Last accessed 14/05/2019)

13. McMahon CG, Cahir CA, Kenny RA, Bennett K. Inappropriate prescribing in older fallers presenting to an Irish emergency department. Age Ageing [Internet]. 2014 Jan 1 [cited 2014 Sep 16];43(1):44–50. Available from: http://ageing.oxfordjournals.org.elib.tcd.ie/content/43/1/44 (Last accessed 14/05/2019)

14. Sjöberg C1 BLKLMDOCWS. Treatment with fall-risk-increasing and fracture-preventing drugs before and after a hip fracture: an observational study. Drugs Aging 2010 Aug 1;27(8)653-61

15. Richardson K, Bennett K, Kenny RA. Polypharmacy including falls risk-increasing medications and subsequent falls in communty-dwelling middle-aged and older adults. Age Ageing [Internet]. Oxford University Press; 2015 Jan 12 [cited 2015 Aug 16];44(1):90–6. Available from: http://ageing.oxfordjournals.org/content/early/2014/10/12/ageing.afu141.full (Last accessed 14/05/2019)

16. National Institute for Health and Care Excellence. Falls: assessment and prevention of falls in older people [Internet]. NICE guidelines [CG161]. NICE; 2013 [cited 2014 Jul 22]. Available from: http://www.nice.org.uk/guidance/CG161/chapter/introduction (Last accessed 14/05/2019)

17. O’Hanlon N. Briefing document on medication use and falls [Internet]. Irish Medication Safety Network Briefing Document. 2013 [cited 2014 Oct 18]. Available from: http://www.imsn.ie/images/briefing/imsn-medication-and-falls-briefing-document-june-2013.pdf (Last accessed 14/05/2019)

18. CampbelL, AJ Robertson, MC Gardner, MM Norton, RN Buchner D. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc [Internet]. 1999 [cited 2015 Sep 5];47(7):850–3. Available from: http://web.a.ebscohost.com.elib.tcd.ie/ehost/detail/detail?sid=6829f07f-e3d7-487e-a6ef-d62dfcd094ce%40sessionmgr4004&vid=1&hid=4114&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#AN=511119203&db=ssf (Last accessed 14/05/2019)

19. van der Velde N, Stricker BHC, Pols HAP, van der Cammen TJM. Risk of falls after withdrawal of fall-risk-increasing drugs: a prospective cohort study. Br J Clin Pharmacol [Internet]. Wiley-Blackwell; 2007 Feb 1 [cited 2014 Sep 22];63(2):232–7. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2000574&tool=pmcentrez&rendertype=abstract (Last accessed 14/05/2019)

20. Carnahan RM, Lund BC, Perry PJ, Pollock BG CK. The Anticholinergic Drug Scale as a measure of drug-related anticholinergic burden: associations with serum anticholinergic activity. J Clin Pharmacol. 2006;46(12):1481–6.

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References 21. Demontiero O, Gunawardene P, Duque G. Postoperative prevention of falls in older adults with fragility

fractures. Clin Geriatr Med [Internet]. 2014 May [cited 2014 Sep 22];30(2):333–47. Available from: http://www.sciencedirect.com/science/article/pii/S0749069014000196 (Last accessed 14/05/2019)

22. British Orthopaedic Association. The Care of Patients with Fragility Fracture (“Blue Book”) [Internet]. 2007 [cited 2014 Oct 18]. Available from: http://www.bgs.org.uk/index.php/nursepublications/nursefalls/338-bluebookfragilityfracture (Last accessed 14/05/2019)

23. Kinahan C, Heery H, 2019, WIDE Review, Abstract 28, HPAI Annual Conference 2019, Portiuncula University Hospital

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Twitter: @NationalQI

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Email:

Phone:

Kathleen Kiernan

Senior Pharmacist MRHT

MPSI 9328

Kathleen.kiernan@hse.ie

Bleep 420 (via MRHT main reception)