September CE Article

September CPE Article

Fall Risk Increasing Drugs and the Pharmacist’s Role in Fall Prevention

Authors: Taylor Elliott, PharmD/MPH Candidate 2021; Asmita Shrestha, MPH; Mark Huffmyer, PharmD, BCGP, BCACP, CACP; Lynne Eckmann, PharmD, BCGP; Daniela C. Moga, MD, PhD; University of Kentucky College of Pharmacy

The authors declare that there are no financial relationships that could be perceived as real or apparent conflicts of interest. Universal Activity # 0143-0000-20-009-H05-P &T 1.0 Contact Hours (0.1 CEU) Expires 10/30/23 Learning Objectives: At the conclusion of this Knowledge-based article, the reader should be able to: 1. 2.

Describe the healthcare burden of falls

Identify risk factors for falls and complications of falls

Define fall-risk-increasing drugs, explain how fall risk is measured, and identify relevant medication classes for intervention

Describe the pharmacist’s role in preventing falls in the elderly population

Introduction Falls are a major public health problem that disproportionately affects adults older than 65 years of age. Every 11 seconds, an older adult is treated in the emergency room for a fall; every 19 minutes, an older adult dies from a fall.(1) The World Health Organization defines a fall as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.”(2)Pharmacists can play an important role in fall prevention in this patient population, which can subsequently decrease fall-related injuries and the associated emotional and economic costs. Healthcare Burden of Falls According to data from the Centers for Disease Control and Prevention (CDC), millions of people aged 65 and older experience a fall each year. This equates to more than one out of four older adults in the United States. Approximately 20 percent of these falls results in a serious injury, such as a fractured or broken bone or a traumatic brain injury (TBI). These injuries often inhibit the person’s ability to perform activities of daily living (ADLs) or live independently. In addition, the fear of falling a second time may cause the person to be less active, which in turn causes weakness, thus increasing the risk for another fall.(3) Injurious falls lead to three million emergency department visits and over 800,000 hospitalizations per year. The majority of these hospitalizations are related to a head injury or a hip fracture.(3) These injuries often have a lasting cascade effect that further debilitates the person. For example, a hip fracture caused by a fall most often requires orthopedic surgical repair. The surgery itself comes with multiple acute risks, including infection and bleeding. Furthermore, the surgery also immobilizes the patient for a prolonged period of time, putting him/her at increased risk for a deep venous thromboembolism (DVT). The prolonged immobilization can also result in muscle atrophy and further weakness, which could contribute to a subsequent fall. In addition, the frequent prescribing of opioids for post-surgical pain control also increases risk for a subsequent fall. The total associated medical costs are exponential – each year about $50 billion is spent on non-fatal

fall injuries and $754 million on fatal falls. For non- cations after a fall. This is because healing can take fatal falls, greater than 50 percent of the economic longer than normal due to the impaired condition cost is paid by Medicare. This percentage is ex- of the bone, which leads to prolonged reduction in pected to increase as the number of Americans activity and subsequent weakness.(9) Lastly, paaged 65 and older continues to grow.(4) tients with dementia are also at increased risk for Risk Factors for Falls and Complications of Falls complications such as exacerbated symptoms or delirium due to immobility and lengthy hospitalizaResearchers have identified numerous risk factors tions. for falls, many of which are modifiable. In general, these risk factors can be subclassified as extrinsic or intrinsic. Extrinsic causes are related to the physical environment, whereas intrinsic causes are related to patient-specific factors.(5) However, extrinsic and intrinsic causes frequently interact with one another, often making it difficult to pinpoint the primary precipitating factor. For example, depression has been shown to be an independent intrinsic Considering the probability of a fall is positively correlated to the number of risk factors present, modifying as many risk factors as possible and minimizing potential complications of falls is essential. For pharmacists and pharmacy technicians, understanding how fall risk is measured and being able to identify fall risk increasing drugs is crucial to preventing falls in older adults. risk factor for falls. Unfortunately, some classes of How is Fall Risk Measured? antidepressants used to treat depression have also been shown to be an extrinsic risk factors for falls. These medications are classified as fall risk increasing drugs, or FRIDs. There are different parameters of gait which help identify and minimize fall risk. The parameters that should be clinically examined include walking speed, cadence (number of steps per unit of time), In addition to the extrinsic and intrinsic risk factors step width (measured from midpoint to midpoint for falls listed above, there are also factors that put of both heels), step length (measured from the patients at high risk for complications of falls. Spe- point of foot contact to the point of contralateral cifically, patients who utilize long-term oral antico- foot contact), stride length (linear distance covered agulants for comorbid conditions such as atrial fi- by one gait cycle), arm swing, freezing, turning, gait brillation or DVT treatment/prevention are at in- initiation, step symmetry, trunk, and walk creased risk for traumatic intracranial hemorrhage stance.(10,11) and subsequent mortality.(8) These patients may also be more susceptible to significant bleeding and/or bruising in comparison to their counterparts not on long-term anticoagulation. In addition, patients with osteoporosis are at high risk for compli-

Extrinsic Causes: (3,5)  

Slipping Uneven floor surfaces, including steps Tripping or stumbling External forces, such as being pushed Insufficient illumination Broken chairs Failure of walking aids Lifting or carrying heavy objects Poor footwear FRIDs and polypharmacy Alcohol use Intrinsic causes: (4,6,7)  

Advanced age Altered mental status Dizziness/vertigo Frequent toileting Lower body weakness or deficits Vitamin D deficiency Vision or hearing problems History of falls/fear of falling Comorbidities (angina, arrhythmias, stroke, asthma, cancer, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), arthritis, depression, diabetes and associated neuropathy, Parkinson’s disease, Huntington’s disease)

Fall risk is measured using multiple tests, including the Tinetti Mobility Test (TMT), Timed up and Go Test (TUG), the Romberg Test, and the Five Times Sit-to-Stand Test (5TSST). See Table 1 below for more detailed information. Table 1

Test Tinetti Mobility Test (TMT) (11)

Timed Up and Go Test (TUG)/Get Up and Go Test (12)

Romberg Test (12) Description of Test  Also known as the Tinetti Balance and

Gait Test or the Tinetti Performance-

Oriented Mobility Assessment

Assesses balance and gait using a 16item test

There are 28 total points possible, 16 for balance and 12 for gait <19 = high fall risk 19-24 = medium fall risk 25-28 = low fall risk

Measures the time period required by the patient to stand up from a chair with arm rests, walk three meters (using usual walking aids if necessary), turn around, walk back, and sit down

Can be scored qualitatively on a scale from 1 to 5 1- No fall risk. Well-coordinated movements, without walking aid 2- Low fall risk. Controlled but adjusted movements 3- Some fall risk. Uncoordinated movements 4- High fall risk. Supervision necessary 5- Very high fall risk. Physical support or stand by physical support necessary

Can also be scored quantitatively

An older adult who takes ≥12 seconds to complete the TUG is considered at risk

Identifies balance impairments in order to detect fall risk

The Romberg sign is present in patients who have significant swaying or a break in position when standing with their feet together, arms by their side, and their eyes closed

Medication Classes of Concern Several medications and medication classes are known to independently impair an individual’s normal physical characteristics, including balance and gait. These changes in balance and gait have been associated with an increased risk for falls. The CDC has designed a program called Stopping Elderly Accidents, Deaths, & Injuries (STEADI). STEADI-Rx provides pharmacists guidance on assessing medications associated with fall risk.(13) Similarly, the American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults also lists medications and medication classes to avoid in patients with a history of falls or fractures.(14) Table 2 below summarizes which medication classes of concern are listed by these two organizations.

Table 2 Medication Class Anticonvulsants STEADI-Rx Beers Criteria

Antidepressants

Antihypertensives

Antipsychotics

Antispasmodics

Benzodiazepines

Opioids

Sedative hypnotics

The Pharmacist’s Role in Fall Prevention

Step 1: Medication Therapy Review As one of the most accessible healthcare providers, A medication therapy review (MTR) is conducted pharmacists can play an important role in prevent- between the patient (and/or caregiver) and the ing falls in the elderly population. Prevention can pharmacist. In a comprehensive MTR, the pharmatake place through one or more of several mecha- cist collects specific patient-related information, nisms, including medication therapy management including all prescription and nonprescription med(MTM), subsequent patient counseling and depre- ications, herbal products, and other dietary supplescribing of potentially inappropriate medications, ments. The pharmacist then assesses each of the and recommendation of gait-stabilizing therapy patient’s medications for indication, safety, efficacy, when appropriate. and adherence. When medication-related problems Medication Therapy Management are identified, the next step is to develop a plan for resolution. Resolution can take place through paMedication therapy management (MTM) is a service tient education, communication with other that can be performed by pharmacists to ensure healthcare providers, or both. the best therapeutic outcomes for patients. MTM includes five core elements: medication therapy Step 2: Personal Medication Record review, a personal medication record, a medication- After completion of the MTR, the patient receives a related action plan, intervention or referral, and comprehensive record of his or her medications documentation and follow-up.(24,25) (prescription and nonprescription medications,

herbal products, and other dietary supplements). This comprehensive record, called the personal medication record (PMR), is intended for patients to use as a perpetual document for medication self-management. Ideally, the patient will carry his or her current PMR at all times and share it with other healthcare providers in order to reduce medication-related errors and adverse events.

Finally, while being cognizant of fall risk increasing drugs and the effects of polypharmacy are both of utmost importance, mitigating the fall risk is even more crucial. This can be done through patient counseling and/or collaboration with other members of the interprofessional healthcare team. Patient counseling can include education on both pharmacologic and non-pharmacologic therapy. Step 3: Medication-Related Action Plan In regard to pharmacologic therapy, the pharmaLike the PMR, the medication-related action plan (MAP) is a document completed after MTR and is a list of actions for the patient to use in tracking progress for self-management. The patient MAP should include only items the patient can act on or that are within the pharmacist’s scope of practice. cist can place notes on the patient’s PMR indicating which medications may contribute to falls. The pharmacist can also place items on the patient’s medication-related action plan such as, “Because this medication lowers your blood pressure, you may feel dizzy when standing or sitting up quickly. Be sure to rise slowly.” Pharmacists can also collabStep 4: Intervention and/or Referral orate with other members of the interprofessional For medication-related problems that cannot be resolved by the patient and are not within the pharmacist’s scope of practice, the pharmacist should collaborate or refer the patient to another member of the interprofessional healthcare team. This helps to improve medication use and adherence and also eases transitions of care. team to help lower fall risk. For example, when appropriate, the pharmacist can suggest deprescribing of potentially inappropriate medications (PIMs) to the respective provider(s). PIMs are defined as “medications that should be avoided due to their risk which outweighs their benefit and when there are equally or more effective but lower risk alternatives available.”(28) In fact, one study showed that Step 5: Documentation and Follow-up withdrawal of fall-risk-increasing drugs is effective The last step of the MTM process is completing documentation and scheduling follow-up. The patient-specific record should include documentation of all patient visits in chronological order in a consistent format. Follow-up should occur regularly to ensure continued resolution of medication-related problems and identification of new issues. as a single intervention for fall prevention.(29) Also, in many cases, patients have multiple providers who are unaware of the patient’s complete medication regimen and therefore the potential risks associated with drug-drug interactions, duplicate therapy, and polypharmacy. Raising awareness when this issue occurs can prove beneficial. Incorporating other members of the interprofessional In regard to fall prevention, MTM can be utilized in healthcare team, such as physical and/or occupaseveral ways. First and foremost, the pharmacist tional therapists, can also decrease a patient’s fall can use MTR to identify which of the patient’s med- risk and improve quality of life. ications are individually classified as fall-riskincreasing drugs. The pharmacist can also use MTR to analyze the patient’s medications for potential drug-drug interactions. In fact, analyzing for potential drug-drug interactions becomes increasingly important as the total number of medications in a patient’s regimen increases. One study reported that for every one increase in number of medications, participants had a seven percent higher risk for incident falls.(26) Another study analyzed the risk of impaired balance in community-dwelling older adults taking medications versus those not taking any medications to assess fall risk. After adjustment for age, depressive symptoms, cognitive While the pharmacist’s role in fall prevention most commonly involves minimizing a patient’s medication regimen in instances of PIMs and polypharmacy, recommending addition of gait-stabilizing therapy in patients with movement disorders can also be of assistance. For example, in a small study of patients with Huntington’s disease, tetrabenazine was found to reduce chorea, which contributes to balance problems and walking difficulties that lead to higher fall rates.(31) Similarly, rivastigmine can improve gait stability and might reduce the frequency of falls in patients with Parkinson’s disease. (32) impairment, vision and hearing impairments, num- The pharmacist can also suggest simple, nonber of chronic diseases, and number of hospitaliza- medication related tips to prevent falls such as betions in the previous year, participants taking five ing physically active and wearing sensible shoes. In or more medications were 80% more likely to expe- addition, the pharmacist can counsel on modificarience impaired balance as opposed to those not tions to the patient’s physical residence and sugtaking any medications.(27) gest durable medical equipment (DME) like a cane or a walker. Some of the physical interventions

might include illuminating stairs, removing throw rugs on the floor, placing a nightlight in the path from the bedroom to the bathroom, and placing grab bars near the toilet and the shower.(30) In addition to the pharmacologic and nonpharmacologic interventions mentioned above, the pharmacist can also play an important role in general patient education. Ensuring patients understand the risks of injurious falls as well as the cascading effects that can ensue after falls (such as loss of personal independence) is essential to prevention. Conclusion In conclusion, falls are a major public health problem that can lead to serious negative health outcomes, especially in adults aged 65 and older. The subsequent burden on individuals’ quality of life, as well as the financial costs on the health care system are enormous. Pharmacists can play a crucial role in fall prevention in this patient population by 1) understanding and recognizing risk factors for falls, 2) identifying medications of concern and polypharmacy, and 3) appropriately managing medication therapy with other members of the interprofessional healthcare team. References

1. Falls Prevention Facts [Internet]. NCOA. 2015 [cited 2020 Sep 21]. Available from: https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-preventionfacts/ 2. Falls [Internet]. [cited 2020 Aug 17]. Available from: https://www.who.int/newsroom/fact-sheets/detail/falls 3. Important Facts about Falls | Home and Recreational Safety | CDC Injury Center [Internet]. 2019 [cited 2020 Jun 29]. Available from: https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html 4. Falls Data | Home and Recreational Safety | CDC Injury Center [Internet]. 2019 [cited 2020 Jun 29]. Available from: https://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html 5. Bueno-Cavanillas A, Padilla-Ruiz F, Jiménez-Moleón JJ, Peinado-Alonso CA, GálvezVargas R. Risk Factors in Falls among the Elderly According to Extrinsic and Intrinsic Precipitating Causes. European Journal of Epidemiology. 2000;16(9):849–59. 6. Callis N. Falls prevention: Identification of predictive fall risk factors. Applied Nursing Research. 2016 Feb 1;29:53–8. 7. Paliwal Y, Slattum PW, Ratliff SM. Chronic Health Conditions as a Risk Factor for Falls among the Community-Dwelling US Older Adults: A Zero-Inflated Regression Modeling Approach. Biomed Res Int [Internet]. 2017 [cited 2020 Jul 8];2017. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5387801/ 8. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Use of Long-Term Anticoagulation is Associated With Traumatic Intracranial Hemorrhage and Subsequent Mortality in Elderly Patients Hospitalized After Falls: Analysis of the New York State Administrative Database. Journal of Trauma and Acute Care Surgery. 2007 Sep;63(3):519–524. 9. General Information about Pain After A Fracture | Osteoporosis Canada [Internet]. [cited 2020 Sep 21]. Available from: https://osteoporosis.ca/bone-healthosteoporosis/living-with-the-disease/after-the-fracture/general-information-aboutpain-after-a-fracture/ 10. Vaught SL. Gait, balance, and fall prevention. Ochsner J. 2001 Apr;3(2):94–7. 11. Pirker W, Katzenschlager R. Gait disorders in adults and the elderly : A clinical guide. Wien Klin Wochenschr. 2017 Feb;129(3–4):81–95. 12. Nordin E, Lindelöf N, Rosendahl E, Jensen J, Lundin-Olsson L. Prognostic validity of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff’s global judgement and fall history in evaluating fall risk in residential care facilities. Age Ageing. 2008 Jul;37(4):442–8. 13. STEADI-Rx | STEADI - Older Adult Fall Prevention | CDC Injury Center [Internet]. 2020 [cited 2020 Aug 31]. Available from: https://www.cdc.gov/steadi/steadi-rx.html 14. By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults: 2019 AGS BEERS CRITERIA® UPDATE EXPERT PANEL. J Am Geriatr Soc. 2019 Apr;67(4):674–94. 15. Williams LJ, Pasco JA, Stuart AL, Jacka FN, Brennan SL, Dobbins AG, et al. Psychiatric disorders, psychotropic medication use and falls among women: an observational study. BMC Psychiatry [Internet]. 2015 Apr 8 [cited 2020 Aug 31];15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4394398/ 16. Landi F, Onder G, Cesari M, Barillaro C, Russo A, Bernabei R, et al. Psychotropic medications and risk for falls among community-dwelling frail older people: an observational study. J Gerontol A Biol Sci Med Sci. 2005 May;60(5):622–6. 17. Galik E, Resnick B. Psychotropic medication use and association with physical and psychosocial outcomes in nursing home residents. Journal of Psychiatric and Mental Health Nursing. 2013;20(3):244–52. 18. Donoghue OA, O’Hare C, King-Kallimanis B, Kenny RA. Antidepressants are independently associated with gait deficits in single and dual task conditions. Am J Geriatr Psychiatry. 2015 Feb;23(2):189–99. 19. Seppala LJ, van de Glind EMM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink AMAT, et al. Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others. J Am Med Dir Assoc. 2018;19(4):372.e1-372.e8. 20. M M, F C, T P. Risk of falls associated with antiepileptic drug use in ambulatory elderly populations: A systematic review. Can Pharm J (Ott). 2017 Mar 1;150(2):101–11. 21. Tinetti ME, Han L, Lee DSH, McAvay GJ, Peduzzi P, Gross CP, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014 Apr;174(4):588–95. 22. Kahlaee HR, Latt MD, Schneider CR. Association Between Chronic or Acute Use of Antihypertensive Class of Medications and Falls in Older Adults. A Systematic Review and Meta-Analysis. Am J Hypertens. 2018 10;31(4):467–79. 23. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc. 1999 Jan;47(1):40–50. 24. CDC. Using Medication Therapy Management to Treat Chronic Disease [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Aug 17]. Available from: https://www.cdc.gov/dhdsp/pubs/guides/best-practices/pharmacist-mtm.htm 25. American Pharmacists Association, National Association of Chain Drug Stores Foundation. Medication therapy management in pharmacy practice: core elements of an MTM service model (version 2.0). J Am Pharm Assoc (2003). 2008 Jun;48(3):341–53. 26. Gnjidic D, Hilmer SN, Blyth FM, Naganathan V, Waite L, Seibel MJ, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify communitydwelling older men at risk of different adverse outcomes. J Clin Epidemiol. 2012 Sep;65(9):989–95. 27. Agostini JV, Han L, Tinetti ME. The relationship between number of medications and weight loss or impaired balance in older adults. J Am Geriatr Soc. 2004 Oct;52(10):1719–23. 28. Alhawassi TM, Alatawi W, Alwhaibi M. Prevalence of potentially inappropriate medications use among older adults and risk factors using the 2015 American Geriatrics Society Beers criteria. BMC Geriatrics. 2019 May 29;19(1):154. 29. 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. 2007 Feb;63(2):232–7. 30. US Department of Health & Human Services; Centers for Disease Control (CDC); National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Check for Safety: A Home Fall Prevention Checklist for Older Adults [Internet]. American Psychological Association; 2004 [cited 2020 Sep 21]. Available from: http://www.crossref.org/deleted_DOI.html 31. Kegelmeyer DA, Kloos AD, Fritz NE, Fiumedora MM, White SE, Kostyk SK. Impact of tetrabenazine on gait and functional mobility in individuals with Huntington’s disease. J Neurol Sci. 2014 Dec 15;347(1–2):219–23. 32. Henderson EJ, Lord SR, Brodie MA, Gaunt DM, Lawrence AD, Close JCT, et al. Rivastigmine for gait stability in patients with Parkinson’s disease (ReSPonD): a randomised, double-blind, placebo-controlled, phase 2 trial. The Lancet Neurology. 2016 Mar 1;15(3):249–58.