November/December 2009

Medication’s Impact on Falls
By Nancy C. Brahm, PharmD, MS, BCPP, CGP, and Kimberly M. Crosby, PharmD, BCPS, CGP
Aging Well
Vol. 2 No. 5 P. 8

Older adults’ fear of falling may correlate to factors such as increasing frailty, history of falling, and increasing age. The prevalence of this problem for adults aged 65 and older has been estimated at greater than 33%. The healthcare costs associated with fall-related injuries are significant. In 2000, healthcare costs for fatal and nonfatal falls in the United States exceeded $19 billion.

Inappropriate medication use leading to medication-related falls has been a concern since the 1990s when Mark H. Beers, MD, and colleagues first developed criteria for inappropriate medication use. Inappropriate medication use in older adults has received increased attention in the literature. Up to 24% of community-based residents and 40% of nursing home populations received at least one medication meeting Beers’ criteria. A recent review of national data found at least one medication considered inappropriate was prescribed in approximately 8% of ambulatory care visits for older adult patients.

The importance and scope of this problem were incorporated into the Healthy People 2000 objectives, which includes two aspects: improving the health of all Americans and ensuring regular medication reviews for older adults.

Contributing Factors
The etiology of falls is multifactorial, related to patient characteristics and external factors. Physiological changes associated with age, sensory deficits, chronic health problems, substance abuse, and environmental hazards have all been identified as fall risk factors. Patients may have a loss of strength and balance related to changes in muscle mass, the presence of a degenerative joint, and/or gait or vestibular disorders. Changes in vision and cognition, such as those occurring with dementia and Alzheimer’s disease, may increase the risk of falls by decreasing patients’ awareness of their surroundings and their ability to discern potential fall hazards in their environments.

Other chronic health conditions that may decrease mobility include osteoporosis, peripheral neuropathy, and congestive heart failure. Hazards in the home environment, such as throw rugs, poor lighting, and multilevel dwellings, can put older adults at risk as well. Finally, income and environmental changes, such as strong winds and water-covered surfaces, are hazards to at-risk older adults.

The use of multiple medications cannot be overlooked as a significant fall risk factor. A variety of medication categories may predispose an individual to falls. Analgesics, including both opioid and nonsteroidal anti-inflammatory drugs (NSAIDs); anticonvulsants; and antidepressants may cause side effects such as sedation, lethargy, confusion, double vision, motor incoordination, dizziness, and weakness. Medications that have significant anticholinergic effects, such as antihistamines, metoclopramide, promethazine, muscle relaxants, and medications used to treat urinary incontinence (oxybutynin and tolterodine), may cause sedation, confusion, incoordination, or dizziness. Many anti-Parkinson’s agents may result in dyskinesia, confusion, and delirium, which can increase the risk of falling.

Medications used chronically to treat hypertension, Parkinson’s disease, and angina can result in orthostatic hypotension-related falls. A meta-analysis of psychotropic drugs and the risk for falls found that the odds ratio for falling was increased when any psychotropic drug was used in an older adult patient.

Risk Reduction Strategies
Reduction strategies can be divided into two broad categories: pharmacological and nonpharmacological. Examples of pharmacological strategies include medication regimen reviews to identify agents that may increase falls and therapeutic duplications. Regimens including at least four medications or any psychotropic agent may increase falls. An example of potential therapy duplications for central nervous system agents are the use of a benzodiazepine for sleep and another for anxiety.

A second strategy to decrease potential medication-related adverse events is the development of clinical practice algorithms integrating evidence-based findings with clinical practice. Anticholinergics are one category identified with increased fall risk. A risk scale was developed to rank the anticholinergic potential for adverse effects of commonly prescribed agents. An example of a high-risk medication on this scale is diphenhydramine; a low-risk agent is trazodone.

Another frequently used medication class, anticoagulants, carries medication use-associated fall risks. Evidence-based information for protocol development is limited. Concurrent use of aspirin, NSAIDs, and/or alcohol increases the risk of bleeding. Algorithms for the following categories of medication have also been developed: anticonvulsants, cardiovascular agents, benzodiazepines, antidepressants, and antipsychotics.

Nonpharmacological strategies may be either formal programs or less rigidly structured activities based on an individual’s interests and abilities. Examples include exercise, programs for improving balance and/or gait, and strength training. The need for additional interventions may be as simple as periodically asking about falls and the ability to arise from a sitting position to a standing position. Addressing environmental hazards by removing clutter, adding assistive devices, and improving lighting are also associated with decreasing falls and improving outcomes.

Preventing Falls
Simple changes such as reviewing medication regimens for those frequently associated with falls and/or duplication of therapy, as well as ensuring environmental changes have been addressed, may reduce the risk for falls among older adults. It’s important for practitioners to remain vigilant regarding the potential for catastrophic falls due to medication interactions. Reevaluate elders’ medication regimens each time a medication is changed or a new one is added.

— Nancy C. Brahm, PharmD, MS, BCPP, CGP, is a clinical associate professor at the University of Oklahoma College of Pharmacy. She is board certified in psychiatric pharmacy and geriatrics.

— Kimberly M. Crosby, PharmD, BCPS, CGP, has served as a faculty member for the University of Oklahoma College of Pharmacy department of clinical and administrative sciences since 2002.

References
Arfken, C. L., Lach, H. W., Birge, S. J., & Miller, J. P. (1994). The prevalence and correlates of fear of falling in elderly persons living in the community. Am J Public Health, 84(4), 565-570.

Beers, M. H. (1997). Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med, 157(14), 1531-1536.

Beers, M. H., Ouslander, J. G., Rollingher, I., Reuben, D. B., Brooks, J., & Beck, J. C. (1991). Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med, 151(9), 1825-1832.

Bulat, T., Castle, S. C., Rutledge, M., & Quigley, P. (2008a). Clinical practice algorithms: medication management to reduce fall risk in the elderly--part 2, summary algorithm. J Am Acad Nurse Pract, 20(1), 1-4.

Bulat, T., Castle, S. C., Rutledge, M., & Quigley, P. (2008b). Clinical practice algorithms: medication management to reduce fall risk in the elderly--Part 3, benzodiazepines, cardiovascular agents, and antidepressants. J Am Acad Nurse Pract, 20(2), 55-62.

Bulat, T., Castle, S. C., Rutledge, M., & Quigley, P. (2008c). Clinical practice algorithms: medication management to reduce fall risk in the elderly-part 4, anticoagulants, anticonvulsants, anticholinergics/bladder relaxants, and antipsychotics. J Am Acad Nurse Pract, 20(4), 181-190.

Fick, D. M., Cooper, J. W., Wade, W. E., Waller, J. L., Maclean, J. R., & Beers, M. H. (2003). Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med, 163(22), 2716-2724.

Goulding, M. R. (2004). Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med, 164(3), 305-312.

Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. (2001). J Am Geriatr Soc, 49(5), 664-672.

Hamilton, H. J., Gallagher, P. F., & O'Mahony, D. (2009). Inappropriate prescribing and adverse drug events in older people. BMC Geriatr, 9, 5.

Hornbrook, M. C., Stevens, V. J., Wingfield, D. J., Hollis, J. F., Greenlick, M. R., & Ory, M. G. (1994). Preventing falls among community-dwelling older persons: results from a randomized trial. Gerontologist, 34(1), 16-23.

Kressig, R. W., Wolf, S. L., Sattin, R. W., O'Grady, M., Greenspan, A., Curns, A., et al. (2001). Associations of demographic, functional, and behavioral characteristics with activity-related fear of falling among older adults transitioning to frailty. J Am Geriatr Soc, 49(11), 1456-1462.

Leipzig, R. M., Cumming, R. G., & Tinetti, M. E. (1999a). Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc, 47(1), 30-39.

Leipzig, R. M., Cumming, R. G., & Tinetti, M. E. (1999b). Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs. J Am Geriatr Soc, 47(1), 40-50.

MacCulloch, P. A., Gardner, T., & Bonner, A. (2007). Comprehensive fall prevention programs across settings: a review of the literature. Geriatr Nurs, 28(5), 306-311.

Navarro, M. C., Sosa, M., Saavedra, P., Lainez, P., Marrero, M., Torres, M., et al. (2009). Poverty is a risk factor for osteoporotic fractures. Osteoporos Int, 20(3), 393-398.

Quigley, P. A. (2007). Clinical practice algorithm: medication management to reduce fall risk in the elderly. Part 1. J Am Acad Nurse Pract, 19(12), 625-626.

Roser, P., Gallinat, J., Weinberg, G., Juckel, G., Gorynia, I., & Stadelmann, A. M. (2009). Psychomotor performance in relation to acute oral administration of Delta9-tetrahydrocannabinol and standardized cannabis extract in healthy human subjects. Eur Arch Psychiatry Clin Neurosci, 259(5), 284-292.

Rudolph, J. L., Salow, M. J., Angelini, M. C., & McGlinchey, R. E. (2008). The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med, 168(5), 508-513.

Stevens, J. A., Corso, P. S., Finkelstein, E. A., & Miller, T. R. (2006). The costs of fatal and non-fatal falls among older adults. Inj Prev, 12(5), 290-295.

Tinetti, M. E., & Speechley, M. (1989). Prevention of falls among the elderly. N Engl J Med, 320(16), 1055-1059.

US Department of Health and Human Services, P. H. S. (1991). Healthy People 2000: National Health Promotion and Disease Prevention Objectives , from http://www.cdc.gov/nchs/data/hp2000/hp2k01.pdf