Learn how to identify and help patients at risk
 
 
rxPassport Pharmacy Newsletter
 
November 2014
 
 
Falls in the Elderly: Risk Factors and Prevention
 
Meet Our Patient – Mrs. FP
 
Mrs. FP (71 yo) presents at the pharmacy counter with a box of diphenhydramine and asks if she can take them to help her sleep.
 
You have known her for a long time and know that she is recently widowed and lives by herself with some family living in the same city. Her chronic conditions include hypertension and since her husband passed away she has been suffering with insomnia.
 
Her current medications include:
 
Hydrochlorothiazide 25 mg daily
 
Oxazepam 10 mg qhs prn (started a month ago - she takes about 1 tablet 3 nights a week)
 
She has run out of oxazepam and wanted to know if she could take diphenhydramine prn for now as her family doctor is not in office for another 4 days.
 
What would you recommend?
 
Prevalence and Consequences of Falls in the Elderly
 
Each year, more than one third of seniors aged 65 or older experience a fall.1 Why is this important?
 
Falls are the leading cause of hospitalizations due to injury in seniors1
 
Around 20-30% of seniors who fall will experience moderate to severe injury, with hip fractures being the most common fall related injury2
 
About one fifth of all injury-related deaths in seniors can be traced back to a fall incident3
 
Falls can also lead to profound social, psychological and economic consequences1
 
This is unfortunate, as falls are preventable! Pharmacists can play an active role in fall prevention and can reduce the number of patient injuries and deaths secondary to falls.
 
Risk factors
 
Falls in the elderly are often due to a combination of multiple risk factors.
 
Table 1. Risk Factors in the Elderly1,4,5,6
Major Risk Factors
 
Cognitive impairment
 
Medications (see table 2)
 
Mobility impairment
 
Older age (≥65 years old)
 
Previous falls
 
Using more than 4 medications
Other Risk Factors
 
Alcohol intake
 
Arthritis and Pain
 
Cardiovascular disease
 
COPD
 
Diabetes
 
Fear of falling
 
Female gender
 
Home and environmental hazards
 
Living alone
 
Parkinson’s disease
 
Urinary incontinence or nocturia
 
Visual or hearing impairment
 
Side effects of medications also play a major role in fall risk. Side effects such as, dizziness, sedation, confusion, visual disturbances, and hypotension can increase the risk of falls.7 The highest medication risk associations occur in patients on complex regimens and psychoactive medications (eg. sedatives, antipsychotics, and antidepressants).6
 
Table 2. Medication Classes That Increase Fall Risk7
1st generation Antihistamines
 
Antiarrhythmics
 
Anticholinergics
 
Anticonvulsants
 
Antidepressants
 
Antihypertensives
 
Anti-Parkinson Agents
 
Antipsychotics
 
Opioids
 
Sedatives/Hypnotics
 
Stimulants
 
Sulfonylureas, meglitinides or insulin
 
Fall Risk Assessment in the Elderly
 
When gathering information and assessing for major risk factors, think HELP5:
 
Has previously fallen
 
Elderly patient
 
Loss of mobility and/or cognition
 
Pills
 
Also consider asking the following questions4,7:
 
Do you exercise throughout the week? If so, how often and what types of exercises?
 
Are you afraid of falling or slipping?
 
Do you live by yourself?
 
Have you had any changes in vision or hearing?
 
Do you drink alcoholic beverages? If so, how many within a week?
 
Do you feel any dizziness when standing up? Throughout the day?
 
On a scale from 1 to 10, how healthy would you say you eat?
 
 
Clinical Practice Tip
 
Most patients will not voluntarily tell healthcare professionals about their history of falls.1 Therefore, it is important to remember to prompt for fall history when you encounter an elderly patient.
 
Refer patients with any of the following for a more in depth fall risk assessment:6
 
1. Previous acute fall (fall resulting in an injury)
 
2. Two falls (with no injury) within the last 12 months
 
3. Any gait or balance impairments
 
 
Revisit Mrs. FP
 
After speaking to Mrs. FP, you obtain the following information:
 
No history of previous falls, but she reports that she almost fell once when going to the bathroom in the middle of the night
 
No recent changes in memory, vision, hearing, or medical conditions (besides insomnia)
 
No trouble when walking; she walks outside 15 minutes a day for exercise
 
She indicates that she feels groggy some mornings, and this has started about 3-4 weeks ago
 
Fall Prevention Interventions
 
Following a patient’s fall assessment, their specific risk factors will guide the fall interventions for the individual patient.
 
Medication Reviews
 
The more medication a patient is taking, the higher the patient’s risk for falling, regardless of the medication type.8 Therefore, it is important to conduct a thorough medication review to ensure that medications are appropriate, safe, and effective. If possible, consider discontinuation or dose reduction of medications.6
 
Clinical Practice Tip
 
Conduct medication reviews with your patients at least once a year, or when they are prescribed a new fall risk enhancing medication (see table 2).
 
Vitamin D
 
Vitamin D’s role in the prevention of falls has been shown to be effective in elderly patients that reside in long-term care homes taking 800 IU of vitamin D daily.6 There has been inconsistent results for vitamin D in other populations, however, there is some evidence that vitamin D supplementation of 800 IU daily may decrease fall risk in studies that had adequate determination of falls.9 For further information see the 2010 Vitamin D guideline statement from Osteoporosis Canada.
 
Reminder: Irrespective of fall prevention, vitamin D should still be recommended for the elderly population. The recommended amount of vitamin D for patients who are older than 50 years old is 800-1000 IU.9
 
Non-Pharmacological Interventions6,10,1,11
 
Interventions Examples
Customized Exercise Program
Exercise regimens should include strength training, balance, gait, and coordination training
 
Eg. Tai Chi and physical therapy
 
Guides for general physical activity for seniors: Canada’s Physical Activity Guide to Healthy Active Living for Older Adults and Physical Activity Tips for Older Adults
Home modifications
Anti-slip floor mats for the tub/shower
 
Reduction of clutter
 
Adequate lighting
 
Items that are used often should be stored in easy to access areas
 
Night lights along the hallways, especially near washrooms
 
Sturdy handrails on stairs
 
Grab bars in the bathroom
Mobility Aids and Assistive Devices
Should be properly maintained and used correctly
 
Ensure that they are within easy reach
Foot ware and clothing
Proper fitting foot ware and clothing
 
Opt for foot ware with high surface contact area
 
During winter and icy conditions wear anti-slip shoes outdoors
Vision related
Cataract surgery should be expedited on the first affected eye
 
Avoid using multifocal lenses while walking or using stairs
Nutrition
Choose healthy choices to help with strength
 
Don’t skip meals
Postural/Orthostatic Hypotension Management
Compression stockings
 
Head should be elevated by 4 inches when sleeping
 
Keep hydrated
 
Counseling Mrs. FP
 
Diphenhydramine can cause drowsiness throughout the day and increase Mrs. FP’s risk for falling, therefore diphenhydramine is not recommended
 
Initiate/reiterate sleep hygiene techniques to maximize ability to sleep at night and reduce need for oxazepam
 
Avoid fluid intake and caffeine close to bedtime to avoid her having to get up frequently at night to urinate
 
Ensure the pathway from bedroom to washroom is clear of clutter
 
Place night lights in the washroom and in hallways
 
Recommend balance exercises such as Tai Chi
 
 
 
Margaret
 
By Margaret Noriel, PharmD Candidate
 
With appreciation to Mike Boivin
 
In this issue
 
Meet our Patient
 
Prevalence and Consequences
 
Risk Factors
 
Fall Risk Assessment
 
Fall Prevention Interventions
 
Interactive Poll
 
Resources
 
References
 
Pharmacy Student Blog
 
Interactive Poll
 
Q: How often do you ask elderly patients about previous falls?
 
Every 6 months
 
Every year
 
When prescribed medications that increase their risk of falling
 
During medication reviews
 
When prescribed medications that increase their risk of falling AND during medication reviews
 
I don’t remember when I last asked a patient
 
 
Osteoporosis, Fractures and Fall Risk
 
If a patient has osteoporosis they are at increased risk of obtaining a fracture due to a fall. There are tools which can be used to assess a patient’s risk of fractures within 10 years: CAROC and FRAX. Results from a 10-year fracture risk assessment will help guide potential pharmacotherapy for your patient.
 
» Get more information
 
 
Resources
 
Health Canada
 
Public Health Agency of Canada: Seniors’ Falls in Canada: Second Report: View Resource
 
AGS/BGS Clinical Practice Guideline for Prevention of Falls in Older Persons – 2011 Updated Summary
 
 
References
 
1. Al-Aama T. (2011). Falls in the elderly: spectrum and prevention. Canadian Family Physician, 57(7), 771-776.
 
2. World Health Organization. (2012). Falls. Retrieved November 14, 2014. View source.
 
3. Public Health Agency of Canada. (2011). The Facts: Seniors and Injury in Canada. Retrieved November 14, 2014. View source.
 
4. Public Health Agency of Canada. (2014). Seniors’ Falls in Canada: Second Report. Retrieved November 10, 2014. View source.
 
5. de Jong MR, et al. (2013). Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. Therapeutic Advances in Drug Safety, 4(4), 147-154
 
6. Panel on prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. (2011). Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59(1), 148-157.
 
7. Safer Healthcare Now!. (2014). Reducing Falls and Injuries From Falls: Getting Started Kit. Retrieved November 10, 2014. View source.
 
8. Tinetti ME, et al. (2010). The Patient who falls: “It’s always a trade-off”. The Journal of the American Medical Association, 303(3), 258-266.
 
9. Hanley DA, et al. (2010). Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada. Canadian Medical Association Journal, 182(12), E610-E618.
 
10. Health Canada. (2006). Seniors and Aging – Preventing Falls in and around Your Home. Retrieved November 14, 2014. View source.
 
11. Figueroa JJ, et al. (2010). Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleveland Clinical Journal of Medicine, 77(5), 298-306.
 
 
 
 
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