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Falls In The Elderly

Falls In The Elderly. Yali Brennan, PharmD , CDE, NBC-HWC UCSF Medical Center. Learning Objectives:. B ring the awareness of falls in the elderly Identify risk factors for falls

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Falls In The Elderly

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  1. Falls In The Elderly Yali Brennan, PharmD, CDE, NBC-HWC UCSF Medical Center

  2. Learning Objectives: • Bring the awareness of falls in the elderly • Identify risk factors for falls • Identify modifiable risk factors, such as medications and develop strategies to minimize falls due to the use of those medications • Promote non-pharmacological modalities for fall prevention

  3. Lets do the numbers… • Each year, 1 out of 4 older adults fall (7 millions/29 millions); less than half of them tell their doctor; falling once doubles the chance of falling again. • Each year, 3 million older people are treated in ED for fall injuries. • Over 800,000 patients are hospitalized due to fall injury, among that, 300,000 are admitted for hip fracture; • In 2015, the total medical costs for falls totaled >$50 billion. Most cost paid for by Medicare and Medicaid Falls are common and serious health threats to adults older than 65. https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

  4. “ Adult over than 65 year old suffer the greatest number of fatal falls..” World Health Orangization

  5. http://www.who.int/ageing/publications/Falls_prevention7March.pdfhttp://www.who.int/ageing/publications/Falls_prevention7March.pdf

  6. Psychological Impact of Falls • Fear of falling • Feeling of helplessness • Social Isolation • Depression • Decreased physical activity deconditioning increase future falls

  7. Risk Factors For Fall IntrinsicFactors ExtrinsicFactors Medications (polypharmacy) Age related changes in cardiac, neuromuscular function, postural reflexes and gait instability FALL Poor fitted footwear Female gender and age Improperly used assistive devices Impaired vision and/or hearing Environmental hazards Previous falls Medical, neurological and psychiatric conditions Pets Robert Kane, Joseph Quslander, Barbara Resnick, Michael Malone. Essentials of Clinical Geriatrics. 8th Edition, 2017

  8. Class Of Medications Implicated For Fall • Benzodiazepines • Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics • Antipsychotics • Anticonvulsants/Mood-Stabilizers • TCAs • SSRIs • Opioids Jong, M., Van der Elast, M., Hartholt, K., Therapeutic Advances in Drug Safety [2013] 4(4) 147-154 J Am Geriatr Soc. 2015 Nov;63(11):2227-46. doi: 10.1111/jgs.13702. Epub 2015 Oct 8. 2015 Updated Beers Criteria

  9. Class Of Medications Implicated For Fall • Anticholingergic • Antihypertensive medications (diuretic, beta blockers) • Blood sugar lowering agents • Muscle Relaxants 11. TDM medications- phenytoin, lithium 12. Misc: Erectile Dysfunction meds, BPH meds, corticosteroid (cataract), statin (myopathy), Ophthalmic agents, non-steroidal anti-inflammatory (NSAID), donepezil (>1% bone fracture), PPI (increase bone fracture) https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-MedsLinkedtoFalls-508.pdf Al-Aama, Tareef. Falls in the elderly Spectrum and prevention. Canadian Family Physician 2011; Vol 57: 771-776

  10. Steps In Successful Drug Therapy Factors that can interfere in older adults: -Cultural - Economic - Physical - Psychological - Altered reporting and presentation of illness - Multimorbidity - Dementia and impaired senses - Polypharmacy - Age related changes in PK/PD Patient/family/caregiver recognize need for care Adherence Absorption Contact with a health professional Distribution Diagnosis Drug Effects Metabolism Treatment plan/prescription Excretion Patient/family/caregiver education Robert Kane, Joseph Quslander, Barbara Resnick, Michael Malone. Essentials of Clinical Geriatrics. 8th Edition, 2017

  11. Strategies To Minimize Medication Related Fall Stop Switch Reduce https://www.cdc.gov/steadi/pdf/STEADIPharmacistTrainingResources-508.pdf

  12. When To STOP • Inappropriate indication • Inappropriate duration • Duplication of therapy • Therapy completion • Adverse side effects • Patient/family preference- willing to accept condition deterioration and consequences BE CAUTION: certain medications need to be tapered off appropriately to avoid withdraw or discontinuation syndrome eg: SSRI, TCA, antipsychotic; benzodiazepines

  13. When To Switch • Select safer alternatives, avoid meds on the Beers criteria • Change timing of administration to avoid side effects • Different drug within the same class that has safer SE profile

  14. When To Reduce • Renal and hepatic function dose reduction/lengthen dosing frequency to achieve benefits>>risks • Whenever experiencing drug-related side effects • Deprescribing stop • Lower pill burden

  15. Lets meet Ms. QQ Ms. QQ is a lovely 84 years old lady, who lives in Shady Pine Assisted Living Facility. She is independent with all her ADLs; enjoy hanging out with her friends on most days. Two nights ago, Ms QQ was found down on the floor for unknown duration. She denied LOC but did say that she tripped on her cat. She sustained a left hip fracture. PMH: • HTN • DM x 50 years • HLD • Osteoarthritis • Osteoporosis, dx in 2009 • Chronic low back pain • Depression & anxiety • Insomnia. Social History: - never smoke - does enjoy her JD (Jack Daniel’s) a few nights/week. “it helps me sleep” Labs: Na 137, K 4.2, BUN 24, Scr 0.8, wt 47kg; ht 4ft 11inches BP 140/90; HR 70; RR 18 WBC 9x10E9/L; temp: 97F A1C 5.9% in 07/04/18 Vitamin D 17 ng/mL Allergies: NKDA

  16. Medications: • Amlodipine 5mg- take 1 tab (5mg) by mouth once daily • Lisinopril 20 mg- take 2 tab (40mg) by mouth once daily • ASA 81mg- 1 tab (81mg) by mouth once daily • Atorvastatin 80mg- take 1 tab (80mg) by mouth once daily • Alendronate 70mg- take 1 tab (70mg) by mouth once weekly on Sunday • Metformin 500mg- take 1 tab (500mg) by mouth twice daily • Sitagliptin 50mg tab- take 1 tab (50mg) by mouth once daily • Glipizide 10mg tab- take 1 tab (10mg) by mouth twice daily with breakfast and dinner • Alprazolam 2 mg- take 1 tab (2mg) by mouth nightly at bedtime • Iburpofen 400mg- take 1 tab (400mg) by mouth three times daily • Tramadol 50mg- take 1 tab (50mg) by mouth every 6 hours as needed for low back pain • Omeprazole 40mg- take 1 cap (40mg) by mouth once daily • Citalopram 20mg- take 1 tab (20mg) by mouth once daily • Diphenhydramine 25mg- take 1 cap (25mg) by mouth as needed for sleep

  17. Medication Assessment: • How many medications total dose Ms. QQ take on regular basis? • Among the medications she is on, how many can potentially contribute to fall? • What can be stopped? • What can be switched? • What can be reduced?

  18. STOP • ASA- as 1o or 2o prevention? Given pt’s advance age, risk>benefits • DM meds (metformin, sitagliptin, glipizide)- overtreatment hypoglycemia fall. Also increase pill burden. Per ADA 2018 guideline, Ms. QQ’s goal A1C = < 7.5% • Alprazolam- clarify indication and duration. Recommend to taper off slowly and monitor for withdrawal symptoms • Omeprazole- indication? Duration? Could patient be taking PPI due to NSAID use? (prescribing cascade) • Diphenhydramine- indication? Avoid if at all possible due to anticholinergic effects. (Anticholinergic Cognitive Burden score 3) • *Alendronate- if lowfracture risk, 5 years-> drug holiday; if high fracture risk, 10 years drug holiday. But since patient came in for fall, will continue.

  19. SWITCH • Ibuprofen to APAP. The affect on cardiac, GI and renal, should avoid NSAID use if possible. Topical NSAID/capsaicin to the joint? Wt lost if pt is overweight • Alprazolam to lorazepam. Lorazepam is metabolized via Phase II reaction inactive metabolite. CBT? Per Beers criteria, no benzo is safe in the elderly. • Tramadol to oxycodone. Tramadol has active metabolite, also inhibits the reuptake of serotonin and norepinephrine mores side effects profile.

  20. REDUCE • Atorvastatin 80mg  20 mg. Statin-induced myopathy is not uncommon in the elderly but often under-recognized. Patient often contribute the symptoms of “aches and pain” to “getting old” • Lisinopril 20mg x 2 pill  40mg x1 pill. Reduce pill burden • Omeprazole reduce daily dose use PRN stop https://deprescribing.org/

  21. Fall Prevention non-pharm ways • Adequate nutrition • Regular physical activity incorporating cardiac, strength, flexibility and balance training • Bone healthy- Calcium 1200mg/day (elemental) and Vitamin D 800U/day • Avoid alcohol (reduce REM sleep) • Making living environment safe • Avoid throw rugs • Pet • Lighting • Kitchen, bedroom, bathroom, doorway/stairs Michael K Abraham, MD; Nicole Cimino-Fiallos, MD | February 1, 2017

  22. Take Home Messages • Falling is not a normal part of agingand its often preventable • Critical evaluation of medication list for appropriateness can help minimize medication related falls. • Accurate medication reconciliation • Medication therapy management • Consider patient preference • Non-pharmacological intervention is critical to keep elderly safe from falling https://www.youtube.com/watch?v=z-tUHuNPStw (balance) https://www.youtube.com/watch?v=1zyWa3vko6k (balance) https://www.youtube.com/watch?v=M5ffOxDIcwc&start_radio=1&list=RDM5ffOxDIcwc (cardio)

  23. Helpful Resources: • https://www.ncoa.org • https://www.cdc.gov/steadi/pdf/STEADIPharmacistTrainingResources-508.pdf • http://www.who.int/news-room/fact-sheets/detail/falls • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135440/pdf/0570771.pdf • 2015 Beers criteria • https://www.pharmacytimes.com/publications/issue/2012/april2012/the-anticholinergic-cognitive-burden- • https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ • https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/#en24 Vitamin D

  24. Question?

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