Medication and Falls

Original Editors - Scott Buxton

Top Contributors -Scott Buxton, Lucinda hampton, Sai Kripa, Kim Jackson, WikiSysop, Evan Thomas and Chelsea Mclene

Introduction

Older adults, aged 65 years and older are commonly prone for falls leading to injuries. Falls are considered as an increasing public health problem in an aging populations worldwide. The highest prevalence of falls are observed in an older population associated with increase in morbidity and mortality rate. There can be numerous risk factors leading to falls includes age, gender, diseases, drugs, environmental factors, vision, balance etc.

Medication and Falls

It is important to focus on the medications an elderly client is taking as they may be significant falls risks.

• Medications are among the most common causes of increased fall risk in older people.

• Medications are usually among the easiest risk factors to change, when it comes to falls in older adults.

• Medication-based risks are often missed by busy regular doctors. Older adults and family caregivers and physiotherapists can help by being proactive in this area.

What is Polypharmacy?

Polypharmacy is typically defined as the use of more than 3 or 4 medications. Take a moment and think of the number of patients you have that are taking more than 3 medications. Thought also needs to be spent on which type of medications the patient is taking as different class of drug influence the risk of falls differently.

A 2017 study reported that almost one-third of the total population using five or more drugs had a significantly increased rate of falls (21%) over a 2-year period. It concluded that exploration of the effects of these complex drug combinations in the real world with a detailed standardised assessment of polypharmacy is greatly required.

Medications Associated with Increased Risk of Falls

As physiotherapists it is important to be aware of which medications can impact on our patients safety, medication is obviously not within a physiotherapist job role specifically however knowing what the potential impact of some medications can be very valuable. Additionally it is important to know about the medications if you work in a triage role. If you are concerned about the type or number of medications a patient is taking then spend time referring to you medical colleagues in the clinic, writing to their GP or discussing at and MDT meeting.

In common language the three types of drugs that can increase falls risks are

• Medications that affect the brain
• Medications that affect blood pressure
• Medications that lower blood sugar.

In more specific terms two main classes of drugs increasing the risk of falls are

• Psychotropic drugs
• Drugs acting on the heart and circulation. These are outlined below.

Note- Diabetic drugs lower blood sugar. Most diabetes medications can cause or worsen hypoglycemia (too low blood sugar). This has been identified as a falls risk. They are not included below.

Psychotropic Drugs

Psychotropic Drugs and Falls Risk

Medication Group	Overall Risk Category	Commonly Used Medications	Effects on Risk
Sedatives	HIGH RISK Can cause falls alone	Lorazepam, Temazepam, Nitrazepam similar -epamsuffix	Drowsiness, slows reactions, impaired balance.
Sedating Antidepressants		Amitriptyline, Nortriptyline	Orthostatic hypotension, drowsiness, slow reactions. DOUBLE THE RATE OF FALLS
Monoamine Oxidase Inhibitors		Phenelzine, Moclobemide	Severe orthostatic hypotension
For Psychosis Agitation		Haloperidol, Chlorpromazine, Olanzapine	Orthostatic hypotension, slow reflexes, loss of balance
Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin and Noradrenaline Reuptake Inhibitor )SNRI)	MODERATE RISK Can cause falls in combination	Fluoxetine, Sertaline, Paroxetine, Venlafaxine, Duloetine	Increased risk of falls with fractures, orthostatic hypotension, bradycardia, impaired sleep quality
Opiate Analegsics	HIGH RISK Can cause falls alone	Codeine, Morphine, Tramadol	Sedates, slows reactions, impairs balance, delirium
Anti Epileptics	HIGH RISK	Phenytoin, Carbamazepine, Phenobarbitone	Cerebellar damage, ataxia, slowed reactions
	MODERATE RISK	Sodium Valporate, Gabapentin	Some association with falls risk
Parkinson's - Dopamine Agonists	HIGH RISK	Roprinerole, Pramipexole	Delirium, orthostatic hypotension
Parkinson's - MAOI-B Inhibitors		Selegiline	Orthostatic hypotension (Difficult to assess due to high falls risk in Parkinson's as the disease process)
Muscle Relaxant	MODERATE RISK	Baclofen	Reduced muscle tone, sedative
Vestibular Sedative	POSSIBLE CAUSES	Prochlorperazine, Cinnarazine, Betahistine	Prochlor... - Dopamine agonist which may cause movement disorder in long term, sedating
Anticholinergics acting on Bladder		Oxybutinin, Solifenacin, Tolterodine, Solifenacin	Known CNS effects.

 

Drugs Actings on the Heart and Circulation

Drugs Acting on the heart and Circulation

Medication Group	Overall Risk Category	Commonly Used Medications	Effect of Risk
Alpha Receptor blockers	HIGH RISK	Doxasozin, Tamsulosin, Indoramin	Severe orthostatic hypotension, urinary retention
Centreally Acting Alpha-2-Receptor Agonsits		Clonidine, Moxonidine	Severe orthostatic hypotension, sedating
Thiazide Diuretics		Bendroflumethiazide, Metolazone	Weakness due to low potassium, hyponatraemia, orthostatic hypotension
Loop Diuretic	MODERATE RISK	Furosemide, Bumetanide	Dehydration, hypotension, low potassium and sodium
Angiotensin Converting Enzyme Inhibitors (ACEIs)	HIGH RISK	Lisinopril, Ramipril -opril	Rely upon kidney elimination and accumulate can cause failure, dehydration.
Angiotensin Receptor Blockers (ARBs)	MODERATE RISK	Losartan or similar -tan	Hypotension
Beta Blockers	HIGH RISK	Atenolol, Propranolol, Sotalol	Bradycardia, hypotension, carotid sinus hypersensitivity, vasovagal syndrome
Antianginals		Glyceryl Trinitrate (GTN), Isosorbide Mononitrate, Nico	Sudden hypotension
Calcium Channel Blockers	MODERATE RISK	Amlodipine, Felodipine, Diltiazem, Verapamil	Hypotension, bradycardia
Other Antidysrhythmics		Digoxin, Flecainide, Amiodarone	Bradycardia, arrythmias
Acetylcholinersterase Inhibitors (For Dementia)	POSSIBLE CAUSES	Rivastigmine, Donepezil, galantamine	Bradycardia and syncope

Prevention

There can be many reasons for falls, in other words, falls are 'multifactorial'. For an effective fall prevention strategy, we need to consider the risk factors that are modifiable or non-modifiable. Physical therapists should work with a team of health care professionals for an effective comprehensive fall prevention programs to reduce the risk factors for older adults . When we consider the modifiable risk factors for falls, drugs are one of the modifiable risk factors that are called as "fall risk increasing drugs". According to researches, it has been proven that withdrawal of psychotropic drugs in patients with 65 years of age were effective in prevention of falls. There were at least 66% reduction in falls was shown in patients who discontinued the intake of psychotropic drugs. Apart from that, reduction in the dosage consumption of benzodiazepines proved high success rate in fall prevention. We need to focus on multifactorial reasons contributing to falls for successful intervention. For example, proper monitoring of medication intake (dose, time, type, number), individual risk factors & environmental factors leading to falls, any specific movement such as reaching, lifting, walking, turning by an individual leading to falls, balance training, gait training, assistive devices, promoting education to family members regarding risk factors. Fall prevention is the first and foremost step in an older adults.