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'''Original Editors '''- [[User:Scott Buxton|Scott Buxton]] | '''Original Editors '''- [[User:Scott Buxton|Scott Buxton]] | ||
'''Top Contributors''' -{{Special:Contributors/{{FULLPAGENAME}}}} | '''Top Contributors''' -{{Special:Contributors/{{FULLPAGENAME}}}} | ||
</div> | </div> | ||
== What is Polypharmacy? == | == Introduction == | ||
[[Older People Introduction|Older adults]], [https://www.physio-pedia.com/Physical_Activity_in_Ageing_and_Falls 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.<ref name=":1" /> | |||
== Medication and Falls == | |||
[[File:Pill banner.png|right|frameless|409x409px]]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.<ref name=":0">Medski.com. Geriatrics – Polypharmacy in the Elderly: By Balakrishnan Nair M.D. Available from: https://www.youtube.com/watch?v=vGcAr9tK_30 (last accessed 20.5.2019)</ref> | |||
== What is Polypharmacy? == | |||
Polypharmacy is typically defined as '''the use of more than 3 or 4 medications'''''<ref name="Ziere">Ziere G. Dieleman J. Hofman A. Pol A. van der Cammen T. Stricker B. [https://scholar.google.com/scholar_url?url=https://bpspubs.onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2125.2005.02543.x&hl=en&sa=T&oi=gsb&ct=res&cd=0&d=7278315896912479069&ei=rN80Y5y6PIOMywSMtaLABA&scisig=AAGBfm1bPXEliqd6KnKlh9-zX99L1lagzw Polypharmacy and Falls in the Middle Age and Elderly Population]. British journal of clinical Pharmacology. 2005:61;218-223</ref><ref name="Evans">Evans J. [https://scholar.google.com/scholar_url?url=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)12502-0/fulltext&hl=en&sa=T&oi=gsb&ct=res&cd=0&d=15612501188726585185&ei=yd80Y8DYCdHsyASNjL-oDw&scisig=AAGBfm1asLxNenNJKVKcQ9jN43bXg6yPaw Drugs and Falls in Later Life]. Lancet. 2003; 361:448</ref>''. 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.<ref>Dhalwani NN, Fahami R, Sathanapally H, Seidu S, Davies MJ, Khunti K. [https://bmjopen.bmj.com/content/7/10/e016358 Association between polypharmacy and falls in older adults: a longitudinal study from England.] BMJ open. 2017 Oct 1;7(10):e016358. Available from: https://bmjopen.bmj.com/content/7/10/e016358 (last accessed 20.5.2019)</ref> | |||
== Medications Associated with Increased Risk of Falls == | == 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.<ref>Better Health while ageing. [https://betterhealthwhileaging.net/preventing-falls-10-types-of-medications-to-review/ Preventing Falls: 10 Types of Medications to Review if You’re Concerned About Falling.] Available from: https://betterhealthwhileaging.net/preventing-falls-10-types-of-medications-to-review/ (last accessed 20.5.2019)</ref> | |||
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 === | |||
{| border="1" cellspacing="1" summary="Adapted from The FallSafe Project" cellpadding="1" width="900" align="left" | |||
|+ Psychotropic Drugs and Falls Risk<ref name="FallSafe">Darowski A. Dwight J. Reynolds J. Medicines and Falls in Hospital: Guidance Sheet [ONLINE] available from https://www.rcplondon.ac.uk/sites/default/files/documents/medicines-and-falls2.pdf date accessed 14/01/2015</ref> | |||
|- | |||
| '''Medication Group''' | |||
| '''Overall Risk Category''' | |||
| '''Commonly Used Medications''' | |||
| '''Effects on Risk''' | |||
|- | |||
| Sedatives | |||
| rowspan="4" | | |||
'''HIGH RISK''' | |||
Can cause falls alone | |||
| | |||
Lorazepam, Temazepam, Nitrazepam | |||
similar '''''-epam'''''suffix | |||
| 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<br> | |||
| Codeine, Morphine, Tramadol | |||
| Sedates, slows reactions, impairs balance, delirium | |||
|- | |||
| rowspan="2" | 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 | |||
| rowspan="2" | '''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 | |||
| rowspan="2" | '''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. | |||
|} | |||
| |||
<br><br> | |||
=== Drugs Actings on the Heart and Circulation === | |||
{| border="1" cellspacing="1" cellpadding="1" width="900" | |||
|+ Drugs Acting on the heart and Circulation<ref name="FallSafe" /> | |||
|- | |||
| '''Medication Group''' | |||
| '''Overall Risk Category''' | |||
| '''Commonly Used Medications''' | |||
| '''Effect of Risk''' | |||
|- | |||
| Alpha Receptor blockers | |||
| rowspan="3" |'''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 | |||
| rowspan="2" | '''HIGH RISK''' | |||
| Atenolol, Propranolol, Sotalol | |||
| Bradycardia, hypotension, carotid sinus hypersensitivity, vasovagal syndrome | |||
|- | |||
| Antianginals | |||
| Glyceryl Trinitrate (GTN), Isosorbide Mononitrate, Nico | |||
| Sudden hypotension | |||
|- | |||
| Calcium Channel Blockers | |||
| rowspan="2" | '''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.<ref name=":1">De Jong MR, Van der Elst M, Hartholt KA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125318/ Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies.] Therapeutic advances in drug safety. 2013 Aug;4(4):147-54.</ref> | |||
== References == | == References == | ||
<references /> | |||
<br> | |||
<br> | |||
[[Category: | [[Category:Balance]] | ||
[[Category:Medical]] | |||
[[Category:Falls]] | |||
[[Category:Older_People/Geriatrics]] | |||
[[Category:Pharmacology]] | |||
[[Category:Pharmacology for Older People]] |
Latest revision as of 01:49, 29 September 2022
Original Editors - Scott Buxton
Top Contributors -Scott Buxton, Lucinda hampton, Sai Kripa, Kim Jackson, WikiSysop, Chelsea Mclene and Evan Thomas
Introduction[edit | edit source]
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.[1]
Medication and Falls[edit | edit source]
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.[2]
What is Polypharmacy?[edit | edit source]
Polypharmacy is typically defined as the use of more than 3 or 4 medications[3][4]. 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.[5]
Medications Associated with Increased Risk of Falls[edit | edit source]
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.[6]
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[edit | edit source]
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[edit | edit source]
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[edit | edit source]
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.[1]
References[edit | edit source]
- ↑ 1.0 1.1 De Jong MR, Van der Elst M, Hartholt KA. Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. Therapeutic advances in drug safety. 2013 Aug;4(4):147-54.
- ↑ Medski.com. Geriatrics – Polypharmacy in the Elderly: By Balakrishnan Nair M.D. Available from: https://www.youtube.com/watch?v=vGcAr9tK_30 (last accessed 20.5.2019)
- ↑ Ziere G. Dieleman J. Hofman A. Pol A. van der Cammen T. Stricker B. Polypharmacy and Falls in the Middle Age and Elderly Population. British journal of clinical Pharmacology. 2005:61;218-223
- ↑ Evans J. Drugs and Falls in Later Life. Lancet. 2003; 361:448
- ↑ Dhalwani NN, Fahami R, Sathanapally H, Seidu S, Davies MJ, Khunti K. Association between polypharmacy and falls in older adults: a longitudinal study from England. BMJ open. 2017 Oct 1;7(10):e016358. Available from: https://bmjopen.bmj.com/content/7/10/e016358 (last accessed 20.5.2019)
- ↑ Better Health while ageing. Preventing Falls: 10 Types of Medications to Review if You’re Concerned About Falling. Available from: https://betterhealthwhileaging.net/preventing-falls-10-types-of-medications-to-review/ (last accessed 20.5.2019)
- ↑ 7.0 7.1 Darowski A. Dwight J. Reynolds J. Medicines and Falls in Hospital: Guidance Sheet [ONLINE] available from https://www.rcplondon.ac.uk/sites/default/files/documents/medicines-and-falls2.pdf date accessed 14/01/2015