Medicines and Falls

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Medicines and Falls

• Louise Tweddell
• PCT Pharmacist

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Aim and objectives

• Aim
• To explore which medicines are potential causes
  of falls in older people and what we can do to
  reduce the risk.
• Objectives
• By the end of this session you will be able to
• Identify medicines that have been associated with
  an increased risk of falling
• List the drug treatments known to decrease the
  risk of fractures in elderly people with
  osteoporosis.
• Make recommendations for the drug treatment of
  patients at risk of falling

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Background

• Elderly people take three times as many medicines
  as younger patients.
• Royal College of Physicians report (1997) noted
  that whiles those over 65 years constitute less
  than 20 of the UK population they consume 45
  of all prescribed drugs.

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Drugs in older peopleOlder people handle drugs
less well

• Homeostatic changes
• Decreased baroreceptors postural hypotension
• Control of body sway - ataxia e.g.
  benzodiazepines
• Glucose and electrolyte control e.g. diuretics
• Decreased renal function
• Renal function decreases by 10 per decade after
  40 !
• Decreased lean body mass
• Increases half life of many drugs
• Decreased plasma albumin
• Increase free fraction of protein bound drugs

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Medicines that make people fall over

• Psychotropics
• Older people on psychotropic medications should
  have their medication reviewed with specialist
  input if appropriate, and discontinued if
  possible to reduce their risk of falling (NICE
  Falls Guidance)

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Medicines that make people fall over

• Antipsychotics
• e.g. chlorpromazine, risperidone
• sedation and dizziness
• dose dependent
• reduce dose
• change to an alternative

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Medicines that make people fall over

• Sedatives/Hypnotics and anxiolytics
• Most data for benzodiazepines.
• e.g. diazepam, temazepam
• only licensed for short term use i.e. 2 to 4
  weeks.
• Drowsiness, next day, confusion
• Nitrazepam 30 hours, temazepam 10 hours. Possibly
  longer in elderly
• avoid
• offer withdrawal
• Dosage rather than half-life was the most
  important factor.

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Medicines that make people fall over

• Insulin and oral hypoglycaemics
• dizziness due to hypoglycaemia
• avoid long acting agents e.g. glibenclamide

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Medicines that make people fall over

• Antihypertensives
• Low blood pressure on standing e.g. alpha
  blockers
• Diuretics
• dizziness
• urgency to pass urine
• postural hypotension
• low sodium - confusion
• Is it needed?
• Is the dose too high?

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Medicines that make people fall over

• Analgesics
• e.g. morphine, co-proxamol
• drowsiness, hypotension- large doses
• switch to alternative e.g. paracetamol
• reduce dose
• NSAIDs
• e.g. ibuprofen, diclofenac
• dizziness and vertigo
• change to paracetamol
• May be due to confounding factors such as the
  presence of arthritis).
• But NSAIDs can cause adverse effects on cognitive
  function

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Medication review

• Regular reviews of medication recommended
• People over 75yrs should have at least yearly
  medication reviews and those on 4 or more
  medications should be reviewed every 6 months
  (NSF 2001)

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Reviewing medicines

• Polypharmacy is it necessary?
• Does it have a purpose?
• Does the patient want it?
• Is it being used to treat a side effect of
  another medicine?
• Even if evidence based is it likely to be
  useful for that patient?
• Has a change been made recently?

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Compliance issues

• Is the patient taking the correct medicines?
• Are they taking too much or too little?
• Are the instructions adequate
• Are they taking medicines that should have
  stopped?
• Do they take anything OTC or borrowed?

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Particular things to consider

• Be suspicious of medicine induced falls if on
  lots of tablets
• Should the dose be smaller?
• Try and reduce benzodiazepine and sedative use
• Have a balanced approach

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Trigger questions to alert need for more in-depth
review

• London Older Peoples Service Development
  Programme
• Area of concern Questions
• Access issues Do you need help getting a
  regular supply of medicines?
• Compliance issues Do you always take all of your
  medicines the way the doctor wants you to?
• Day to day medicines Can you swallow your
  medicines and get al management issues of your
  medicines out of containers?
• Clinical issues Do you think your medicines
  could work better?

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Role of Calcium and Vitamin D

• Vitamin D
• Prevents falls?
• Only 15 people need to be treated to prevent one
  person falling.
• (JAMA 20042911999-2006)
• If fall occurs less likely to fracture

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How Much Calcium?

• These each contain approximately 230mg calcium
• 1 glass 190ml/1/3pint milk whole,
  semi-skimmed, skimmed
• 1 x 140g 5oz carton of yoghurt
• 28g 1oz hard cheese, for example, cheddar

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Who should be on Calcium and vitamin D? e.g.
Adcal D3, Calcichew D3 forte

• Elderly patients with a history of falling
• Patients of south asian origin
• Elderly patients either housebound or living in
  residential /nursing accommodation.
• Patients who have a low body weight (BMI lt19
  kg/m2)
• Patients who have been taking a corticosteroid
  e.g. prednisolonegt 7.5mg daily for 6 months or
  more.

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Just about every old person could benefit from
calcium and vitamin D!

• Over the age of 75 years.
• Female (being that females fall more than males)
• At risk of falling
• Long term immobility.
• No/poor contact with sunlight.
• Poor diet (especially lacking in dietary foods).
• Low body mass.
• Previous fracture.
• Family history of hip fracture.
• Smoker
• Heavy drinker
• Early menopause

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Conclusion

• Medicines are just one of the factors associated
  with an increased risk of falls.
• Older people may have increased sensitivity to
  some medication
• Certain medications can increase the risk of
  falling.
• People on four or more prescription drugs are at
  increased risk of falling.
• Refer to GP to review medicines and make changes.
• Effective treatments are available for
  osteoporosis that reduce the incidence of
  fractures.

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Key reading (Three papers that provide a good
overview)

• Tinetti ME. Preventing falls in Elderly Persons.
  N Eng J Med 200334842-49Woolf AD.
• Åkesson K. Preventing fractures in elderly
  people. BMJ 200332789-95.
• Keys PA, Tress DR. Preventing Falls in the
  Elderly The Role of The Pharmacist. J of Pharm
  Practice 200417149-152