May 16, 2017
Every year 1 in 4 individuals 65 years and older fall and more than 2.8 million end up in emergency departments for treatment of fall-related injuries, according to the Centers for Disease Control and Prevention (CDC). The CDC recently launched the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) program to give providers the tools and resources they need to focus on incorporating fall prevention strategies into clinical practice.
The program calls for providers to stop medications whenever possible, switch to safer alternatives when medications pose fall risks, and reduce medications to the lowest effective dose. It also recommends that providers develop patient care plans that include monitoring drug regimens for potential medication-related side effects.
Danielle Fixen, PharmD, a clinical pharmacy specialist in the Seniors Clinic at University of Colorado Hospital, recently discussed the role pharmacists play in implementing the CDC’s strategies and how they can help ensure elderly patients take medications that keep them safe and upright.
Why are older individuals at increased risk of falls and what need does the STEADI program meet?
As people age, they suffer from an increased number of medical conditions, impaired vision and hearing, age-related changes, and are on multiple medications. All of these factors increase the risk of falls. The STEADI program provides tools that elderly patients can use to help decrease fall risks. For example, the program provides a "Check for Safety Brochure," which allows patients to examine different parts of their living environment for fall risks. The STEADI program also provides resources providers can use to screen for medications that increase fall risks.
Which conditions and which medications make elderly patients more susceptible to falls?
Conditions that increase the risk of falls include neurological disorders such as stroke, Parkinson's disease, gait disorders, and dementia. Musculoskeletal disorders — osteoarthritis, muscle weakness — and cardiovascular conditions — orthostatic hypotension and syncope — also increase fall risks. Patients are at risk if they suffer from chronic medical conditions, including diabetes, depression, and vitamin D deficiency. Medications that increase the risk of falls include anticonvulsants, antipsychotics, benzodiazepines, nonbenzodiazepine hypnotics, tricyclic antidepressants, selective serotonin re-uptake inhibitors, opioids, acetylcholinesterase inhibitors, and peripheral alpha blockers.
I believe health care providers — specifically geriatric clinicians — are aware of high-risk conditions and medications. Overall, providers are starting to do a better job of screening for fall risks, but they need to continue to look at the entire patient, instead of a single medication or condition, to consider the full impact multiple medications and disease states might have on safe care.
What can providers do to improve the coordination of care for elderly patients?
It’s important to review a patient’s medication list at each appointment to make sure therapies prescribed by other specialists have been added and the list is current. Additionally, clinical pharmacists can screen medications for fall risk and suggest alternative therapies. If no alternative therapies are available, pharmacists can talk to patients about risks within their home. For example, older adults can become dizzy when standing up if they have been sitting for a long time. We recommend that patients stand up slowly with the help of an assistance device and remain in place for a minute before walking. If new medications are started that may increase the risk of falls, we call patients 3 to 5 days after they’ve begun the therapies to assess side effects and to see how they’re doing.
How much responsibility do pharmacists have in preventing patient falls?
I believe health-system pharmacists can play a vital role in reviewing medications and screening the medication lists of patients who have recently had a fall. They can also provide medication recommendations and alternatives if they see a drug that could potentially increase the risk of falling or that could have contributed to a patient's previous fall. We’re currently involved in a transition of care medication review program, which provides a complete medication review after patients have been discharged from the hospital or a skilled nursing facility. During this review, we screen for appropriateness of medications, including dose, frequency, and laboratory monitoring. Additionally, we screen for medications that increase the risk of falls and can cause common geriatric side effects such as hypotension, hyponatremia, and confusion.
How can pharmacists educate patients about the fall risks they face?
Pharmacists inform patients about potential side effects of the medications they’re taking and can discuss specific medications that increase fall risks. The most common time to provide this education is during transitions of care conversations and disease state management. There are a few ways to improve communication with patients during those times. For example, our hospital’s electronic health record allows providers to see notes specialists within the health system have added to patients’ files. Outside specialists often fax office visit notes to primary care physicians, who can review of medication changes, additions, and discontinuations. I believe that’s a great method. Additionally, our providers reach out to specialists if they feel a medication is causing harm or increasing fall risks for older adults.