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9/19/2014
1
Workshop 4: Preventing Falls through Medication
Vigilance Nancy L. Losben, R.Ph., CCP, FASCP, CG
Chief Quality OfficerOmnicare, Inc.
&Diane C. Vaughn, RN, C-DONA/LTC, LNHA
VP, Clinical ServicesBenedictine Health System
Goals
� Describe how medication risk awareness is involved with the HATCh model
� Identify the effect falls have on the elderly
� Describe common pharmacologic issues and meds that contribute to falls
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Holistic Approach to Transformation Change Model
(HATCh) � Six Competency Domains
� Care Practices
� Competency 1.1Demostrate an Understanding of risks that lead to falls� 1. Identify Medications that May Contribute to Falls and
Fall Risk
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Competency-Based Education(CBE)
“… ‘a cluster of related knowledge, skills, and attitudes that affects a major part of one’s job (a role or responsibility), that correlates with performance on the job, that can be measured against well-accepted standards, and that can be improved via training and development.”
� Training focuses on learning desired outcomes
� Design makes statements of observable and measurable behavior
� Staff must have the necessary knowledge, skill and attitude to attain the highest level of performance.
Competency Based Education
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Background
� 2nd most common adverse event
� Occur in 30-60% of the older adults / year
� 10-20% result in serious injury, hospitalizations, and / or death
� 10% of ER and 6% of hospitalizations >65 YO
� Falls are the leading cause of injuries in older adults
Medications
� 32,000 Seniors Suffer Hip Fractures Caused By Medications
� 20% Will Die Within 5 Years
� On average, individuals 65 to 69 years old take nearly 14 prescriptions per year, individuals aged 80 to 84 take an average of 18 prescriptions per year
� ≥ 4 medications is considered a falls risk
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Falls Risk Factors
� Weakness
� Unsteadiness
� Confused State
� Sleep Quality
� Medications
Medications and Falls
� Common Pharmacologic Mechanisms:� Orthostatic hypotension
� Dizziness
� Decreased postural reflexes
� Extrapyramidal symptoms
� Myorelaxant effects
� Visual impairment
� Impaired cognition / CNS effects
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AHCA/NCAL Webinars
Preventing Falls through Medication Vigilance
Nancy L. Losben, R.Ph., CCP, FASCP, CG
Chief Quality Officer
Omnicare, Inc.
Objectives
� To recognize the medication regimen as a risk for safety and falls.
� To identify the timeframe when a resident is at his/her highest risk to fall after a change in in the medication regimen.
� To enhance and coordinate safety and quality improvement activities.
12Fall Prevention
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Centers for Disease Control and Prevention
5% of adults 65 and older live in nursing homes but 20% of deaths from falls (1,800 yearly) Up to 20% of falls cause serious injuries
Reasons for falls in LTF facilities: frailty, chronic conditions, gait disturbances, memory problems, ADL decline, medications
Fall risk is significantly elevated during the 3 days following any drug that affects the central nervous system
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Any one of these medication related problems (MRP) can increase the risk
for falling
� Drowsiness
� Dizziness
� Low blood pressure
� Low heart rate
� Parkinson’s effect
� Ataxia/gait disturbance
� Vision disturbance
� Low blood sugar
� Urinary urgency
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Adverse Consequences
� Some adverse consequences occur quickly or abruptly, while others are more insidious and develop over time.
� Adverse consequences may become evident at any time after the medication is initiated, e.g., when there is a change in dose or after another medication has been added.
� When reviewing medications used for a resident, it is important to be aware of the medication’s recognized safety profile, tolerability, dosing, and potential medication interactions.
� Although a resident may have an unanticipated reaction to a medication that is not always preventable, many ADRs can be anticipated, minimized, or prevented.
In theory, any medication, or a lack of one, can be the underlying cause of a fall.
� But do you know which medications are most likely to increase the risk of falling?
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Medication Categories Recognized asRisks for Falling
� Opioid analgesics� Anticonvulsants� Antidepressants� Anti-Parkinson’s� Anxiolytics� Antipsychotics� Antihistamines
� Antiarrhythmic� Appetite stimulant� Barbiturates� Diuretics� Hypoglycemics; insulin� Medications to treat continence
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Medications associated with Injury with a Fall
� Anticoagulants
� Anti-seizure medications
� Chemotherapy
� Laxatives
� Psychopharmacologics
� Sedatives/hypnotics
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Diuretics
� Hypotension� Urinary urgency� Incontinence� Dehydration� Electrolyte imbalance� Temporal effect
� Onset � Peak
19Fall Prevention
Cardiovascular Drugs
� Hypotension� Low heart rate� Lethargy� Delirium� Syncope, dizziness� Bleeding � Immediate release Vs. Sustained release
Fall Prevention20
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Antipsychotics
� Routine, seldom PRN � Lowest Possible Dose� Recent Dose Increase or Reduction� Extrapyramidal Side Effects� Blurred Vision� Lethargy � Somnolescence� Is it efficacious?
21Fall Prevention
Anxiolytics
� Routine vs. PRN orders� Short acting benzodiazepines preferred� Lowest possible dose� Recent dose increase or reduction� Lethargy� Efficacy
22Fall Prevention
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Hypnotics
� Routine Vs. PRN
� Short Acting Benzodiazepines or newer non-benzodiazepines
� Given while in bed
� Used no more than 10 consecutive days or manufacturer’s suggested direction
� Morning functionality/hangovers
� Falls out of bed
23Fall Prevention
Antidepressants
� Tricyclic's
� Highly anticholinergic
� Blurred Vision
� Confusion
� Changes in heart rate
� Restlessness, sleeplessness
� Drug Interactions
� SSRI’s and SSNRI’s have a better safety profile
24Fall Prevention
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Muscle Relaxants and Antiparkinson Drugs
� Muscle weakness
� Central nervous system effects
� Behavioral symptoms
� Temporal relationship to administration and ADL performance
25Fall Prevention
Laxatives
� Cathartics/bowel urgency
� Electrolyte imbalance
� Tolerance, Impaction
� Toileting plan
� Opioid therapy and anticholinergics can cause constipation
26Fall Prevention
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Pain Medications
� Opioids
� Risk vs. Benefit� Drowsiness/dizziness Vs. Relief
� Constipation Vs. Mobility
� Non-steroidal anti-inflammatory drugs
� GI effects
� Confusion, other CNS effects
27Fall Prevention
Anticholinergic Medications
� Medications that could affect function, level of consciousness, gait, balance, visual acuity, or cognitive ability,
� Causing symptoms such as dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium, excitability, memory loss, unsteadiness, dizziness, or hallucinations.
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Anticholinergic Effect
“Blind as a bat. Mad as a hatter, red as a beet, hot as Hades, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone."
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Anticholinergic Drugsoften antihistamines, antidepressants,
over active bladder medicationsexamples
Generic Brand Name Generic Brand Name
Amantadine Symmetrel® Hydroxyzine Vistaril®
Clozapine Clozaril® Meclizine Antivert®
Cyclobenzaprine Flexeril® Ranitidine Zantac®
Diphenoxylate/atropine
Lomotil® Olanzapine Zyprexa®
Diphenhydramine Benadryl® Oxybutynin Oxytrol®
Desipramine Norpraminl® Paxoxetine Paxil®
Furosemide Lasix® Tolterodine Detrol®
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Syncope
� Diuretics
� Calcium channel blockers
� ACE inhibitors
� Nitrates
� Antipsychotics
� Antihistamines
� Anti-Parkinson's medications
� Opioids
� Alcohol
Managing Medication- Related Syncope
� The first 72 hours following modification of any of these medications is the timeframe of highest risk to fall� Alert care staff to any affected resident with a change in
their medication regimen to a higher risk of fall� Focus on residents who are usually independent in ADL’s� Remind residents to rise slowly� Temporarily use a gait belt� Monitor blood pressure daily� Observe and document the resident’s response to the
medication� Report findings to the physician and and pharmacist
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Sometimes, adding a medication to a resident’smedication regimen can help to reduce falls and
minimize injuries.
Unmanaged Pain as a Risk for Falls
� Residents in pain will likely avoid painful stimulus by sitting and lying down
� Increases the risk of fall as a result of deconditioning
� Residents in pain will also attempt to change position to find a more comfortable state
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Managing PainClassification
� Acute
� Recent onset
� Chronic� nociceptive- somatic, visceral� neuropathic� mixed/unspecified� psychologically mediated
� Chronic Malignant
� Chronic Non-malignant
WALA36
Identify Underlying Conditions that May Cause Pain
Neurological•Herpes Zoster
• Spinal and nerve injury
PAIN
HeartAngina
Heart AttackThrombosisPeripheral vasculardisease
SkinWoundsUlcers
Incisionsinfections
MusculoskeletalArthritisFracture
OsteoporosisBack
problemsAmputation
CancerNeurological
•Diabetic Neuropathy• Herpes Zoster
• Spinal and nerve injury GI PainDental Pain
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Treating Pain to Achieve
Mobility and Strength
WALA38
Principles for Analgesics
� Choice of Drug� Appropriate for patient's type of pain
� What has worked in the past� Appropriate for patient’s severity of pain
� At level appropriate to assessed pain� Use combinations of drugs
� Not necessarily combined drugs� Ongoing evaluation
� Benefit� Risks
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WALA39
Principles for Analgesics
� Administration
� Adequate doses
� Titrate to individual needs� Patient response
� Drug itself
� Onset
� Peak effect
� Duration
� Around the clock
WALA40
Principles for Analgesics
� Administration� Address breakthrough pain
� Same drug if possible� Monitor benefit
� Consider risk for ADRs� Address early� Advise resident
� Oral route whenever possible� Or other non-invasive
� Review and evaluate
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Vitamin D
� Can reduce falls by reducing osteoporosis and preventing sarcopenia (loss of muscle mass)
� Benefits of Vitamin D are distinct from its effect on bone.
� Controversial
Evaluating Falls at Care Conference
� Previous fall, initial fall� Circumstances, use incident report with Vital Signs
for analysis� Medication Regimen as a risk
� 4 or more drugs, new drug� Drug therapy class� Temporal relationship to fall� Chemical restraints
� Review behavior monitoring sheets� Blood sugars, blood pressures, pulses� Lab tests: glucose, electrolytes, hydration,
hemoglobin/hematocritFall Prevention42
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Reducing the RiskApproaches
� Eliminate unnecessary drugs
� Find lowest effective doses of medications through dose reduction
� Monitor efficacy and resident responses to medications
� Monitor labs
Fall Prevention43
Evaluation of Falls at Quality Improvement Meetings
� Interdisciplinary- Don’t forget to include:� Rehab Services
� Dietitian
� Pharmacist
� Environmental Services
� Bring List of those who have Fallen� Crosswalk to Psychotropic Drug list
� Crosswalk to changes in condition
� Crosswalk to those who experienced infection
� Crosswalk it to those who had changes in their medication regimen
Fall Prevention44
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Evaluation of Falls with Injury
� Crosswalk it to residents on anticoagulants
� Crosswalk it to residents with a diagnosis of osteoporosis
� Crosswalk it to residents treated for seizures
� Crosswalk it to residents who use hypnotics
� Crosswalk it to resident with a history of impaction and/or laxative use
Summary
A fall may be the result of an adverse drug reaction of any medication or combination of medications
A resident is most likely to fall within the first 3 days of a change in the medication regimen
Planning to minimize falls during QA/PI meetings requires comparison of data from multiple sources.
Fall Prevention46
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� Tuesday, September 23
www.ahcancal.orgahcancalahcancal