Post on 06-Aug-2018
Don’t Let Your Medications Trip
You Up
Dr Kate Ingram
Geriatrician
SCGH Falls Clinic, SCGH Falls Prevention
Committee, State Falls Network
Outline
• How medications increase the risk of falling
• Evidence that modifying medications
decreases falls risk
• Good medications
• Discharge from hospital
• Cases
Medications that Decrease Sensory inputs
• Peripheral Sensation
-chemotherapy eg cisplatin, bortezomib
-antibiotics eg isoniazid, chloroquine, HIV meds
-amiodarone (heart)
-meds for autoimmune disease eg leflunamide, infliximab
• Vestibular- gentamicin
• Visual
-worsen glaucoma-
anticholinergics eg oxybutinin,
antihistamines, prednisolone
-Cardiac meds eg digoxin,
amiodarone
-retinal toxicity eg
antimalarials, tamoxifen
-tamsulosin
-TB meds
-erectile dysfunction meds
Medications that Impair Your Motor
Function
• Proximal myopathy- prednisolone, colchicine
• Myositis- statins (painful)
• Arthritis
• Tendon damage- ciprofloxacin
Medications that impair central (brain)
processing **Most Important!**
• Benzodiazepines- diazepam (valium), oxazepam
(serepax), temazepam, alprazalam
• Major tranquillizers/ anti psychotics- haloperidol,
respiradone, olanzepine, maxalon, quetiapine
• Antidepressants- tricyclics (dothiepin, amitryptline),
SSRIs (sertraline, citalopram), mirtazepine (avanza)
Antipsychotics • Increased risk of death in patients with dementia
(meta-analysis: death rate 2.3% Vs 3.5%) JAMA 2005
• Increased risk of stroke- 4% Vs 2% CMAJ 2002, 2004
• Increased risk of falls
• Has a FDA ‘Black box’ warning in USA
• NNT: 9 patients, Vs NNH (fatal stroke) 14
Medications causing dizziness/ presyncope/
syncope
• Heart block/ bradycardia
b blockers
Digoxin
verapamil
• Postural hypotension
Diuretics
any BP meds
Anticholinergics
Parkinson’s meds
tricyclic ADPs
Increasing the Risk of Injury
• Anticoagulants- Warfarin,
rivaroxaban, apixaban,
dabigatran, heparin, clexane
• Anti-platelets- aspirin,
clopidegral, ticegrelor,
asasantin
• Osteoporosis inducing- prednisolone
‘Good’ Medicines
• Vitamin D deficiency screening is suggested by
ACSQH 2009 Falls Guidelines
Treat levels < 50
• Drugs to treat Postural hypotension
Fludrocortisone
Midodrine
• Drugs to treat Osteoporosis
Meta-analysis
-Woolcott et al, JAMA 2009
• Medication
Antihypertensives
Sedative/ hypnotics
Antipsychotics
Antidepressants
Benzodiazepines
Anti- inflammatories
Diuretics
• Odds ratio of falls
1.24
1.47
1.59
1.68
1.57
1.21
1.07
ACSQH 2009 Falls Guidelines- Hospital
Footwear- ensure it is well fitting, non- slip
Assessment and management of postural hypotension, medication review
Vestibular dysfunction- needs to be identified, investigated & managed
Medications- on admission should be reviewed and modified, and
psychoactive medications reduced or stopped if possible
Vision- provide adequate lighting, identify & manage new visual problems,
make patients glasses available, avoid bifocals when walking
Surveillance- use as appropriate, falls risk alert cards/ symbols, consider
volunteer sitter program , high risk patients near nursing station
Medication Management is
Multidisciplinary
• Doctors
• Nurses
Laxatives
Non medical management of dementia, delirium, insomnia
• Pharmacists- home reviews, Webster packs
• OTs- sleep hiegiene, distraction
• Social workers- compliance strategies
• Physios/ Falls specialists
Can we change medications and
reduce falls?
Is a core component of multi factorial interventions that
reduce falls in hospitals (Cochrane 2012- RRa0.69, RR0.71)
Haumschild M et al Am J Health Sys Pharm 2003
• Small hospital study of medication review
• RR falls 0.53 (0.3- 0.95)
Nursing Homes
Zermansky Age and Ageing 2006
• Pharmacist review of medications with
recommended medications changes
• Reduced falls (Controls 1.3 falls, Cases 0.8 falls)
What is the Evidence?
-Community
Campbell et al JAGS 1999
• 2 x 2 RCT of psychotropic medication withdrawal and
home based exercise program
• 66% reduction in falls in medication withdrawal group
• BUT at 1 month post study- 47 % had restarted them
Methods to Improve Compliance
• Form alliance with patient
• Negotiate the goals
• Help patients find their own solutions
Discharge from Hospital • Beware discharging on new sleeping tablets
Hospital audit (general medical ward):
38% benzodiazepines (>1/2 were new prescriptions)
• Pifalls:
-patients may still have resolving delirium (decreased capacity
to understand instructions) and are deconditioned
-marrying new provided meds with cupboard of old medications
at home
-Brand names Vs generic names
• Strategies:
-written and verbal effective communication
-Webster pack
-Once daily dosing if possible
A Typical Falls Clinic Case:
• 82 yo lady, lives with husband, help with cleaning and meals
• Poor mobility for years.
• Falls for last 3 years ? Onset related to starting antidepressant
4 falls in last month
Trips or LOB, indoors, often at night
Sometimes trips over shower hob
Some postural dizziness (no LOC)
Gluteal muscle rupture with recent fall
Further History
• Short term memory and concentration have declined over the last few years, but especially in the last 6 months. Disorientated to time.
• 4 kg weight loss, poor appetite
• Husband now feels that he cannot leave her at home alone.
• Urinary incontinence on standing. Nocturia x 2
• Uses trifocals
Past Medical History
• Osteoarthritis
-Back- spinal fusion 1998, lumbar laminectory 2008
-hands and feet
• IHD- stents 2009, CCF
• Depression- commenced on treatment past 3- 4 years
• Asthma
Medications
Aspirin
Clopidogrel
Carvedilol 3.25 bd
Fosinopril/ hydrochlorthiazide 20/12.5 mg
Spironolactone 25mg mane
Nortriptyline 50mg nocte
Dothiepin 150 mg nocte
Oxazepam
Oestrone 0.625 mg nocte
Atorvastatin
Meloxicam 15 mg nocte
Examination
• Lethargic and slow
• BP 90/40 lying, 70/40 standing
• Gait: very unsteady with tendancy to fall backwards.
• Too dizzy on standing to complete a TUG.
• MMSE 23/30
Investigations
• CT cerebral atrophy, small vessel ischaemic changes
• Sodium low (120)
• Vitamin D very low (13)
Risk Factors for Falls?
• Postural hypotension secondary to medications (fosinopril/hydrochlorthiazide, spironolactone, carvedilol, dothiepin, nortriplyline)
• Polypharmacy
• Centrally acting medications- oxazepam, dothiepin, nortriptyline
• Poor cognition- secondary to medications and hyponatremia +/- underlying emerging dementia
• Poor gait, exacerbated by gluteal rupture causing Trendelenberg pattern
• Vitamin D deficiency
• Urinary incontinence
• Environmental
Management?
• Medical
Reduced fosinopril 20/ Hydrochlothiazide 12.5 to
fosinopril 10 mg
Wean oxazepam
Stop meloxicam, start panadol osteo
Loaded with vitamin D
In liaison with psychiatrist and GP, both
antidepressants were slowly withdrawn
• Physiotherapy
Gait aids- single elbow crutch inside, 4WW outside
Upon resolution of postural hypotension to start hydrotherapy
based strength and balance program
Avoid trifocals when walking
• Occupational therapy
Remove shower hob
Bedside commode
Grabrail along route to ensuite
Offered HACC services but couple refused
Follow up
• “Today Mrs M looked like a completely different person”
• No falls, continues to use 4WW, no postural dizziness
• Mood and cognition significantly improved
• Urinary incontinence resolved although continues to have nocturia
• Couple planning a holiday
Case 2
53 year old, lives with her husband
Referred to clinic- 12 falls in 12 months
-Declining mobility over last 5 years, due to shortness of
breath and declining balance more recently. Now has
very unsteady gait using 4 wheel walker. Veers to side.
-falls inside, getting out of bed or overbalancing
-no dizziness or blackouts, quick recovery
-sustained fractured rib
Medical history:
-Severe asthma- regular admissions and use of
prednisolone
-Osteoporosis- vertebral (vertebroplasty) and rib fractures
-Chronic back pain- Medications initiated by a Pain Clinic
-Depression
Medications
Paracetamol
Calcium 1200mg/d
Vitamin D 1000iu/d
Diazepam 5mg bd
Montelukast 10 mg/d
Omeprazole 20 mg bd
Targine 40/20mg bd
Pregabalin 150 mg bd
Quetiapine 100 mg mane, 200mg nocte
Tramadol 200mg SR bd
Ventolin/ tiotropium/ seretide inhalers
Falls Risk Factors
• Cognition: Declining memory in last 12 months. Disorientated, doesn’t read or pursue hobbies. Can be drowsy, vague and have slurred speech. Stopped driving 6 months ago. Sleeps a lot.
• Continence: nocturia x 2
• Feet/ Footwear good
• Vision good
• Alcohol little
Further Multidisciplinary Assessment
• No postural drop in BP
• MMSE 21/30, Clock drawing impaired, ACE-R 77/100
• Timed Up and Go 45 secs
• Gait: slow, shuffled, reduced foot clearance, trunkal
sway
• Rhombergs test positive
• Proximal leg weakness
What do you think?
• Contributors to Falls Risk
Medications- tramadol, targine, quetiapine, diazepam,
pregabalin
Proximal weakness- deconditioning and prednisalone
Crush fractures spine, chronic back pain
• Osteoporosis
Increased risk of fracture when she falls
Due to prednisolone use
Not on adequate treatment at present
Plan
• Slowly reduce medications- tramadol, quetiapine, targine. Liaise with GP and pharmacist
• Osteoporosis: dental review then denosumab
• Refer to SCGH pain clinic for consideration of the SCAMP Program
• Falls specialist physio:
Attend SCGH for pool based strength and balance program
Teach patient and husband how to get up off floor
• OT: pressure care cushion
Follow up • Medications now
pregabalin 25 mane, 50 nocte
Targin 20/10mg bd
Quetiapine 12.5mg nocte
Tramadol and diazepam ceased
• No further falls!
• Improved proximal strength, improved sit to stand
• No walking aids, driving, doing housework
• Husband and patient delighted
Case- Mrs KC
95 year old, living alone, supportive daughter,
frail ++
Seeing Falls Specialist at home for falls and poor
mobility
Referred in for urgent medical assessment for
subacute decline- fatigue, worsening mobility,
poor appetite & wt loss, incontinence
Functional outcomes confirm deteriorating Timed
Up and Go s 28- 51 secs
PMH -Polymyalgia Rheumatica- quiescent
-OA- TKRs
-Urge urinary incontinence- KEMH
-Macular degeneration
-TIA and ? Seizure x 1 10 years ago
Medications
prednisolone 5 mg
solifenacin 5 mg
vitamin D 2 tabs
phenytoin 200mg
thyroxine 125 mcg
nexium 20mg
perindopril plus 5/125mg
actonel
• Examination
BP 130 systolic lying- 80 mmHg standing, dizzy ++
Hypovolaemic
• Investigations
B12 120 (Low)
Vitamin D 117
ESR and CRP normal
TSH 0.22 (low)
Sodium 124 (Low)
Management
-stop vesicare, phenytion, perindopril plus
-load with B12
-reduce thyroxine
-stop actonel, continue with calcium & vit D
-wean prednisolone
Review at 4 months
• No further falls
• Mobility improving with Falls Specialist- TUG improved
54- 23 secs
• No return of PMR symptoms
• Sodium normalised
Take Home Messages
• Try non medical management of insomnia, agitation and
delirium first
• Minimise the use of sleeping tablets and other sedatives
• Measure patients lying and standing BPs if falling or on
any BP lowering meds
• Recognition that patients on centrally acting meds or with
polypharmacy are at risk of falling