Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly...

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Medication Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient Safety Center Assistant Professor, Department of Internal Medicine,USF COM, Tampa, FL

Transcript of Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly...

Page 1: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

Medication Management to Reduce Fall Risk in the Elderly

Tatjana Bulat,MDMedical Director, Patient Mobility Clinical

Services,VISN 8 Patient Safety CenterAssistant Professor, Department of Internal

Medicine,USF COM, Tampa, FL

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Definition

! A sudden unintentional change in position causing one to land on a lower level not due to an overwhelming external force

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FALLS

! Mortality-unintentional injury-sixth leading cause of death in elderly

! Morbidity-10-15% serious injury! Fractures-hip fracture 20% mortality/yr! Soft tissue injuries, subdural hematomas,

accidental hypothermia ! Loss of confidence-fear of falling (up to 50%)! Contributing factor in up to 40% of NH

admissions! 20 billion in direct health care costs annually

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Prevalence in elderly

! Community living 325/1000/yr! Hospital 1,500/1000/yr! Long-term care 1650/1000/yr

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Risk factors-intrinsic

! Cognitive impairment (delirium, dementia, depression)

! previous falls, fear of falling! cardiac arrhythmias, transient ischemic attacks,

stroke! Parkinson’s disease! acute and subacute medical illness! orthostatic hypotension, dehydration,

hypoglycemia

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Cont.

! Musculoskeletal conditions, problems with gait and mobility, ADL impairment

! incontinence (bowel or bladder)! Vision (both contrast sensitivity and acuity) or

auditory impairment! Sensory impairments (proprioception), vestibular

dysfunction! Foot problems, ankle dorsiflexion! Normal aging-increased postural instability and

increased sway

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Extrinsic

! Use of restraints- deconditioning, pressure ulcers, functional incontinence, aspiration pneumonia, DVTs, increased agitation, etc.

! decrease number of falls but risk of serious injury the same

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Extrinsic risk factors, cont.

! Environmental factors-dim lighting, glare, inappropriate footwear, uneven flooring, loose carpet, wet, slippery floor, old and unstable furniture, etc.

! Polypharmacy vs. Polymedicine- more then 4 meds

! Certain classes: benzodiazepines, diuretics,psychotropics

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Medications and falls

! What is the mechanism and how strong is the association?

! RCT’s/Case series: Adjustments of meds and falls risk- overall benefit

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Adverse medication effects

! POSTURAL HYPOTENSION-decrease in systolic BP >20mmHg 1 min after standing

! Tricyclic antidepressants! Antypsychotics! L-dopa! Antihypertensives! Diuretics! Nitrates

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Orthostatic hypotension

! Altered systems in frail/elderly:! decreased arterial compliance ! blunted response of volume/BP regulation (lower

renin, angiotensin, aldosterone)! Decr B receptor response! Decr sympathetic response (less tachy with

dehydration)! Can reduce OH by 50% with med adjustment

(Fotherby M, Postgraduate Med J 70:878-81,1994)

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Cont.

! DRUG-INDUCED PARKINSOMISM-increased muscle tone, rigidity, resting tremor, impaired postural responses to change in position

! Antipsychotics! Metoclopramide! Reserpine

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Cont.

! ATAXIA-toxic effect on cerebellum, vestibulosensory, or proprioceptive control systems-increased body sway, loss of balance

! PSYCHOMOTOR SLOWING-difficult to measure clinically; lack of attention or a distraction from gait and balance problems, effect on judgment and reflexes

! Benzodiazepines! Anticonvulsants-phenytoin, carbamazepine,

phenobarbital

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Cont.

! MYOPATHIES-muscle wasting, weakness! Long-term steroid use! HMG CoA reductase inhibitors! -increased osteoblast activity, use of statins

in either prior 180 days (OR 0.50) or prior 3 yrs (0.57) decreased risk of hip fracture in elderly over 65 (did not measure BMI)

Wang P.S. et al. HMG-CoA Reductase inhibitors and the risk of hip fracture in elderly patients.JAMA,283(24),3211-3216, 2002.

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Cont.

! PERIPHERAL NEUROPATHIES-gait dysfunction

! Amiodarone! Hydralazine! Phenytoin

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Medication review in falls risk

! On admission, Change in condition, Post fall! Systematic review of all high risk med’s! Review indication and efficacy, potential ADE-

evaluate potential to an individual’s fall risk; what is target Sx, is it working?

! Discontinue, change to alternative or no change! Document decision in chart

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BENZODIAZEPINES

! Mechanism of association-sedation, “hangover effects”, dizziness, impaired balance, decreased neuromuscular function, decreased central processing/alertness, cognitive impairment, delirium

! 7-15% of community living elderly are prescribed a benzodiazepine

! 15.6% of nursing facility residents (CMS Oscar data, 2001)

! Increased risk of falls and hip fracture

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Cont.

! All benzodiazepines- 1.48 OR! Long-acting benzos-1.32 OR (diazepam,

clonazepam,chlordiazepoxide, flurazepam)! Intermediate-acting benzos- (lorazepam,

temazepam, oxazepam), Short-acting benzos-1.44 OR (triazolam, alprazolam) (Leipzig, RM et al.JAGS 47:30-39, 1999.)

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Overview of research

! Risk of fall-related fracture related to dose (too high), not elimination half life (Herings et al.,1995)

! Pharmacodynamics-lower doses and lower plasma concentrations needed to achieve sedation

! Balance/Peripheral neuromuscular dysfunction(increased EMG muscle latency)-motor coordination impaired at baseline, deteriorates to a critical level after drug administration

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Benzodiazepines, cont.

! Short-acting benzodiazepines associated with higher risk of nocturnal falls in NH residents (Ray et al.,2000) but less then with longer acting agents

! Metabolism-Hepatic biotransformation-oxidation (alprazolam, diazepam) vs. conjugation (lorazepam, oxazepam)

! Nonoxidative benzodiazepines do not carry a lower risk of fall-related fracture than oxidativebenzodiazepines (Sgadari et al.,2000) except for the oldest old at high doses

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Cont.

! Risk of fall related fracture highest within 15 days of new prescription; risk decreases with increase in time from fill date (Neuta et al., 1996)

! Risk of fall highest within 7 days of new prescription in nursing home residents and remain elevated after 30 days from fill date (Ray et al., 2000.)

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SEDATIVE-HYPNOTIC USE

! 4.8% of nursing home residents are prescribed a sedative-hypnotic (CMS OSCAR data, 2001)

! What does the research tell us?! 1.54 OR (Leipzig, RM et al. JAGS 47:30-39,1999)

! Sleep hygiene! Fall risk - Newer agents not safer (zolpidem)

Wang PS and el. Zolpidem use and hip fractures in older people. JAGS 49:1685-1690, 2001.

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ANTIDEPRESSANTS

! Mechanism of association-orthostatic hypotension, dizziness, sedation, blurred vision, decreased central processing /alertness

! Effect of antidepressants on obstructed vs. unobstracted gait in healthy seniors; RDBPC crossover study-amytriptyline, paroxetine,desipramine, placebo in random order; unobstucted & with obstacle (6cm dowel) timed 9.5m; little effect on unobstructed gait but slowing with obstacle (Draganich J.,2001)

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Cont.

! 8% of community-living elderly are prescribed an antidepressant (Ray, Griffin, 1990) and 35.5% NH residents (CMS OSCAR data, 2001)

! OR 1.66-any antidepressant (Leipzig et al, 1999)! Higher doses associated with higher fall rates! Little difference in fall rates between TCAs and

SSRIs ; RR 2.0 (1.8-2.2) for TCA, 1.8 (1.6-2.0) for SSRI, 1.2 (1.0-1.4) for trazodone; RR incr with dose, persisted beyond 180 days of Rx (Thapa et al., 1998)

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ANTIPSYCHOTICS

! Mechanism of association-sedation, dizziness, orthostatic hypotension, blurred vision, decreased central processing/alertness, confusion, EPS

! OR 1.51-typical (Leipzig et al, 1999)! Typical (haloperidol, fluphenazine,thioridazine)

vs. atypical antipsychotics (risperidone, olanzapine, quetiapine)-less anticholinergic, less EPS, less TD

! abstract (olanzapine vs.risperidone)-retrospective; falls 17.8% vs. 6.9% (Martin et al., 2001)

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ANTIPSYCHOTICS

! Typical antipsychotics (haloperidol, etc.)-poorly tolerated in PD, CVA, Lewy body dementia

! Atypicals: risperidone often exacerbates PD, quetiapine better choice

! Clozapine improves PD! ECT often effective for mood and

psychotic symptoms

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ANTIPSYCHOTICS

! Improvement of psychosis vs. worsening of motor function in schizophrenia (Factor, 1999)

! Risperidone 77% vs. worse 28%! Olanzepine 70% vs. worse 46%! Quetiapine 83%, worse 17%

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ANALGESICS

! Mechanism of association-dizziness, sedation, decreased central processing/alertness, impaired judgment, decreased neuromuscular function

! Narcotics-propoxyphene, meperidine! Narcotics 0.97 OR (Leipzig, 1999)

! Non-narcotic analgesics- OR 1.09 ! NSAIDs-1.16 OR (? confounding by indication)

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Chronic pain adjuvants

! Gabapentin vs. amitryptiline for diabetic neuropathy- mean age 60, n=25, DB crossover –gabapentin had sig’ly more dizziness (28% vs. 8%) and trend (NS) more sedation (48vs32), ataxia (20vs.8) and OH (24vs20) Morello CM, 1999

! Nortryptiline or desipramine

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ANTIHYPERTENSIVES

! Centrally acting-clonidine, methyldopa,alphablockers-OR 1.16; mechanism of action-hypotension, sedation, decreased alertness

! Beta blockers-postural hypotension, sedation! Diuretics-OR 1.08-volume depletion, electrolyte

imbalance, urgency to rush to toilet, direct vestibular toxicity (high dose loop diuretics)

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OTHER CARDIAC MEDICATIONS

! Digoxin-1.22 OR! Type 1a antiarrhythmics-1.59 OR

(quinidine, procainamide,disopyramide)! Calcium channel blockers-0.94 OR! ACE inhibitors-1.20 OR! Nitrates 1.13 OR

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ANTIHYPERTENSIVES

! Measure BP as close to fall incident as possible! If significant OH, stop diuretic, remove Na

restriction in diet, review timing! If ACE inhibitor preferred, and OH/sx’s-after d/c

diuretic, less renal metabolized-fosinopril (OH enalapril 6.7%, lisinopril up to 5%, fosinopril <1% (renal excretion 93% enalapril, >95% captopril, 50% fosinopril )(Facts and Comparisons, 1987)

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Anticoagulation with falls risk (Man-Son-Hing M,1999)

! Risk of embolic CVA with a.fib. 5%>65, incr’d>75, CHF,HTN, Hx CVA (8%)

! Reduced risk of CVA: warfarin 68%, ASA 21%! Risk of falling >65: 33%/yr! Subdural hematomas are rare! Persons taking warfarin must fall 295 times in 1 yr

for warfarin not to be the optimal therapy (risk of SDH outweights the benefit)

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Anticoagulation with falls risk

! Did not account for adverse outcomes other then SDH (increased morbidity or mortality with injury)

! Risk of bleeding increased if ETOH use, NSAID’s, GI bleed, noncompliance with med or lab monitoring

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OTHER MEDICATIONS

! Antihistamines-sedation, blurred vision, confusion, acute urinary retention with overflow incontinence, orthostasis- OTC but not necessarily safe

! H2 antagonists (cimetidine)-confusion, ataxia

! Sulfonylureas-dizziness, sedation

Page 36: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

Clinical practice algorithm: Consensus based medication

management to reduce fall risk in the elderly

Bulat T., Castle S.C., Marasco R., Fiuzat M. ; in review

Page 37: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury in the Elderly at Risk for Falls

1. Patient entry toFall Clinic

7. Indications(see worksheet)

11." Recommend

DC/Modify orReduce Rx

" Notify PCC

10. No

8. Yes

4. Yes

6. No

2. Patient Medication Assessment:Prescription for: Benzodiazepines,

Cardiovascular agents, Antidepressants,Antipsychotics, Anticholinergics/Bladderrelaxant, Anticonvulsants, Anticoagulants

3. Presentation ofUrgent/Emergent

Medication Side Effects/Symptoms?

SUMMARY ALGORITHM

5

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5." Notify PCC

Immediately" Send to ER

if needed

9. For EACH class of medications, assess:Prescribing Patterns:

" Type/Class" Dose/Frequency" Combinations" Duration" Compliance

Refer to Specific Algorithm for Main Classesof Medications.

12a.Benzo-diaze-pines

12b.Cardio-vascularagents

12d.Anti-

coagu-lants

12c.Anti-

depres-sants

12e. Bladderrelaxant/ACH

Receptorantagonist

12f.Anticonvul-sant for pain

control

12g. Anti-psychotic

y p

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13a. Correctprescribing

patterns

23a." Recommend

taper to off." Educate patient

about theincreased risk offalling/hipfracture with anybenzodiazepineuse.

15a. Insomnia20a. Generalizedanxiety disorder/

depression

16a." Do not use longer than 2 weeks.

Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury in the Elderly at Risk for Falls

22a. No14a. Yes

19a. Yes

12a. Benzodiazepines(Odds Ratio 1.48)1

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benzodiazepineuse.16a.

" Do not use longer than 2 weeks." Emphasize sleep hygiene measures

(eliminate naps, daily exercise, nocaffeinated beverages in afternoon, usebed only for sleep, etc.).

" Treat underlying medical problemsdisrupting sleep (like pain, shortness ofbreath, symptomatic BPH, etc.).

" Environmental modifications (room toocold/hot, noise control, etc.).

" Evaluate for prescription/over the countermedications contributing to insomnia(sympathomimetics, diuretics, etc.).

21a." Consider conversion to

buspirone.6

" Maximize theantidepressant dose.

" Educate patient about theincreased risk of falling/hip fracture with anybenzodiazepine use.

" Consider referral topsychiatry

17a." Evaluate dose/frequency (for elders onlong-acting benzodiazepines, consider switchto short-acting or alternatives--still increasedrisk for falls/hip fracture).2

18a." Encourage to taper off" Educate patient about the risk of falling/hip fracture with any benzodiazepine use." Refer to sleep lab if suspicion of sleepapnea or restless leg syndrome

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13b. CorrectPrescribing

Patterns

27b." Refer to clinical

guidelines for CHF,HTN, CAD4

17b. No or Mildsymptoms from

orthostasis

20b." Stop diuretic first" Decrease salt restriction" Consider splitting the dose or changingadministration times" Decrease if not tolerated or patient atrisk for injury

Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury in the Elderly at Risk for Falls

19b. Yes

26b. No14b. Yes

12b. Cardiovascular Agents(Odds Ratios: Diuretics 1.08; Centrally acting

antihypertensives 1.16; ACE inhibitors 1.20; Nitrates1.13; Type Ia antiarrhytmics 1.59; Digoxin 1.22)3

15b. Severesymptoms due to

orthostasis

16b. No

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18b." Patient Education" Behavioral Adjustments (change

position slowly, sit at the edge ofthe bed for a few minutes, etc.)

" Eliminate centrally-acting agents,use tamsulosin if needed for BPHsymptons

" Reserve use of hydralazine andnitrates for CHF patients that failedACE-I/ARB, loop diuretics for CHF/CRI patients

" Use thiazides for ISH patients thatcannot be controlled on otherpreferred agents

" For BP alone use ACE-I, B-blockersor Ca channel blockers preferably

" Elastic stockings

23b.Ensurepatientunderstandsand agreeswith plan ofcare

22b. Yes

21b. BP goal:

Normal 140/90 DM < 130/85 CRI < 125/75

25b.EDUCATION: * Recommend Home BP kit; *Data sheets for recording; * Teach how to doorthostatics, especially when dizzy; * Considergiving written instruction on med adjustment ifcertain readings (like adjusting blood sugars)

24b. No

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13c. Correctprescribing for indication

(depression, chronic pain,PTSD, OCD)

22c.Recommend to d/c,educate patient aboutincreased risk of falls/injury

15c." Use SSRIs as first line therapy(although fall risk is increased, they arebetter tolerated than tricyclics or MAOinhibitors)10

" If failed SSRIs, use nortryptilinepreferably to amitryptiline (lessanticholinergic)5

Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls

14c. Yes21c. No

16c.

12c. Antidepressants(Odds Ratio 1.66)1

f

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ly to amitryptiline (lessinergic)5

18c." Continue, or consider

decrease to maintenancedose

" Educate patient aboutincreased risk of falls

16c.Determine if dose is

effective (e.g. use shortform GDS, 1-10 pain

scale, etc.)

20c." Refer back to PCC

for dose increase andfollow-up

" Educate patientabout increased riskof falls

17c. Yes

19c. No

, ypb

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13d. Correctprescribing for

indication

24d.# Recommend

discontinue# Notify PCC

Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls

14d. Yes

23d. No

12d. Anticoagulants

20d. Yes

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15d.Any high risk condition:# concomitant NSAID use# history of GI bleed# use of ETHOH# non-adherence to

prescribed regimen# greater than weekly falls.8

22d.Continue anticoagulation

21d. No

17d.Patient Education:Refer to anticoagclinic if available

16d. Yes

19d.Considerthe ongoingrisk/benefitanalysis ofcontinuedtherapy

18d. Yes

20d. Yes

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13e. Correctprescribing

30e.Recommend todiscontinue, educatepatient about increasedrisk of falls/injury

17e.# Consider GU referral

Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls

14e. Yes 29e. No

12e. Bladder RelaxantACH Receptor Antagonist

15e. Hi postvoid residual

Low flowrate (men)

16e. Yes

20e.Acceptable

Control

19e. No or PVR datanot available

21e Yes

28e.# Recommend

decrease# Monitor urgency# Falls/Gait &

Balance# Scheduled

toileting

27e. No

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17e.# Consider GU referral# Consider decreasing

dose or discontinuing# Monitor urgency# Falls/Gait & Balance

24e.# Consider decreasing

dose or trial oftolterodine9

# Examine CV drugs forneed and timing ofdoses--especiallydiuretics

22e. Signs/Symptons of

orthostasis, dry mouth, poorcompliance or CHS/

Psychomotorslowing dec.

attention

26e.# Educate patient

about increasedrisk for falls

# Refer to PCC forfollow up

23e. Yes

25e. No

18e.Refer toPCC forfollow up

21e. Yes

# Scheduledtoileting

Balance

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13f. Correctprescribing

26f.# Recommend change# Refer to PCC/Pain

clinic

Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls

14f. Yes

25f. No

12f. Anticonvulsantfor pain control

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17f.# Consider decreasing dose# Consider topical capsaicin# Recommend non-

pharmacological adjuvanttreatment (exercise,modalities) in addition tomeds

22f.# Consider decreasing

dose# Examine CV agents--

especially diuretics# Eliminate and/or

decrease dose basedon symptom control

15f. CNSSide Effects

16f. Yes

18f.Refer to PCC forfollow up

20f. Signs/Symptoms ofOrthostasis

19f. No

21f. Yes

24f.# Educate pt about

increased risk forfalls

# Refer to PCC/Pain clinic forfollow up

23f. No

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13g. Correctprescribing

30g.# Recommend change# Refer to PCC/Psych

17g.# Consider decreasing

dose# Consider atypical

agent11

# Examine CV agents-especially diuretics

Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls

29g. No

12g. Antipsychotic(Odds Ratio 1.51)1

15g.Signs/Sx

Orthostasis16g. Yes

14f. Yes

19g. No

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agent11

# Examine CV agents-especially diuretics

22g.# Consider decreasing

dose or change to(another) atypical agent

18g.# Refer to PCC/

Psych for followup

Orthostasis

20g. Signs/SymptomsCNS/Psychometric slowing,

decreased attention21g. Yes

24g. EPSParkinsonian

stiffness

23g. No

26g.# Consider decreasing dose11

# Consider change to (another)atypical agent11

# Consider non-antipsychotic# Perform risk/benefit analysis

of symptom control vs. sideeffects

28g.# Educate patient about

increased risk for falls# Refer to PCC/Psych for

follow up

25g. Yes

27g. No

Page 53: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

14. Yes

Clinical Practice Algorithm: Consensus-Based MedicationManagement to Reduce Fall Risk and Injury Among the Elderly at Risk for Falls

13. Risk Factors forOsteoporosis

21. No

22. Refer toPCC for AnnualAssessments

SUMMARY ALGORITHM(Continued)

Page 54: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

15. Bone densitometry (DEXA)

18. Treat osteopenia, osteoporosis(e.g. alendronate, risedronate,raloxifene; calcitonin ifcontraindicated; estrogens withunknown effectiveness)7

# Start calcium/vitamin Dsupplementation

# Hip protectors (if falling)

14. Yes

20. Consider calcium/vitamin Dsupplementation

16.Osteopenia orOsteoporosis17. Yes

19. No

Page 55: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

Upper Gastrointestinal Complications

Preferable•Raloxifene –SERM

•Calcitonin

Caution•Bisphosphonates(alendronate, risedronate)

! Bisphosphonates may be irritating to upper GI mucosa

Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition

Page 56: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

Nasal/Sinus Complications

Preferable•Bisphosphonates

•Raloxifene

Caution•Calcitonin

! Potential for increased nasal irritation

Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition

Page 57: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

NSAID Usage

Preferable•Calcitonin

•Raloxifene

Caution•Bisphosphonates

! Bisphosphonates should be used with extreme caution due to the potential for increased GI irritation

Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition

Page 58: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

GI Motility Complications

Preferable•Calcitonin

•Raloxifene

Caution•Bisphosphonates

! Bisphosphonates may precipitate esophageal erosions

Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition

Page 59: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

Renal Dysfunction

Preferable•Calcitonin

•Raloxifene

Caution•Bisphosphonates

!Bisphosphonates are contraindicated when creatinine clearance is less than 30-35 cc/min

Adapted from the Omnicare Geriatric Pharmaceutical Care Guidelines, 2001 edition

Page 60: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

Hip protectors

Page 61: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

Hip protectors

! Designed to absorb or re-distribute (shunt) the energy of the impact

! Hard or soft shell! Decrease hip fracture rates by 50-84% if

worn at the time of fall! Long-term adherence poor

Page 62: Medication Management to Reduce Fall Risk in the … Management to Reduce Fall Risk in the Elderly Tatjana Bulat,MD Medical Director, Patient Mobility Clinical Services,VISN 8 Patient

“No risk factor for falls is as potentially preventable or reversible as medication use”

Leipzig RM et al. JAGS, 47:30-39, 1999.


PDI Hospital Overview PATIENT DISCHARGE INSTRUCTIONS Patient Discharge Instructions can improve outcomes and reduce readmission rates by sending patient.

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Behavioral Health Support Model€¦ · o Reduce behavioral restraint episodes o Provide BH qualified support staff o Reduce staff/patient injury o Reduce BH inpatient cost o Reduce

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Convolutional aggregation of local evidence ... - Adrian Bulat · BULAT, TZIMIROPOULOS: CONVOLUTIONAL AGGREGATION OF LOCAL EVIDENCE 3 learn a cascade of regressors, applied in a progressive

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