You Up · •Increased risk of stroke- 4% Vs 2% CMAJ 2002, 2004 •Increased risk of falls •Has a...
Transcript of You Up · •Increased risk of stroke- 4% Vs 2% CMAJ 2002, 2004 •Increased risk of falls •Has a...
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