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

OUTPUTS

Gaze Stability

Postural Stability

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Balance Control

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)

• Parkinsonism- stemetil, haloperidol, respiradone

• Ataxia/ unsteadiness -phenytoin

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

Other Mechanisms

• Urinary/ Bowel urgency- frusemide, laxatives

11 June 2015 Slide 12

MEDICATION

•Polypharmacy

> 4 medications

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

Guideline Care

(AGS, BGS 2011)

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