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I’ve Fallen, and I Can’t Get Up: Screening, Prevention, and the Impact of Medications

      Falls are a serious problem that could quickly move an older adult from an assisted living community into a skilled nursing facility. Prevention of falls that contribute to disability in older adults is a high priority for maintaining their independence and quality of life. Ensuring the highest level of functionality for older adults is an important element in preventing disability for as long as possible (Int J Gen Med 2012;5:805–813).
      Multiple studies have identified factors that increase the risk for falls in older adults, and medications are associated with this increased risk due to causes including sedation, drops in blood pressure, drug interactions, and polypharmacy. Adverse drug events (ADEs) are a common cause of patient harm, and they have been the focus of national patient safety initiatives, including in the Patient Protection and Affordable Care Act of 2010.
      ADE prevention within hospitals and during care transitions from inpatient to outpatient settings has been in the spotlight for over a decade now. Strategies including periodic review by a pharmacist have been adopted to assist in preventing falls in older persons who reside at home in the community, in assisted living, and in long-term care facilities.

      Perform Medication Reviews

      Federal requirements exist for medication review in skilled nursing facilities that participate in programs funded by the Centers for Medicare & Medicaid Services — specifically a monthly medication regimen review by a licensed pharmacist. The standards for Medicare Part D beneficiaries, regardless of where they reside, include the opportunity for an annual comprehensive medication review by a pharmacist. And, although not required, best practices for assisted living communities include a periodic review of medications performed by a pharmacist. The standards and requirements also differ by state.
      Federally funded Medicare Advantage Plans and other third-party insurance programs adhere to quality measures that include medication reviews by a nurse or pharmacist. These measures include ratings related to the use of medications that appear on the National Committee for Quality Assurance’s Healthcare Effectiveness Data and Information Set drug list as high-risk medications (“Medication Management in the Elderly,” Dec. 28, 2020; https://bit.ly/3yWXteJ).

      Screen, Assess/Prevent, Intervene: Tools and Strategies

      The Centers for Disease Control & Prevention has a program for fall prevention in older adults called STEADI — Stopping Elderly Accidents, Deaths & Injuries (https://www.cdc.gov/steadi/). This program has an algorithm with three core elements to reduce fall risk: screen, prevent/assess, and intervene.
      1. Screen. Individuals should be screened for fall risk annually or if they have experienced a fall. For example, the CDC offers Stay Independent (https://bit.ly/36DYTyO), a 12-question screening tool:
      • If the score is ≥ 4, the person is at risk.
      • If the score is < 4 and the person has experienced a fall in the past 365 days, the person is at risk.
      • If the answer is “yes” to any of these three questions, the person is at risk:
        • Do you feel unsteady when walking or standing?
        • Do you worry about falling?
        • Have you fallen in the past year?
      2A. Prevent. If the screening tool determines that the person is not at risk, effective strategies can be recommended to prevent future risk:
      • Educate the person, family, and caregivers on fall prevention strategies to implement.
      • Recommend a daily vitamin D supplement if person has a vitamin D deficiency.
      • Refer the person to a fall prevention and/or exercise program.
      • Reevaluate annually or if the person reports a fall.
      2 B. Assess. If the person has been screened and is at risk for falling, the patient’s modifiable risk factors and fall history should be assessed.
      • Evaluate gait, strength, and balance. Refer to a physical or occupational therapist for screening and a treatment, exercise, strength improvement program.
      • Identify medications that increase fall risk. See the Beers Criteria discussion for more on these drugs.
      • Have a consultant or other qualified pharmacist perform a comprehensive medication review. Certified geriatric consultant pharmacists or certified Medication Therapy Management (MTM) pharmacists are highly trained and are experts on reviewing medications and offering practical medication regimen adjustment solutions.
      • Ask about potential hazards. For instance, are there throw rugs, a slippery tub floor, rooms cluttered with furniture, or halls or passageways with poor lighting? How far and navigable is the distance to get from the bed to the bathroom, especially at night?
      • Measure orthostatic blood pressure (standing up and lying down positions). The CDC offers recommendations to perform this evaluation (“Assessment: Measuring Orthostatic Blood Pressure,” 2017; https://bit.ly/3xTus3P).
        • Instruct the person to lie down; after five minutes, measure the blood pressure and heart rate.
        • Next, have the person stand up; after one minute, repeat the blood pressure and pulse rate measurements; after three minutes, repeat the measurements.
        • A drop in systolic blood pressure of ≥20 mm Hg, or a drop in diastolic blood pressure of ≥10 mm Hg, or feeling lightheaded or dizzy are considered orthostatic hypotension.
        • Check visual acuity by using the Snellen eye test or other tool.
        • Evaluate vitamin D intake.
        • Assess feet and footwear.
        • Identify comorbidities such as depression and osteoporosis.
      3. Intervene. Interventions using effective strategies can reduce the person’s identified risk factors for falls. This can be accomplished by discussing the health goals of both the person and provider, and developing an individualized care plan.

      Consult the Beers Criteria

      The Beers Criteria for Potentially Inappropriate Medications in the Elderly is maintained by the American Geriatrics Society, with the medications assessed with high confidence by an expert panel (Pharmacy Today, Nov. 2019, 42-54; https://bit.ly/2UOhJAI). The Beers Criteria note which medications may increase the risk of falls in older adults and should be avoided or be used with caution to reduce the potential for falls in older patients and in patients with a history of falls or fractures. These drugs include:
      • Antidepressants, including tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs)
      • Some anticonvulsants
      • Antipsychotics
      • Benzodiazepines (short, intermediate, and long-acting)
      • Nonbenzodiazepine, benzodiazepine receptor agonist hypnotics (z drugs)
      • Dextromethorphan/quinidine
      • Opioids
      If an older adult is prescribed one of these medications, it is recommended that the therapy be changed to a safer alternative. Medications on the Beers list are not absolutely contraindicated, but the risk of experiencing an ADE has been demonstrated to outweigh the benefit in many cases. Prescribers should evaluate the risks and benefits of all medications for older adults and individualize decisions to reduce the risks of fall and injury and preserve the individual’s independence and ambulatory status whenever possible.

      Join the New Initiative

      Polypharmacy, described as the use of nine or more medications, is an identified risk factor for ADEs, including an increased risk of falls. In May 2021, AMDA – The Society for Post-Acute and Long-Term Care Medicine rolled out a new initiative to achieve a reduction in the number of medications prescribed and optimize medication prescribing. For more information on this exciting program, initiated by the Society in collaboration with the American Society of Consultant Pharmacists, visit the Society’s website (“AMDA Introduces National ‘Drive to Deprescribe’ Initiative,” May 19, 2021; https://bit.ly/36BtUmV).
      Falls are the leading cause of injury among older adults and can result in increased medical treatment, health care costs, and long-term rehabilitation, with negative social consequences (Ther Adv Drug Saf 2013;4:147–154). Because medications are a modifiable risk factor, a systematic review of the medications used by older adults is a best practice and should be incorporated into a fall prevention program in an assisted living environment.

      Collaborate With Colleagues

      As the medical director or key medical provider in your facility, you can advocate by sharing resources with administrators and family members, and continue the conversation about risk reduction programs at your site. You also may not be the only prescriber for your assisted living or community age-in-place patients.
      Multiple organizations have published reference materials on how to help prevent falls in older adults. These programs are designed to be implemented with community-based, age-in-place populations and assisted living residents (Innov Aging 2018;2[Suppl 1]:766; U.S. Preventive Services Task Force, Final Recommendation Statement: “Falls Prevention in Community-Dwelling Older Adults: Interventions,” Apr. 17, 2018; https://bit.ly/3wGQk0O).
      The National Council on Aging (NCOA) provides resources and opportunity for discussion with the professional colleagues responsible for provision of care and fall reduction programs. One example, which can be used as a resource for education with patients and residents, is the NCOA’s Evidence-Based Falls Prevention programs (Jan. 1, 2021; https://bit.ly/3xGDG38).

      Collaborate With Residents

      Discussions with residents and their families about medications and safety must include obtaining accurate information from them. The NCOA has suggestions for having dialogue with residents and their family members (“Falls Prevention for Caregivers: 6 Falls Prevention Steps to Help Your Older Loved Ones,” May 22, 2015; https://bit.ly/36z9ECq).
      If the residents are having a hard time keeping track of medicines or are experiencing side effects, encourage them to discuss their concerns with you or another member of the health care team, such as the pharmacist or nurse. Suggest that they have their medications reviewed each time they get a new prescription. Provide a list or spreadsheet that can help them keep track of their medications and schedules or use a timed medication dispenser that notifies them of doses and refills.
      Also, caution residents about nonprescription medications that contain sleep aids — including painkillers with “PM” in their names. These can lead to cognition and balance issues and dizziness. If they are experiencing problems sleeping, encourage them to talk to a health care professional about safer alternatives.