Falls prevention and the role of the pharmacist
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This a short presentation that looks at actions and processes that pharmacists can take to help reduce medicine related falls and hospital admissions due to falls in the older patient. it also looks at addressing polypharmacy and prescribing cascades and how to simplify medicines regimes.
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Falls prevention and the role of the pharmacist
- 1. Falls Prevention and the Role of the Pharmacist Richard Harris MRPharmS 1
- 2. Introduction • The aetiology of falls is usually multifactorial • Patients on FOUR or more medicines are at greater risk of falls. • Regular medication reviews play an important part in falls prevention. • Requires a collaborative multidisciplinary and patient-centered approach • Medicines Optimisation identifies patient safety issues and help reduce falls by: for the early detection, intervention and resolution of adverse medicines performance, inappropriate prescribing and compliance issues Comprehensive evidence based clinical screening Medications reconciliation, review, monitoring & optimisation Collaborative Multidisciplinary working ADE reporting, recommendations & referral Advice, education & Level 3 engagement 2
- 3. Pharmacist Interventions Medicines Review Assessing the Risk • Screen for polypharmacy/ prescribing cascades & ADEs • Orthostatic hypotension - increased risk of injurious fall during the first 45 days antihypertensive treatment • High risk medicines such as hypnotics • Medicines adherence issues • Previous fall history • Co-existing disease-undiagnosed disease • Physical /cognitive impairment • Environmental hazards 3
- 5. Putting Theory into Practice Key Pharmacist Interventions • Prioritise: • Identify vulnerable groups • Aim: • Keep regimes as simple as possible-reduce pill burden • Modify: • Make recommendations including cessation- “is the drug still needed?” • Prevent : • Identify where supplementation is beneficial-quantify ‘as directed’ • Adherence: • Recognise issues, check patient understanding, resolve barriers, explain changes 5
- 6. Case study - Elsie 74 years old Elsie has just been discharged from hospital after a minor fall. She lives alone but a neighbour pops in each day to check she’s Ok. Elsie says her mobility and eye sight are getting worse. She takes Furosemide 40mg OM and the hospital has prescribed 28 days worth of Nitrazepam 5mg ON to help Elsie with poor sleep. She also reports feeling thirsty and is worried now about taking the ‘water tablets’. What are the risk factors? • Age • Previous falls history • Adherence concerns • Additional medication (hypnotic) prescribed • Undiagnosed disease? • Isolation How can the pharmacist support medicines optimisation? • Is the diuretic suitable? Consider recommending an alternative antihypertensive • Recommend switch to a shorter acting benzodiazepine e.g. Zopiclone - assess efficacy and consider cessation • Increased thirst may suggests the presence of undiagnosed diabetes-suggest -referral • Is Elsie managing to take her tablets OK on her own?- Ask the patient-check her medicines with her-advise on correct use consider compliance aid • Question over Elsie’s independence engage with OT/MDT/arrange care package 6
- 7. Commonly Prescribed Medicines Associated with an Increased Risk of Falls HIGH RISK DRUGS • Antipsychotics including atypicals • Anti-muscarinic drugs • Benzodiazepines & Hypnotics • ‘Older’ TCAs MODERATE RISK DRUGS • ACE inhibitors • Beta-blockers • Diuretics • Opiate analgesics LOWER RISK DRUGS: • Vasodilators: Calcium channel blockers, Nitrates • Oral anti-diabetic drugs • PPIs & H2 Antagonists (except cimetidine = High risk) 7
- 8. Summary MOVING FORWARD Better Together Accurate medicines reconciliation and communication across health sectors Safe, appropriate evidence & policy led prescribing Anticipate risk with medication assessment and review Patient engagement, collaboration & support 8
- 11. Resources CG161: Falls : Assessment and prevention of falls in older people (2014) http://guidance.nice.org.uk/CG161 Assessment of falls risk in older people (Falls Risk Assessment Tool-FRAT ) www.bhps.org.uk/falls/documents/FRATtool.pdf East Berkshire Falls & Fracture Prevention-Health Promotion in Berkshire http://bhps.org.uk/falls/ Older People: Managing Medicines: The Presentation & management of diseases commonly affecting older people : a factfile http://www.cppe.ac.uk/LearningDocuments/pdfs/Older_People.pdf http://www.cppe.ac.uk/LearningDocuments/pdfs/OlderPeople_Factfile.pdf Prevention of Falls in the Elderly (2014) www.patient.co.uk/doctor/prevention-of-falls-in-the-elderly-pro 11
Notes de l'éditeur
- Medicines optimisation is a risk assessment process who’s purpose is to ensure that the right patients get the right choice of medicine, at the right time. By focusing on patients and their experiences, the goal is to help patients to: improve their outcomes; take their medicines correctly; avoid taking unnecessary medicines; reduce wastage of medicines; and improve medicines safety. It is a multi- disciplinary approach to maximize beneficial clinical outcomes for patients from medicines with emphasis on safety, governance, professional collaboration and patient engagement and moves a step forward from medicines adherence to encourage patients to take ownership of their treatment
- Standard 6 in the National Service Framework (NSF) for the elderly is to reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen.” Falls are traumatic events and have many long lasting implications-secondary admission is common and costly. Pharmacists can play a major important role in helping prevent falls in the elderly HOW? Ensuring safe, accessible & cost effective use of medicines Identifying and resolving causes of medicines wastage-reducing NHS medicines costs by promoting adherence – reducing unplanned hospital admission & relapse-Provide clear plain written and verbal instructions tailored to suit the needs and abilities of the individual-explain reasons for changes
- The risk of having a fall or recurrent falls increases with the number of risk factors above:
- Helping care home rehabilitation staff with medicines management
- (>85) ‘inappropriate’ polypharmacy (>4 medicines) prescribing cascades, falls history, ‘High Risk’ drugs (Hypnotics Narrow TI ) Toxicity-concomitant medication e.g. SSRIs-Diuretics & co-existing disease states (Parkinson’s) Acute confusional state (signs and symptoms of toxicity eg withdrawal of benzodiazepines) Dementia/Alzheimer’s onset & undiagnosed disease e.g. type 2 diabetes and electrolyte imbalance (Hyponatraemia). Syndrome of inappropriate ADH secretion (SIADH) Causative drugs include:•Drugs: chlorpropramide, carbamazepine, selective serotonin reuptake inhibitor (SSRI) antidepressants, tricyclic antidepressants, lithium, tramadol, haloperidol, fluphenazine. Whilst at level 3 intervention or home settings we may spot other C4Cs e.g. malnutrition/low body weigh/difficulty reading labels/opening containers/reluctance/lack of motivation-depression and isolation-assess clinical response and effectiveness of anti depressant therapy. (START LOW_GO SLOW) Nanny and undiagnosed diabetes(insidious disease state-increasing prevalence with age) –if patients choose to self monitor advise what to do and the implications when the results are out of range-850g metformin may be difficult to swallow. Encouraging the participation of older people in falls prevention programmes
- Antidepressants: Avoid Tricyclic antidepressants esp. TCAs with high anti-muscarinic activity e.g. Amitriptyline. SSRIs are associated with a reduced incidence of side effects in the elderly. Antipsychotics-inc aytpicals: Risk of hypotension is dose related reduced by the ‘start low go slow approach.’ Attempted withdrawal MUST always be gradual to avoid precipitation of withdrawal symptoms e.g. rebound agitation. All anti-pyschotics are capable of inducing extra-pyramidal disorders although incidence is less with atypical. The phenothiazine Prochlorperazine (Stemetil) is frequently inappropriately prescribed for dizziness due to postural instability and the most frequently implicated drug causing drug induced Parkinson’s disease. Anti-muscarinics : Used in treatment of urinary incontinence and in Parkinson’s disease. Oxybutynin may cause acute confusional states in the elderly especially those with pre-existing cognitive impairment. ACE inhibitors :Risk of hypotension is potentiated by concomitant diuretic use. Alpha-Blockers Anti-arrhythmics :Dizziness and drowsiness are possible signs of Digoxin toxicity – risks of toxicity greater in renal impairment. Aim to reduce to the minimum effective dose (Ref BNF). Avoid long acting benzodiazepines e.g., Nitrazepam. All licensed for short-term use only. Avoid Cimetidine in polypharmacy patients – high risk of potential drug interactions.
- Co-ordinated (Joined-up) care-Quality driven Engaging commissioning services Ensure sufficient supply of release /transfer medication Formulary development –allay fears of side affects and addiction-set goals with the patient and monitor effectiveness with regular medication review-review guidance