The Health Innovation Network Polypharmacy programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications. Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely. To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Identifying Orthostatic Hypotension caused by Medication, can be viewed here. For more information about the polypharmacy programme, please visit https://thehealthinnovationnetwork.co.uk/programmes/medicines/polypharmacy/

1. Falls within the elderly frail population is a growing concern due to its link to morbidity, mortality and hospitalisation.[1,2,3] Recent Worlds Falls Guidelines
(WFG) published in 2022 set out key multifactorial assessments to help reduce risk of falls. One part of the assessment was to screen for orthostatic
hypotension (OH) routinely [4]. The WFG identified older patients who live in settings such as care homes as being at an increased risk of falls [4].
I n t r o d u c t i o n
Utilising recent Worlds Falls Guidance on falls prevention to help
minimise falls risk by identifying orthostatic hypotension caused by
medication in a care home population.
Reports ran on system one to identify patients that aligned
with the practice’s care homes.
Identified patients are reviewed in line with the medication
lasted in table 1.
Patients identified with OH or being borderline were
reviewed at the practice by the multi-disciplinary team
(MDT) consisting of GP’s, Pharmacists and Advanced Nurse
Practitioners to make changes to appropriate medication
4
Patients identified on the search had sitting and standing
blood pressure (BP) taken. A drop in BP of >20mmhg systolic
or >10mmhg diastolic upon standing was classed as OH with
a variation of +/- 2 mmhg being classed as borderline.
2
3
1
M e t h o d R e s u l t s
The aim of the project was to implement part of the WFG in patients taking medication known to cause OH in a care home setting.
A i m s
Across the two care homes a total of 64 patients were assessed, to identify anyone on
OH causing medication, such as antihypertensives, beta-blockers and diuretics[5]. A
total of 35 patients were identified as being at risk of OH (see chart 1). 25 of the 35
patients were able to provide sitting and standing BP readings. Of the 25 blood
pressure readings taken, 6 were identified as having OH or being borderline. A drop in
blood pressure of >20mmhg systolic or >10mmhg diastolic upon standing was classed
as OH with a variation of +/- 2 mmhg being classed as borderline. 5 of the 6 patients
were then flagged to the multi disciplinary team to have their medication reviewed.
The changes made to their medication included reducing doses of hypertensive
medication such as lisinopril and amlodipine. Follow up sitting and standing bp were
taken 2 months after dose changes and 4 of the 5 patients who had their medication
changed no longer had OH (see chart 2).
Screening asymptomatic patients in a care home setting for OH in
line with WFG has highlighted that asymptomatic patients were
present in a care home setting. The number of patients on OH
causing medication was more than 50% of the care home
population looked at, showing there is a need for opportunistic OH
case finding in this population. Screening patients for OH allowed
for changes to be made to medication that was potentially causing
or worsening the OH subsequently putting patients at a higher risk
of falls. This intervention has shown practices can proactively
engage with care homes to help reduce patients falls risk. With
more of an ageing population and the increase in prevalence of
multimorbidity and polypharmacy the number of falls will likely
increase[1]; further highlighting the importance of engaging with
this population to establish if OH is a concern. It is recognised only
20% of the 25 patients had interventions made via the MDT,
however it is important to remember only one part of the
multifactorial assessment recommended by the WFG was
implemented. As more of the guideline is implemented potentially
more interventions can be made further reducing falls risk and its
associated morbidity and mortality risk. The next steps would be to
roll out opportunistic findings of OH in other care homes as this
sample was small. Not all of the patients identified had medication
changes made, therefore could conduct a qualitative study to look
into what affected the MDT’s decisions.
C o n c l u s i o n & D i s c u s s i o n
Class of medicine Examples
Antihypertensive Furosemide, Spironolactone
Lisinopril, Losartan
Amlodipine and Diltiazem
Atenolol, Bisoprolol
Anti-anginal Glycerol trinitrate, Hydralazine, Isosorbide Mononitrate
Antidepressant Amitriptyline, Impramine
Anti-parkinsonian Levodopa, Dopamine agonist
Antimuscarinic Oxybutynin, Solifenacin, Tolterodine
Patients not at
risk of OH, 45%
Patients at risk
of OH, 55%
Number of patients identified as being ‘at risk’ of
OH after a medication review.
Patients who
still had OH
20%
Patients who no
longer had OH
80%
Follow up of patients after having medication
changes made
References
1. James SL, Lucchese LR, Bisignano C, Castle CD, Dingels ZV, Fox JT, et al. The global burden of falls: global, regional and national estimates of morbidity and mortality from the
Global Burden of Disease Study 2017. Injury Prevention. 2020 Jan 15;26(2):injuryprev-2019-043286.
2. World Health Organization. Falls [Internet]. World Health Organization. 2021 [cited 2023 Mar 11]. Available from: https://www.who.int/news-room/fact-sheets/detail/falls
3. Tinetti ME, Williams CS. The Effect of Falls and Fall Injuries on Functioning in Community-Dwelling Older Persons. The Journals of Gerontology Series A: Biological Sciences and
Medical Sciences. 1998 Mar 1;53A(2):M112–9.
4. Montero-Odasso M, van der Velde N, Martin FC, Petrovic M, Tan MP, Ryg J, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age and
Ageing [Internet]. 2022 Sep [cited 2023 Jan 15];51(9). Available from: https://academic.oup.com/ageing/article/51/9/afac205/6730755
5. Gibbon, J.R. and Frith, J. (2020) ‘Orthostatic hypotension: A pragmatic guide to diagnosis and treatment’, Drug and Therapeutics Bulletin, 58(11), pp. 166–171.
doi:10.1136/dtb.2020.000056.
Table 1 – Examples of OH causing medication[5]
Jaspanth Kaur
Foundation pharmacist
jaspanth.kaur@nhs.net
Chart 1
Chart 2