Falls prevention and the role of the pharmacist
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How pharmacists can help prevent primary & secondary falls in the elderly population.
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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 & ‘risk’ medicines e.g. hypnotics • Aim: • Keep regimes as simple as possible-reduce pill burden • Modify: • Make recommendations including cessation- “is the drug still needed?” • Prevent : • Identify & resolve issues-the patient experience • Adherence: • Explain & review changes 5
- 6. Case study - Elsie 74 years old •Recently discharged after a minor fall •Lives alone •Elsie says her mobility and eye sight are getting worse •Takes Furosemide 40mg OM and hospital has prescribed Nitrazepam for poor sleep. •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 • Recommend switch to a shorter acting benzodiazepine e.g. Zopiclone - assess efficacy 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. Summary MOVING FORWARD Better Together Safe, appropriate evidence & policy led prescribing Anticipate Medication Risk – Review-De-Prescribe Patient engagement, collaboration & support 7
- 10. 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 10
Editor's Notes
- 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
- 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