a step forward: promoting independence through falls ......a step forward: promoting independence...
TRANSCRIPT
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A Step Forward: Promoting Independence through
Falls Prevention
2014 Geriatric UpdateMeharry Consortium Geriatric Education Center
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A Step Forward: Promoting Independence through
Falls Prevention
Moderator: Ronald De Vera Barredo, PT, DPT, EdD, GCSProfessor and Chair, Department of Physical Therapy
Tennessee State University
Michelle Valentine Moseley, PharmD, BCPSClinical Pharmacy Specialist, Geriatrics, Dept. of Veterans Affairs
Tennessee Valley Healthcare System Assistant Professor, Lipscomb University College of Pharmacy
Elena Wong Espiritu, OTD, OTR/LAssistant Professor, School of Occupational Therapy
Belmont University
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Objectives
Describe the multifactorial causes of falls among older adults
Identify tools geriatric health practitioners could use to evaluate a patient's fall risk
Outline strategies that will mitigate fall risk
Identify drugs that increase fall risk in geriatric patients
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No Disclosures
• Ronald De Vera Barredo, PT, DPT, EdD, GCS• Michelle Valentine Moseley, PharmD, BCPS• Elena Wong Espiritu, OTD, OTR/L
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FallsinOlderAdults:TheRoleofMedicationManagement
Michelle Moseley, PharmD, BCPSClinical Pharmacy Specialist in Geriatrics, VA TVHS
Assistant Professor, Lipscomb University College of Pharmacy
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LearningObjectives
• Identify drugs that increase fall risk in geriatric patients
• Outline strategies that will mitigate fall risk
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WhyDoOlderAdultsFall?• Major causes
– Accident & environment‐related– Gait and balance disorders or weakness– Drop attack– Confusion– Postural hypotension– Visual disorder– Syncope– Other unspecified causes: arthritis, acute illness, drugs, alcohol, pain, epilepsy, and falling from bed
Rubenstein LZ, Josephson KR. Clin Geriatr Med 2002;18:141–158.
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EfficaciousComponentsofaFallPreventionProgram
Exercise and physical activity
Medical assessment
and management
Medication adjustment
Adaptation or Adaptation or modification of home
environment
2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons.
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MedicationsandFalls• Strongest risk factors
– Polypharmacy– Psychotropic medications
– Potentially inappropriate prescribing
• Beers List• Screening Tool of Older Persons’ Prescriptions (STOPP) criteria
Examples of Psychotropic Medication Classes• Antipsychotics• Serotonin‐reuptake inhibitors• Tricyclic antidepressants• Benzodiazepines• Hypnosedatives
Examples of Psychotropic Medication Classes• Antipsychotics• Serotonin‐reuptake inhibitors• Tricyclic antidepressants• Benzodiazepines• Hypnosedatives
Huang AR, et al. Drugs Aging 2012; 29:359–76.van der Hooft CS, et al. Br J Clin Pharmacol 2008; 66:276–82.
JAGS 2012;60(4):616‐31Gallagher P, et al. Int J Clin Pharmacol Ther. 2008;46(2):72–83.
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MedicationEffectsThatMayPotentiateFallRisk
Confusion, delirium, impaired cognition
Dizziness, drowsiness, sedation
Hypotension, arrhythmias
Hypoglycemia, hyperglycemia
Dehydration, electrolyte disturbances
Constipation, frequency of urination
Muscle weakness, ataxia
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ExamplesOfMedicationClassesAssociatedWithTheseEffects
Alpha blockers BenzodiazepinesAnalgesics Cardiovascular medicationsAntibiotics Diabetes medicationsAnticonvulsants DiureticsAntidepressants Histamine‐2 blockersAntihistamines HypnosedativesAntimuscarinics LaxativesAntipsychotics Steroids
Tinetti ME, et al. JAMA Intern Med. 2014;174(4):588‐595.Rafiq M, et al. Journal of Clinical Epidemiology 2014;67(8):877‐886.
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MitigatingFallRisk:LessIsMore• Recommendations
– Minimize the number of medications– Discontinue psychotropics, or at least reduce the dose
2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons . http://www.medcats.com/FALLS/frameset.htm. Accessed 5/30/14.
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GoodPalliative‐GeriatricPracticeAlgorithm
Garfinkel D, Mangin D. Arch Intern Med 2010;170(18):1648‐1654
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CaseStudy:Mr.Wilson
A 76 year‐old man who was referred to your outpatient falls evaluation clinic by his PCP. He has fallen three times in the last three weeks.
Past Medical History: Type 2 diabetes, BPH, hypertension, hyperlipidemia, depression and osteoarthritis
Medication list:• Metformin 1000mg twice daily• Furosemide 20mg every
morning• Amlodipine 10mg daily• Lisinopril 20mg daily• Glipizide 10mg twice daily• Terazosin 5mg at bedtime• Citalopram 10mg daily• Simvastatin 20mg at bedtime• Hydrocodone/acetaminophen
7.5/325mg every 6 hours as needed
• Aspirin EC 81mg daily• OTC Docusate 100mg daily • OTC Tylenol PM® at bedtime
as needed
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CaseScenarios
A. Fell in the bathroomB. Fell when he got up at night to go to the
bathroomC. The room was spinning just before he fellD. He felt sweaty and shaky when he fellE. His thigh muscles felt extremely weak and
sore
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Summary• Medication use is one of the most modifiable risk factors for falls in geriatric patients
• Direct and indirect effects of many commonly prescribed medications may increase fall risk in older adults
• Utilize tools such as the Good Palliative‐Geriatric Practice algorithm in conjunction with patient preferences, disease‐specific guidelines, and drug utilization review criteria to reduce medication burden and fall risk
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Elena Wong Espiritu, OTD, OTR/LBelmont University
School of Occupational Therapy
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FALL
Behavioral
EnvironmentalIntrinsic
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Older Adults
LOW
physiological fall risk
LOW perceived fall risk
(vigorous)
HIGH perceived fall risk
(anxious)
HIGH physiological
fall risk
LOW perceived fall risk
(stoic)
HIGH perceived fall risk
(aware)
Based on Delbaere et al., 2010
Perceived vs. Physiological Fall Risk
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http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html
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Type DefinitionSingle one interventionMultiple combination of
interventions, same for all people
Multifactorial* combination of interventions based on individualized assessment
* Recommended by AGS/BGS guideline
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Moderate/high challenge to balance
At least 2 hours/weekOngoing basis
(Sherrington et al., 2011)
Tai Chi: Moving for Better Balance
Otago Exercise Programme
ExerciseMedical managementMedication adjustment
Environmental modificationEducation
Stepping OnMatter of Balance
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Self-Management
Client
AttitudesBehaviors
Skills
education information sharing
skill development
create situations
SE
LF-M
AN
AG
EM
EN
T
SU
PP
OR
T
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SYMPTOM MONITORING
PROBLEM SOLVING
DECISION MAKING
ACTION PLANNING
LOCATING & USING
RESOURCESCOMMUNICATION
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http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_
recommendations/prevention_of_falls_summary_of_recommendations
Retrieved
September 20 http://www.coag.uvic.ca/cdsmp/documents/What_is_Self‐Management.pdf