Psychotropic Medication Reviews and Preventing Falls
Falls are common among nursing home residents, and medication review is one strategy that can help reduce the risk. About half of nursing home residents fall every year, according to the Agency for Healthcare Research and Quality. Falls can lead to injuries, fractures, pain, and disability, eroding quality of life for residents. September is Fall Prevention Awareness Month, an opportune time to consider risk interventions, especially for residents living with dementia.
Shao et al. recommend that “use of medications should be included as key elements in the fall risk assessments of older people in nursing homes.” Because of associations with the incidence of falls, psychotropic medications warrant specific attention in a comprehensive falls risk assessment.
Risk factors for falls
What places a resident at risk? A history of falls, impaired ADL performance, insomnia, and depression top the list, report Shao et al. Next are these factors: vertigo, poor balance, use of antidepressants, use of benzodiazepines, use of antipsychotics, use of anxiolytics, polypharmacy, dementia, unsteady gait, and hearing problems. Use of walking aids has been reported as both a risk factor and a protective factor.
In Parkinson’s disease, problems like postural instability, freezing gait, and attention deficit increase the risk of falls, say Shao et al. In dementia, mobility disorders as well as mental and behavioral abnormalities “can lead directly to falls,” the researchers comment. Nursing home residents living with dementia have a high rate of falls, report van Doorn et al., averaging about 4 falls per year.
Frailty, which is closely linked to dementia, can also make a resident more likely to experience sudden changes in status, such as a fall or delirium.
The side effects of psychotropic medications can significantly exacerbate the risk of falls in nursing home residents. A multi-pronged falls risk assessment should include a medication review, advise van der Velde et al., outlining the World Guidelines for Falls Prevention and Management. As part of a comprehensive geriatric assessment, this review should be “structured, personalized, and patient-centered,” they say. Deprescribing strategies are recommended.
Psychotropic medications of concern
Many classes of medications can be poorly tolerated by older adults, as defined by the Beers Criteria. With regard to falls risk, psychotropic medications stand out, say van der Velde et al. Antiepileptics, anticholinergics, and some classes of cardiovascular medications also heighten the risk. Shao et al. recommend a careful review of the specific medications chosen, as well as dosage and duration. Gradual dose reduction (GDR) is a fundamental standard, as specified by CMS 605.
Drug-specific side effects that can increase the risk of falls include the following, note van der Valde et al.:
- Anticholinergics can affect the central nervous system with symptoms such as sedation, confusion, delirium, dizziness, cognitive impairment, impaired concentration, blurred vision, and tachycardia. “Practitioners may not always have an awareness of what medications have anticholinergic action,” notes Steven Posar of GuideStar, and this class of drugs is to be avoided in dementia care.
- Antidepressants can cause sedation, impaired balance/reaction time, orthostatic hypotension, cardiac conduction and rhythm disorders, visual impairment, hyponatremia, delirium, and drug-induced movement disorders.
- Antiepileptics can cause drowsiness, fatigue, dizziness, unsteadiness, vertigo, imbalance, diplopia, cognitive impairment, confusion, drug-induced movement disorders, and hyponatremia.
- Antipsychotics can cause sedation, drowsiness or somnolence, dizziness or vertigo, orthostatic hypotension, hypotension, drug-induced movement disorders, cardiac effects (QTc prolongation and tachycardia), anticholinergic effects (e.g., blurred vision), delirium, confusion, and hyponatremia.
- Benzodiazepines and benzodiazepine-related drugs can cause muscular weakness, ataxia, sedation, extrapyramidal symptoms, imbalance and/or dizziness, visual disorders, delirium, and orthostatic hypotension.
- Opioids can cause orthostatic hypotension, hypotension, drowsiness, somnolence, dizziness or vertigo, sedation, confusion, delirium, eye disorders, and muscle problems (e.g., rigidity).
Psychotropic polypharmacy is of serious concern in assessing falls risk, explain Shao et al. They point to additive and synergistic side effects of psychotropic drugs, such as drowsiness, dizziness, and hypotension.
Before prescribing
Before prescribing any drug that could increase the risk of falls, van der Valde et al. advise an accurate assessment of the problem, a focus on the treatment objective, and an evaluation of risks vs. benefits. Ongoing monitoring is essential, as is a plan for deprescribing.
The risk-benefit equation can change over time, they caution. This is one of the reasons a regular medication review is essential. In addition, new side effects can emerge with an existing medication regimen. Avoiding a prescribing cascade is also critical. When psychotropic medications trigger side effects, it’s important to avoid prescribing an additional psychotropic drug to manage them.
When psychotropic medications are being considered to manage behavioral and psychological symptoms of dementia (BPSD), attempts at nonpharmacological interventions must come first, according to CMS F605. At GuideStar Eldercare, clinical psychologists, licensed clinical social workers, and mental health counselors use clinical skills to identify root causes of behaviors and guide nonpharmacological intervention strategies.
Steps for a medication review
A medication review should be multidisciplinary, advise van der Valde et al. The steps are:
- Conduct a comprehensive medication history
- Identify potentially inappropriate medications
- Determine if medications can be prioritized for deprescribing (GDR)
- Plan and initiate withdrawal
- Monitor and document
Medication regimens in people living with dementia are frequently complex and often include medications that increase the risk of falls. Because of their potential side effects, psychotropic medications deserve extra scrutiny. The clinical approach to Long-Term Care Antipsychotic Stewardship® at GuideStar Eldercare includes diagnostic accuracy, polypharmacy review, GDR, education, and documentation—all essential steps for helping to prevent falls. This is core to our mission of enhancing the quality of life for the residents we serve by easing suffering and actively promoting their safety, functionality, and dignity.