January/February 2012 Issue

Medication-Related Elder Fall Prevention
By Jennifer Van Pelt, MA
Social Work Today
Vol. 12 No. 1 P. 12

Understanding medications and their side effects is critical to a successful fall prevention approach for older adults.

Falls and related complications are the fifth leading cause of death in older adults. More than 30% of adults over the age of 65 will fall at least once annually. Falls are also responsible for 85% of all injury-related hospital admissions and more than 40% of nursing home admissions (Woolcott et al., 2009). Fall prevention efforts have been highly publicized, and most healthcare professionals are familiar with the exercise programs and home modifications needed to avoid falls and their potentially severe aftermath.

It is commonly assumed that falls are a natural part of aging, a result of weaker muscles and fragile bones. However, one common cause of falls—medication—is often overlooked, even by healthcare professionals. Medications and their side effects contribute significantly to the risk of falling in older adults.

According to research by the American Society of Consultant Pharmacists Foundation, 75% of older adults take one or more prescription drugs, and 25% take five or more drugs regularly (Clark, 2008). Despite the high percentage of older adults using medications and more than 10 years of research into the medications that increase fall risk (Leipzig, Cumming, & Tinetti, 1999; Brahm & Crosby, 2009), no statistics have been reported that document how many falls are medication related (Woolcott et al.).

“Medication-related falls are grossly underreported,” notes Pamela Braun, MSW, LCSW, C-ASWCM, LF, founder and owner of Geriatric Assessment, Management & Solutions, LLC, a company that acts as a liaison for caregivers and families of older adults and evaluates medical, legal, and psychosocial issues associated with geriatric care. “My staff and I are constantly working with elders who sustain medication-related falls. Falls and medication issues are a primary reason that families retain care management services for the oversight and safety of their elders.”

It’s often difficult to determine whether medication, or a specific medication, is the cause of these falls, according to Braun, since the elder may not want to or be able to clearly answer questions about it. Even a skilled social worker experienced in interviewing elder clients may not be able to ascertain that medications are causing falls.

Therefore, it is essential that social workers in geriatric care be aware of the medications that may increase fall risk and the medications their clients are taking. While inappropriate medication prescribing practices and medication misuse among elders has been flagged as important contributors to falls, properly prescribed medications and compliance can still result in falls simply because certain drugs have side effects that increase fall risk (Brahm & Crosby, 2009).

Medication Education
“A wide variety of prescription and over-the-counter [OTC] medications can be related to falls in elders,” says Maura Conry, PharmD, MSW, LCSW, a pharmacist, psychotherapist, and clinical social worker specializing in interdisciplinary collaboration between pharmacists and social workers. Her work, which seeks to integrate the skill sets of pharmacy and social work to improve care, focuses on in-home medication mismanagement that is difficult to address by medical professionals alone.

Certain classes of drugs, such as antidepressants, pain medications, antipsychotics, and antihypertensives, can be particularly problematic for elders, says Conry. She advises social workers to learn the drug classes that may contribute to falls and to be aware that almost any medication, especially if newly prescribed, can be a factor in falls. OTC medications can also increase risk as much as prescription drugs, and some medications, such as diphenhydramine and naproxen, which are available in both OTC and prescription strengths, interact with prescribed medications. Further complications occur when patients use them without reading or following precautions on the label, she adds.

After educating themselves, social workers should teach their older clients and the families and/or caregivers. “Whether social workers work with older clients in their own homes, retirement communities, hospitals, or community-based agencies, they need to educate them that certain medications contribute to falls,” says Caroline Cicero, PhD, MSW, MPL, a gerontologist, director of the Southern California Health and Aging Public Policy Institute, and an instructor in health and aging policy at Pepperdine University’s School of Public Policy. Cicero trained at the Fall Prevention Center of Excellence at the University of Southern California Andrus Gerontology Center, where she researched outdoor falls, evidence-based fall prevention programs, and fall-related hospitalizations.

Explaining medication side effects may help an older adult avoid a fall. For example, sedatives can make an elder more likely to fall not only because these medications can cause dizziness but also because they may impair vision, balance, response time, and functioning, which further increases fall risk. A combination of factors, such as medication side effects combined with environmental factors, can also cause falls. “Some medications can make older adults need to go to the bathroom more often, and if they are rushing to the bathroom, especially in the dark at night, they are at greater risk of falling,” Cicero cites as an example.

Don’t Assume
Social workers should not assume that physicians have educated older patients about the prescribed medications or that the prescribing physician is even aware of medication-related fall risks. Many physicians who see older patients have not been adequately trained in medication interactions in elders, says Cicero. And when new drugs are tested on older adults, trials generally include “younger,” healthier older adults instead of the oldest and most frail elders, she notes. Because elders do not metabolize and excrete drugs as fast as younger individuals, drugs can build up in their system and cause more side effects. Even a physician knowledgeable about medication side effects may not realize how they affect older patients.

Newly prescribed medications also increase fall risk for older adults. “Heart, respiratory, sleep, and psychiatric medications can present issues when newly prescribed, especially if an elder mistakenly over- or underdoses,” says Braun. Side effects can be more prominent during the first few days of taking a new medication until the older adult becomes accustomed to it, she notes. For example, an elder who is taking a sleep medication for the first time may be at greater risk of falling, especially if he or she also drinks alcohol, she says.

If falling is a new behavior for an older client, Conry advises social workers to find out if a new medication was prescribed or if the medication dosage was changed. She also suggests instructing older adults to take the first dose of a new medication at home to better monitor any side effects. She cites the example of an 87-year-old man who picked up a prescription for tramadol, a newly prescribed pain reliever; took his first dose at the pharmacy; and then drove to meet friends. He became dizzy and unsteady and needed help to get home.

Pharmacy and Social Work — A Valuable Collaboration
Busy social workers may not have time to learn every medication and the side effects. Conry recommends collaborating with pharmacists, who are a valuable but underused resource. “Social workers just don’t think about calling pharmacists,” she says.

Conry uses her unique dual degrees and experiences to teach social workers about the role of pharmacists, how to refer clients to pharmacists, and how to collaborate with them regarding medication safety. Her efforts to promote collaboration arose because “neither social workers nor pharmacists have a grasp of what the other profession does, much less how to collaborate interprofessionally,” she says. Given the rapidly growing aging population, social workers and their older clients can benefit from a relationship with a pharmacist.

When working with older adults experiencing or at risk of falls, the social worker’s initial assessment should include compiling a list of and reviewing all medications, including prescription and OTC medications, vitamins, and herbal supplements. Pharmacists are an ideal resource to assist social workers with this assessment.

Conry suggests social workers do what is informally called a “brown bag consult”: Gather all the medications in an older adult’s home, put them in a bag, and make an appointment with the client’s primary pharmacist to review the medications. If the client does not use one pharmacy exclusively, the social worker can assist in finding a pharmacy that is convenient for the patient and assist in transferring all his or her prescriptions there. Conry recommends using only one pharmacy to ensure that all prescriptions are on record in a single location and to facilitate ongoing monitoring of medication use and new prescriptions by the social worker and caregivers.

Using one pharmacy and developing a working relationship with the pharmacists and technicians on staff there is especially important for older adults with multiple medical conditions who are prescribed medications by more than one physician. Called polypharmacy*, or informally medication chaos, this situation frequently occurs with older patients and complicates geriatric social work. “Medications are prescribed by several doctors and filled at different pharmacies. The older adult adds OTC drugs, vitamins, supplements, and/or borrowed medications from spouses. Polypharmacy is not intentional drug abuse; it is the consequence of simply getting mixed up,” says Conry.

Some older adults also don’t realize why they are taking certain medication and may continue using ones that were prescribed for a condition they no longer have, adds Cicero. Therefore, multiple medications may be creating a dangerous polypharmacy “cocktail” inside an older client’s body, she notes. “I have had clients who were dizzy and fell. I suspected overmedication or improper mixing of medications. If my clients had multiple physicians prescribing medications, then I would refer the client to see a geriatric specialist. It is very important for those taking many medications to see a physician who specializes in caring for older patients,” advises Cicero.

Health insurance may limit how many and what types of physicians an older client can consult, and depending on the physicians and medical facilities involved, coordination among physicians may be challenging or impossible for the social worker. “The social worker may need to do the extra work in researching medications and their possible interactions,” Cicero says. “Sometimes it takes a social worker to put the puzzle together to realize that medications may be working against each other and causing dizziness and imbalance.”

Pharmacists can help solve many medication-related problems, Conry reiterates. “Pharmacists have ready access to physicians and are easy to reach, as pharmacies are open long hours as well as weekends and holidays,” she says. Pharmacists may also be able to help social workers better communicate with their clients or identify geriatric specialists.

Practical Medication Management Strategies
While pharmacists can assist social workers, physicians should still be held accountable to justify prescriptions, says Braun. “I continually request that all physicians involved with an elder’s care evaluate their medication list carefully. I believe that falls occur because one doctor doesn’t know what other doctors have prescribed, and there may be duplications or contraindications.”

A geriatric care manager can assist by keeping an updated medication list and by accompanying older clients to physician visits to help communicate and keep track of medication changes, she suggests.

Fall prevention does not stop after the initial medication assessment; it is an ongoing process since older adults will not only be prescribed new medications but may also have difficulties with medication compliance. “Falls also result when medications are not taken at all. Proper administration and management of medications is key to preventing falls,” says Braun.

Health-related barriers to medication compliance, such as limited eyesight, cognitive impairment, and mental health issues, should be identified, and strategies to improve compliance should be devised. These strategies can be as simple as placing reminder notes around the home and using compartmentalized pill organizers or as complex as getting sophisticated medication dispensers that provide preportioned medications on a timer, according to Braun.

Medication compliance may also be challenging due to the complexity of a patient’s medication regimen, a lack of transportation or finances to fill prescriptions, or mixing up new medications with old ones. “Elders tend to keep old prescriptions for years ‘in case they need it again.’ Their medicine cabinets need to be cleaned out regularly to avoid the elder taking unnecessary medications, those that may interact with current medications, and/or those that have expired,” Braun explains.

For proactive interventions to be successful in minimizing medication-related fall risk, Braun says elders must be open to receiving assistance with medication management. “It is a delicate subject. Most elders do not want to admit they cannot manage their own medications, or they may feel resentful if their independence is impinged upon,” she says.

Braun suggests starting with posting a current list of medications and dosage instructions on the refrigerator or in plain view in the house. Additional interventions may be required, depending on the older adult’s habits and mindset. These may include using pill organizers with recorded reminder features, at-home companion or nursing care, or medication dispensers with programming for timed doses.

Braun cites the example of an 82-year-old widower who lived alone. He could fill his pill organizer but was having difficulty remembering when and how often he needed to take his medications. He was very conscientious about taking his medications but also overmedicated, thinking “more” was better. Braun suggested employing an emergency response system with a medication reminder feature using his son’s recorded voice. “Prior to using this system, he was having multiple falls, which I suspect were from overmedicating because he didn’t remember if or when he initially took the pills,” Braun says.

As the elder population continues to grow rapidly, geriatric social workers will assume greater responsibility in elder care. Understanding the many side effects of medications commonly used by older adults will improve the social worker’s ability to serve older clients and their families and caregivers. Medication-related falls are preventable with increased awareness and implementation of practical strategies.

“No risk factor for falls is as potentially preventable or reversible as medication use” (Leipzig et al.).

— Jennifer Van Pelt, MA, is a Reading, PA-based freelance writer.

* Polypharmacy is defined as the use of several different drugs, usually prescribed by different doctors and filled at different pharmacies, by a patient who may have one or several health problems. Polypharmacy often involves using a higher dose of one or more medications than is clinically indicated or warranted. Increased adverse drug reactions and drug-drug interactions can result.

Resource
For more information about helping elders manage their medication to eliminate or reduce the risk of falling, visit the Fall Prevention Center of Excellence for numerous tools and other resources: http://stopfalls.org/service_providers/sp_mm.shtml.

References
Brahm, N. C., & Crosby, K. M. (2009). Medication’s impact on falls. Aging Well, 2(5), 8.

Clark, T. R. (2008). Startling statistics about seniors and medication use. American Society of Consultant Pharmacist. Retrieved from http://www.spectrumhomehealthcare.com/docs/senior_medication_statistics.pdf.

Leipzig, R. M., Cumming, R. G., & Tinetti, M. E. (1999). Drugs and falls in older people: a systematic review and meta-analysis: I. psychotropic drugs. Journal of the American Geriatrics Society, 47(1), 30-39.

Woolcott, J. C., Richardson, K. J., Wiens, M. O., Patel, B., Marin, J., Khan, K. M. (2009). Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Archives of Internal Medicine, 169(21), 1952-1960.