Pharmacists can assist in fall prevention programs
Medications among most common causes
When St. John Medical Center of Tulsa, OK, started a fall prevention program in 2006, the group included a pharmacist.
"We wanted anyone on the group who could possibly prevent a patient from falling," says Polly Robinson, PharmD, clinical pharmacist with St. John Medical Center.
Robinson, as the pharmacy representative on the committee, assessed safety by reviewing and assessing each patient's risk for falling, including patients' potential risk from their medication regimen.
"The group wanted a pharmacist to assess each patient's medication as they entered the hospital," Robinson recalls. "That would be nice, but we didn't have the money to hire 10 more pharmacists to do that."
So Robinson researched the issue and found that one of the most preventable and reversible causes of falls is patient medications and that patients who've already fallen are most likely to fall again.
"So we chose to focus on those patients who've already fallen," she explains. "We review their medication and identify common causes of falls."
Each time a patient falls, a nurse enters data into a hospital computer system, and that information is reviewed regularly.
A pharmacist reviews the charts of patients who've had a fall and sees which of their medications could be changed, such as lowering the drug dosage, Robinson says.
When a change is made and approved by a physician, the pharmacist documents the change and labels it in the "falls" category, she adds.
This information is stored electronically and can be used to chart trends and for quality improvement initiatives. (See sample information from Falls Review Sheet.)
For example, the hospital has made some changes in standard prescription dosages to prevent falls, including changing temazepam (Restoril®) 30 mg orders to 15 mg dosages for patients who are 65 years or older. Or these patients are changed to a more selective GABA agonist, such as zolpidem (Ambien®), with 10 mg prescribed for patients who are younger than age 65 or 5 mg prescribed for patients who are 65 years or older, Robinson says.
"We noticed Restoril often was the culprit in falls," Robinson notes. "So we focused on that medication and reviewed a lot of preprinted order forms."
With physicians' approval the dosage was lowered and changed.
Now that zolpidem is available in a generic form, it can be used as a safer drug that is not more expensive for the hospital, Robinson says.
"Before zolpidem was a more expensive drug and it was prescribed in 10 mg for everyone," she adds. "So we added age-dosing."
Also, physicians previously would select a pain medication from 4 or 5 different opioid choices. Now they're steered to one opioid that has a lower risk of causing falls, Robinson says.
"As another example of changes made to decrease fall risk, we have simplified the choices of pain medications on our preprinted order forms," she adds. "And we've enacted a policy limiting the use of meperidine (Demerol®), an inferior pain medication with increased risk for CNS side effects."
A medication review for falls turned up another trend: "We noticed a lot of patients were taking diuretics right before bedtime," Robinson says.
"The peak of action of those diuretics was right when they were sleeping, so they'd wake up and need to go to the bathroom, and then they'd fall in the bathroom," she explains. "So we changed the automatic times of those diuretics to be given no later than 5 pm, and with the change we saw a trend of decreased falls at night."
The number of falls decreased from 1.4 falls per night per 1,000 bed days of care down to 1.1 falls per night in a very short timeframe, Robinson adds.
The falls sheet used by pharmacists includes one side with medications that are known to increase the risk of falls, based on a recent literature review. The list includes psychotropics, cardiovascular medications, and others, including anticholinergics, anticonvulsants, post-anesthesia, and opioid analgesics.
This educational piece also includes details about why the listed medications have the potential to increase risk of falling, including this information:
• Selective serotonin reuptake inhibitors (SSRIs):
- New use of SSRIs is associated with a greater risk for falls. Recommend starting with a low dose for the first week, then slowly increasing to therapeutic levels.
- Doses ≥ the equivalent of 20 mg of fluoxetine have a higher risk for falls.
- May induce hypnoatremia, which can lead to delirium; recommend monitoring electrolytes.
• Antihypertensives:
- Antihypertensives have been proposed to contribute to fall risk via postural hypotension (drop in SBP of ≥ 20 mm Hg, in DBP of ≥ 10 mm Hg, or to a pressure of < 90 mm Hg when standing).
- Diuretics have been significantly associated with falls (vertigo, orthostatic hypotension, frequent urination). Most studies have found a non-significant relationship between antihypertensives and falls.
- Inadequate treatment of a cardiovascular disease may also be a factor in increasing fall risk.
• Post-anesthesia:
- Risk for falling is greatest within 48 hours post-anesthesia.
Pharmacists also make suggestions to physicians when they note a prescription that might entail a fall risk.
For instance, a pharmacist might say, "This patient is elderly and taking temazepam and on 30 mg every night at bedtime for sleep, and that's a very high dose for an elderly patient," Robinson says.
This approach is short and to-the-point, she says.
Then the pharmacist would recommend to reduce the temazepam prescription to 15 mg or to try some other sleep regimen, such as seeing if there were other medications that were keeping the patient awake and which could be adjusted, Robinson explains.
"We look at the medication profile to reduce the medicines that cause falls risk," she adds. "The goal is to review the patient's medication and back-up your suggestion with detailed information about risks for falls."
When St. John Medical Center of Tulsa, OK, started a fall prevention program in 2006, the group included a pharmacist.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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