Medication and Falls

Original Editors - Scott Buxton

Top Contributors -Scott Buxton, Lucinda hampton, Kim Jackson and Evan Thomas  

Medication and Falls

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It is important to focus on the medications an elderly client is taking as they may be significant falls risks.
  • Medications are among the most common causes of increased fall risk in older people.
  • Medications are usually among the easiest risk factors to change, when it comes to falls in older adults.
  • Medication-based risks are often missed by busy regular doctors. Older adults and family caregivers and physiotherapists can help by being proactive in this area.[1]

What is Polypharmacy?

Polypharmacy is typically defined as the use of more than 3 or 4 medications[2][3], take a moment and think of the number of patients you have that are taking more than 3 medications. Thought also needs to be spent on which types of medications the patient is taking as different classes of drug influence the risk of falls differently. The video below gives a good brief summary of polypharmacy in the elderly.

[1]

A 2017 study reported that almost one-third of the total population using five or more drugs had a significantly increased rate of falls (21%) over a 2-year period. It concluded that exploration of the effects of these complex drug combinations in the real world with a detailed standardised assessment of polypharmacy is greatly required.[4]

Medications Associated with Increased Risk of Falls

As physiotherapists it is important to be aware of which medications can impact on our patients safety, medication is obviously not within a physiotherapist job role specifically however knowing what the potential impact of some medications can be very valuable. Additionally it is important to know about the medications if you work in a triage role. If you are concerned about the type or number of medications a patient is taking then spend time referring to you medical colleagues in the clinic, writing to their GP or discussing at and MDT meeting.

In common language the three types of drugs that can increase falls risks are

  • Medications that affect the brain
  • Medications that affect blood pressure
  • Medications that lower blood sugar.[5]

In more specific terms two main classes of drugs increasing the risk of falls are 1. Psychotropic drugs and 2. Drugs acting on the heart and circulation. These are outlined below.

Note- Diabetic drugs lower blood sugar. Most diabetes medications can cause or worsen hypoglycemia (too low blood sugar). This has been identified as a falls risk. They are not included below.

Psychotropic Drugs

Psychotropic Drugs and Falls Risk[6]
Medication Group Overall Risk Category Commonly Used Medications Effects on Risk
Sedatives

HIGH RISK

Can cause falls alone

Lorazepam, Temazepam, Nitrazepam

similar -epamsuffix

Drowsiness, slows reactions, impaired balance.
Sedating Antidepressants

HIGH RISK

Can cause falls alone

Amitriptyline, Nortriptyline Orthostatic hypotension, drowsiness, slow reactions. DOUBLE THE RATE OF FALLS
Monoamine Oxidase Inhibitors

HIGH RISK

Can cause falls alone

Phenelzine, Moclobemide Severe orthostatic hypotension
For Psychosis Agitation

HIGH RISK

Can cause falls alone

Haloperidol, Chlorpromazine, Olanzapine Orthostatic hypotension, slow reflexes, loss of balance
Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin and Noradrenaline Reuptake Inhibitor )SNRI)

MODERATE RISK

Can cause falls in combination

Fluoxetine, Sertaline, Paroxetine, Venlafaxine, Duloetine Increased risk of falls with fractures, orthostatic hypotension, bradycardia, impaired sleep quality
Opiate Analegsics

HIGH RISK

Can cause falls alone

Codeine, Morphine, Tramadol Sedates, slows reactions, impairs balance, delirium
Anti Epileptics HIGH RISK Phenytoin, Carbamazepine, Phenobarbitone Cerebellar damage, ataxia, slowed reactions
MODERATE RISK Sodium Valporate, Gabapentin Some association with falls risk
Parkinson's - Dopamine Agonists HIGH RISK Roprinerole, Pramipexole Delirium, orthostatic hypotension
Parkinson's - MAOI-B Inhibitors HIGH RISK Selegiline Orthostatic hypotension (Difficult to assess due to high falls risk in Parkinson's as the disease process)
Muscle Relaxant MODERATE RISK Baclofen Reduced muscle tone, sedative
Vestibular Sedative POSSIBLE CAUSES Prochlorperazine, Cinnarazine, Betahistine Prochlor... - Dopamine agonist which may cause movement disorder in long term, sedating
Anticholinergics acting on Bladder POSSIBLE CAUSES Oxybutinin, Solifenacin, Tolterodine, Solifenacin Known CNS effects.

 



Drugs Actings on the Heart and Circulation

Drugs Acting on the heart and Circulation[6]
Medication Group Overall Risk Category Commonly Used Medications Effect of Risk
Alpha Receptor blockers HIGH RISK Doxasozin, Tamsulosin, Indoramin Severe orthostatic hypotension, urinary retention
Centreally Acting Alpha-2-Receptor Agonsits HIGH RISK Clonidine, Moxonidine Severe orthostatic hypotension, sedating
Thiazide Diuretics HIGH RISK Bendroflumethiazide, Metolazone Weakness due to low potassium, hyponatraemia, orthostatic hypotension
Loop Diuretic MODERATE RISK Furosemide, Bumetanide Dehydration, hypotension, low potassium and sodium
Angiotensin Converting Enzyme Inhibitors (ACEIs) HIGH RISK Lisinopril, Ramipril -opril Rely upon kidney elimination and accumulate can cause failure, dehydration.
Angiotensin Receptor Blockers (ARBs) MODERATE RISK Losartan or similar -tan Hypotension
Beta Blockers HIGH RISK Atenolol, Propranolol, Sotalol Bradycardia, hypotension, carotid sinus hypersensitivity, vasovagal syndrome
Antianginals HIGH RISK Glyceryl Trinitrate (GTN), Isosorbide Mononitrate, Nico Sudden hypotension
Calcium Channel Blockers MODERATE RISK Amlodipine, Felodipine, Diltiazem, Verapamil Hypotension, bradycardia
Other Antidysrhythmics MODERATE RISK Digoxin, Flecainide, Amiodarone Bradycardia, arrythmias
Acetylcholinersterase Inhibitors (For Dementia) POSSIBLE CAUSES Rivastigmine, Donepezil, galantamine Bradycardia and syncope

References

  1. 1.0 1.1 Medski.com. Geriatrics – Polypharmacy in the Elderly: By Balakrishnan Nair M.D. Available from: https://www.youtube.com/watch?v=vGcAr9tK_30 (last accessed 20.5.2019)
  2. Ziere G. Dieleman J. Hofman A. Pol A. van der Cammen T. Stricker B. Polypharmacy and Falls in the Middle Age and Elderly Population. British journal of clinical Pharmacology. 2005:61;218-223
  3. Evans J. Drugs and Falls in Later Life. Lancet. 2003; 361:448
  4. Dhalwani NN, Fahami R, Sathanapally H, Seidu S, Davies MJ, Khunti K. Association between polypharmacy and falls in older adults: a longitudinal study from England. BMJ open. 2017 Oct 1;7(10):e016358. Available from: https://bmjopen.bmj.com/content/7/10/e016358 (last accessed 20.5.2019)
  5. Better Health while ageing. Preventing Falls: 10 Types of Medications to Review if You’re Concerned About Falling. Available from: https://betterhealthwhileaging.net/preventing-falls-10-types-of-medications-to-review/ (last accessed 20.5.2019)
  6. 6.0 6.1 Darowski A. Dwight J. Reynolds J. Medicines and Falls in Hospital: Guidance Sheet [ONLINE] available from https://www.rcplondon.ac.uk/sites/default/files/documents/medicines-and-falls2.pdf date accessed 14/01/2015