We pay a lot of attention to falls in the elderly population. When someone has sustained a fall, it usually signals a decline in clinical status. A fall often results in injuries, bone fractures, loss of mobility, independence, and eventually death.
While most people point to psychotropic drugs as the culprit of falls, there are many other factors to consider when completing a fall risk assessment pertaining to medications.
When I complete a post-fall medication assessment, I often consider the following factors:
- Diagnoses and medical conditions – two main conditions at very high risk of falls are Parkinson’s Disease and Huntington’s disease. Although we may not be able to prevent falls, there are strategies to implement to minimize injuries associated with falls.
- Hemodynamic stability – A review of the blood pressure and heart rate patterns may shed light into the heart function, or whether their cardiac medications may be responsible or contribute to the fall(s).
- Glycemic control – If the patient is diabetic, a review of the blood sugar readings is also important to determine if there has been any pattern of hypoglycemia, as this may also be part of the etiology.
- Cognitive status – The patient’s cognition including his or her orientation to time, space and person may also be important. However, this factor on its own is unlikely to be the cause of fall. But any abrupt changes of cognition may warrant further investigations (e.g. infection) and may be linked to the fall(s).
- Cumulative Effects of Medications – I will consider the cumulative effects of many different medications as to how they may worsen sedation, cognition or dizziness and other effects on the mental status of the patient.
- Bone Health – Finally if the individual is considered to be at high risk for fall, I would assess if strategies have been implemented to improve bone and muscle strength (e.g. physiotherapy, exercise, vitamin D supplementation, treatment of osteoporosis).
However, I think the biggest factor that predicts fall is when there is a change. This can be a clinical status change such as a COPD exacerbation, an infection, new admission, recent discharge or transfer. Or it can be a change in the medication regimen such as adding a new medication or adjusting the doses of current medication(s).
Recently, the ISMP Canada Safety Bulletin has released an article describing a multi-incident analysis on medication incidents that increase the risk of falls. It has identified the following medication classes as associated with falls:
The analysis also points to four main themes that may be linked to increased risk of falls:
So if we want to minimize the risk of fall, we need to be cognizant of these key themes and how to implement measures to prevent future falls. These measures can range from increasing monitoring to more effective communication or having effective systems or processes in place to manage these changes (e.g. medication reconciliation). But the most important ingredient to success in preventing falls is to have a positive culture within the institution setting – that when an individual has sustained a fall, the entire team will come together to discuss how to make specific recommendations to help the individual to prevent future falls.
Let’s take falls seriously.