"Medication Interventions for Fall Prevention in the Older Adult." J

ReviewsMedication interventions for fallprevention in the older adultJames W. Cooper and Allison H. BurfieldAbstractObjective: To review fall epidemiology, risk factors, assessments and interventionmethods, and outcomes in order to provide guidance to pharmacists.Data sources: Recently published articles listed in Medline and resources on theAgency for Healthcare Research and Quality website (www.ahrq.gov) identified usingthe search terms falls, medications and falls, fall risk factors, and falls interventionsand outcomes; personal data in preparation for publication consideration by the authors;and bibliographies from gathered articles.Data synthesis: Falls may result from multiple risk factors that should be consideredto both prevent falls and intervene when a fall has occurred. Careful considerationof the total psychoactive drug load, especially psychotropic drugs, andwell-planned recommendations for tapering, discontinuing, and/or replacing drugsimplicated in increasing fall risk are presented. A fall risk assessment method thatincorporates fall history and risk factors, current disease states and conditions, andmedications that may increase fall risk is provided. Two cases with interventions andoutcomes are detailed. Because anemia may increase fall risk, adequate assessmentof the cause(s) of anemia and conservative recommendations to correct it may decreasefall risk. Adequate vitamin D and calcium intake also may be essential to bothdecrease falls and fall-related fracture risk. Suggested alternatives and tapering fordrugs implicated in increasing falls are considered. Osteoporosis risk assessment isa further area requiring delineation for possible pharmacist assistance to the patientand prescriber to reduce the risk of both fall-related and nontrauma fractures. Interventionsto change medications may reduce falls by up to 70%. Additional fall-relatedresources on the Internet are provided.Conclusion: Pharmacists can play an important role by identifying patients whomay have fall risk factors and history and by providing information for drug changesthat may reduce fall risk.Keywords: Falls, medications, psychoactive medications, interventions.J Am Pharm Assoc. 2009;49:e70–e84.doi: 10.1331/JAPhA.2009.09044Received March 25, 2009, and in revisedform April 21, 2009. Accepted for publicationApril 23, 2009.James W. Cooper, BPharm, PhD, BCPS, CGP,FASCP, FASHP, is Emeritus Professor andConsultant Pharmacist, College of Pharmacy,University of Georgia, and Clinical AssistantProfessor of Family Medicine, Medical Collegeof Georgia, Augusta. Allison H. Burfield,MSN, RN, is Doctoral Candidate and ProvostFellow, College of Nursing, University of CentralFlorida, Orlando.Correspondence: James W. Cooper,BPharm, PhD, BCPS, CGP, FASCP, FASHP,College of Pharmacy, University of Georgia,1200 Colliers Creek Rd., Watkinsville, GA30677-1867. E-mail: jcooper@mail.rx.uga.eduContinuing pharmacy education (CPE)credits: See learning objectives belowand assessment questions at the end ofthis article, which is ACPE universal activitynumber 202-000-09-122-H01-P in APhA’seducational program. To take the CPE testfor this article, go to www.pharmacist.com/education, and follow the links to theAPhA CPE center.Disclosure: Other than continuing educationprograms developed by the authorsor APhA and mentioned as resources formore information, the authors and APhA’seditorial staff declare no conflicts of interestor financial interests in any products orservices mentioned in this article, includinggrants, employment, gifts, stock holdings,or honoraria.Published concurrently in Pharmacy Todayand the Journal of the American PharmacistsAssociation.e70 • JAPhA • 49:3 • M a y /Ju n 2009www.japha.orgJournal of the American Pharmacists Association

Fall prevention in older adults ReviewsFalls are the leading cause of injury-related deaths andthe most common cause of nonfatal injuries and hospitaltrauma admissions among older adults. The injuries andsecondary effects sustained in and after a fall can considerablyaffect elder patients’ mobility and independence long afterthey leave the hospital. More than one-third of adults age65 years or older fall every year. As the population ages, therate of occurrence of falls will increase unless strategies areimplemented to reduce the number of falls and their cumulativeadverse effects. 1–3To assess the causes of falls and compile recommendedactions that pharmacists can take to decrease patients’ risksof falling, we searched Medline and the Agency for HealthcareResearch and Quality’s website (www.ahrq.gov) using thesearch terms falls, medications and falls, fall risk factors, andAt a GlanceSynopsis: Pharmacists can identify elderly patientsat risk for falls and minimize fall risk by assessingcurrent medications both prescribed and possiblyneeded to reduce fall risk. A comprehensive fall-reductionstrategy should address physical mobility and abilityto accomplish activities of daily living, medicationmanagement, home/room safety, and environmental(community) safety. Total psychoactive drug load, particularlypsychotropic drugs, must be considered carefully,and efforts should be made to taper, discontinue,and/or replace drugs implicated in increasing fall risk.A fall risk assessment method that incorporates fallhistory and risk factors, current disease states andconditions, and medications that may increase fall riskis presented in the current work.Analysis: Efforts to correct anemia in elderly patientsmay decrease fall risk. Falls and fall-related fracturerisk can also be decreased by ensuring adequatevitamin D and calcium intake. Evidence suggests thatbuspirone intervention in place of benzodiazepinesand/or antipsychotics, careful drug withdrawal by stepwisediscontinuance with tapering of 10% to 25% ofthe dose per week, or both interventions can reducefalls by up to 70%.falls interventions and outcomes. Additional resources wereidentified from personal data in preparation for publicationconsideration by the authors and bibliographies from gatheredarticles.Causes of fallsResearch indicates that falls are caused by multiple factorsthat are both internal and external to elder patients. 1–3 The followingfour areas of risk have been identified:(1) Physical mobility and ability to accomplish activitiesof daily living (ADLs). Fall risk can be increased by thedeconditioning that can occur with normal aging (e.g., “ifyou do not use it, you lose it”) and by the loss of musclestrength that can occur with multiple conditions, such asstroke, heart failure, and osteoarthritis. The best exampleof this loss is the ability to transfer between bed and walkeror wheelchair to do ADLs of toileting, bathing, meals, andsocial interaction within the older adult’s living environment.Physical therapy aimed at maintaining and improvingmuscle strength with daily exercise is the cornerstoneof this area of risk reduction. Routine encouragement ofexercises such as partial deep knee bends and arm dipsthat use muscles that enable movement from bed or wheelchairfor transfers to the walker or tripod cane and walkingas permitted with assistance can help to “retrain” deconditionedleg and arm muscles. An elevated toilet seator plastic piece that fits on the seat and elevates the seat8 to 12 inches can help to increase the safety of transfersfor toileting. (For references and resources to address thisarea, see Appendix 1 in the electronic version of this article,available online at www.japha.org.)(2) Medication management. The need for a comprehensiveevaluation of all medications both before and especially aftereach fall is the main emphasis of this article. 1 –55(3) Home/room safety. A simple evaluation is required of theareas contacted by patients in their homes or in long-termcare facilities to ensure safe transit and support. Looserugs should be removed, and handrails to support the patientin bathrooms and walking around quarters and bedsshould be installed. Adequate lighting and floors that allowgood traction with shoes or slippers are also important tohome/room safety (online Appendix 1).(4) Environmental (community) safety. The patient andcaregiver must have a means of contact with the outsideworld. This could be achieved with a call button or radioLearning objectives■■ State the causes and risk factors for falls.■■ List medications implicated in both increasing and reducing fall risk.■■ Describe a fall risk assessment method.■■ List approaches and medication alternatives for reducing fall risk.■■ Describe how the pharmacist may offer medication assessment to assist prescribers and patients in determining whether theirprescription and nonprescription drugs may be increasing or decreasing fall risk.ACPE Activity Type: Knowledge-BasedJournal of the American Pharmacists Association www.japha.org M a y /Ju n 2009 • 49:3 • JAPhA • e71

Reviews Fall prevention in older adultsdevice that summons help when one is unable to ambulateor needs assistance. A cell phone kept on the patient is anothersimple method for letting caregivers know that helpis needed (online Appendix 1).Comprehensive strategyA comprehensive fall-reduction strategy that addresses allfour of the above areas can be effective. However, many previousefforts have been hampered by several factors:(1) Failure to consider all possible causes of falls, especiallymedications and the need for physical assistance to improvestrength and ambulation ability.(2) Failure to translate research into practice, especially whenmedications are concerned. (This article concentrates onremedying this apparent failure.)(3) Lack of coordination among interested but disparate organizationsthat support the older adult and their caregivers.(4) Minimization and trivialization of the issue, sometimesthrough media images casting older people as powerlessand pathetic (e.g, the “I’ve fallen and I can’t get up” commercials).(5) Scarcity of approaches that are culturally sensitive and appropriatefor older adults of all literacy levels. Adult daycareand senior centers, as well as assisted-living and personalcare facilities, are ideal locations for training bothpatients and caregivers to decrease fall risk. Online Appendix1 has numerous resources that document these factorsand can aide educational efforts.Numerous studies show the benefit of multifactorial fallrisk interventions and improved outcomes with comprehensivestrategy implementation, and guidelines for fall preventionhave been published. 35–43Psychoactive drug medication interventions are limited bythe lack of validation of currently available assessment instruments;most falls are caused by multiple risk factors that alsoshould be taken into account but are not covered in this review(e.g., gait assessment, strength training, environmental assessmentand changes). Online Appendix 1 lists resources thatmay be of value in fall risk-reduction educational programs.Fall risk assessment methodsFalls in the older patient clearly lead to increased healthcare use and decreased functional status. 1 A fall risk indexbased on the number of chronic disabilities has been advocated.2 Earlier studies of fall factors, incidence, and morbidityfound that those who sustained falls were more likely to be sufferingfrom dementia, were prescribed more sedating drugs,and had abnormal balance and gait compared with age- andsex-matched control patients. In addition, orthostasis, arthritides,incontinence, and strokes were more prevalent in thesepatients. 3–5 A fall risk assessment that incorporates psychotropicand other psychoactive medications has been developed(Figure 1), 6 and medications implicated in falls have beendescribed. 7 A multifactorial intervention to reduce the risk offalling among the elderly living in the community has been developed.8Basic patient assessment method for pharmacistsThe pharmacist may benefit from using a universal problem-orientedmedical record (POMR) or medication therapymanagement (MTM) method to assess and recommendchanges in the patients’ drug regimen 51 as well as physical andlaboratory assessments that may be needed to optimize drugtherapy. We developed an online 15-hour (1.5–continuing educationunit) course on physical and laboratory assessment ofthe older adult; it is available at www.rxugace.com or www.shca-ga.org.The POMR method has four steps:(1) Perform a history of patients problems, including past andcurrent diagnoses, conditions, all medications, past operations,immunizations, and adverse drug reactions, as wellas abnormal physical and lab findings that need to be addressed.Some practitioners prefer to group problems byorgan system (e.g., cardiovascular, endocrine, pulmonary,gastrointestinal, genitourinary, neuropsychiatric, dermatologic).(2) Match the medications found with the problems list; actionmay be needed if there are medications or problems that donot match or are not addressed.(3) Assess how adequately each problem is being addressedby using the SOAP method for each problem: subjective (S)or complaints of the patient; objective (O) or things thatcan be assigned numerical values such as physical findingsof the vital signs of blood pressure, pulse, respiration,and temperature and lab values; assessment (A) of S and Ofindings for each problem; and plan (P) for communicationof the assessment of each problem.(4) Communication of the problems that need to be addressedto the appropriate prescriber, patients and their caregivers,and administrators responsible for the patient is themost important step of the process.The POMR process may be thought of as a part of the MTMprocess. The American Pharmacists Association (APhA) andNational Association of Chain Drug Stores released version 2.0of an MTM service model, which can be downloaded at www.nacdsfoundation.org, and a certificate training program developedby APhA and the American Society of Consultant Pharmacistsis available at www.pharmacist.com.DefinitionsPsychotropics are defined as anxiolytics, hypnotics, antipsychotics,and antidepressants. Psychoactives or central nervoussystem (CNS)-active agents include psychotropics and theprokinetic agent metoclopramide, narcotic or opioid analgesics,antiparkinson agents, anticonvulsants, muscle relaxants,antihistamines, and centrally acting antihypertensives. 7A patient’s total psychoactive drug load is best definedas the total number of psychotropic and other psychoactivemedications given on a regular (i.e., at least weekly) basis. Asneededmedications given on a less-than-weekly basis may beconsidered relevant if their usage occurred within 1 week of afall and the drugs involved were antipsychotics or longer-actingbenzodiazepines (BZs). 7e72 • JAPhA • 49:3 • M a y /Ju n 2009www.japha.orgJournal of the American Pharmacists Association

Fall prevention in older adults ReviewsFigure 1. Fall risk assessment instrumentAbbreviations used: CHF, congestive heart failure; NSAID, nonsteroidal anti-inflammatory drug.Original work not copyrighted; please copy and use in your practice. 6Journal of the American Pharmacists Association www.japha.org M a y /Ju n 2009 • 49:3 • JAPhA • e73

Reviews Fall prevention in older adultsFalls are defined as a patient found on the floor with noother explanation for position or unintentionally coming to theground or some lower level and other than as a consequenceof sustaining a violent blow, loss of consciousness, or suddenonset of paralysis as in stroke or epileptic seizure. Falls may benoted by the caregiver or from the charts and periodic reportsof the quality-assurance department of the facility. A multifactorialfall risk assessment instrument that emphasizes medicationshelps to quantify the risk of falls (Figure 1). 1–55Case 1 and self-assessment questionsCase 1A 77-year-old patient and her caregiver in your home careand assisted-living practice has concerns about falling. She hasa history of high blood pressure, depression, and osteoarthritis.You use Figure 1 to assess her fall risk (points per Figure1). From questioning her and her caregiver, she has no historyof falls but gets dizzy when she changes position from lyingdown to sitting and sitting to standing. You take her blood pressureand note that both systolic and diastolic pressure dropafter position change (124–130/70–74 to 105–110/55–60 mmHg). Both of these are evidence for orthostasis and dizziness(2 points for orthostasis and 1 point for dizziness on positionchange; 3 points total).You notice that she smells of urinary incontinence and cautionher and her caregiver about adequate fluid intake and notgetting up abruptly when she feels dizzy and waiting 10 to 15seconds to get over dizziness and holding onto her bed or chairuntil the dizziness subsides. Her forearm skin “tents” when theskin is held and pulled outward gently between two fingers anddoes not go down for 10 to 20 seconds; this poor skin turgorand the urine “sniff” test give a suspicion of urinary incontinence(2 points) that contributes to the orthostasis/dizzinessproblem.If you have lab data available and a recent urinalysis hasbeen done, checking the urine specific gravity (N = 1.005–1.030) and seeing recent values greater than 1.015 may indicaterelative dehydration and personal as well as caregiverfluid deprivation. Simply put, both the patient and her caregiverslearn that fluid taken in orally may leak without warningbecause of incontinence. The patient may be concerned thatshe cannot afford the incontinence underpads that prevent embarrassingleakage into the outer garments. She uses a walkerto access the toilet, which is in the next room. You recommenda closer placement of the bed to the toilet and a bedside toiletor bedpan for use when the patient feels she cannot make it tothe toilet “in time.”The patient is also taking hydrochlorothiazide 25 mg daily(1 point) for high blood pressure and propoxyphene napsylate/acetaminophen (2 points) 10 to 15 doses per week for chronicosteoarthritis pain. The diuretic may contribute to the patient’sincontinence, orthostasis, and dizziness, which she says occursseveral times per day. Safer alternatives for her high bloodpressure may be an angiotensin-converting enzyme inhibitorsuch as lisinopril 5 to 20 mg/day or an angiotensin receptorblocker such as valsartan 80 to 120 mg/day. Propoxyphene isinappropriate for pain in the older adult 30 because of increasedrisk of falls, abnormal heart rhythms, emergency room visits,hospitalizations, and deaths in the older adult. 17–31 Plain acetaminophen500 mg every 4 hours as needed or on an every-4-hour schedule (e.g., 6:00 am, 10:00 am, 2:00 pm, 6:00 pm,10:00 pm) for pain may be a much safer alternative for thispatient’s pain. 31 Regular use of acetaminophen 3.0 g/day alsohas been shown to decrease behavioral symptoms by 63% andallow 75% of psychotropic medications to be stopped in patientswith cognitive impairment. 32 Further anecdotal evidencefor acetaminophen intervention in frequent fallers given psychotropicswith cognitive impairment found that up to three offive (60%) of these patients exhibited less agitation when givenacetaminophen on a regular basis in place of the stepwise (i.e.,one-drug-at-a-time) and carefully tapered (Table 3) schedulefor each psychotropic drug(s). 33A check for any other conditions, drugs, and diagnosesreveals that she does have a new prescription for zolpidem 5mg as needed for sleep (2 points) that you dispensed the previousweek. You ask about her sleep patterns and learn thatshe takes a 1- to 2-hour nap after each meal and discover thatneither she nor her caregiver understand that this may be thereason she can not sleep well at night. She has only taken twodoses in the previous week but felt very weak and groggy andunstable on her feet the morning after each dose and almostfell each time she got up during the night and on awakening inthe morning. Past research also has shown that medicationsgiven for sleep more than once or twice a week may increasefall risk markedly. 13You counsel her and her caregiver on changing her daytimesleep patterns and staying out of bed until she is ready to go tosleep at night. A recent study suggests that by avoiding longdaytime naps and giving hypnotics no sooner than 11:00 pmto midnight, patients may request fewer doses of hypnotics. 34Her depression is not being currently treated with medications,and she has signs and symptoms consistent with depression.This assessment will not be addressed until all other medicationchanges are made.According to the fall assessment (Figure 1), the patient hasa total of 10 points, which places her at high risk for falling.Which of the following changes in her medications would yourecommend?Self-assessment questions1. In place of her hydrochlorothiazide, you recommendwhich of the following?a. An angiotensin-converting enzyme inhibitor such aslisinoprilb. An angiotensin II receptor blocker such as valsartanc. A calcium channel blocker (e.g., diltiazem) or a betablocker (e.g., atenolol)d. Alternative a or b is correct.2. In place of her propoxyphene/acetaminophen, yourecommend which of the following?e74 • JAPhA • 49:3 • M a y /Ju n 2009www.japha.orgJournal of the American Pharmacists Association

Fall prevention in older adults Reviewsa. Acetaminophen alone on a regular or as-needed scheduleb. Hydrocodonec. Tramadold. Fentanyl3. In place of her zolpidem, you recommend which ofthe following?a. No naps after mealsb. Activities to prevent sleep after mealsc. If zolipdem is needed, hold until 11:00 pm to midnightd. All of the above alternatives are correct.4. If the patient had been taking other psychotropicmedications such as anxiolytics and/or antipsychotics,her fall risk could be decreased by which of thefollowing?a. Abruptly stopping all psychotropic drugsb. Stepwise discontinuance of her psychotropic drugs(i.e., one drug at a time)c. Careful tapering of each psychotropic drug to avoidwithdrawal reactionsd. Alternatives b and c are correct.Answer key: 1. d; 2. a; 3. d; 4. dEvidence for medication association withfalls and fracturesA study of physical and pharmacologic “restraint” of 307nursing home patients with dementia showed that 43% to 45%of residents received medications that could be viewed as pharmacologicrestraints. Residents with physically abusive behavior,infrequent family visits, and severe cognitive impairment(i.e., lack of recall or orientation to time, place, or person) weremore likely to receive pharmacologic restraints. 9 An earlier1-year study of 33,351 Illinois nursing home residents foundthat 60% received at least one psychotropic medication duringthat year. 10 In 4,501 cases of hip fracture among ambulatorypatients 65 years of age or older, 11 BZs with a longer half-lifehave been associated with a greater risk of falls and hip fracturecompared with BZs with a shorter half-life.Self-assessment questions5. The nursing home patient with which of the followingmay be more likely to receive pharmacologic “restraints”with psychotropics?a. Physically abusive behaviorb. Infrequent family visitsc. Severe cognitive impairmentd. All of the above alternatives are correct.6. Severe cognitive impairment may involve lack of patientrecall or orientation to which of the following?a. Timeb. Placec. Persond. All of the above alternatives are correct.Answer key: 5. d; 6. dBoth long- and shorter-acting BZs markedly increase therisk of falls. Serum diazepam blood levels have been directlycorrelated with the incidence of falls. 12 Even shorter-actingBZs (e.g., triazolam, oxazepam) given more often than one totwo times per week have been associated with increased fallrisk. 13 A study of the sensitivity of elderly individuals to triazolamfound that pharmacokinetic rather than pharmacodynamicdifferences between older and younger patients explained thegreater sensitivity to the drug. Peak serum triazolam concentrationwas approximately 50% higher and triazolam clearance50% lower in the elderly versus the younger group of patients. 14Both antipsychotics and antidepressants also have been shownto increase fall risk. 15 An association between antihistamines,narcotic analgesics, anticonvulsants, metoclopramide, antihypertensives,and falls in those taking other multiple psychoactive(i.e., both with and without psychotropics) medicationsalso has been reported. 16–20 The risk of falls is doubled for eachpsychotropic added to the patient’s drug regimen, both with andwithout other psychoactive medications (e.g., antihistamines,narcotic analgesics, anticonvulsants, metoclopramide, antihypertensives).24–28Self-assessment questions7. Both long- and shorter acting BZs have been shownto increase fall risk.a. Trueb. False8. Fall risk has been shown to be increased by both singleand multiple agent use of which of the following?a. Anxiolyticsb. Antipsychoticsc. Antidepressantsd. All of the above alternatives are correct.9. Fall risk has been shown to be increased by which ofthe following?a. Single psychoactivesb. Multiple psychoactivesc. Alternative a or b is correct with or without psychotropicdrugs.d. All of the above alternatives are correct.10. Fall risk increases by roughly how much for each psychotropicadded to a patients drug regimen?a. One-halfb. Two timesc. Three timesd. Four timesAnswer key: 7. a; 8. d; 9. d; 10. bMedication interventions and fallsBeneficial changes in psychotropic medications 17 and themultidisciplinary interventions of nurses, consultant pharmacists,and attending clinicians to reduce falls, injuries, andJournal of the American Pharmacists Association www.japha.org M a y /Ju n 2009 • 49:3 • JAPhA • e75

Reviews Fall prevention in older adultscosts 18–20 are also important means of fall prevention. In onestudy, buspirone intervention in place of BZs and/or antipsychotics,careful drug withdrawal by stepwise discontinuancewith tapering of 10% to 25% of the dose per week, or both alsohave been shown to decrease falls by 70% and improve cognitioncompared with similar patients. 17 The provisions of theOmnibus Budget Reconciliation Acts of 1987 and 1990 on appropriateuse of psychotropic drugs in the United States mandateat least two to three tapering attempts of anxiolytics andantipsychotic psychotropics within the first 6 to 12 months ofplacement within a nursing facility. Effective October 1, 2008,Medicare no longer reimburses for falls occurring in acute caresettings, as a “hospital-acquired condition.” 21 The newest Centersfor Medicare & Medicaid Services (CMS) guidelines stressthe need for gradual reduction of all psychotropic medicationdoses, including buspirone, unless patient dementia or otherneuropsychiatric illness worsens during attempts at tapering.Examples of the concept of adverse effects on rapid or suddenversus gradual drug withdrawal include seizures with BZs, tardivedyskinesia or return of schizophrenia signs and symptomswith antipsychotics, and serotonin syndrome and worsening ofdepression with rapid withdrawal of antidepressants. See www.cms.hhs.gov for the latest CMS guidelines for medications.A meta-analysis of 57 studies on the contribution of psychotropicdrugs to falls in older patients concluded that a small butconsistent association exists between the use of most classesof drugs and falls. The meta-analysis did not consider or defineinappropriate polypharmacy. 22 Falls were second only to nonsteroidalanti-inflammatory drug (NSAID) adverse drug reactionsas causes for adverse drug reaction hospitalizations fromthe long-term care facility. 23 A 1966–1999 review of psychotropicsand falls suggested that all psychotropics may increase therisk of falls and that each additional agent may increase theoverall risk by a factor of 2.0 per psychotropic. 24 A communitybased6-month study of 305 male veterans (age 70–104 years)using psychoactive CNS-active medications were screenedat study entry for mobility, cognition, and depression. CNSactivemedications were categorized as BZs, other sedative–hypnotics, neuroleptics, tricyclic antidepressants, and opioidanalgesics. Patients were prospectively followed for 6 monthsto monitor falls; at the end of this time period, patients wereclassified as fallers (at least one fall) or nonfallers. The relationshipbetween CNS-active drug use and falls was examinedusing multivariable analyses. The risk of falls was significantlygreater in CNS-active medication users compared with nonusers.Adjusted odds ratio (OR) was 1.54 (95% CI 1.07–2.22)for one CNS-active drug and 2.37 (1.14–4.94) for two or moreagents. In community-dwelling elderly, use of multiple CNS-activemedications is associated with enhanced fall liability comparedwith use of one CNS-active drug. 25Inappropriate polypharmacy and multiplepsychoactive drugsMultiple psychotropic and psychoactive drugs should betaken into account when fall interventions are evaluated, andreduction in total psychotropic and psychoactive drug load mayreduce fall occurrence and recurrence. 26–28 Simply put, eachadditional psychotropic doubled the rate of falls, as suggestedby an earlier review 24 and research. 26–28 An earlier study in thispopulation indicated that those who had psychotropic drugs tapered,changed to other agents, and/or discontinued had fewerfalls and injuries and less cognitive decline over 1 year. 17 A differencewas observed in the mean Reisberg global deteriorationscale 29 in those with a diagnosis of dementia between usersof psychotropic drugs (5.8 on 7-point scale) and those taperedto nonuse of psychotropic drugs (4.7) in the groups at the beginningof the study. 17The most recent finding is that all causes of hospitalizationof the older adult from long-term care are directly proportionalto the total psychoactive drug load. 28 The recent black boxwarning relabeling of all antipsychotics states that this classof medications should not be used for long periods in patientswith dementia because of greater risk of death—more evidencethat these drugs have high risk for the older adult. Pharmacistsshould review these black box warnings on antipsychotic packageinserts and patient education materials or at the Food andDrug Administration drug safety website (www.fda.gov/medwatch/safety).Anemia and vitamin D deficiency and fallsIn community-dwelling elderly, anemia is associated witha number of health-related functional declines, such as frailty,disability, and muscle weakness. These may contribute to falls,which, in the elderly, result in serious injuries in perhaps 10%of cases. Whether anemia increased the risk of injurious falls inan elderly population was investigated using health insuranceclaims and laboratory test results data from January 1999 toApril 2004 for 47,530 individuals 65 years of age or older enrolledin more than 30 managed care plans. 45Anemia in nursing home residents appears to be underrecognized.For residents older than 70 years, the prevalence ofanemia in one study for both men (Hb

Fall prevention in older adults ReviewsAnemia was significantly and independently associated withan increased risk for injurious falls. Furthermore, the risk ofinjurious falls increased as the degree of anemia worsened.Correction of anemia, which is a modifiable risk factor, warrantsfurther investigation as a means of preventing falls in theelderly. 45After a cause of anemia has been determined, perhaps thebest assessment and intervention by the pharmacist is to recommendiron 325 mg not more than once daily with vitaminC 500 mg to facilitate absorption if Hb is less than 10 g/L andthe anemia is normochromic and normocytic (i.e., hematocritto-Hbratio [H/H] of 3:1) or microcytic (H/H 3:1). Adding a proton pump inhibitor(PPI) to low-dose aspirin (ASA), which is used to lowerheart attack and stroke risk, may help prevent anemia from useof ASA or other NSAIDs and decrease iron and calcium absorption.To assess the effects of vitamin D on falls and fractures, asystematic review was conducted on the benefits and harms ofcalcitriol and alfacalcidol in reducing fracture and fall risk. 46Randomized controlled trials comparing these agents with placeboor calcium and reporting fracture and fall incidence wereretrieved from Medline, Embase, and the Cochrane CentralRegister of Controlled Trials. Two reviewers independently determinedstudy eligibility, assessed trial quality, and extracteddata. A total of 23 randomized controlled trials were included(2,139 participants), and 16 trials had sufficient data for metaanalysis.Vertebral fractures were not significantly reducedbased on the combined results of 13 trials; however, subgroupanalyses demonstrated a significant reduction with alfacalcidol(OR 0.50 [95% CI 0.25–0.98]) but not with calcitriol. A significantreduction in nonvertebral fractures (six trials; 0.51 [0.30–0.88]) and falls (two trials; 0.66 [0.44–0.98]) was observed.An increased risk of hypercalcemia (3.63 [1.51–8.73]) anda trend toward an increased risk of hypercalciuria were alsoseen. Evidence suggests that vitamins D agents may reduce theincidence of nonvertebral fractures and falls; however, theirbenefit on vertebral fracture reduction may depend on the typeof active vitamin D. Hypercalcemia and hypercalciuria are potentialadverse effects. 46The practical assessment of vitamin D status is to examinea current vitamin D level. If the level is less than 30 ng/mL (80 mmol/L), vitamin D 1,000 to 1,200 units/day may berecommended, although some prescribers are now using vitaminD 2doses as high as 50,000 units/week for 8 weeks. 56 Inadequatevitamin D levels and inadequate calcium supplementationalso have been implicated in increasing fall risk; vitamin Dsupplementation when serum levels are low may decrease fallrisk. 47,48The salt form of calcium is very important in the older adult.The citrate form is better absorbed and less likely to cause constipationcompared with carbonate, gluconate, or glucobionatesalts because of the high frequency of gastric achlorhydriaand gastroesophageal reflux disease (GERD) in the older adult.Therefore, use of histamine-2 (H 2) blockers (e.g., ranitidine)or PPIs (e.g., omeprazole), which further decrease calciumabsorption when salts other than the citrate are used, is mandated.At least 1,000 to 1,500 mg/day elemental calcium isrecommended in divided doses with meals to improve absorptionalong with adequate vitamin D to improve bone density anddecrease fracture risk, especially if the patient does not like oruse dairy products. 49 If constipation is noted on starting anycalcium supplement, recommend adding a polyethylene glycol(PEG) or sorbitol laxative rather than a fiber-based laxative,which can worsen constipation because of the inadequate fluidintake frequently seen in older adults. 50Intervention strategiesTable 1 lists intervention approaches for medications implicatedin falls. 1–55Case 2 and self-assessment questionsCase 2An 80-year-old male patient with a history of stroke, moderateto severe dementia, osteoarthritis, and numerous fallspresents to your nursing home on February 14, 2009, from anassisted-living facility that had admitted him on February 1,2009. His admission medication orders (date of order) includeASA 81 mg/day (December 15, 2008), olanzapine 5 mg twicedaily (January 6, 2009), quetiapine 50 mg at bedtime for sleep(January 31, 2009), oxycodone 10 mg/acetaminophen 325 mgonce every 6 hours as needed for pain (January 10, 2009; 27doses in previous month), methylphenidate 20 mg every morning(January 24, 2009), memantine 10 mg twice daily (February6, 2009), and phenytoin 300 mg every morning (January14, 2009). He has an ataxic, drunken-like gait on walking; hasnystagmus; has fallen six times with bruising but has no fractureson repeat emergency department visits and X-rays; is notoriented to time, place, or person; and is alert only in the morningfor a few hours after methylphenidate is given. He sleepsmost of the day, especially after meals. He has had four impactionsduring the previous 2 months that resolved with enemas.He had grand mal seizure activity after methylphenidate andmemantine were started. Seizures were no longer present afterhis phenytoin was started, but he is toxic on 300 mg/day. His vitalsigns (temperature, pulse, and blood pressure) are all withinnormal limits, and he does not get dizzy or have considerableblood pressure decrease on arising from a prone position. Hislab work shows a low Hb (9 g/L) and hematocrit (27%) and avitamin D level of 21 ng/ml. His phenytoin level is very high at28 µg/mL (normal 5–12 µg/mL) with normal serum albumin.His stool is positive for occult blood and his serum chemistriesfor electrolytes, renal, thyroid, parathyroid, and hepatic functionare all within normal limits, except for an elevated bloodurea nitrogen–to–serum creatinine ratio that further indicatesoccult gastrointestinal bleeding. His creatinine clearance wasalso calculated to be 42 mL/min, which mandated a decrease inJournal of the American Pharmacists Association www.japha.org M a y /Ju n 2009 • 49:3 • JAPhA • e77

Reviews Fall prevention in older adultsTable 1. Intervention approaches for medications implicated in falls 1–55Drug(s)Multiple psychoactivemedicationsBenzodiazepinesAntidepressantsAntipsychoticsNarcotic/opioid analgesicsAntihistaminesAnticonvulsantsAntiparkinson agentsAntihypertensivesAnemia (hemoglobin

Fall prevention in older adults Reviewsrepeat drug level in 2 weeksb. Alternative a and taper phenytoin by 50 mg/day eachweek after the other drugs are tapered to discontinuanceif no further seizures occurc. Alternatives a and b are correct.d. Leave dose as is17. His vitamin D level is low. Does any evidence existthat vitamin D supplementation may prevent fallsand injuries from falls?a. Yesb. No18. What dose of daily vitamin D is recommended forlow vitamin D levels?a. 400–600 unitsb. 600–800 unitsc. 800–1,000 unitsd. 1,000–1,200 units19. You also note that he is not taking any calciumsupplement and does not like dairy products. Whichcalcium salt is preferred in the older adult?a. Citrateb. Carbonatec. Gluconated. Glucobionate20. How much elemental calcium needs to be takendaily?a. 500 mgb. 500–750 mgc. 750–1,000 mgd. 1,000–1,500 mg21. The patient received 27 doses of oxycodone/acetaminophenthe past month or roughly one dose perday. What first-line drug could have been given on aTable 2. Medications that increase the risk of falls for patients 65 years of age or olderAlprazolam (Xanax) Fentanyl (Duragesic) Paroxetine (Paxil)Amitriptyline (Elavil) Fluoxetine (Prozac) Pentobarbital (Nembutal)Amobarbital (Amytal) Fluphenazine (Permitil, Prolixin) Perphenazine (Trilafon)Amoxapine (Asendin) Flurazepam (Dalmane) Phenelzine (Nardil)Aripiprazole (Abilify) Fluvoxamine (Luvox) PhenobarbitalBaclofen (Lioresal) Gabapentin (Neurontin) Phenytoin (Dilantin)Bupropion (Wellbutrin, Wellbutrin SR) Halazepam (Paxipam) Pimozide (Orap)Buspirone (Buspar) Haloperidol (Haldol) Pregabalin (Lyrica)Butabarbital Hydrocodone (Vicodin) Primidone (Mysoline)Carbamazepine (Tegretol, Tegretol XR, Carbatrol) Hydromorphone (Dilaudid) Propoxyphene (Darvon, Darvocet)Chloral hydrate Imipramine (Tofranil) Protriptyline (Vivactil)Chlorazepate (Tranxene) Isocarboxazid (Marplan) Quazepam (Doral)Chlordiazepoxide (Librium, Limbitrol, Librax) Levetiracetam (Keppra) Quetiapine (Seroquel)Chlorpromazine (Thorazine) Levorphanol (Levo-Dromoran) Risperidone (Risperdal)Citalopram (Celexa) Lorazepam (Ativan) Secobarbital (Seconal)Clidinium-chlordiazepoxide (Librax) Loxapine (Loxitane, Loxitane C) Sertraline (Zoloft)Clomipramine (Anafranil) Maprotiline (Ludiomil) Temazepam (Restoril)Clonazepam (Klonopin) Mephobarbital Thioridazine (Mellaril)Clozapine (Clozaril) Meprobamate (Miltown, Equanil) Thiothixene (Navane)Codeine (Tylenol with Codeine) Mesoridazine (Serentil) Tiagabine (Gabatril)Desipramine (Norpramin) Methadone (Dolophine) Topiramate (Topamax)Diazepam (Valium) Methsuximide (Celontin) Tranylcypromine (Parnate)Digoxin (Lanoxin) Mirtazapine (Remeron) Trazodone (Desyrel)Disopyramide (Norpace) Molindone (Moban) Triazolam (Halcion)Divalproex sodium (Depakote, Depakote ER) Morphine (MS Contin) Trifluoroperazine (Stelazine)Doxepin (Sinequan, Zonalon, Prudoxin) Nefazodone (Serzone) Trimipramine (Surmontil)Duloxetine (Cymbalta) Olanzapine (Zyprexa, Zyprexa Zydis) Venlafaxine (Effexor, Effexor XR)Escitalopram (Lexapro) Oxazepam (Serax) Ziprasidone (Geodon)Estazolam (Prosom) Oxycodone (Percocet) Zolpidem (Ambien)Ethosuximide (Zarontin) Oxymorphone (Numorphan) Zonisamide (Zonegran)Felbamate (Felbatol)Listed as generic name (brand name).Related University of North Carolina at Chapel Hill news release: http://uncnews.unc.edu/news/health-and-medicine/some-drugs-increase-risk-of-falling-unc-researchers.html.Journal of the American Pharmacists Association www.japha.org M a y /Ju n 2009 • 49:3 • JAPhA • e79

Reviews Fall prevention in older adultsregular basis to possibly decrease the need for theoxycodone?a. Acetaminophenb. Propoxyphenec. Tramadold. Alternative a and topical NSAID22. What laxative may need to be given on a regularbasis for this patient to decrease the need for enemas?a. Fiberb. PEGc. Sorbitold. Alternative b or c is correct.23. What drug may need to be added to prevent occultgastrointestinal bleeding from the ASA?a. Antacidsb. H 2blockersc. A PPId. None of the above alternatives is effective in decreasingASA bleeding.Answer key: 11–13. d; 14. c; 15. d; 16. c; 17. a; 18. d; 19. a; 20.d; 21. a; 22. d; 23. cCase discussion. This patient illustrates the complexity ofan older patient’s drug regimen and the sequence of eventsthat can occur. This patient was being treated by five differentphysicians during the course of his home care, assisted-livingplacement, and subsequent nursing home placement. Afterreviewing the prescribing sequence, dates, and suspected adversedrug events that occurred in this patient, the pharmacistcan discuss these findings with the attending prescribers andhopefully ensure that the primary care clinician is knowledgeableabout and agrees with the changes suggested. This teamintervention can improve the quality of the patient’s overallhealth care. Careful tapering to discontinuance or lower doseof the medications that contributed to falls and fracture risk(antipsychotics, oxycodone and phenytoin, and memantine)is appropriate in this patient. His seizures were attributed tohis stroke, use of the CNS stimulant methylphenidate, and ahigher dose of memantine that was subsequently decreasedbecause of his renal function. He had some suspected seizureactivity at phenytoin 100 mg, and his dose was increased backto 150 mg/day. His cognitive impairment was ascribed to thetotal psychoactive load, especially olanzapine, quetiapine, andoxycodone and phenytoin toxicity. His anemia was thought toresult from a history of GERD and taking ASA without gastroprotection,and a PPI was added. His constipation was consideredto result from inadequate fluid intake, the antipsychotics,and oxycodone, and a PEG laxative was started. His daytimesleeping and nighttime insomnia were considered to becaused by the adverse drug reaction sequence of the olanzapineleading to oversedation, then methylphenidate was startedto “perk him up” according to one prescriber, which led to theneed for quetiapine from another prescriber taking call overthe weekend. All of the mentioned medication changes haveled to an improvement in his cognition (he now recognizesfamily and friends), constipation (no impactions, formed stooldaily), anemia (Hb 12.8 g/dL), and phenytoin (8 µg/mL), andno falls or seizures have occurred on the following regimen:Activity. The patient was up on a walker with assistance threetimes a day, before meals, and before bed, was not nappingmore than 15 to 20 minutes after meals, and was engaging incraft activities in the morning and afternoon. He was using abedside urinal and shaving and showering daily.Medications. Acetaminophen 500 mg was given every 4 hours(6:00 am, 10:00 am, 2:00 pm, 6:00 pm, and 10:00 pm), andthe patient could have a sixth dose as a “sleep aid” if he awokeduring the night no sooner than 2:00 am; 5% ketoprofen gelwas applied in “pencil eraser size” to knees and shoulderstwice daily.■■ PEG powder (Miralax): one capful with full glass of waterevery morning■■ Memantine: 10 mg every morning■■ Phenytoin: 150 mg daily at bedtime■■ASA: 81 mg daily■■ Iron sulfate: 325 mg with ascorbic acid 500 mg everymorning■■ Calcium citrate: 630 mg with vitamin D 400 units withTable 3. Key points of current article assessing fall prevention in older adult patients 1–54Multifactorial risk assessment is a helpful tool to evaluate fall risk.Psychoactive/psychotropic polypharmacy greatly increases fall risk; carefully inventory and reduce, taper, and/or discontinue medicationsthat may be associated with falls and that do not cause adverse drug withdrawal events.Do not abruptly stop medications; tapering doses drug by drug, one at a time is recommended. A rule of thumb is 10%–25% of the daily doseevery week to 2 weeks depending on the half-life of the drug. The longer the half-life, the longer the tapering period may be (e.g., diazepamand fluoxetine have half-lives of the parent drug and active metabolite that exceed 150 hours). 49Consider PRN medications as a possible cause if a fall occurred within 1 week of use and the medications were longer-acting BZs (e.g.,diazepam) or antipsychotics.OBRA ‘90 mandates two to three tapering attempts of anxiolytics and antipsychotics within the first 6–12 months of long-term care facilityplacement in the United States.Falls may be reduced by at least 70% by psychoactive medication interventions. 17 Recommend treatment of anemia and calcium citrate/vitamin D supplements in every older adult.Abbreviations used: BZ, benzodiazepine; OBRA ‘90, Omnibus Budget Reconciliation Act of 1990; PRN, as needed.e80 • JAPhA • 49:3 • M a y /Ju n 2009www.japha.orgJournal of the American Pharmacists Association

Fall prevention in older adults Reviewsbreakfast and supper meals■■ Omeprazole: 20 mg every morningIntervention outcome. The patient and his family are nowconsidering his return to assisted living with one attendingprescriber, medication supervision, and monthly medicationreview by the pharmacist at a savings of $3,500 to $4,000 permonth in care costs versus the skilled nursing facility.Table 2 lists some psychoactive medications that increasethe risk of falls for patients 65 years of age or older. Pleasealso see the related University of North Carolina at ChapelHill news release (available at http://uncnews.unc.edu/news/health-and-medicine/some-drugs-increase-risk-of-fallingunc-researchers.html).Table 2 does not include antihistamines,all anticonvulsants and opioids, and centrally actingsympatholytic antihypertensives. The complete list can bedownloaded at http://uncnews.unc.edu/images/stories/news/health/2008/drugslist.pdf.SummaryThis article has reviewed the effects of medications onfalls and offers suggestions to minimize fall risk by assessingall medications both prescribed and possibly needed toreduce fall risk. The recommendations that can be made aresummarized in Table 3. References 1 through 54 and onlineAppendix 1 give further evidence for the need and effectivenessof multimodality interventions.References1. Kiel DP, O’Sullivan P, Teno JM, et al. Health care utilizationand functional status in the aged following a fall. Med Care.1991;29:221–8.2. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderlybased on the number of chronic disabilities. Am J Med.1986;80:429–34.3. Prudham D, Evans JG. Factors associated with falls in the elderly:a community study. Age Ageing. 1981;10:141–6.4. Gryfe CL, Amies A, Ashley MJ. A longitudinal study of falls inan elderly population. I. Incidence and morbidity. Age Ageing.1977;6:201–10.5. Wild D, Nayak USL, Isaacs B. Characteristics of old people whofell at home. J Clin Exp Geront. 1980;2:271–7.6. Cooper JW. Preventing falls and fractures in nursing facility patients.Nurs Home Pract. 1994;2:28–30.7. Cooper JW. Drugs that cause falls in the nursing home. NursHomes. 1993;42:45–7.8. Tinetti M, Baker DI, McAvay G, et al. A multifactorial interventionto reduce the risk of falling among elderly living in the community.N Engl J Med. 1994;331:821–7.9. Sloane PD, Mathew LJ, Scarborough M, et al. Physical and pharmacologicrestraints of nursing home patients with dementia.JAMA. 1991;265:1278–82.10. Buck JA. Psychotropic drug practice in nursing homes. J AmGeriatr Soc. 1988;36:409–18.11. Ray WA, Griffin MR, Downey W. Benzodiazepines of long andshort elimination half-life and the risk of hip fracture. JAMA.1989;62:330–7.12. Jansen EC, Wachowiak-Andersen G, Munster-Swendsen J, etal. Postural stability after oral premedication with diazepam.Anesthesiology. 1985;65:557–9.13. Cooper JW. Falls and fractures in nursing home patientsreceiving psychotropic drugs. Int J Geriatr Psychiatry.1994;9:975–80.14. Greenblatt DJ, Harmatz JS, Shapiro L, et al. Sensitivity to triazolamin the elderly. N Engl J Med. 1991;324:1691–8.15. Cooper JW. Falls in nursing home patients receiving classicalantihistamines while stabilized on psychoactive medications. JPharmacoepidemiology. 1996;5:45–51.16. Ray WA, Griffin MR, Schaffner W, et al. Psychotropic drug useand the risk of hip fracture. N Engl J Med. 1987;316:363–9.17. Cooper JW, Cobb HH, Burfield AH. Buspirone conversion effecton falls, injuries, behavior and costs in a rural geriatric nursinghome population. Consult Pharm. 2001;16:358 –63.18. Cooper JW. Consultant pharmacist assessment and reduction offall risk in nursing facilities. Consult Pharm. 1997;12:1294–304.19. Cooper JW. Consultant pharmacist assessment of fall injuryincidence and costs within a nursing facility. Consult Pharm.1997;12:1305–9.20. Cooper JW. Reducing falls among patients in nursing homes.JAMA. 1997;278:1742.21. Centers for Medicare & Medicaid Services. Hospital-acquiredconditions (HAC) in acute inpatient prospective payment system(IPPS) hospitals. Accessed at www.cms.hhs.gov/Hospital-AcqCond/Downloads/HACFactsheet.pdf, February 15, 2009.22. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in olderpeople: a systematic review and meta-analysis. I. Psychotropicdrugs. J Am Geriatr Soc. 1999;47:30–9.23. Cooper JW. Adverse drug reaction-related hospitalizationsof nursing facility patients: a 4-year study. South Med J.1999;92:485–90.24. Sleeper R, Bond CA, Rojas-Fernandez C. Psychotropic drugs andfalls: new evidence pertaining to serotonin reuptake inhibitors.Pharmacotherapy. 2000;20:308–17.25. Weiner DK, Hanlon JT, Studenski SA. Effects of central nervoussystem polypharmacy on falls liability in community-dwellingelderly. Gerontol. 1998;44:217–21.26. Cooper JW. Drugs may have reduced effect of falls intervention.BMJ. 2001;322:675.27. Cooper JW, Freeman MH, Cook CL, Burfield AH. Psychotropicand psychoactive drug load assessment and falls in nursing facilityresidents. Consult Pharm. 2007:22:483–9.28. Cooper JW, Freeman MH, Cook CL, Burfield AH. Psychotropicand psychoactive drugs and hospitalization rates in nursing facilityresidents. Pharmacy Practice. 2007;5(3):140–4.29. Reisberg B, Ferris SH, deLeon MJ, et al. A global deteriorationscale for assessing dementia. Am J Psychiatry. 1982:139:1136–9.30. Fick DM, Cooper JW, Wade WE, et al. Updating the Beer’s criteriafor potentially inappropriate medication use in older adults.Arch Intern Med. 2003;163:2716–24.31. Perri M, Menon AM, Desspande AD, et al. Adverse outcomesassociated with inappropriate drug use in nursing homes. AnnPharmacother. 2005;39:405–11.32. Douzjian M, Wilson C, Schults M, et al. A program to use paincontrol medication to reduce psychotropic drug use in residentswith difficult behavior. Ann Long Term Care. 1998;6(5):174–8.33. Cooper JW, Burfield AH. Acetaminophen intervention in agitatedolder adults with cognitive impairment and multiple fallswith psychotropic agents. In preparation.Journal of the American Pharmacists Association www.japha.org M a y /Ju n 2009 • 49:3 • JAPhA • e81

Reviews Fall prevention in older adults34. Cooper JW, Burfield AH. Changes in hypnotic use with staffcaregiver education and medication order changes. In preparation.35. Shumway-Cook A, Silver IF, LeMier M, et al. Effectiveness of acommunity-based multifactorial intervention on falls and fallrisk factors in community-living older adults: a randomized,controlled trial. J Gerontol A Biol Sci Med Sci. 2007;62:1420–7.36. Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-relatedinjuries in long-term care: a randomized controlled trial of staffeducation. Arch Intern Med. 2005;165:2293–8.37. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomisedtrial of a targeted multifactorial intervention to prevent fallsamong older people in hospital. BMJ. 2008 ;336:758–60.38. Daal JO, van Lieshout JJ. Falls and medications in the elderly.Neth J Med. 2005;63(3):91–6.39. Reifkohl EZ, Bieber HL, Burlingame MB, Lowenthal DT. Medicationsand falls in the elderly: a review of the evidence and practicalconsiderations. P&T. 2003;28:724–33.40. American Geriatrics Society, British Geriatrics Society, AmericanAcademy of Orthopedic Surgeons Panel on falls prevention.Guideline for the prevention of falls in older persons. J AmGeriatr Soc. 2001;49:664–72.41. Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventionsfor preventing falls in elderly people. Cochrane Database SystRev. 2009;Apr 15(2):CD000340.42. Tinetti ME. Preventing falls in elderly persons. N Engl J Med.2003;348:42–9.43. McClure R, Turner C, Peel N, et al. Population-based interventionsfor the prevention of fall-related injuries in older people.Cochrane Database Syst Rev. 2005;Jan 25(1):CD004441.44. Pandya N, Bookhart B, Mody SH, et al. Study of anemia in longtermcare (SALT): prevalence of anemia and its relationship withthe risk of falls in nursing home residents. Curr Med Res Opin.2008;24:2139–49.45. Duh MS, Mody SH, Lefebvre P, et al. Anaemia and the risk of injuriousfalls in a community-dwelling elderly population. DrugsAging. 2008;25:325–34.46. O’Donnell S, Moher D, Thomas K, et al. Systematic review ofthe benefits and harms of calcitriol and alfacalcidol for fracturesand falls. J Bone Miner Metab. 2008;26:531–42.47. Prince RL, Austin N, Devine A, et al. Effects of ergocalciferoladded to calcium on the risk of falls in elderly high-risk women.Arch Intern Med. 2008;168:103–8.48. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, et al. Effectof vitamin D on falls: a meta-analysis. JAMA. 2004;291:1999–2006.49. American Hospital Formulary Service Drug Information 08. Sectionson oral calcium salts and vitamin D. Bethesda, MD: AmericanSociety of Health-System Pharmacists; 2008:2722, 3658.50. Wade WE, Cooper JW. Bowel obstruction associated with fiberadministration within an entire nursing facility population. JGeriatr Drug Ther. 1997;12(1):94.51. Cooper JW, Burfield AH. Medication therapy management(MTM) strategies for geriatric patient interventions: MedicarePart D implementation. Ann Long Term Care. 2007;15(7):33–8.52. Centers for Disease Control and Prevention, National Centerfor Injury Prevention and Control. Web-based Injury StatisticsQuery and Reporting System (WISQARS). Accessed at www.cdc.gov/ncipc/wisqars, January 15, 2007.53. Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall riskin community-living older adults: a 1-year prospective study.Arch Phys Med Rehabil. 2001;82(8):1050–6.54. Hornbrook MC, Stevens VJ, Wingfield DJ, et al. Preventing fallsamong community-dwelling older persons: results from a randomizedtrial. Gerontologist. 1994:34(1):16–23.55. Cooper JW. Reducing psychotropic drugs reduces falls in elderlypeople. BMJ. 2001;323:402.56. Holick MF. Vitamin D deficiency. N Engl J Med. 2007;357:266–81.e82 • JAPhA • 49:3 • M a y /Ju n 2009www.japha.orgJournal of the American Pharmacists Association

Fall prevention in older adults ReviewsAssessment QuestionsInstructions: The assessment test for this activity must be taken online; please see “CPE Processing” below for further instructions.There is only one correct answer to each question. This CPE will be available online at www.pharmacist.com no later thanMay 31, 2009.1. Falls are the leading cause of injury-related deathsand the most common cause of nonfatal injuries andhospital trauma admissions among older adults.a. Trueb. False2. Fall risk may involve which of the following?a. Physical mobility issuesb. Medicationsc. Home and environmental safetyd. All of the above alternatives are correct.3. A comprehensive fall-reduction strategy that addressesphysical mobility and ability to accomplishactivities of daily living, medication management,home/room safety, and environmental (community)safety can be effective. However, failure of the strategyresults from which of the following?a. Single causeb. Multiple causesc. Not considering drugsd. Alternatives b and c are correct.4. In addition to the four areas noted in question 3,most falls result from multiple risk factors thatshould also be taken into account.a. Trueb. False5. Psychotropics are defined asa. Anxiolytics and hypnotics.b. Antipsychotics.c. Antidepressants.d. All of the above alternatives are correct.6. Psychoactives or central nervous system–activeagents are considered psychotropics anda. Metoclopramide and narcotic or opioid analgesics andantiparkinson agents.b. Anticonvulsants and muscle relaxants.c. Antihistamines and centrally acting antihypertensives.d. All of the above alternatives are correct.7. According to the risk assessment for falls shown inFigure 1, what point total is considered high risk forfalls?a. 2–5b. 5–7c. ≥8d. ≥108. Regular use of acetaminophen 3.0 g/day in patientswith dementia has been shown toa. Decrease behavioral symptoms by 63%.b. Allow 75% of psychotropic medications to be taperedand stopped in patients with cognitive impairment.c. Alternatives a and b are correct.d. Have no effect.9. Giving hypnotics more often than how many timesper week has been shown to increase fall risk?a. Once or twiceb. Two to three timesc. Three to five timesd. NightlyCPE Credit:To obtain 2.0 contact hour of continuing pharmacy education credit (0.2 CEUs) for “Medication interventions for fall preventionin the older adult,” go to www.pharmacist.com and take your test online for instant credit. CPE processing is freefor APhA members and $15 for nonmembers. A Statement of Credit will be awarded for a passing grade of 70% or better.You have two opportunities to successfully complete the posttest. Pharmacists who complete this exercise successfullybefore May 1, 2012, can receive credit.The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider ofcontinuing pharmacy education. The ACPE Universal Activity Number assigned to the program by the accredited provider is202-000-09-122-H01-P.“Medication interventions for fall prevention in the older adult” is a home-study continuing education activity for pharmacistsdeveloped by the American Pharmacists Association.Journal of the American Pharmacists Association www.japha.org M a y /Ju n 2009 • 49:3 • JAPhA • e83

Reviews Fall prevention in older adults10. For each psychotropic added to a patient’s drug regimen,the risk of falls isa. The same.b. Doubled.c. Tripled.d. Quadrupled.11. Buspirone conversion and discontinuance of psychotropicshas been shown to decrease falls by whatpercentage?a. 20%b. 40%c. 70%d. 90%12. Medicare will no longer pay for falls that occur inwhich care setting?a. Acute careb. Skilled carec. Assisted livingd. Personal care13. Recent literature indicates that the number of hospitalizationsof residents of long-term care facilities isdirectly proportional toa. The number of adverse drug reactions and falls theyexperience.b. The number of adverse drug reactions they experience.c. The number of falls they experience.d. None of the above alternatives is correct.14. Which psychotropic class has been found to increasethe death risk for older adults with dementia?a. Anxiolyticsb. Antidepressantsc. Antipsychoticsd. Anticonvulsants15. The nursing home patient with which of the followingmay be more likely to receive pharmacologic “restraints”with psychotropics?a. Physically abusive behaviorb. Infrequent family visitsc. Severe cognitive impairmentd. All of the above alternatives are correct.16. Anemia increases fall risk in which of the following?a. Long-term careb. The communityc. Alternatives a and b are correct.d. Neither alternative a nor b is correct.17. Which may decrease fall and fracture risk?a. Vitamin Db. Calciumc. Alternatives a and b are correct.d. Neither alternative a nor b is correct.18. The best way to decrease psychoactive load is toa. Abruptly stop all psychoactives.b. Carefully taper to lower dose or stop one agent at atime.c. Taper slowly and watch for adverse drug withdrawaleffects.d. Alternatives b and c are correct.19. As a general rule, the half-life of a drug has what effecton the tapering schedule?a. The shorter the half-life, the longer it takes to taper.b. The longer the half-life, the longer it takes to taper.c. The longer the half-life, the shorter the tapering time.d. The half-life has no effect on the tapering.20. Fall risk prevention and intervention should be theresponsibility of thea. Prescriber.b. Pharmacistc. Nurse and caregivers.d. All of the above alternatives are correct.CPE Processing:Get your documentation of credit now! Completing a posttest at www.pharmacist.com/education is as easy as 1-2-3.1. Go to Online CE Quick List and click on the title of this activity.2. Log in. APhA members enter your user name and password. Not an APhA member? Just click “Create one now” to open anaccount. No fee is required to register.3. Successfully complete the CPE exam and evaluation form to gain immediate access to your documentation of credit.Live step-by-step assistance is available Monday through Friday 8:30 am to 5:00 pm ET at APhA Member Services at 800-237-APhA (2742) or by e-mailing InfoCenter@pharmacist.com.e84 • JAPhA • 49:3 • M a y /Ju n 2009www.japha.orgJournal of the American Pharmacists Association

Appendix 1. Partnerships and websites for prevention of fallsA number of innovative partnerships on the local, state, and national levels haveformed to address falls reduction using evidence-based approaches. Please seewebsites below for access to these approaches.For more information on falls prevention, consult the following resources:PARTNERSHIP WEBSITESSenior Injury Prevention Program, Alameda County Department of Public Healthhttp://www.acgov.org/PublicHealth/organization/divisions/ems/Resource/Falls_Manual_2003.pdfDownloadable version of the programs Preventing Falls for 60+ Adults manual. Toorder the associated video, contact Colleen Campbell at (510) 577-3535.Fall Prevention Center of Excellencehttp://www.stopfalls.orgThis website contains extensive information and resources on falls prevention, theStop Falls Newsletter, and directions on how to join the StopFalls NetworkCalifornia.Falls Free: Promoting a National Falls Prevention Action Planhttp://www.healthyagingprograms.com/content.asp?sectionid=98This website contains the action plan developed during the Falls Free Summit, aswell as background research and related information.Fallproof! A Comprehensive Balance and Mobility Training Program by Debra J.Rose (available from Human Kinetics)http://www.humankinetics.com/products/showproduct.cfm?isbn=0736040889This evidence-based, multidimensional, practical manual provides detailedresearch and instruction on mobility and balance.Generations Winter 2002–2003 issuehttp://www.generationsjournal.org/generations/gen26-4/toc.cfmThis issue of ASA’s quarterly journal is devoted to falls and fall-related injuries.The Generations website lists the full table of contents. Back issues are alsoavailable for purchase.Home Safety Councilhttp://www.homesafetycouncil.orgThis website includes resources and research on home safety, a home assessmentchecklist, and the Safe Steps Program, a falls-prevention curriculum distributed toolder adult activity centers.National Resource Center on Supportive Housing and Home Modificationshttp://homemods.orgThis website has information and training on home modifications, including linksto home-safety checklists.

Perceptions of Risk and Sociocultural Barriers to Home Safety for Elders by JudithC. Barkerhttp://www.asaging.org/networks/NEST/max-124.cfmArticle in the spring 2005 issue of Maximizing Human Potential, the newsletter ofASA’s Network on Environments, Services, and Technologies for MaximizingIndependence.Research abstracts and articles from the Connecticut Collaboration for FallPreventionhttp://www.fallprevention.org/pages/abstracts_articles.htmThis website includes the American Geriatrics Societies Guideline for thePrevention of Falls in Older Persons.Tool Kit to Prevent Senior Fallshttp://www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htmThis CDC toolkit contains factsheets, informational graphics, and brochures aboutfalls prevention for older adults. There are also two books available from CDC asof 2008 : (1) Preventing falls: how to develop community-based fall preventionprogram for older adults and (2) Preventing Falls: What Works by J.A. Stevens andE.D. Sogolow.