OLDER PEOPLE
upright posture requires adequate blood flow. A systolic reading of 110 mmHg or below increases the risk of falling. Any drug that reduces blood pressure or slows heart can cause falls. Stopping cardiovascular medicines reduces syncope and falls by 50 per cent.
A traffic light system has been developed to identify which drugs are more likely to cause falls[6]
. Examples
of red drugs are: benzodiazepines, sedating antidepressants, antipsychotics, thiazide diuretics, alpha blockers, beta blockers, opioid analgesics and alcohol. Amber drugs include: loop diuretics, SSRI’s and calcium channel blockers. Yellow drugs will include: antihistamines, acetylcholinesterase inhibitors, vestibular sedatives and anticholinergic drugs.
TABLE 1: TRAFFIC LIGHT SYSTEM Colour
Risk Red High Risk: can
commonly cause falls alone or in combination
Amber Moderate Risk: can cause falls especially in combination
Yellow Possibly causes falls, particularly in combination
Green NICE guidelines
MANAGING MEDICINES Pharmacists can help to reduce the incidence of falls related to medicines, by having medication reviews with patients. NHS Scotland has outlined a seven-step approach to conducting a
TABLE 2: MEDICINES REVIEW SEVEN--STEP APPROACH Steps
Aims
1.Identify objectives of drug therapy.
2. Identify essential drug therapy Need
3. Does the patient take unnecessary drug therapy?
medication review[7] . , which can also
be used to de-prescribe unnecessary medication[8]
FALL INTERVENTION NICE recommends that all older people with recurrent falls or assessed at increased risk of falling should be considered for multifactorial intervention[9]
. This would include:
strength and balance training, home hazard assessment and intervention, vision assessment and referral and a medication review with modification or withdrawal of some medicines[9]
.
The community pharmacy team can help identify patients who are at risk of falling in several ways, including: medicines use reviews to identify medicines that might cause a person to fall and refer to the GP where appropriate, giving advice and information to older people
Process
Review diagnoses and identify therapeutic objectives with respect to: - -
Management of existing health problems Prevention of future health problems
Identify essential drugs (not to be stopped without specialist advice): - -
Identify and review the (continued) need for drugs: - - - -
with temporary indications with higher than usual maintenance doses
with limited benefit in general for the indication they are used for with limited benefit in the patient under review
Effectiveness
4. Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy in order: - - - -
to achieve therapeutic objectives to achieve symptom control
to achieve biochemical/clinical targets to prevent disease progression/exacerbation
Safety
5. Does the patient have ADR or is at risk of ADRs?
Identify patient safety risks by checking for - - - - -
drug-disease interactions drug-drug interactions
robustness of monitoring mechanisms for high-risk drugs drug-drug and drug-disease interactions risk of accidental overdosing
Identify adverse drug effects by checking for - -
Cost effectiveness 6. Is drug therapy cost effective?
specific symptoms/laboratory markers (eg, hypokalaemia) cumulative adverse drug effects drugs that may be used to treat ADRs caused by other drugs
Identify unnecessarily costly drug therapy by: -
Consider more cost-effective alternatives (but balance against effectiveness, safety, convenience)
Adherence/ Concordance
7. Is the patient willing and able to take drug therapy as intended?
Identify risks to patient non-adherence by considering - - - - -
Is the medicine in a form that the patient can take? Is the dosing schedule convenient?
Is the patient able to take medicines as intended?
Might the patient benefit from the Chronic Medication Service (CMS)? Is the patient’s pharmacist informed of changes to regimen?
Ensure drug therapy changes are tailored to patient preferences by - -
24 - SCOTTISH PHARMACIST Discuss with the patient/carer/welfare proxy therapeutic objectives and treatment priorities
Decide with the patient/carer/welfare proxies what medicines have an effect of sufficient magnitude to consider continuation or discontinuation
Drugs that have essential replacement functions (eg, thyroxine) Drugs to prevent rapid symptomatic decline (eg, drugs for Parkinson’s disease, heart failure)
and their families on healthy living, including exercises and signposting to other services, such as sight and hearing. Information can be provided through leaflets and posters about suitable local exercise classes and online resources; however, muscle strengthening and balance programmes should be individually prescribed and monitored by a trained professional. The information provided should also be available in languages other than English.
SUPPORTING INDEPENDENT LIVING Older people are reluctant to accept advice on how to prevent falls, for a number of reasons. First, they think the information is only relevant to people much older and more frail than them. They also feel confident in their mobility and do not want to be labelled as ‘old’ or ‘frail’. Rather
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