Falls Risk in Older Patients

It is estimated that each year in Australia falls occur in 30% of people aged over 65 years living in the community, and 50% of people in residential aged-care facilities(1, 2). In 2018, around 28,000 Australians were hospitalised for hip fracture(3). Complications following hip fractures can be devastating, with 5% of patients dying in hospital, 10% of patients requiring ongoing care in an aged-care facility and more than 50% experiencing a persistent mobility-related disability one year after their fracture(4).

Other adverse outcomes include fear of falling, loss of independence and lower quality of life(2). Many falls can and should be prevented and healthcare workers should be evaluating falls risks regularly (at least annually).

There are multiple factors that may contribute to a person’s falls risk (2, 5): • Alcohol misuse (currently or previously) • Inappropriate footwear • Inappropriate eyewear • Poor lighting • Pets

• Rugs • History of previous falls • Cognitive impairment • Depression • Advancing age • Arthritis

• Dizziness

• Being female • Incontinence

• Certain medications

Medications are a modifiable risk factor that can be managed. The use of multiple (>5) medications increases the risk of falls, possibly due to an increased risk of adverse events, drug interactions or incorrect use of medicines(2). Additionally, certain types of medications are particularly likely to contribute to falls and fracture risk, including antihypertensives, benzodiazepines, antidepressants, antiepileptic medications, antipsychotics and opioids(2, 6).

Common medication side effects that may increase falls risk include medications that can cause postural hypotension, drowsiness, feeling unsteady, confusion, blurred or double vision and memory problems.

It is important to review all medications regularly and MedsChecks, Home Medicine Reviews and Dosage Administration Aids are all available options to assist with reviewing and managing medications and their side effects.

Strategies that reduce the patient’s exposure to medications contributing to falls risk should always be considered. This could include slow withdrawal under prescriber supervision, or using an alternative medication(5).

For example, a common drug interaction that should be avoided is selective serotonin reuptake inhibitors (SSRIs) with benzodiazepines. This combination leads to an increased risk of hip fractures in the elderly (notably, the risk is five-fold when both medications are newly initiated) and falls risks should be assessed before prescribing(7).

Other combinations that increase the risk of fractures in elderly patients include SSRIs with opioids and SSRIs with antipsychotics(7).

Another example would be switching from sedative medications for insomnia to melatonin, which causes less day time sedation. Cognitive behavioural therapy and sleep restriction may also benefit insomnia in older patients(8).

Other approaches to management of falls risk include:

• Incorporating exercise - A 2017 systematic review and meta-analysis found that exercise reduces the rate of falls in community patients by 21%, with greater benefit (rate reductions of 39%) in patients who used programs that challenged balance and exercised more than 3 hours each week(9).

• Employing a multidisciplinary approach - Encourage review of patient by allied health professionals such as occupational therapists (reduce hazards in the home), podiatrists (advise on appropriate footwear or exercises), and optometrists (monitor for changes to vision and give advice on eye wear).

• Consider vitamin D and calcium supplementation to improve bone mineral density and muscle function. Patients with low vitamin D levels should receive supplementation with at least 1000IU of cholecalciferol per day(8).

• Encourage the patient to sit and stand up slowly, and ensure adequate hydration(5)

Finally, we should always encourage our older patients to be active participants in their own fall prevention plan that encourages them to stay independent for longer.

References on the NorDocs website.

Alannah Mann is a Northern Rivers

Pharmacist