Now that you’ve screened patients for increased fall risk, assess for ways to optimize therapy
to create your patient care plan.
Medication review and management is one of the most effective tools in reducing fall
risk.
Begin by gathering information on all your patient’s medications.
If your patient is on an opioid or benzodiazepine, check prescription monitoring data for medications
from all prescribers. Pharmacists are really busy people, but
spending that time with patients or their medication records and just quickly reviewing
the records for fall risk is really important.
In the pharmacy setting, a few minutes can go a long way in those medication reviews.
For a medication review we include anything the patient is taking. It could be prescription
or non-prescription.
And for non-prescription medication, we’re including over-the-counter medications (OTCs)
and even herbal supplements. In older adults, some medications may need
to be tapered or changed. Generally: STOP medications when possible. SWITCH to
safer alternatives. And REDUCE medications to the lowest effective dose.
While it’s often hard to stop medications in older adults, optimizing medications can
improve patient safety.
We want to identify those potentially inappropriate medications, and then work with the patient
to find out what they are using it for,
and if it is something they absolutely need to be on, and how we can work with the other
providers, prescribers in the area, and to see if we can reduce the dose, or actually
get them off the medication, if that’s appropriate.
Consider medications without a current indication, look for duplicate prescriptions, and identify
any medication with risks that outweigh benefits.
Some medications require tapering to safely discontinue use, such as benzodiazepines.
Tapering is recommended for medications like antidepressants and opioids where gradually
reducing the dose is better tolerated.
I approach tapering a variety of different ways.
Looking at the half-life to see how long the medication is staying in the patient’s system,
but then also, importantly looking at the kidney function and the liver function of
the patient.
In general, I think most patients can taper off medications with a 10 to 25% dose reduction
every two to four weeks depending on the drug, so that would be my general approach,
and then I’ll taper that approach depending on, again, how long the patient’s been taking
the medication or what the potential risks are of stopping the medication quicker.
When tapering, working with the patient is key to success.
I also want to see if the patient is going to buy in to the tapering at all, because
we really need the patient to be able to follow a schedule and to be able to taper off that
medication successfully.
For medications with potentially harmful side effects, consider switching to an alternative
with a better safety profile.
For instance, for a patient taking Diphenhydramine for allergies, consider switching to a product
that does not increase drowsiness or dizziness, such as nasal saline or a second-generation
antihistamine.
Some suggested alternatives for common conditions are presented in the supplement to the updated
Beers criteria. Finally, for any needed medication, periodically
consider reducing the dose to find the lowest effective dosage.
Dosage reduction is important because as patients age, pharmacokinetics and pharmacodynamics
can change.
For example, an 85-year-old taking antihypertensive medication for decades may now be experiencing
orthostatic hypotension and need a lower dose.
Additionally, older adults may experience new and harmful side effects from medications.
For example, an acute illness can cause new side effects like dizziness, balance problems
or confusion.
As the patient ages, consider whether the benefits of aggressively controlling blood
pressure or blood sugar outweigh the potential harms.
We want to make sure that we use the minimum dose and a minimum number of medications that’s
going to give them a therapeutic outcome and not put them at risk of an adverse drug reaction.
When optimizing therapy, include non-pharmacologic recommendations to manage common symptoms
or conditions like sleep problems, pain, and anxiety.
Insomnia is a really tough condition to manage for patients because medications can cause
so many side effects, but there are non-pharmacologic options that could replace the patient’s
pharmacotherapy.
For example, cognitive behavioral therapy is a really evidence-based approach to helping
the patient sleep naturally and to get good restful sleep.
For sleep hygiene tips, click on “about sleep” at www.cdc.gov/sleep.
One of the non-pharmacological alternatives for pain would be physical therapy.
I think physical therapists are able to work with patients who have pain and allow them
to either decrease their pain through certain exercises or even become stronger through
those exercises.
It is important to focus on progress toward functional goals when managing chronic pain.
Effective non-pharmacologic options include: Physical treatments provided by a physical
therapist (such as exercise therapy and weight loss) and
Behavioral treatment provided by a mental health or behavioral health specialist (such
as cognitive behavioral therapy). For more information on alternatives to opioid
therapy, refer to CDC’s “Nonopioid Treatments for Chronic Pain”.
See www.cdc.gov/drugoverdose for the prescribing guideline and additional resources.
Anxiety is really a condition that often can be treated without pharmacologic treatment.
Patients will often benefit from breathing exercises for example,
and if they really do have severe anxiety, psychotherapy is going to be helpful for them,
and often in combination with low dose pharmacologic therapy if it’s really severe.
No matter what your practice setting or how you review medications, the goals are the
same: to optimize therapy, improve patient safety, and optimize health outcomes.
Use the JCPP process to evaluate the appropriateness of all medications. Consult clinical resources
and recent guidelines when necessary.
And, use your clinical judgment when making recommendations to prescribers.
I would advise pharmacists to be proactive when they’re working with older patients
and concerns about fall risks.
I would make sure that they understand that there are certain questions they need to be
asking the patient.
There are tools out there that they can be using that can help them to assess the patient’s
fall risk.
Making sure they are very aware of the literature, reading the most current information out there
regarding potentially inappropriate medications, making sure they are familiar with that.
Making sure they always have options that they’re going to make a recommendation to
discontinue therapy, so that we are not just identifying a problem and not giving a recommendation
to the prescriber.
Making sure that patients are educated.
Making sure that we have educational materials that are readily available to the patient,
and just making sure that we work collaboratively with the patient, physician and the pharmacy
are all working in unison.
Take a moment to review a patient case scenario. This is the first of three activities in the
training.
In each activity, you will act as the pharmacist and will have the opportunity to screen, assess,
and intervene in a different pharmacy setting.
You can download and print the full case from the resources section if you’d like.
In each of the activities, you will also have access to the patient’s medical history,
medication list, and lab results for the knowledge checks.
First, let’s meet our patient, Mr. Adams.
Mr. Adams is a 72-year-old African American male who comes to the emergency department.
He reports swelling in his legs, needs 3-4 pillows to sleep, has gained 5 pounds over
the past 2 days, and is having difficulty walking two blocks to the grocery store without
becoming short of breath.
He reports having sleep problems, worrying more, and feeling down.
To help him sleep, he has been taking Clonazepam 1 mg nightly for the past year, and reports
forgetting conversations he has in the early morning.
The emergency department staff concludes that he is experiencing a congestive heart failure
exacerbation. He is admitted to the hospital for diuresis and re-assessment of
his heart failure. Mr. Adams’ medical, family and social history
and medication list was compiled upon hospital admission.
As the pharmacist on the transitions of care team, you take a moment to review these.