Drugs that cause falls in the nursing home.

They are always a prime suspect

Many of the medications used in the nursing home patient may contribute to the tendency to experience falls. The newest OBRA guidelines regarding antipsychotics and benzodiazepines stress the need for careful and well-documented usage of psychotropic medications. However, many other drugs are psychoactive, in the sense that they affect patient cognition, balance and motor coordination, as well as pulse and blood pressure.

As many as one-half of nursing home patients are reported to have experienced a fall sometime during their stay.(1) This may be a conservative estimate, as other earlier studies detected a fall rate of two episodes per patient per year.(2) Falls are the leading cause of accidents and mortality due to injury in persons over 65 years of age.(1) Many falls go unreported unless physical injury results from the fall; the most common physical injury is a hip fracture. Additional acute complications from a fall include painful soft tissue injuries or bruises, subdural hematomas if the fall involves the head, and possible burns if the fall is in hot water of a shower or bathtub. The secondary complications from a fall may include immobility, hypothermia, deep vein thrombosis, stasis pneumonia, joint contractures, dehydration, urinary tract infection (especially if inappropriate indwelling catheterization is used), and pressure sores.

There has been a tendency for nursing facilities to use physical restraints to decrease falls. Unfortunately, there is also evidence that there is increased non-fall related injury with the use of physical restraints. The OBRA mandate to decrease use of ALL restraints, both physical and chemical, may have a paradoxical effect: the decreased use of physical restraints may lead to an increased risk of falls; the use of chemical restraints only for documented indications and where the patient is physically harming themself or others may also increase the risk of falls.

Case

L.L., an 83-year-old white female with moderate dementia was wearing a "sheet" restraint applied to her upper body. When it was removed, she fell from her wheelchair three times, and a Posey-type vest restraint was employed. No falls were recorded, but she became physically abusive and repeatedly kicked, bit and scratched her caregivers and any person with whom she came in contact. An order for haloperidol 1mg TID was started, and the physical restraint removed subsequent to a state inspection. The patient fell 13 times during the next month, but had only 4 episodes of hurtful behavior, compared to her daily abusive actions of the prior month.

A recommendation was made by her consultant pharmacist for a monthly drug regimen review to taper her haloperidol to 1mg BID for one week, then to once daily for a week, then 0.5mg daily for subsequent doses. On the next month's review the patient had fallen only twice and had 5 episodes of hurtful behavior.

Intrinsic and Extrinsic Factors in Falls

Host-related or intrinsic factors increasing the risk of falls include:

1. Dementia, especially more advanced stages.

2. Orthostasis, defined as a fall in systolic blood pressure of 20mm, or diastolic of 10mm mercury or more, when moving from supine to upright position; this tendency may be enhanced by urination and/or defecation syncope from the Valsalva maneuver, or "straining on voiding/stool," and post-meal syncope due to blood pooling in the gut to aid digestion. Many drugs, especially antihypertensives and psychotropics, produce additional orthostasis.

3. Arthritis, especially when mobility is limited. If narcotic analgesics are used (e.g. Darvocet-N 100, Talwin, Percocet, Vicodin, Lortabs), usually inappropriately, for arthritic pain, there is an increased tendency to fall and to experience confusion.

4. Incontinence of urine and/or bowel, past stroke or TIAs, abnormal balance and/or gait, Parkinsonism or seizures.

5. Age-related decreases in sight, hearing, reaction time, sensory awareness and increased body sway and impairment of righting reflexes. All the anticonvulsants (e.g. Dilantin, Depakene, Tegretol, etc.) may increase the possibility of falls, especially when the patient is ambulatory and may have a toxic level that is manifested as sedation or an ataxic (drunken) gait.

6. Metabolic (drug-related) causes, to include uncorrected hypothyroidism, hypoglycemia (insulin and oral antidiabetics), anemia (NSAIDs), low serum sodium and potassium and dehydration (diuretics).

7. Certain drugs, either singly or in combination (e.g. polypharmacy).

The following case serves to illustrate polypharmacy with unfortunate results:

G.J. was an 87-year-old black female with both mild to moderate dementia and depression who received thioridazine 25mg every morning and amitriptyline 25mg at bedtime. She had occasionally fallen, and had infrequent daytime sedation. On complaining of cold symptoms, she received an order for a chlorpheniramine maleate and phenylpropanolamine sustained-release preparation (i.e. generic Ornade) twice a day for 10 days. She became increasingly sedated over the next 3 days, and fell and fractured her hip on the fourth day of receiving her cold capsule along with both of her other drugs. She died within the week.

Key Point: Except for anticonvulsants in documented seizure history, all central nervous system depressants should be stopped when a sedating antihistamine is given to a frail older nursing home patient. An alternative for symptomatic cold treatment or chronic allergy is the use of the relatively non-sedating antihistamines Seldane or Hismanal. However, neither antihistamine should be given with erythromycin, Biaxin, Zithromax, Nizoral or Sporanox. This interaction may product a fatal torsades de pointes arrhythmia.

As for extrinsic factors, these include such environmental conditions as slippery floors or rugs, thick-pile carpeting, inadequate lighting, bed located too far from toilet and chairs, and beds and shelves rising too high for easy access.

Drug-Related Contributions to Falls

Perhaps the most studied drugs in relation to falls are the long-acting benzodiazepines (LABZs), e.g. Valium, Dalmane, Librium, Tranxene, Doral, Centrax, Paxipam, and Klonopin. The OBRA guideline for usage of these agents is that the use of any of these LABZs should be for no more than 10 consecutive days for sleep (although only Dalmane and Doral have FDA approval for sleep), or 4 consecutive months for anxiety or dementia UNLESS gradual dose reduction is attempted (not more than 10 to 15% of dose per week) and functional improvement is noted with use of the LABZ. The LABZ should also NOT BE USED initially in a patient unless a trial with a shorter-acting benzodiazepine (SABZ), e.g. Serax, Ativan, Xanax, Restoril or Prosom has failed to show similar functional improvement in anxiety, dementia or sleep disorder (NOTE: only Restoril and Prosom are FDA-approved for sleep).(3) A final caveat on the use of even SABZs: these drugs may also increase the risk of falls when used more often than 3 times per week.(4)

The antipsychotic drugs, e.g. Mellaril, Haldol, Navane, Prolixin, Stelazine, Moban, Serentil, Loxitane, Thorazine and Taractan, should NOT be used at all in nursing home patients unless, according to OBRA '90, the patient has an indication from the following:

Schizophrenia or schizo-affective disorder, delusional disorders, acute psychosis or mania with psychotic mood, brief reactive psychosis, atypical psychosis, Tourette's syndrome, schizophreniform disorder, Huntington's chlorea, short-term need of symptomatic treatment of nausea, vomiting, hiccups or itching, or dementia associated with psychotic or violent features that represent a danger to the patient or others. Continuous crying, screaming, yelling or pacing are indications if they impair functional capacity. Psychotic symptoms such as hallucinations, paranoia or delusions not otherwise related to the above which cause distress to the resident or impairment in functional capacity may also justify antipsychotic usage.

Antipsychotic drugs should NOT be used for the following if they are the ONLY indication:

Anxiety, restlessness, fidgeting, or wandering; insomnia; depression; memory impairment; uncooperativeness; poor self-care; unsociability; agitation; sedation; a need for calming; "inability to manage patient."

Reasons for the usage of antipsychotic drugs must be documented on the physician's orders or progress notes and in the patient care plan.

Antipsychotic drugs MUST be used in the minimal dose necessary to control the above indications. This minimalization may be assured by:

1. Gradual dose reductions attempted at least TWICE a year in an attempt to discontinue the drug if patient improvement is noted.

2. Using staff intervention to find out why the patient may have a behavioral problem.

3. Monitoring and documenting the HARMFUL patient target symptom or behavior (e.g. biting, scratching, kicking), and whether the target symptom is actually affected on a month-to-month basis by the antipsychotic.

4. Observing and documenting the adverse effects (e.g., sedation, falls, worsened behavior or disorientation/confusion, extrapyramidal symptoms (EPS) and tardive dyskinesia (TD)) on a monthly basis. The latter two movement disorders (EPS and TD) should be assessed at least every 6 months using an AIMS or similar scale.

5. The most common side effects of all drugs in use in the nursing home should be a part of the doctor's orders and medication administration record (MAR).

Other drugs may increase the risk of falls. Antihypertensives and cardiovascular drugs that lower blood pressure and/or pulse may predispose the patient to falls. Antidiabetics as well as diabetes itself may also predispose the patient to precipitous falls in blood pressure, especially on getting out of bed or a chair to the standing position. Aides must be given repeated inservices on the proper transfer of patient between the lying, sitting and standing positions. The observation of orthostasis, as evidenced clinically as patient complaints of "light-headedness," dizziness, fainting or acute weakness, should signal the need for increased vigilance.

In conclusion, whenever a patient falls in the nursing home, the drugs in use must be questioned. Prevention, however, is always the preferable approach. Any patient with three or more of the intrinsic risk factors mentioned above should be carefully evaluated. Special precautions to prevent falls should be part of the care plan and minimum data set. Alternative treatments to drugs -- especially psychotropics -- should also be considered.

James W. Cooper, Pharm.Ph.D., FASCP, FASHP, is Professor and Asst. Dean, College of Pharmacy, University of Georgia, Athens.

References

1. Kay AD, Tideiksaar R. Falls and Gait Disorders, in Merck Manual of Geriatrics, 1991; 52-61.

2. Sherman DS. Medication use and falls. Contemp Long Term Care 1991 (Nov); 66-68.

3. Cooper JW. Community and Nursing Home Practice Drug Therapy, OBRA Monitoring and Patient Education Guidelines-1993. Consultant Press, 1200 Colliers Creek Rd., Watkinsville, GA 30677; 22-23.

4. Cooper JW. Falls and fractures in nursing home patients receiving psychotropic drugs. Submitted for publication.