Medications and their side effects are a leading cause of falls in older Americans, and one that long-term care pharmacy providers needs to remain vigilant about. Falls in older adults can be debilitating, so it is important that all providers look out for medications that are known to have exaggerated side effects in older adults. Whenever possible, providers should stop medications, switch to safer alternatives, and reduce medications to the lowest effective dose. There are certain medications that should be monitored closely and are included in the BEERS Criteria, which are guidelines for providers to help improve the safety of medications in older adults.
What Is the BEERS Criteria?
For more than 20 years, the BEERS Criteria for Potentially Inappropriate Medication Use in Older Adults has been the gold standard for information on safe medication prescribing for seniors. The criteria are referenced in post-acute care pharmacy as part of regular medication reviews. The American Geriatrics Society has continued to regularly update and expand this resource to continue to help prevent adverse drug effects and other medication-related problems in older adults.Why Do We Need the BEERS Criteria to Mitigate Fall Risk?
As residents age, their bodies change. These changes include things such as decreased renal clearance and increased body fat percentage. Due to the way the body changes as we age, older adults are at an increased risk of having unintended side effects from medications they are taking. [Tweet “Every year one in three adults 65 and older has one or more adverse reactions to a medication http://bit.ly/2ld6EFN”] Every year one in three adults 65 and older has one or more adverse reactions to a medication. It’s important to remember that healthcare providers should not make prescribing decisions based only on the BEERS Criteria. The criteria does not apply to all residents in all situations. Furthermore, different residents respond differently to the same medication, and so it is possible that a medication on the list may be the best choice for some residents. As always use the best clinical judgment when making prescribing choices.Anticholinergic Burden and Fall Risk
Anticholinergic burden refers to the cumulative effect of using multiple medications with anticholinergic properties concomitantly. Medications with anticholinergic properties are commonly used in the elderly population. Some medications, such as atropine, benztropine, and oxybutynin are used specifically for their anticholinergic properties, and others such as diphenhydramine, cyclobenzaprine, and olanzapine have anticholinergic properties unrelated to their primary use. Studies have shown that medications with anticholinergic properties are associated with clinically significant adverse events such as blurred vision, dry mouth, urinary retention, constipation, cognitive impairment, confusion, delirium, increased heart rate, and drowsiness. While this list is in no way exhaustive of all of the potential adverse events associated with anticholinergic medications, it does highlight many of the adverse events that should be of concern to long-term care facilities and their residents, especially because of the ability of many of these adverse effects to increase fall risk. The risk of these adverse events increases with medications that have strong anticholinergic properties, higher doses of medications with anticholinergic properties, or a greater total number of medications with anticholinergic properties. Older adults are also more susceptible to the adverse events of anticholinergic medications due to physiological changes and preexisting clinical conditions. Older adults are both more likely to use medications with anticholinergic properties and are more sensitive to their adverse effects. It is important to assess anticholinergic burden in this population and take steps to reduce the burden. Medications with anticholinergic properties should be avoided in older adults whenever possible, unless deemed clinically necessary. If the medication is deemed a clinical necessity, it should be used at the lowest dose and for the shortest duration possible. The anticholinergic burden can be further reduced by replacing medications that have strong anticholinergic properties with alternatives or non-pharmacologic interventions.When a Fall Occurs
While it’s important to reduce fall risk through effective medication management, it’s impossible to eliminate falls in a long-term care setting. When a fall occurs, it is vital to assess the resident’s medications and determine what may have contributed to the fall. For instance, if a resident has recently fallen, take the time to look back and see if a medication dose has been increased, a new medication has been added, or if the resident has been requesting more of an as-needed medication that could contribute to a fall. By constantly reviewing resident’s therapies and creating an action plans when a fall occurs, a long-term care facility can provide residents with the best possible care. The chart below includes a sample of commonly prescribed medications which may contribute to falls:
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