IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read
The female athlete triad: Patients do best with a team approach to care; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to
www.aapa.org and searching for keyword
JAAPA post-tests. All others may complete and submit the post-test online at no charge at
www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.
KEY POINTS
■ Falls in older adults are common, estimated to occur in one-third of those 65 years and older and in 50% of those older than 80 years.
■ The CDC estimates that one older adult dies every 35 minutes as a result of fall-related injuries.
■ A review and modification of medications can significantly decrease the risk of falls in older adults.
A 75-year-old woman comes to your office for a routine physical examination. Her BP is 152/92 mm Hg, but her health has otherwise not changed from her previous appointment 1 year ago. She has a history of hypertension, osteoarthritis, osteoporosis, insomnia, macular degeneration, and depression. Her current medications include acetaminophen, 1,000 mg every 6 hours; alendronate, 70 mg once weekly; aspirin, 81 mg daily; diazepam, 5 mg at bedtime as needed for sleep; escitalopram, 10 mg daily; hydrochlorothiazide, 25 mg daily; and ramipril, 5 mg daily.
Most PAs would consider the hypertension to be the primary concern at this appointment. However, a comprehensive approach to this patient should also include an assessment of her risk of falling. The patient has several risk factors for falls, including a vision problem, age, polypharmacy, and the use of medications associated with an increased risk of falling.
FALLS: POTENTIALLY DEADLY BUT
LARGELY PREVENTABLE
Falls are common among older adults and result in substantial economic and quality-of-life burdens to individuals and society. An estimated one-third of older adults (65 years or older) will fall annually, with the percentage increasing to 50% for those older than 80 years.1 Of older adults who fall, up to 30% will sustain moderate to severe injuries, including hip fractures and traumatic brain injuries.2 Falls represent the leading cause of nonfatal injuries as well as the most common cause of injury-related death among older adults.3 Furthermore, the CDC estimates that one older adult dies every 35 minutes as a result
of fall-related injuries. The consequences of falls are substantial for both the individual and the health care system, with current annual expenditures for fall-related injuries exceeding $19 billion.3
Research over the past two decades has shown that falling is not inevitable but rather is a largely preventable consequence of having a multitude of modifiable risk factors; this research also shows that the incidence of falls increases as the number of risk factors increases.4 Guidelines for preventing falls have been developed by a variety of agencies, including the National Council on Aging (NCOA), the CDC, and the American Geriatrics Society (AGS). All these guidelines stress the importance of a multifactorial approach to prevention, including identification and resolution of medication issues.5-7
Despite the consequences of falls and their preventability, fall risk assessment remains largely ignored by health care providers. A 2003 survey of older US adults indicated that only 37% of them were asked about falls during routine office visits.8
Medications are well-recognized as a contributing factor to falls in older adults.5,6,9,10 Careful medication review is valuable for any patient but particularly so for older adults, who tend to take more medications, have more comorbid illnesses, and suffer more adverse drug reactions.11 Review and modification of medications have been shown to reduce the risk of falls, particularly when done as part of a multifactorial falls reduction plan.9 Potentially inappropriate and unnecessary medication use in older adults has been associated with impaired muscle strength and functional status, increased health care expenditure, and increased risk of hospitalization and death.12,13 After medication review and modification, the risk of falls decreases significantly.14 Overall, the hazard ratio was 0.48 (95% confidence interval [CI], 0.23-0.99); for cardiovascular medication withdrawal, it was 0.35 (95% CI, 0.15-0.82); and for psychotropic medication withdrawal it was 0.56 (95% CI, 0.23-1.38).14 Notably, cardiovascular medication withdrawal had the most marked results.
Economic benefits are also anticipated, though they have not been directly measured in the United States. In the Netherlands, withdrawal of medications associated with an increased risk of falls resulted in economic savings that were extrapolated to equal 15% of fall-related costs on a national level.15 These estimated savings also included the cost of assessment and follow-up and savings from decreased prescription and medical costs. If similar success was achievable in the United States, $2.85 billion could be saved annually.
This article provides an overview of medications most commonly associated with an increased risk of falls. This overview is followed by a discussion of the strategies PAs can employ to decrease the possibility of medication-related patient falls.