While medications might not be the sole contributor to fall risk, they are often a modifiable risk factor. Pain, which also affects mood, mobility, and sleep, can be successfully managed to reduce fall risk with the use of effective analgesics. Patients are often referred to the Bruyère Continuing Care Geriatric Day Hospital (GDH) in Ottawa, Ont, for management of these and other conditions over a 10- to 12-week admission period. During this time, medication review focuses on reduction of polypharmacy while maximizing effective therapy and minimizing medications that contribute to symptoms or that are no longer required.
This case illustrates how various cardiovascular therapies (eg, β-blockers, calcium channel blockers, loop diuretics) can contribute to dizziness, orthostatic hypotension, and subsequent falls in elderly patients. We describe how some of these medications were successfully tapered and discontinued with beneficial patient outcomes. Management of chronic pain is illustrated along with subsequent effects on mood, effects on sleep, and reduction in sedative use. Finally, the case demonstrates how 2 common undertreated conditions, anemia and low vitamin D levels, can contribute to falls.
Case
An 83-year-old woman was referred to the GDH for uncontrolled chronic pain and recurrent falls. Her pain was most pronounced in her low back, right hip, neck, and shoulder, hindering her sleep and affecting her ability to perform instrumental activities of daily living (IADLs), such as doing laundry. She had a history of falling about once per month, likely as a result of dizziness, loss of balance, and tripping over objects. Her medical history was relevant for rheumatoid arthritis, osteoporosis, osteoarthritis, and coronary artery disease (triple bypass 30 years previously), with a remote history of angina, pelvic fracture, depression, iron deficiency anemia, diet-controlled diabetes, gastroesophageal reflux pain, macular degeneration, insomnia, and previous minor stroke. Despite her medical history, she performed activities of daily living and IADLs independently (although with difficulty as indicated), with the exception of assistance for bathing. Bloodwork revealed a ferritin level of 18 μg/L, a hemoglobin level of 115 g/L, a vitamin D level of 76 nmol/L, and other results within the reference ranges; creatinine clearance was 31 mL/min (using the Cockcroft-Gault equation with ideal body weight). She organized her medications every night into a daily pill organizer but was unaware of the reasons for each medication.
During the initial assessment, falls and pain management were highlighted. It was believed that multiple factors contributed to the falls, including poor vision, lower extremity weakness, hypotension (initial blood pressure was 92/52 mm Hg), orthostatic hypotension, pain, mildly depressed mood, and anxiety. Poor sleep might have been contributing, as well as medications such as antihypertensives and benzodiazepines. The GDH pharmacist, nurse, social worker, occupational therapist, and physiotherapist were consulted. The pharmacist conducted a medication assessment that included a 45-minute comprehensive patient interview, chart review, and communication with both the patient and the community pharmacist. Each medication was assessed for indication, effectiveness, safety, compliance, and patient understanding.1 The results of the initial part of this assessment are outlined inTable 1.
History of medication experience: Medication history was relevant for amitriptyline and gabapentin, both of which were stopped in summer 2011 possibly to reduce fall risk, as well as iron supplements, which the patient had stopped taking on her own. The patient was allergic to acetylsalicylic acid (which caused a rash), possibly allergic to penicillin, and possibly allergic to rofecoxib (the patient said she was unaware of penicillin and rofecoxib allergies).
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If you are using this case report for group discussion, you can obtain instructions, discussion questions, and a blank worksheet on identifying drug-related problems and developing an interprofessional medication care plan from CFPlus.* You might print out the above case description and Table 1 for discussion before moving on to reading about the results of the medication assessment.
Signs and symptoms were assessed to determine potential drug causes, and drug-related problems were identified.2 The complete medication assessment is outlined inTable 2.
Medication care plan
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If you are using this case report for group discussion, you can obtain instructions, discussion questions, and a blank worksheet on planning interventions from CFPlus.* You might print out the above case description and Table 2 for discussion before reading about how the care plan was implemented.
On review of the medications and considering the need to reduce fall risk; optimize pain control, mood, and sleep; and reduce pill burden, the following changes were made without exacerbation of existing cardiac history: metoprolol, amlodipine, and furosemide were discontinued and the nitroglycerin patch dosage was reduced. Opioids for pain were changed from codeine with acetaminophen to controlled-release hydromorphone. Pain improved with visual analogue scores improving from 9 out of 10, to 2 to 3 out of 10; her sleep improved (zopiclone was discontinued). Her balance and mobility improved substantially, with a change in Berg Balance Scale score from 30 out of 56 to 45 out of 56 and an increase in 6-minute walking distance from 61 m to 347 m. She reported a resolution of her dizziness and had no further falls during her GDH admission. Chronologic steps taken to implement the medication changes throughout the admission are outlined inBox 1and a final medication list is presented inBox 2.
Discussion
Falls.
Low blood pressure and orthostatic hypotension might contribute to falls in elderly patients. Given the patient’s history of cardiac disease and hypertension, it is easy to see how she initially began medications such as metoprolol, amlodipine, nitroglycerin patches, and furosemide, all of which can lower blood pressure. As people age, they might become more susceptible to adverse effects of cardiovascular medications, particularly orthostatic and postprandial hypotension.3 In addition, the optimal blood pressure targets in this population are not known. We individualize blood pressure targets based on study data from octogenarian populations.4 This patient’s blood pressure was well below the target range, with concern rising especially from low systolic and diastolic readings (which can increase cardiovascular risk) and orthostatic hypotension.
Given that the patient’s bypass and angina occurred many years previously, metoprolol was tapered first. Withdrawing β-blockers can cause potential adverse drug withdrawal events including recurrent or unstable angina, hypertension, exacerbation of congestive heart failure, tachycardia, and anxiety.5 Therefore, we slowly tapered the dose (Box 1) and monitored for appearance of these symptoms; none was reported. Despite these changes, her blood pressure remained lower than the target level and this, along with her ankle edema, prompted discontinuation of amlodipine. The patient was happy that her chronic epigastric pain resolved following these changes. Her intermittent dizziness and low blood pressure persisted, with an automated blood pressure monitor reading of 86/53 mm Hg, and so furosemide was tapered and discontinued next, and the transdermal nitroglycerin patch dosage was reduced. These medication changes were not associated with any worsening of ankle edema, shortness of breath, or chest pain, and resulted in improved blood pressure readings of 94/54 mm Hg to 122/54 mm Hg (with only 1 systolic reading < 100 mm Hg in the last month of the program).
Other approaches to reducing fall risk included treating iron deficiency anemia (hemoglobin level increased to 126 g/L at discharge) and increasing vitamin D levels (subsequently increased to 131 nmol/L at discharge).6 She reported that her fracture risk was being assessed by her rheumatologist and, therefore, we did not add a bisphosphonate.
During her admission, the patient participated in balance, strength, and mobility exercises with the physiotherapist. The nurse provided education on management of orthostatic hypotension. Equipment needs were addressed by the occupational therapist.
Pain
Elderly patients commonly experience chronic pain. Worry over narcotic use and possible side effects in this population limits the use of potentially effective opioid therapy and leaves patients with inadequately controlled pain.7 Both uncontrolled pain and opioid use have been associated with falls and risk of injury.8,9 The latter might have prevented prescribers from considering stronger narcotics in this patient. The lack of effectiveness of codeine might have been an alert that this patient was unable to convert codeine to its active morphine metabolite. This case illustrates that a switch from codeine to an equivalent dose of controlled-release hydromorphone (titrated upward using regular hydromorphone) can be effective for pain in elderly patients. By reducing pain, resulting in improvements in balance, and by addressing safe transfers and facilitating walker use, fall risk was reduced. Improvement in pain scores from 9 out of 10, to 2 to 3 out of 10 using 3 mg of controlled-release hydromorphone twice a day also led to improvement in sleep. The patient did not report any substantial nausea or constipation and reported more independence and ease with activities of daily living and IADLs.
Poor sleep
Benzodiazepines and other sedative medications are associated with impaired balance and increased fall and fracture risk. Evidence for substantial improvement in sleep quality and quantity is limited.10 We have found that with gradual tapering and team support, most patients can discontinue sleeping medications with no adverse effects and often with improved sleep.11 With effective pain control, the patient’s sleep improved and we were able to successfully taper and stop zopiclone (chosen first for tapering because of its awful taste for the patient) without any evidence of withdrawal. Following this, we planned to taper her oxazepam; however, she experienced a substantial life stressor toward the end of the program, and we recommended to the patient’s family physician that oxazepam be tapered once her life circumstances had settled.
Intervention timeline:Initial pill burden = 21 pills daily; initial number of medications = 17; final pill burden = 21 pills daily; final number of medications = 14.
Week 1
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Medication schedule at discharge
am
Nitroglycerin spray when needed Polyethylene glycol eye drops when needed |
Other drug-related problems
The need for escitalopram was reviewed and it was believed that the benefit of mood improvement, particularly given the low dose, outweighed risk of falls, bleeding, or serotonin syndrome. Re-evaluating the ongoing need for this medication was to be pursued with the patient’s family physician.
Once pain and falls were well controlled, we attempted to taper pantoprazole, as it was contributing to a high pill burden and did not have a clear indication once the patient’s epigastric pain resolved (after stopping metoprolol and amlodipine). Pantoprazole might have been contributing to low ferritin levels and higher atorvastatin levels. Stopping proton pump inhibitors can result in rebound hypersecretion and thus we first switched 40 mg of pantoprazole to a lower dose of rabeprazole (the only low-dose proton pump inhibitor covered by the Ontario Drug Benefit program). However, the patient experienced nausea and nonspecific abdominal symptoms. While these might have been related to her new life stressors, we switched back to the original pantoprazole dose and recommended future tapering to the family physician.
Strategies for medication management
To organize her medications, the patient opted for a pharmacy-prepared pill organizer instead of preparing a pill organizer herself every night. Because of her low vision, the community pharmacist was asked to provide labels in a large font. To reduce pill burden, vitamin C was stopped. A medication chart outlining specific reasons for each medication, description of changes, and rationale for changes was prepared and reviewed periodically with the patient. A final copy was sent to her family physician with the discharge summary. The patient was encouraged to share this chart as a communication tool with all her health care providers.
Conclusion
This case highlights the importance of reviewing an elderly patient’s medications, as they might be causing or aggravating existing symptoms. By assessing each medication for indication, effectiveness, safety, and compliance, we were able to gradually taper and discontinue cardiovascular medications in order to improve balance and reduce fall risk. Gradual tapering of medications with monitoring for adverse drug withdrawal events was accomplished with biweekly visits to the GDH over a 10-week period. Optimizing treatment of pain with adequate hydromorphone treatment (starting with a low dose and increasing it slowly) contributed to improvements in mobility, function, and sleep. This further highlights that even frail elderly patients can benefit substantially from opioid use. The reduction in sedative use further reduced her fall risk. Our experience is that interprofessional team members, working together, can contribute to reducing polypharmacy while optimizing symptom management.
Acknowledgments
Financial support for this project is provided by the Bruyère Academic Medical Organization.
Notes
EDITOR’S KEY POINTS
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By assessing each medication for indication, effectiveness, safety, and compliance, we were able to gradually taper and discontinue cardiovascular medications in order to improve balance and reduce fall risk. Gradual tapering of medications with monitoring for adverse drug withdrawal events was accomplished with biweekly visits to the Bruyère Continuing Care Geriatric Day Hospital over a 10-week period.
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Optimizing treatment of pain with adequate hydromorphone treatment (starting with a low dose and increasing it slowly) contributed to improvements in mobility, function, and sleep.
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Our experience is that interprofessional team members, working together, can contribute to reducing polypharmacy while optimizing symptom management.
POINTS DE REPÈRE DU RÉDACTEUR
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En évaluant l’indication, l’efficacité et la sécurité de chaque médicament, ainsi que l’observance de la pharmacothérapie, nous avons été en mesure de procéder à un sevrage graduel et de cesser les médicaments cardiovasculaires pour améliorer l’équilibre et réduire les risques de chutes. Le sevrage progressif des médicaments avec une surveillance des incidents indésirables associés à la cessation de la médication a été accompli dans le contexte de visites aux 2 semaines à l’Hôpital gériatrique de jour, Soins continus Bruyère, sur une période de 10 semaines.
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L’optimisation du contrôle de la douleur grâce à une thérapie adéquate aux hydromorphones (en débutant par une faible dose augmentée lentement par la suite) a contribué à des améliorations sur les plans de la mobilité, du fonctionnement et du sommeil.
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Notre expérience est que les membres d’une équipe interprofessionnelle, collaborant ensemble, peuvent contribuer à réduire la polypharmacie tout en optimisant la prise en charge des symptômes.
Footnotes
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This article is eligible for Mainpro-M1 credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.
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Competing interests
None declared
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↵* Instructions, discussion questions, and worksheets on identifying drug-related problems and developing an interprofessional medication care plan and planning interventions are available at www.cfp.ca. Go to the full text of the article online and click on CFPlus in the menu at the top right-hand side of the page.
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This article is one of several prepared as part of a collaboration among the Bruyère Continuing Care Geriatric Day Hospital, the CMAJ, Canadian Family Physician, and the Canadian Pharmacists Journal to assist clinicians in the prevention and management of polypharmacy when caring for elderly patients in their practices.
- Copyright© the College of Family Physicians of Canada
