Use of Psychotropic Medications by Older Adults Presenting to the Emergency Department After Fall-Related Injuries

Abstract

Falls are among the leading causes of morbidity and mortality in older adults in Hawai‘i. According to a recent report, 101 older adults in Hawai‘i died from falls from 2011 to 2015, while another 9,158 had fall injuries resulting in hospitalizations or emergency department visits. Because certain medications can increase the risk of falls, medication reviews should be a component of any fall treatment plan. The purpose of this column is to examine medication interventions attempted before hospital discharge in patients taking psychotropic medications upon admission after a fall. A retrospective review of electronic medical records was conducted for the year 2016. All older adults admitted to a large hospital in Hawai‘i after a fall-related injury who were taking a psychotropic medication were included. During the study period, 19 patients were admitted to the hospital on a psychotropic medication after a fall. Of the 19 patients, 18 (95%) had no change in their psychotropic medication during hospitalization. In 15 patients (79%), EMR documentation did not demonstrate an attempt to review psychotropic medications. The study confirms the need for medication reviews to address potentially inappropriate medications in older adults who are admitted to the hospital after a fall.

Introduction

Hawai‘i ranks eighth in the United States for the percentage of the state population that is aged 65 or older, with 16.5% of the population belonging to this group.1 Falls are a serious problem for older adults and are one of the primary causes of injuryrelated death in this age group in Hawai‘i and nationally. Over the 2011 to 2015 period, 101 Hawai‘i residents ages 65 and older died from fall-related causes, while another 9,158 people in this age group with fall injuries were treated at hospitals and emergency departments.2 Fall-related injuries continue to be a leading cause of functional decline, hospitalization, and early entry into residential care.3–5

Although most falls are multifactorial in etiology, medications play a significant role in increasing the risk of falls. Psychotropic medications are drugs that affect brain activities associated with mental processes and behavior. Psychotropic medications represent an independent modifiable risk factor for falls and should be included in any medication assessment.6,7 Psychotropic medications can impair mood, decision making, and behavior. Antipsychotics, antianxiety medications, antidepressants, and hypnotic medications are considered psychotropic medications based on the Centers for Medicare and Medicaid Services’ Minimum Data Set 3.0 definitions.8 The American Geriatrics Society / British Geriatrics Association Clinical Practice Guideline: Prevention of Falls in Older Persons recommends that those who present for medical attention because of a fall, report recurrent falls in the past year, or report difficulties in walking or balance (with or without activity curtailment) should have a multifactorial fall risk assessment.9 The multifactorial fall risk assessment includes numerous medication-related interventions. The medication risk assessment starts with a medication review of all prescribed and over-the-counter medications. Interventions to discontinue or minimize psychotropic medications should be considered as these medications are consistently linked to increased risk for falls.7, 10–13

We have heard anecdotally that, upon hospital admission and through discharge, medication reviews and other interventions geared toward eliminating psychotropic medications seldom occur; however, published literature on the topic is scarce. This problem is significant for all health care organizations because patients who have fallen are at high risk for future falls.14,15 Therefore, steps must be taken to prevent falls and minimize fall-related injuries. This paper aims to determine if psychotropic medications are being assessed as potential contributing factors to falls and if any intervention is being attempted.

Methods

This descriptive study used data from a retrospective review of electronic medical records (EMR) of older adults who presented to the emergency department and were subsequently admitted after a fall-related injury to a single community hospital in Hawai‘i in 2016. The determination of a diagnosis of fall was based on the International Statistical Classification of Diseases and Related Health Problems (ICD 10) codes of W00 to W19, as either a primary or secondary diagnosis. This study examined whether any medication assessment or intervention was attempted in order to modify the medication regimen before discharge.

Psychotropic medications were divided into 4 broad categories: antipsychotics, antidepressants, antianxiety medications, and hypnotic medications. The use of psychotropic medications upon admission and on discharge was recorded in detail. Furthermore, documentation on whether any intervention or recommendation for discontinuation or dose adjustments was attempted during the hospital stay was gathered. A medication was considered discontinued only if a patient was taking it upon admission and it was discontinued before hospital discharge.

Demographic and clinical information was also collected to identify and compare relationships between psychotropic medication use, patient characteristics (age, sex, race, comorbidities), and falls. The number of falls was also assessed, with frequent fallers being defined as 2 or more falls in a 6-month timeframe.

All patients aged 65 or older admitted to the hospital after presenting to the emergency department for a fall-related injury with an ICD 10 code of W00 to W19 and prescribed a psychotropic medication were included in this study. Patients who died before discharge, those whose diagnoses fell under ICD 10 codes other than W00 to W19, patients not taking any psychotropic medications, and patients without a full admission were excluded. IRB approval for the study was obtained from the Hawai‘i Pacific Health Research Institute (HPHRI Study Number 2017-095).

Results

Patient Characteristics

The initial review of the EMR was conducted, and 457 patients who presented to the ED with a fall were identified. Of these, 72 patients (16%) were taking psychotropic medications upon presentation to the ED. Nineteen patients were admitted and met the inclusion criteria.

Most of the included patients (58%; n = 11) were 80–89 years old. There were more women (n=13) than men (n=6). The most common ethnicities were Asian (47%) and white (42%). Patients’ demographic and clinical characteristics are presented in Table 1. Of the 19 patients, 14 (74%) patients had at least 1 psychiatric comorbidity. Dementia was the most prevalent psychiatric comorbidity with 8 (47%) patients with dementia, and 1 (5%) patient with both dementia and depression. There were also 3 (21%) patients with depression, 1 (5%) patient with schizophrenia, and 1 (5%) patient with anxiety.

Table 1.

Demographic and Clinical Data of the Sample

Factor	Frequency	Percentage
Age (years)
65–69	2	11%
70–74	2	11%
75–79	3	16%
80–84	6	32%
85–89	5	26%
>90	1	5%
Sex
Male	6	32%
Female	13	68%
Ethnicity
Asian	9	47%
White	8	42%
Native Hawaiian / Pacific Islander	1	5%
Hispanic	1	5%
Psychiatric Comorbidities
Anxiety	1	5%
Dementia	8	47%
Depression	3	21%
Schizophrenia	1	5%
Dementia + Depression	1	5%

Falls were categorized by the researcher based on the identified cause as documented in the EMR by the admitting physician. A mechanical fall was defined as a slip, trip, or loss of balance. Medical causes of falls include conditions such as hypotension, seizure, and dizziness. Medication-related falls were defined as any fall that can be attributed to a medication side effect. Most falls were classified in the ED as mechanical falls (68%). Medical (26%) and medication (5%) made up the other causes of falls. There was a total of 6 frequent fallers, including 1 patient with a previous admission to the hospital for a fall. Table 2 summarizes the characteristics of the falls.

Table 2.

Cause and Fall History

Type of Fall	Frequency	Percentage
Mechanical	13	68%
Medical	5	26%
Medication	1	5%
Previous Admission with Fall	1	5%
History of falls	5	26%

Several types of psychotropic medications were used by the study population (Table 3). The most common type was antidepressants (74%), followed by antianxiety medications (32%) and antipsychotics (16%). None of the patients were on hypnotics. Patients’ antidepressant medications varied widely, but citalopram was the most commonly prescribed antidepressant. Of the 19 patients, 5 (26%) were taking multiple psychotropic medications.

Table 3.

Psychotropic Medications

Psychotropic Medication	Frequency	Percentage
Antidepressant	14	74%
Amitriptyline	1
Buspirone	1
Bupropion	1
Citalopram	5
Duloxetine	2
Mirtazapine	3
Trazodone	2
Fluoxetine	1
Nortriptyline	1
Antipsychotics	3	16%
Fluphenazine	1
Olanzapine	1
Quetiapine	2
Antianxiety	6	32%
Alprazolam	2
Diazepam	1
Lorazepam	3
Multiple Medications	5	26%
Olanzapine + Citalopram	1
Mirtazapine + Lorazepam	1
Buspirone + Bupropion + Fluphenazine + Quetiapine + Lorazepam	1
Duloxetine + Mirtazapine	1
Citalopram + Trazodone	1

Twelve patients sustained an injury as a result of their falls (Table 4). Fracture (42%) was the most common injury sustained, followed by subdural hematomas (16%).

Table 4.

Type of Injury

Injury	Frequency	Percentage
None	7	37%
Fracture not Requiring Surgery	2	11%
Fracture Requiring Surgery	6	32%
Subdural Hematoma	3	16%
Lung Rupture	1	5%

In terms of interventions, 4 of the 19 patients had documentation in their EMRs that indicated their medications were reviewed (Figure 1). Only 1 patient had a medication discontinued (quetiapine), while 3 patients’ medication regimens were reviewed and no changes were made. Fifteen patients (79%) had no documentation in the EMR indicating that any medication assessment was conducted.

Figure 1.

Intervention for Elderly Patients on Psychotropic Medications Hospitalized for a Fall

Discussion

In 2016, 457 patients presented to the emergency department for falls, a rate of 1.25 patients per day. The findings of the study suggest that most older adults who are admitted to the hospital with a fall-related injury who are taking a psychotropic medication do not have their medications reviewed as a potential contributing factor. Moreover, only one patient had a psychotropic medication changed during the hospitalization following their fall. Even though patients were taking psychotropic medications, many of their falls were attributed by the admitting provider to either mechanical or medical causes, rather than seen as medication-related; however, medication side effects cannot be ruled out as a potential contributing factor. For example, 13 falls were attributed to mechanical reasons such as slips, trips, or loss of balance without mention of possible contributory effect of psychotropic medications. In these 13 events, psychotropic medications may have caused drowsiness, dizziness, cognitive impairment, or slowed reaction times that could either have directly contributed to or served as the root cause of the fall. Medical-related causes of falls may also be directly related to psychotropic medications either through bradycardia, syncope, or orthostatic hypotension.

There could be many barriers that prevent medication interventions designed to reduce fall risk from routinely occurring. Some of those barriers may be related to limited time providers and hospital staff have to fully conduct a comprehensive fall assessment that includes identification of a potential medicationrelated fall. Secondly if a medication is identified, there may be hesitancy by the hospital provider to discontinue or adjust a medication that was initiated by an outpatient provider. Anecdotally, providers are reluctant to discontinue or adjust medications for an indication that they have not been managing especially without an adequate understanding of the patient's complete medication history.

Providers often classified falls as mechanical without further documentation about other causes or circumstances that may have been present. Each event should be carefully assessed and analyzed because falls are often multifactorial. Without a complete understanding of the exact etiology of the fall, the patient remains at risk for future incidents especially if medications may be involved. Because it is well established that psychotropic medications play a direct or contributing role in falls, there should be an increased focus on considering psychotropic medications as a possible contributing factor irrespective of the cause of the fall.6,9

In this retrospective study, it was challenging to identify the reason(s) why psychotropic medications were initially prescribed. However, knowing the reason for prescribing the medication is essential in order for clinicians to make an accurate assessment of whether a mediation intervention is indicated. Medications should be routinely evaluated for appropriate indication as well as continued efficacy and safety. This review also identified that documentation in EMRs about medication reviews is lacking. It was difficult to determine whether any medication evaluation was conducted and whether the appropriateness of the psychotropic medication was assessed because most patients did not have documentation addressing this topic during this retrospective study. It is possible that other patients did receive a medication evaluation, but it was not adequately documented in the EMR.

A limitation of the study was that the EMR review captured data from a single institution over one year, so the sample size was small. Another limitation was the inability to identify patients’ history of taking a psychotropic medication. Another shortcoming was the inability to review all patients’ outpatient medication histories to identify their indication for taking psychotropic medications, as these drugs may be used for more than 1 indication (eg, duloxetine can be taken for depression or chronic pain). Also, dementia was present in 47% of the patients included in the study. Dementia represented the most common psychiatric illness in the study. Patients with dementia often are unable to articulate their complaints of depression or pain. These symptoms often manifest as behavioral issues that without careful assessment may result in the inappropriate use of psychotropic medications.

Recommendations for Practice

These findings may provide opportunities for pharmacists to expand their services by providing comprehensive medication reviews for patients who are admitted for a fall-related injury and entering appropriate documentation. Recommendations from the pharmacist could help bring potential medication issues to a patient's care team for intervention or could be forwarded to the patient's primary care provider for further evaluation. In conjunction with providers, pharmacist-led deprescribing initiatives may also help decrease medication-related adverse events by discontinuing medications that may no longer appropriate.

Other pharmacist interventions may include medication education targeted at raising the awareness of patients, families, and caregivers about potential side effects that should be brought to the provider's attention. Pharmacists should also encourage patients to give each of their providers an updated medication list with each visit. Pharmacists should also be included as a critical member of the institution's fall committee and as part of a team charged with preventing, managing, and monitoring in-house fall events.

Conclusion

Overall, in this retrospective review, 79% of patients admitted to the hospital through the emergency department with a fall while on a psychotropic medication did not have any documented medication review or intervention. Only 1 patient had a medication discontinued. Emergency departments should call on pharmacists to provide comprehensive medication reviews of patients with a fall admission. Pharmacists also can engage with the care team and provider to recommend medication interventions designed reduce falls that may be related to psychotropic drug use, especially in older adults.