Mitigating Medication-Related Fall Risk Through Pharmacist–Prescriber Collaboration

Abstract

Medications are known to increase the risk for fall in older adults, and pharmacists can contribute to fall risk prevention through medication therapy management services. STEADI-Rx is an initiative developed to facilitate fall risk reduction through pharmacist–prescriber collaboration. Key components of the STEADI-Rx algorithm are described as well as evidence supporting its integration in practice.

…tools may help pharmacy professionals streamline integration of a fall risk assessment service…

While various factors are associated with an increased risk of falls among older adults, medications are often implicated.^1,2 Polypharmacy (or use of at least three drugs) predisposes older adults to falls and the risk of fall increases with the number of drugs used per day. ² Several classes of medications are associated with a significant risk of falls even when fewer than three medications have been prescribed. These so-called fall risk increasing drugs (FRIDs) include anticonvulsants, antidepressants, antihypertensives, antipsychotics, antispasmodics, benzodiazepines, sedatives and hypnotics, anti-inflammatory drugs, and opioids.^3-5 Interprofessional collaborations between pharmacists and prescribers may mitigate medication-related fall risk through drug therapy modifications. It has been estimated that medication therapy management interventions could prevent 42 735 medically treated falls and avert $418 million in direct medical costs annually in the United States. ⁶

STEADI-RX is a pharmacy initiative developed by the University of North Carolina through a grant from the Centers for Disease Control to reduce falls in older adults by way of collaboration between prescribers and pharmacists. ⁷ While the initiative was designed for use in the community pharmacy setting, many program components can also be applied in other practice sites where pharmacists come in contact with community dwelling older adults (primary care clinic, emergency department, etc.). The key components of STEADI-RX are described below.

Patient Screening

While not all patients benefit from a medication review for fall risk, STEADI-RX recommends screening patients 65 years of age and older who take four or more chronic medications, take one or more high-risk medications, and/or present with an acute fall. ⁷ Age is an independent risk factor for falling and as discussed previously, polypharmacy and use of FRIDs are also associated with an increased risk of fall; thus, the aforementioned criteria help identify patients who may benefit most from a fall-specific medication review.^2,3,8 Fall risk should then be further assessed in eligible patients using the Centers for Disease Control and Preventions Three Key Questions ⁹ :

• Have you fallen in the past year?

• Do you feel unsteady when standing or walking?

• Are you worried about falling?

A response of yes to any of the Three Key Questions indicates an increased risk of fall. All patients with an increased risk of fall should be referred for assessment by a pharmacist.

Assessment

Patients at increased risk should be assessed for modifiable risk factors, specifically, medication-related fall risk factors. This includes polypharmacy, the use of FRIDs, and screening for medical conditions or drug interactions that may increase falls through vascular, neurologic, physical function, or pharmacokinetic changes. STEADI-RX recommends assessing specifically for postural hypotension (a ≥ 20/10 mmHg drop in blood pressure or experiencing dizziness/lightheadedness when changing positions) as several classes of medication are associated with this adverse drug event which has been linked to falls.

Care Coordination

If a medication-related fall risk is identified, the pharmacist should share this information, along with a recommendation for mitigating the risk with the patient’s primary care provider. Interventions aimed at addressing FRIDs have been shown to be effective in reducing fall risk.^10-12 For example, a 66% reduction in falls was demonstrated in patients when psychotropic drugs were gradually withdrawn, compared to those who continued them in a randomized controlled trial by Campbell et al. ¹⁰ Similar effects (a reduction in falls) have been demonstrated when withdrawing or dose reducing benzodiazepines and cardiovascular drugs.^11,12

The impact of the STEADI-RX intervention was recently evaluated in the community pharmacy setting. ¹³ A total of 10 565 adults age 65 years and older from community pharmacies in North Carolina were included in the randomized controlled trial. Of the 65 participating pharmacies, 34 were randomized to the “no-treatment” control group, while the remaining 31 pharmacies provided the medication therapy management intervention. At the intervention sites, patients at high risk for fall were eligible to receive a pharmacist-administered medication review with applicable recommendations sent to the patient’s prescriber following the review. Among intervention site patients who screened positive using the process outlined above (n = 1901), 72% received a medication review and 27% had at least one medication related problem identified and recommendation for modification forwarded to their primary care provider. Despite a total of 716 medication-related recommendations made, prescribers reported plans to implement the recommended changes in less than 15% of the cases. No difference in the risk of fall or use of medications associated with an increased risk of fall was demonstrated.

Next Steps and Implementation

Research indicates that modifying medication therapy is an effective strategy to reduce fall risk in older adults.^10-12 A challenge lies in translating these findings to routine practice. The aforementioned study demonstrated that STEADI-Rx can be successfully integrated into practice to effectively identify patients with fall risk increasing medication-related problems. ¹³ However, neither the rate of fall nor the use of medications associated with an increased risk of fall decreased. The authors noted several important considerations that may explain these findings. First, only 15% of the pharmacist recommendations were accepted by the prescriber. This low acceptance rate has been demonstrated in previous attempts to integrate STEADI components into clinical practice and warrants further investigation to determine the rationale and implications for why recommended changes were not made. ¹⁴ Second, the Drug Burden Index (DBI) used to assess exposure to high-risk medications in the study may not be sufficiently sensitive to capture the improvements in pharmacotherapy prompted by the pharmacist-administered medication reviews. Specifically, the DBI did not weigh different medications based on the extent to which they increase risk for fall. The majority (75%) of recommendations made in the study involved switching one medication to another potentially safer medication (i.e., a sedating agent with a shorter half-life from the same class), rather than decreasing the dose or withdrawing an existing drug. Last, claims data were used to assess fall risk which may underestimate the true incidence of falls, including those that did not result in the patient seeking medical care.

Despite these limitations, the STEADI-Rx initiative provides a framework and resources that support increased fall risk assessment by pharmacy professionals with expertise in addressing potential or actual medication-related problems. The STEADI-Rx toolkit is available online at https://www.cdc.gov/steadi/steadi-rx.html and contains resources for marketing, screening, evidence-based medication assessment, communication, and documentation. These tools may help pharmacy professionals streamline integration of a fall risk assessment service in their practice. In order to realize the potential beneficial effects of this intervention, further study is needed to optimize the pharmacist–prescriber collaboration and identify tools to accurately measure high-risk medication exposure and fall risk.