Falls with osteoporosis
Antidepressants: Quality prescribing - a guide for improvement
Background (age, sex, occupation, baseline function)
- 74-year-old female
- Retired
History of presentation/reason for review
- Falls – no dizziness or light headedness. Has experienced a number of falls over the years. Main cause is balance and mobility. Has been referred to falls team
- At review:
- Pains in feet. States that ‘lack of feeling in feet possibly to do with plantar fasciitis’
- Higher dose of sertraline (100mg daily) ‘made no difference’ Depression resolved
- Sometimes forgets to take alendronate – due to timing of dose
Current medical history and relevant co-morbidities
- Osteoporosis – one year
- Fractured neck of femur (right). Total hip replacement – two years ago
- Depression – three years. Related to death of husband after long illness
- Plantar fasciitis – four years
- Acne rosacea
- High blood pressure – five years
- Chronic kidney disease stage three to seven years
- Lower back and knee pain – chronic
- Dyspepsia – eight years
- Cerebral lacunar infarct – seven years
Current medication and drug allergies (include OTC preparation and herbal remedies)
- Aspirin 75mg tablets - one tablet daily
- Alendronate 70mg tablets – one tablet once weekly (takes before breakfast)
- Co-codamol 30/500mg tablets - two tablets up to four times a day if needed
- Co-codamol 8/500mg tablets - two tablets up to four times a day if needed
- Fludrocortisone 50mcg tablets – one tablet daily
- Salicylic acid 2.0%, mucopolysaccharide polysulfate (MPS) 0.2% gel (Movelat®) - apply up to three times a day if needed
- Omeprazole 20mg capsules – one capsule daily
- Senna 7.5mg tablets – two tablets at night (last ordered 12 months ago)
- Sertraline 100mg tablets – one tablet daily (initiated two years ago after death of husband)
- Simvastatin 40mg tablets - one tablet at night
- Colecalciferol 1000 unit tablets – one tablet daily
Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity
- Lives alone
- Supportive family and neighbours. Contact with sister and brother regularly
- Ex-smoker
- Does not drink alcohol
- Walks with stick
“What matters to me” (patient ideas, concerns and expectations of treatment)
- Reducing frequency of falls
- Invite individual to complete questions to prepare for the review (PROMs)
Results e.g., biochemistry, other relevant investigations or monitoring
Note: local lab reference ranges may vary
- U&Es, LFTs, bone profile, HbA1c and FBC – all within normal range. eGFR = 45ml/min - over estimating renal function
- Weight 65kg, Height 1.62m IBW 54.2kg. Estimated creatinine clearance 35ml/min (CKD G3b)
- DEXA scan – one year ago, severe osteoporosis
- BP 143/91 mmHg sitting, 116/78 mmHg standing. No symptoms of postural BP drop
- Pulse 74 bpm, regular
Most recent relevant consultations
- Fall in garden one week ago. Laceration to forehead. Six stitches in situ. Wound closed and dry with large black scab. No signs of infection. Six stitches removed, no issues. Care advice given. No dressing.
7 Steps: Person specific issues to address for case study
1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
- Ask individual to complete Patient Reported Outcomes Measures (PROMS) before the review
Person specific actions
- Reduce frequency of falls
- Where appropriate reduce/minimise prescribed medicines that may add to the risk of falls
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice*)
- Drugs that have essential replacement functions
- Drugs to prevent rapid symptomatic decline
* with advice from healthcare professional with specialist interest
Person specific actions
- None considered essential
3. Does the patient take unnecessary drug therapy?
Identify and review the continued need for drugs
- what is medication for?
- with temporary indications
- with higher than usual maintenance doses
- with limited benefit/evidence for use
- with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)
Person specific actions
- First episode of depression after death of husband – states ‘higher dose sertraline not made much difference’. Consider a tapered reduction. SSRIs and higher doses associated with increased risk of falls
- Hypertensive while sitting. Previous stroke
- Unclear indication for fludrocortisone. Consider stopping if no indication as increases blood pressure
- Osteoporosis – forgets to take alendronate. Advised to take at 11am on Fridays (two hours before and after meals)
- Senna not required – stop
4. Effectiveness: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives
- to achieve symptom control
- to achieve biochemical/clinical targets
- to prevent disease progression/exacerbation
- is there a more appropriate medication to achieve goals?
Person specific actions
- Depression resolved – trial stopping sertraline – taper gradually
- As required co-codamol, using both strengths depending on pain intensity, finds effective – not causing drowsiness, constipation
- Stroke prevention medicines: simvastatin, aspirin, hypertension control
- Osteoporosis treatment: alendronic acid and colecalciferol
- Forgetting to take alendronic acid - discuss strategies to help, such as calendar reminder or phone alarm
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?
Identify individual safety risks by checking for
- appropriate individual targets
- drug-disease interactions
- drug-drug interactions (see ADR table)
- monitoring mechanisms for high-risk drugs
- risk of accidental overdosing
Identify adverse drug effects by checking for
- specific symptoms/laboratory markers
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
Medication Sick Day guidance
Person specific actions
- Two strengths of co-codamol for knee and back pain. Paracetamol only is ineffective. Takes 8/500 during day and 30/500 at night. Knows not to take both at same time. Uses sparingly
- Fludrocortisone increasing risk of high blood pressure – stop
- GI protection – aspirin and sertraline, GI bleed risk
- Omeprazole to continue as needed for GI protection
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
Identify unnecessarily costly drug therapy by
- considering more cost-effective alternatives, safety, convenience
Consider the environmental impact of
- Inhaler use
- Single use plastics
- Medicines waste
- Water pollution
Person specific actions
- Formulary preferred list medicines options being prescribed.
- Advise to take unused or expired medicines back to community pharmacy for safe disposal
- Unnecessary/ineffective medicines stopped
7. Patient centeredness: Is the patient willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
- Consider teach-back
- Involve the adult where possible. If deemed to lack capacity, discuss with relevant others, e.g. welfare guardian, power of attorney, nearest relative if one exists. Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place
Ensure drug therapy changes are tailored to individual’s preferences. Consider
- is the medication in a form they can take?
- is the dosing schedule convenient?
- what assistance is needed?
- are they able to take medicines as intended?
Agree and communicate plan
- discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
- include lifestyle and holistic management goals
- inform relevant health and social care providers of changes in treatments across the transitions of care
Ask individual to complete post-review PROMS questions after their review
Agreed plan
- Trial reduction of sertraline, reducing every four weeks: 100mg to 50mg to 25mg then stop
- Osteoporosis – forgets to take alendronate. Advised to take at 11am Fridays (two hours before and after meals)
- Plantar fasciitis – refer for podiatry review
- Understands and agrees to changes to medicines
- Poor sleep since retired – uses sleep hygiene techniques: low caffeine intake, reads when has insomnia/night-time wakening
- Has capacity and is independent and capable of looking after her own medicines
Key concepts in this case
- Importance of regular review of long-term antidepressant therapy
- Higher dose SSRIs associated with increased risk of falls43
- eGFR overestimating renal function. Although eGFR is routinely reported with U&Es it does not routinely reflect older adults’ renal function therefore it may be prudent to calculate individual’s creatinine clearance – see BNF Prescribing in Renal Failure section
- Minimise the number of unnecessary medicines
- Fludrocortisone – increases blood pressure, and borderline hypertensive with a previous history of stroke. Fludrocortisone may have increased the risk of future strokes
- Podiatry assessment not included in routine falls team review therefore referral was needed.
Click on the table image to view a PDF version of the full 7 steps table for case study 3.
