Post-fall medication review (Guidelines)

Warning

Audience

  • All NHSH
  • Primary and Secondary care, including Care Homes and Community Hospital settings
  • Adults only

The following medicines can contribute to falls in older patients and should be reviewed. This list is NOT exhaustive.

For in-patients, if there are ongoing concerns, discuss with the senior medical team.

The greater the number of medicines a patient takes, the greater their risk of sustaining a fall, especially if these medicines affect the central nervous or cardiovascular system.

When reviewing medicines consider:

  • Is there any NEW medication or recent change in dosage?
  • Consider the level of compliance pre-admission.
  • See Scottish Polypharmacy guidance and consider Realistic Medicine. What matters to the patient?

Medication review

MEDICINE TYPE

Primary and Secondary Care 

Further action in Secondary Care

Anticholinergics: These include antidepressants, overactive bladder meds, antihistamines, anti-emetics.

See: Anticholinergics | Right Decisions (scot.nhs.uk)

  • Check that the indication is still relevant.
  • These medicines increase the risk of cognitive impairment, blurred vision and drowsiness. Toxicity is often the cumulative effect of several of these medicines.
  • Check the full list of medicines that the patient is prescribed, and if an anticholinergic burden (ACB) score has been calculated: ACB calculator
  • Consider effectiveness and necessity.
  • Optimise emollients for dry, itchy skin.
  • Calculate ACB score.
  • Discuss rationalising medicines on ward round.

Analgesics

  • Check that the indication is still relevant.
  • Is pain relief being achieved with the current prescription or is a review required?
  • Consider GI protection if NSAIDS are prescribed, and ensure that renal function has been checked.
  • If opioids are prescribed, ensure that the duration is limited and laxatives are prescribed.
  • Avoid opioids where possible, including tramadol in older adults.
  • Stop NSAID if AKI, hypotension or D&V.
  • Review on ward round.

Atypical Analgesics:

Eg: amitriptyline, duloxetine, gabapentin, pregabalin.

  • Check that the indication is still relevant.
  • These medicines can cause neuropsychiatric side effects and hypotension.
  • Look for low BP and orthostatic hypotension.
  • Consider indication and dose reduction but avoid abrupt withdrawal.
  • Ensure review on ward round.

Antibiotics

Eg: gentamicin.

 

 

Anticoagulants

  • Check that the indication is still relevant.
  • Consider withholding if head injury or active bleeding, unless for metal valve or recent or high risk recurrent PE.

Anticonvulsants

  • These medicines can cause sedation, disorientation and impaired balance.
  • These are time critical medicines. Do not withhold unless immediate concern.
  • Ensure relevance but do not stop abruptly without consultant discussion.

Antidepressants

  • Check that the indication is still relevant.
  • Check that there has been a timely review with initial prescriber.
  • Review on ward round.

Antipsychotics

  • Check that the indication is still relevant.
  • Check what the indication is, do antipsychotics have a role and have they been regularly reviewed for efficacy?
  • Are there symptoms of distress and what are the trigger factors for distress?
  • Avoid abrupt withdrawal, but consider clinical need and discuss dose alterations with MHLT.

Benzodiazepines and Z drugs.

  • Check that the indication is still relevant.
  • Review indication and dose.
  • Avoid abrupt withdrawal but review clinical need and benefit on ward round.

Bladder medicines

Eg: tamsulosin, solifenacin, tolterodine.

  • Check that the indication is still relevant.
  • Look for low BP and orthostatic hypotension.
  • Is there evidence of efficacy documented?
  • Has patient been catheterised since admission?
    Keep, if planning to remove catheter.

Blood pressure lowering drugs

Eg: ACE Inhibitors, alpha blockers, diuretics.

  • Check that the indication is still relevant.
  • Look for BP consistently <140/80mmHg.
  • Is there evidence of AKI or electrolyte imbalance?
  • Obtain a lying and standing BP.
  • Does the patient suffer dizziness on standing?
  • Consider indication and withhold if possible.
  • Review dose if AKI.
  • Review on ward round.

Eye treatments

  • Risk of blurred vision if not administered.
  • Check time of prescribing.
Hypoglycaemics
  • Check that the indication is still relevant.
  • Are BMs <6
  • Recent HbA1C
  • Withhold sulphonylurea if BMs <6.
  • Involve Diabetes Specialist Nurse.
  • Review on ward round.

Muscle relaxants

Eg: baclofen.

  • Check that the indication is still relevant.
  • Review indication and dose.
  • If recently started, does this coincide with increase in drowsiness.
  • Reduce dose or withhold if possible.
  • Review on ward round.

Parkinsonian medicine

  • These are time critical medicines.
  • Check that the correct dose, formulation and times are prescribed.
  • Is the dose too much or too little?
  • Be aware of medicines that are contraindicated in Parkinson’s, eg: metoclopramide, prochlorperazine, haloperidol.
  • These are time critical medicines. Ensure that all staff caring for the patient are made aware.
  • Refer to patients usual Parkinson’s consultant.

ABBREVIATIONS

  • ACB: Anticholinergic burden
  • AKI: Acute kidney injury
  • BM: Blood sugar level
  • BP: Blood pressure
  • D&V: diarrhoea and vomiting
  • HbA1c: Glycated haemoglobin
  • Mental Health Liaison Team
  • NSAID: non-steroidal anti-inflammatory drug
  • PE: Pulmonary embolism

Editorial Information

Last reviewed: 16/07/2024

Next review date: 31/08/2027

Author(s): Falls Steering Group , Care for the Elderly.

Version: 1

Approved By: TAMSG of the ADTC

Reviewer name(s): Dr D Gray, Associate Specialist, H McCloughlin, Senior ANP, A Warren, Pharmacist.

Document Id: TAM647

Related resources

Further information for Health Professionals

References
Evidence method
  • Clinical Governance Checklist