Medications & Fall Risk
Anticholinergic Burden - A Hidden Hazard
While not as evident of a risk factor as ill-fitting footwear or trip hazards, anticholinergic drugs present an undeniable fall risk when administered to older residents.
Anticholinergics, commonly prescribed for conditions such as allergies, depression, and urinary incontinence, exhibit a class side effect profile that implicate them in many falls — especially among the elderly. These medications work by blocking the neurotransmitter acetylcholine in the central and peripheral nervous systems, which can lead to dizziness, confusion, and blurred vision — all of which increase the likelihood of a fall.
The term anticholinergic burden (ACB) refers to the cumulative effects exerted by medications with anticholinergic properties. It incorporates both the number of anticholinergic drugs as well as their relative anticholinergic potencies. Studies have shown that an increased ACB is strongly associated with a higher risk of falls and fractures among the elderly.
A JAMA-published study developed the Anticholinergic Risk Scale (ARS), which ranked commonly prescribed anticholinergic medications on a scale of 0-3 per their anticholinergic potential (0, limited or none; 1, moderate; 2, strong; and 3, very strong). This scale was developed by a three-member panel consisting of one geriatrician and two geropharmacists, then empirically tested to determine if higher ARS values were associated with increased risk of anticholinergic adverse effects in older adults. The results of this study showed statistically significant increases in anticholinergic adverse effects with higher ARS scores (P < 0.001), validating the use of this four-point scale.
STEADI-RX and Other Suspect Medications
The Centers for Disease Control and Prevention (CDC), in collaboration with the UNC Eshelmann Schools of Pharmacy and Medicine, developed the STEADI-RX program for fall prevention, which highlights medications known to elevate fall risk (beyond just anticholinergic drugs). The program incorporates a total of nine drug classes for healthcare providers to review when conducting a resident-specific fall risk evaluation. Consultant pharmacists are available to provide medication regimen reviews (MRRs) that align with the STEADI-RX concept of “SAFE” reviews for fall risk management – Screen, Assess, Formulate, and Educate – with focused attention applied to these notable drug classes associated with increased falls. Through such MRRs, consultant pharmacists may identify opportunities to improve a resident’s fall-risk potential through deprescribing, de-escalation, and drug optimization.
STEADI-RX Fall Risk Drug Classes
Anticonvulsants
Antidepressants
Antihypertensives
Antipsychotics
Antispasmodics
Benzodiazepines
Opioids
Sedative Hypnotics
Tricyclic Antidepressants