Our interest in this topic was kindled by the anecdotal finding of a drop in fall rates at an SNF that coincided with a change in the psychiatric consulting pattern at the facility. Use of psychotropic drugs in nursing homes is common. In the late 1980’s and 1990’s there was great concern that psychotropic drugs were often being inappropriately used, often for convenience of staff rather than to improve the functional status of patients. Hence, considerable regulatory oversight at both the state and federal levels was introduced in attempt to improve appropriateness of use of such drugs. CMS (known as HCFA at that time) issued guidelines that required documentation of the reason(s) for use of these drugs, regular reviews, and periodic attempts to wean patients off these drugs.
A review by the Office of the Inspector General in 2001 concluded that psychotropic drug use in nursing homes was generally appropriate. It was deemed medically appropriate and within Medicare guidelines for 85% of patients. In 8% it was felt that use of psychotropic drugs was inappropriate (which could mean that an appropriate indication was not documented, dose was improper, periodic tapering not done, etc.) and in the remaining 7% appropriateness could not be determined because of insufficient records. However, a new study published this month (Agashivala 2009) shows that inappropriate use of psychoactive medications continues to contribute to falls in the nursing home setting. That study analyzed data from the large 2004 National Nursing Home Survey database and performed logistic regression methods to look at potentially inappropriate psychoactive medications (PIPM’s), using Beer’s criteria, and the risk of falls (see our January 15, 2008 Patient Safety Tip of the Week “ “ and our June 2008 What’s New in the Patient Safety World column “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients” for discussions on Beer’s List). They found a significantly increased risk of falls in patients on PIPM’s compared to those patients taking no psychoactive medications or other psychoactive medications not designated as PIPM’s on Beer’s List.
Concerns have also arisen over the past 10 years about the increased mortality rates seen in nursing home patients treated specifically with antipsychotic drugs, both the newer “atypical” antipsychotics and the older antipsychotics (Gill 2007). A recent study (Kamble 2009) showed that about a third of nursing home residents with dementia are treated with such drugs. Another recent study (Bronskill 2009), done on Canadian nursing homes, found considerable variation in the prescribing rates for antipsychotic drugs. They found that rates of prescribing such drugs varied from 11.6% in SNF’s in the lowest quartile to 30% in the highest. More importantly, they showed that 30-day and 120-day mortality rates were higher in those facilities prescribing more antipsychotic drugs despite similar clinical characteristics at all facilities. Their work supports using antipsychotic drug prescribing rates as a measure of quality of SNF care.
There are, of course, many reasons why nursing home residents are at greater risk of falls. First and foremost, they tend to have physical disabilities that impair their mobility. That includes not only neurological conditions that may impair strength and balance but also arthritic and orthopedic conditions. Second, a big contributor to falls in the elderly is what we refer to as the “multiple sensory deficit syndrome”. This means that impairments of sensation, vision, hearing, etc., each of which may be mild and not enough to cause falls by itself, are additive and collectively increase the risk of falls. Third, orthostatic hypotension is common in the nursing home population. This may be a side effect of several medications a patient may be taking or it may be part of their underlying condition (eg. diabetic autonomic neuropathy) and it may be aggravated by “deconditioning” from lying in bed for prolonged periods. Fourth, confusion or dementia may lead to behaviors (eg. wandering) in which the patient is more likely to fall. Fifth, incontinence may lead to falls both because it increases the risk of slipping on a wet surface and because a patient may be hurrying to the bathroom and slip.
But the biggest contributor to the increased fall risk in the elderly is medication. Polypharmacy is problematic in the elderly, whether they are in nursing homes or the community. And drugs may increase the risk of falls both individually and in combination with other drugs. Drugs most likely to contribute to falls are long-acting benzodiazepines, tricyclic antidepressants, antipsychotic drugs, and any drug that causes sedation as a primary or side effect. An epidemiologic study done on elderly ambulatory nursing home residents (Thapa 1995) controlled for many other variables and concluded that the attributable risk for recurrent falls for psychotropic drugs was 36%.
So what should you do in your nursing home to reduce the risk of falls? Obviously a good fall prevention program looks at both intrinsic and extrinsic fall risk factors. A good program looks at the risk factors of the individual patient, with particular attention to those risk factors that may be amenable to correction. Attention to the environment to ensure adequate lighting, safe floors (eg., no carpet edges to trip on), timed toileting, assisted toileting, grab bars in bathrooms, etc. are very important. Proper implementation of restraint policies is beyond the scope of today’s column and the relationships between restraints and falls are very complex. The same applies to the bedrail issue we have previously discussed (see our December 18, 2007 Patient Safety Tip of the Week “Bed Rails” and our August 2009 What’s New in the Patient Safety World column “Bed Rails: Taking Emotion Out of the Debate”).
But review and regular re-review of medications is essential. When drugs in the high-risk categories noted above are used, there should be clearcut indications and usually also documentation that less invasive interventions have not sufficiently helped. The desired goals of the drug therapy should be made clear to all involved and progress toward these goals clearly documented in the chart. The medications generally should be started in low doses and titrated as needed, monitoring very carefully for side effects or other unintended consequences. Your monitoring tool should include not only general assessments (such as ability to ambulate) but also side effects that are specific to the drug being used (eg. orthostatic hypotension or drowsiness from tricyclic antidepressants, extrapyramidal symptoms and signs from antipsychotic drugs, etc.). The goals should clearly specify how long it is anticipated the patient will need to be on the drug and then attempts to taper the patient off that drug should take place. Most states have regulations regarding how often such evaluations and attempts to taper patients off these drugs must be made. Regular review of the medication regimen by a consulting clinical pharmacist, consulting psychiatrist, or the SNF medical director are important. Since in many cases the patient was admitted from an acute care setting already on such drugs, good medication reconciliation is important and the same questions should be asked (eg. why?, how long?, goals? etc.) at the time of transfer to the SNF.
Falls are also a frequent reason for SNF patients requiring readmission to acute care hospitals. So as CMS and other payors move to penalize acute care hospitals for readmissions, suddenly it is important that you pay attention to fall rates, prescribing patterns, and other quality factors at SNF’s even if your facility does not own its own SNF.
Update: See also our Patient Safety Tips of the Week for January 15, 2008 “ and October 19, 2010 “ ” and our What’s New in the Patient Safety World columns for June 2008 “Potentially Inappropriate Medication Use in Elderly Hospitalized Patients” and September 2010 “Beers List and CPOE”.
Department of Health and Human Services Office Of Inspector General. Psychotropic Drug Use in Nursing Homes. November 2001
Agashivala N, Wu W. Effects of Potentially Inappropriate Psychoactive Medications on Falls in US Nursing Home Residents+: Analysis of the 2004 National Nursing Home Survey Database. Drugs & Aging 2009; 26: 853-860
Gill SS, Bronskill SE, Normand S-LT, et al. Antipsychotic Drug Use and Mortality in Older Adults with Dementia. Annals of Internal Medicine 2007; 146: 775-786
Kamble P, Chen H, Sherer JT, Aparasu RR. Use of Antipsychotics among Elderly Nursing Home Residents with Dementia in the US: An Analysis of National Survey Data. Drugs & Aging 2009; 26: 483-492
Bronskill SE, Rochon PA, Gill SS, et al. The Relationship Between Variations in Antipsychotic Prescribing Across Nursing Homes and Short-Term Mortality: Quality of Care Implications. Medical Care 2009; 47: 1000-1008
Thapa PB, Gideon P, Fought RL, Ray WA. Psychotropic Drugs and Risk of Recurrent Falls in Ambulatory Nursing Home Residents. American Journal of Epidemiology 1995; 142: 202-211