correlation between pharmacotherapy and high risk of fall based

Cent Eur J Nurs Midw 2018;9(2):832–839

doi: 10.15452/CEJNM.2018.09.0012

 

 

 

© 2018 Central European Journal of Nursing and Midwifery 832

ORIGINAL PAPER

PHARMACOTHERAPY AS A FALL RISK FACTOR

Ivana Bóriková, Martina Tomagová, Katarína Žiaková, Michaela Miertová

Department of Nursing, Jessenius Faculty of Medicine in Martin, Commenius University in Bratislava, Slovakia

Received October 6, 2017; Accepted March 3, 2018. Copyright: This is an open access article distributed under the terms of the Creative

Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

Abstract

Aim: To determine the correlation between pharmacotherapy and high risk of fall based on the Morse Fall Scale (MFS score

≥ 45) in acute and long-term care settings. Design: A quantitative cross-sectional descriptive correlation study. Methods: The

study was conducted at a University Hospital in Martin (UHM) and a selected long-term care facility (LTC) in Martin

(Slovakia) June–October 2016. The pharmacotherapeutic data were obtained from the health documentation of the

respondents. The fall risk was assessed by using the MFS screening tool within 24–48 hours of admission to the facility.

Results: For the group of UHM patients (n = 63), the mean MFS score for fall risk was high (60.6 ± 22.4), and the correlation

(p = 0.030) between the number of medications administered in 24 hours and high risk of fall was significant. For the group o f

LTC patients (n = 89), the mean MFS score for fall risk was moderate (35.4 ± 15.9). The correlations were not significant.

Conclusion: Pharmacotherapy is an important fall risk factor; therefore, it is necessary to determine it within the assessment of

overall fall risk. The risk management of pharmacotherapy is an effective and important multifactorial intervention in

programmes of fall prevention in acute and long-term care.

 

Keywords: fall, hospital, long-term care, Morse Fall Scale, pharmacotherapy, screening, senior.

Introduction

According to the Joint Commission Centre for

Transforming Healthcare, an analysis of falls with

injury reveals several common factors that increase

the number of falls, including, among others,

inadequate assessment of risk by patients (Joint

Commission, 2015). It is the assessment and

identification of individual amenable fall risk factors

that facilitates selection and implementation

of preventive interventions, significantly reducing the

number of falls (Registered Nurses’ Association

of Ontario, 2011; Watson, Salmoni, Zecevic, 2016).

The key, readily identifiable, predictors of fall

in acute and long-term care include the presence

of chronic disease and polymorbidity,

with subsequent polypharmacy and its adverse

effects. In connection with pharmacotherapy, there

are some indication groups of medications that

increase fall risk, such as benzodiazepines,

psychotropic medications (antipsychotics, sedatives,

hypnotics, anxiolytics, antidepressants), analgesics

(paracetamol, NSAIDs, opioids, narcotics),

antiepileptics, antiparkinsonians, cardiac medications

Corresponding author: Ivana Bóriková, Department of Nursing,

Jessenius Faculty of Medicine in Martin, Comenius University in

Bratislava, Malá Hora 5, Martin, Slovakia; e-mail:

borikova@jfmed.uniba.sk

(antihypertensives, antiarrhythmics, anticoagulants,

diuretics), antidiabetics, and laxatives (Mamun, Lim,

2009; Agency for Healthcare Research and Quality,

2013; Ambrose, Paul, Hausdorff, 2013; National

Institute for Health and Care Excellence, 2013;

Obayashi et al., 2013; Severo et al., 2014; Callis,

2016; Gu et al., 2016).

Assessment of pharmacotherapy as a separate fall

risk factor is a multifactorial and targeted

intervention in the programme of fall prevention and

fall reduction from admission to the facility, as well

as after a fall (Registered Nurses’ Association

of Ontario, 2011; Agency for Healthcare Research

and Quality, 2013; Chu, 2017). This is normally

performed in conjunction with use of multiple

prescription medications, or use of medications with

adverse effects including sedation, confusion,

impaired balance, and changes of orthostatic blood

pressure, associated with higher risk of fall (Agency

for Healthcare Research and Quality, 2013).

Screening of pharmacotherapy in connection with fall

risk is an effective method of identifying

an individual with fall risk, by using a universal tool

that contains this item. There is no gold standard, but

the most tested tools include the Morse Fall Scale

(MFS), which is recommended for an initial

assessment of fall risk of adult patients in various

 

 

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© 2018 Central European Journal of Nursing and Midwifery 833

clinical settings (Kim et al., 2007; Morse, 2009;

Registered Nurses’ Association of Ontario, 2011;

Cumbler et al., 2013; National Institute for Health

and Care Excellence, 2013; Severo et al., 2014; Cruz

et al., 2015; Joint Commission, 2015; Callis, 2016;

Gu et al., 2016; Majkusová, Jarošová, 2017).

Competences of interprofessional team members

vary, but after screening of fall risk, a nurse should

subsequently also be involved in assessing risk

pharmacotherapy in cooperation with a physician and

a clinical pharmacologist (Centre for Studies in

Aging & Health, 2010; Registered Nurses’

Association of Ontario, 2011; Agency for Healthcare

Research and Quality, 2013; National Institute for

Health and Care Excellence, 2013).

Aim

To determine the correlation between

pharmacotherapy (the key fall risk factor) and high

fall risk on the Morse Fall Scale (MFS score ≥ 45)

in acute and long-term care settings.

Methods

Design

Quantitative cross-sectional descriptive correlation

study.

Sample

The first group of respondents consisted of 63

patients of the Internal and Surgical Clinic of the

University Hospital in Martin (UHM), of which 32

were women and 31 were men. The mean age of the

whole group was 68.3 ± 16.1 years (min. 21;

max. 90).

The second group of respondents consisted of 89

clients of a long-term care facility (LTC), of which

72 were women and 17 were men. The mean age

of the whole group was 82.8 ± 5.9 years (min. 70;

max. 95).

Most of the respondents in both groups were from the

oldest age group (Table 1).

Data collection

The study was conducted in the clinical settings

of UHM (June–August 2016) and in the LTC settings

(July–October 2016) in Martin (Slovakia).

The assessment was made within 24–48 hours after

admission to the facility, and the data were verified

from the health documents of the respondents.

The assessment focused on identification

of polymorbidity (the number of chronic diseases

≥ 4) and prescription of pharmacotherapy (use ≥ 5

indication medication groups linked to fall risk, and

the number of medications administered orally, as

well as by injection, in the course of 24 hours).

Screening for fall risk by means of the MFS tool,

which identifies six significant fall risk factors:

1. History of falling (no 0; yes 25); A history of falling was coded if the patient had had a fall

in the three months prior to admission/transfer to

the unit.

2. Presence of a secondary diagnosis (no 0; yes 15); A secondary diagnosis was coded if the

patient had more than one medical diagnosis.

3. Use of an ambulatory aid (none/bed rest/nurse assist 0; crutches/cane/walker 15; furniture for

support 30). Ambulatory aids were coded if they

were required for mobility.

4. Intravenous (IV) therapy/saline lock (no 0; yes 20); IV therapy was coded if the patient had

a continuous IV or a saline lock for intermittent

IV therapy.

5. Type of gait (normal/bed rest/wheelchair 0; weak 10; impaired 20). Gait was assessed for

normal, weak or impaired gait which required

greater assistance.

6. Mental status (oriented to own ability 0; overestimates ability or forgets limitations 15).

 

Table 1 Characteristics of sample

Variables UHM (n = 63)

n (%)

mean ± SD

(min.–max.)

LTC (n = 89)

n (%)

mean ± SD

(min.–max.)

Unit

internal

surgical

 

37 (58.7)

26 (41.3)

–

Gender

female

male

 

32 (50.8)

31 (49.2)

 

72 (80.9)

17 (19.1)

Age (year)

whole

sample

age groups:

< 65

65–74

> 74

 

68.3 ± 16.1

(21–90)

21 (33.4)

14 (22.2)

28 (44.4)

 

82.8 ± 5.9

(70–95)

 

10 (11.2)

79 (88.8)

UHM – University Hospital in Martin; LTC – long-term care; SD –

standard deviation; min. – minimum; max. – maximum

 

The total score ranges from 0 to 125, whereby low

fall risk is ≤ 20, moderate 25–44 and high ≥ 45.

The cut-off score ≥ 45 identifies patients with high

fall risk, and enables the development of targeted

preventive interventions to reduce risk of fall. On the

basis of this score, the sensitivity of the MFS in the

original study by Morse was set at the value of 78%,

the specificity was 83%, and the inter-rater reliability

was 0.96. The tool is designed for identification

 

 

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© 2018 Central European Journal of Nursing and Midwifery 834

of fall risk factors for older adults, and lies within the

competency of nurses (Morse, 2009).

Data analysis

To process the data, Microsoft Office Excel was

used, and to make an analysis of the data, SPSS

Statistics 16.0 software was used. The descriptive

statistics methods present a frequency distribution

of variable values in absolute (n) and relative figures

(%), arithmetic mean, standard deviation (SD),

minimum (min.) and maximum (max.) values. To test

the associations of binary variables, the Pearsonʼs

chi-square test (χ2) was used, and for the continuous

variable, the Mann-Whitney test (M-W) was used.

Statistical significance was calculated at the level

of 5% (p < 0.05).

Results

In the UHM group (n = 63), 40 patients (63.5%) were

polymorbid, and polypharmacy was found in 37

patients (58.7%). The most used medication groups

included antihypertensives (61.9%), analgesics

(54.0%), and diuretics (44.4%). The mean number

of administered medications in 24 hours was

13.9 ± 4.6 (min. 7; max. 28). There was a significant

correlation (p = 0.030) found between the number

of administered medications in 24 hours and high risk

of fall (Table 2). The mean MFS score of fall risk

was high, 60.6 ± 22.4 (min. 15; max. 105) (Table 3).

In the LTC group (n = 89), 86 seniors (96.6%) were

polymorbid, and polypharmacy was found in 79

seniors (88.8%). The most used medication groups

included antihypertensives (97.8%), anticoagulants

(75.3%) and analgesics (47.2%). The mean number

of administered medications in 24 hours was

13.1 ± 6.2 (min. 3; max. 31). The correlations

between the studied variables were not significant

(Table 2). The mean MFS score of fall risk was

moderate, 35.4 ± 15.9 (min. 15; max. 105) (Table 3).

 

Table 2 Variables in the sample

Variables UHM (n = 63)

n (%)

mean ± SD

(min.–max.)

UHM (n = 63)

MFS score ≥ 45

p < 0.05

LTC (n = 89)

n (%)

mean ± SD

(min.–max.)

LTC (n = 89)

MFS score ≥ 45

p < 0.05

Number of secondary diagnosis ≥ 4*

no

yes

 

23 (36.5)

40 (63.5)

0.924a

 

 

3 (3.4)

86 (96.6)

0.313a

 

Medication – type

Analgesics

Antiarrhythmics

Antihypertensives

Anticoagulants

Antidepressants

Antipsychotics

Antiparkinsonians

Benzodiazepines**

Digoxin

Diuretics

Insulin

Laxatives

Vasodilators

 

34 (54.0)

8 (12.7)

39 (61.9)

27 (42.9)

15 (23.8)

19 (30.2)

2 (3.2)

24 (38.1)

5 (7.9)

28 (44.4)

15 (23.8)

9 (14.3)

18 (28.6)

–

42 (47.2)

34 (38.2)

87 (97.8)

67 (75.3)

21 (23.6)

22 (24.7)

8 (9.0)

8 (9.0)

11 (12.4)

28 (31.5)

14 (15.7)

3 (3.4)

13 (14.6)

–

Medication ≥ 5

no

yes

 

26 (41.3)

37 (58.7)

0.159a

10 (11.2)

79 (88.8)

0.681a

Number/24 hours 13.9 ± 4.6 (7–28) 0.030b 13.1 ± 6.2 (3–31) 0.853b *item in MFS; **sedatives, hypnotics, anxiolytics; aPearson’s chi-squared test; bMann-Whitney test; UHM – University Hospital in Martin; LTC – long-term

care; SD – standard deviation; min. – minimum; max. – maximum

Table 3 MFS score

MFS score UHM (n = 63) mean ± SD (min.–max.) LTC (n = 89) mean ± SD (min.–max.)

Whole sample

Age groups

 

 

< 65

65–74

> 74

60.6 ± 22.4 (15–105)

58.8 ± 21 (15–95)

63.6 ± 17.6 (35–95)

60.4 ± 25.9 (15–105)

35.4 ± 15.9 (15–105)

–

38.3 ± 10.5 (15–50) 35.1 ± 16.5 (15–105)

UHM – University Hospital in Martin; LTC – long-term care; SD – standard deviation; min. – minimum; max. – maximum

 

 

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© 2018 Central European Journal of Nursing and Midwifery 835

Discussion

The results of our study – the prevalence of the

female gender, the mean age of the respondents,

existence of polymorbidity and polypharmacy in both

groups are indicative of the persistent aging of the

Slovak population, and their deteriorating health

indicators. In the long-term, the most frequent

reasons for admission to a health care facility are

cardiovascular, gastrointestinal, and oncological

diseases (Health statistics yearbook of the Slovak

Republic, 2015). Oncological diseases are considered

a critical fall risk factor in adult hospitalized patients

(Costa-Dias et al., 2014). The fall risk increases with

the number of chronic diseases and comorbidities,

and subsequent polypharmacy. Meanwhile,

medications influencing cognitive, neurosensory,

cardiovascular, and musculoskeletal functions may

potentially increase fall risk independently of the

number of diagnoses (Voyer et al., 2007; World

Health Organization, 2007; Centre for Studies

in Aging & Health, 2010; Registered Nurses’

Association of Ontario, 2011; Marshall, 2012;

Ambrose, Paul, Hausdorff, 2013; National Institute

for Health and Care Excellence, 2013; Jung, Shin,

Kim, 2014). Due to the mean age of our respondents,

the incidence of polymorbidity was high in both

groups. It is a phenomenon typical of senior

populations, and in connection with falls, it becomes

an issue with ≥ 2 chronic diseases. Weber (2012)

defines it as the concurrent presence of several

(usually three),, often mutually independent diseases

either with or without a causal link. The Concept

of geriatric health care (Koncepcia zdravotnej

starostlivosti v odbore geriatria, 2007) mentions more

than five concurrent serious diagnoses of geriatric

patients. In our study, we opted for a compromise

of between three to five chronic diseases, and we

took into consideration number of diseases ≥ four.

The hospital population of patients is more

heterogeneous than the population of seniors in LTC,

which is a result of the fact that acute diagnoses were

concurrent with chronic diagnoses. Such a change

in the health condition impairs physical and mental

conditions, has an impact on the pharmacotherapeutic

regimen, and significantly increases fall risk

and iatrogenic complications (Shuto et al., 2010;

Callis, 2016). The initial and cumulative effect

of a new pharmacotherapy (mainly antihypertensives,

anti-Parkinsonian medications, anxiolytics and

hypnotics) is linked to significantly higher fall risk

than with use of the same therapy in the long term

(Shuto et al., 2010; Chung, Coralic, 2016). Strong

associations between the use of psychotropic

medications and repeated falls (an increase of up to

50%), and the use of antiarrhythmics, digoxin, and

diuretics and falls is indicated in the study by Costa-

Dias et al. (2014). Although we did not deal with

falls during hospitalization in our study, this would

probably have been evidenced in the group

of hospitalized patients. The number of administered

medications in 24 hours (13.9 ± 4.6) in the group

of UHM was comparable to that of the group of LTC

(13.1 ± 6.2). However, regarding high fall risk, it was

significant, and the fall risk on the MFS scale was

also substantially higher (Table 3). Regarding item

No. 4 in the MFS, the intravenous administration

of therapy increases the fall risk score by up to 20,

and this method is rarely used in LTC. In LTC,

the health conditions of seniors are relatively stable,

and the pharmacotherapeutic regimen does not

change significantly. As with hospitalized patients,

risk of fall increases considerably with the use

of psychotropic medications, opioid analgesics,

antiarrhythmics, antihypertensives, benzodiazepines,

digoxin, and diuretics. Risk is particularly linked to

the use of psychotropic medications (Hartikainen,

Lönnroos, Louhivuori, 2007; Bloch et al., 2011),

which are an independent internal risk factor for falls.

The fall risk increases with the first prescription

(especially in the first days of use), with higher doses,

and with concurrent use of other psychotropic

medications, mainly in the presence of other

comorbidities and functional disorders (Registered

Nurses’ Association of Ontario, 2011). Elimination

of such pharmacotherapy reduces falls by up to 66%

(Department of Health, 2014).

The incidence of adverse effects and reactions

increases with age (with age ≥ 70 years, they are five

to six times more frequent), and with the growing

number of diagnoses and pharmacotherapy. The

effect of medications can be influenced by concurrent

use of several medication groups (medication-

medication interaction), the presence of a current

disease (medication-disease interaction), or food

(medication-food interaction) (Červený et al., 2014).

Adverse effects are most often linked to indication

groups of medications: cardiac, diuretics,

anticoagulants, non-steroidal anti-inflammatory

medications, antibiotics, and hypoglycemics (Shah,

Hajjar, 2012). Adverse effects in relation to risk are

different, e.g., sleepiness, dizziness, confusion,

altered gait and balance, slow reactions, visual

disturbances, orthostatic hypotension, muscle

weakness, and changed frequency and urgency

of urination (Mamun, Lim, 2009; Registered Nurses’

Association of Ontario, 2011; Červený et al., 2014;

Callis, 2016; Chung, Coralic, 2016; Komjáthy,

2016). Račanská (2014) points to a higher tendency

 

 

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© 2018 Central European Journal of Nursing and Midwifery 836

to orthostatic hypotension with use of

benzodiazepines, which may be manifested by

psychomotor attenuation with administration of the

usual dose, and thus it may increase the risk

of cognitive dysfunction, fall, injury, and

hospitalization. Mitro (2014) underlines the problem

of underestimation of syncope states of seniors, as

they overlap with falls. Changes in pharmacokinetics

and pharmacodynamics in seniors can lead to

increased sensitivity to effects of medication

(Mamun, Lim, 2009; Centre for Studies in Aging &

Health, 2010; Červený et al., 2014; Komjáthy, 2016);

therefore, in assessing the pharmacotherapy, not only

their main but also their adverse effects, the

cumulative effect, the number of used medication

groups and their interactions need to be considered

(Shah, Hajjar, 2012).

There is no consensus on defining polypharmacy;

the simultaneous use of two to nine indication groups

has been suggested (Shah, Hajjar, 2012), often ≥

three-four groups (Royal College of Nursing, 2004;

Ziere et al., 2005; Registered Nurses’ Association

of Ontario, 2011; Hammond, Wilson, 2013), and also

≥ five, when the fall risk increases (Costa-Dias et al.,

2014), and this is the limit we used in our study. Such

a number results in a range of medication interactions

and is considered to be a high fall risk, particularly in

the case of seniors (Centre for Studies in Aging &

Health, 2010; Registered Nurses’ Association

of Ontario, 2011; Carpenito, 2013; Department

of Health, 2014). A use of ≥ ten medication groups

(Shah, Hajjar, 2012; Weber et al., 2016) is considered

excessive. The studies by Costa-Dias et al. (2014)

and Shuto (et al., 2010) refer to a mean of 7.4 per

patient, whereby psychotropic medications account

for a substantial part. Regarding the prevalence

of polypharmacy, a range from 5–78% is indicated,

depending on the definition used and on the group. It

is more common in women, and increases with age

(Shah, Hajjar, 2012). Slovak authors (Wawruch et al.,

2008) recorded a use of ≥ six medication groups for

hospitalized patients aged ≥ 65 years (60.3%

of patients upon hospital admission, and 62.3%

of patients upon discharge). As the number

of medication groups used rises, the number

of potential medication interactions increases

exponentially (Suchopár, Prokeš, 2011). Dangerous

interactions include those that cause hypoglycaemia,

increase susceptibility to bleeding, and induce

arrhythmias, central cramps and hypertensive crises.

It follows that oral antidiabetics, oral anticoagulants,

cardiac glycosides and antiepileptics (Komjáthy,

2016) pose a particularly high risk. Polypharmacy

has been shown to be an independent predictor of one

or several falls as a result of an increase in the

additive and synergic effects of medications. When

using one group, the fall risk is 25%, and with ≥ six,

it increases by up to 60% (Ziere et al., 2005;

Registered Nurses’ Association of Ontario, 2011).

Some authors, however, point out that the number

of groups used is not always a good fall predictor,

and instead, the use and combination of high-risk

groups in relation to falls, and adherence should be