Pharmacists in “unique” position to reduce fall risk

senior has fallen down

Falls are behind the vast majority of external-cause deaths among Australian nursing home residents, study finds

The retrospective study of a cohort of nursing home residents used routinely recorded coronial data and was published in the Medical Journal of Australia.

It found that of the 21,672 deaths of nursing home residents, 3289 (15.2%) resulted from external causes.

The most frequent mechanism of death were falls (2679 cases, 81.5%), choking (261 cases, 7.9%) and suicide (146 cases, 4.4%).

The incidents leading to death usually occurred in the nursing home (95.8%), but the deaths more frequently occurred outside the nursing home (67.1%).

The annual number of external cause deaths in nursing homes increased during the study period (from 1.2 per 1000 admissions in 2001–02 to 5.3 per 1000 admissions in 2011–12).

The incidence of premature and potentially preventable deaths of nursing home residents has increased over the past decade,” the researchers found.

“A national policy framework is needed to reduce the incidence of premature deaths among Australians living in nursing homes.”

In an upcoming MJA editorial, Dr Catherine Yelland, Director of Medicine at Brisbane’s Redcliffe Hospital, discusses ways to reduce the risk of falls including reducing the use of medicines associated with falls, particularly sedatives.

She says that the study showed Australia “could be doing better” at caring for the often vulnerable residents of aged care facilities.

Dr Harvey Lander, director, systems improvement, Clinical Excellence Commission (which provides leadership for the NSW Falls Prevention Network) told the AJP that pharmacists, whether in the community, in hospitals and working with aged care facilities, are in a “unique” position to help reduce the risk of falls.

“There’s quite a number of medicines which increase a person’s risk of falling: antipsychotics, antidepressants, sedatives, opiates and other drug classes as well: anything that affects balance,” he says.

“And obviously people who are on multiple medicines are at a particularly high risk: four or more, or a combination of drugs that individually increase falls risk.

“Pharmacists who provide services to residential aged care facilities are in a unique position to identify those who are at risk, and to work together with GPs and nursing home staff in reducing that risk through optimising appropriate use of medicines and highlighting risks in order to ensure preventive measures are put in place.”

He encouraged those working in community pharmacy to not only make formal referrals to GPs regarding medicines reviews, but also to consider less formal referrals to allied health professionals in their area to reduce other risk factors.

“So for example, if a person has poor sight, refer to the optometrist, if they have poor mobility, there’s occupational therapists, if people have issues with their feet, podiatrists – so you get a multidisciplinary review of independent risk factors for falls.”

He encouraged pharmacists to refer older people with risk factors to resources such as the “Staying active and on your feet” booklet, which can be accessed here.

Dr Lander warned that falls among older people are more common than many may be aware.

“One on three people over 65 fall at least once a year,” he told the AJP. “Many fall more often. They’re more common among residents of aged care facilities, where up to half fall at least once a year.

“The consequences of a fall can be minor and if there’s no injury may be neglected. If there’s no injury you [carers] might not think about it again, but the person can begin to fear falling, and reduce their activity level, and that alone can reduce quality of life.”

He says the CEC is currently focusing its falls risk prevention strategies on hospital in-patients, and that hospital pharmacists should be a significant part of this.

This includes medication reconciliation and medicines review in hospitals, working with doctors and the interdisciplinary team “to try to assist appropriate and quality use of medicines”; and “addressing any of these identified issues in terms of the types of drugs, the range of drugs, the number of drugs and if there are changes that need to be made, suggesting to medical staff who prescribe and working with them closely to do that.”

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  1. Notachemist

    Good quality RMMRs will address all these factors. They need to be done independently by an accredited consultant pharmacist who collects the data, interviews the resident and writes the report. In addition case conferencing between the accredited consultant pharmacist, the GP and the RNs and other staff involved in care would be a far more efficient process of addressing falls and improving quality of life. It would be great to see payment systems introduced for accredited pharmacists to participate in case conferencing and bedside visits with the GP.

    • Jarrod McMaugh

      I’m assuming that “independently” means separate from the supplying pharmacy? I’m not convinced that RMMR services need to be independent of the supplying pharmacy, other than from the point of view of giving the reviewer a “clean slate” when viewing the patient (ie the patient is new to them, so they may see things that are overlooked by familiarity).

      I think the professionalism of pharmacists is such that they can perform the role of review and supply (or at least have one pharmacy that employs pharmacists in both roles) without impacting on their clinical roles

      With regards to case conferencing, if the RMMR pharmacist is independent of the supply pharmacist, then the supply pharmacist needs to be included as well…. and both of these pharmacist need to be remunerated for their clinical input.

  2. Jarrod McMaugh

    I have a hard enough time getting GPs that service my local facility to follow through on writing prescriptions, let alone take in to account recommendations for appropriate medication management and risk reduction.

    Even something as simple as requesting a dose-time on a chart to be amended to a more appropriate time is often ignored or overlooked, while facility nursing staff are not empowered to implement advice from my staff regarding QUM.

    There is a significant issue in the way residents of nursing homes are funded for health care in Australia – those health professionals who are engaging in this area are severely underfunded, resulting in poorer delivery than these people deserve.

    Yes, there should be greater collaboration and communication for the sake of patients in nursing facilities. Unless this is funded in a way that ensures that each health professional is adequately remunerated, and that these health professionals aren’t incentivised to be as “efficient” with their time as possible, then none of the recommendations that Dr Yelland proposes will make it off the paper (or screen, as it were).

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