Falls Risk Assessment

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Anticholinergics

Side effects caused by anticholinergics that increase the risk of falls include blurred vision, neurological impairment, light-headedness, weakness and dizziness.1,2

Drug permeability of the blood-brain-barrier, metabolism and elimination have major impacts on anticholinergic-related toxicity.2 Elderly patients with chronic kidney changes are likely to have a higher incidence of these adverse effects.2 

In one study, a significant association between anticholinergic effects and physical performance was found before and after adjusting for confounding factors. The results showed patients on drugs with anticholinergic effects had a lower 4-metre walking speed, physical performance battery score and hand grip strength score.2,3

  • Consider using anticholinergic burden scale to assess the risk of adverse effects.1,4
  • Always identify any drugs with additive anticholinergic effects.3,4

Anticholinergics for overactive bladder:

  • Oxybutynin is the least favourable anticholinergic drug due to its ability to cross the blood-brain-barrier leading to central effects.5
    • Both the immediate release and extended release formulation of oxybutynin have been associated with cognitive impairment.6
  • Most favourable is trospium as it is least likely to cross the blood-brain-barrier, and is not metabolised by CYP450.5
  • Insufficient data available for; Tolterodine, Darifenacin, Fesoterodine and Solifenacin.5

Antihistamines:

  • For hay fever, consider less sedative antihistamines such as loratadine, cetirizine or desloratadine.5
  • Avoid chlorpheniramine, diphenhydramine, promethazine and cyclizine unless the benefits outweigh the risks of adverse effects.3,5
  • Diphenhydramine may be appropriate to use in short term treatment for acute allergic reaction.7

Anti-diarrhoeals:5

  • Avoid Diphenoxylate and Atropine if possible.
  • Consider Loperamide as first-line drug therapy, or non-drug approaches.

Inhaled anticholinergics:5

  • Ipratropium, tiotropium: lack central action, favourable adverse effect profile.

Other anticholinergics:5

  • Hyoscine hydrobromide: lacks central action, favourable adverse effect profile.

References

  1. O’Donnell LK, Gnjidic D, Nahas R, Bell JS, Hilmer SN. Anticholinergic burden: considerations for older adults. J Pharm Prac Res 2017; 47:67-77.

  2. Collamati A, Martone AM, Poscia A, Brandi V, Celi M, Marzetti E, et al. Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence. Aging Clin Exp Res 2016; 28:25-35.

  3. Landi F, Russo A, Liperoti R, Cesari M, Barillaro C, Pahor M, et al. Anticholinergic Drugs and Physical Function Among Frail Elderly Population. Clin Pharmacol Ther 2007 February; 81(2):235-241.

  4. Topic 39: Thinking clearly about the anticholinergic burden [Internet]. University of South Australia; 2014 September [cited 2017 August 18]. Available from: https://www.veteransmates.net.au/VeteransMATES/documents/module_materials/M39_TherBrief.pdf

  5. Browne Claire. Falls risk medication review tool. 2012 February.

  6. Bulat T, Castle SC, Rutledge M, Quigley P. Clinical practice algorithms: Medication management to reduce fall risk in the elderly-Part 4, Anticoagulants, anticonvulsants, anticholinergics/bladder relaxants, and antipsychotics. J Am Acad Nurse Pract 2008; 20:181-190.

  7. The American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc [Internet]. 2015 [cited 2017 Aug 10]; 63(11):2227-46. Available from: http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/epdf 

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