This month’s column invokes several previous columns, one about medications and the other about knowing if we know what we don’t know. 

A recent medical journal article concluded that falls in skilled nursing facilities are common and cause significant complications, death, and also use of healthcare resources. The authors asserted that we need more research to try to prevent injurious falls in nursing homes.

Really?

This is nothing new or surprising. In nursing homes, falling remains a huge challenge and a common reason for serious injury, incident reports and ER transfers. It has become a major source of litigation. Nursing homes often get blamed for failing to prevent falls due to staffing shortages, inadequate resident supervision and insufficient environmental intervention. If only everyone recognized how often the real issues have little or nothing to do with any of these!

Falls-related issues, including identified risk factors and causes, haven’t changed in decades. Many patients are on multiple medications that simultaneously potentiate one another’s risks. By affecting various body functions, medications often slow or inhibit the body’s ability to react and adjust. For example, blood pressure medications may interfere with blood pressure and heart rate adjustments that are needed to stand up quickly from a sitting or lying position and perform tasks while upright.

Over the years, I have reviewed many cases of nursing home residents who have fallen repeatedly for months or even years, despite the falls care plans and the usual generic interventions such as low beds and mattresses. As with most seemingly intractable problems in long-term care, I find that the answer has been staring everyone in the face but was either not recognized, not understood or not acted upon adequately. Significant medication-related effects and side effects are only sometimes recognized and addressed. 

This relates to last month’s discussion about knowing if we know what we don’t know. Maintaining an upright position while standing or moving is actually quite complicated, and involves the coordination of every organ system (heart, kidneys, skin, lungs, etc.). The body continually reacts and adjusts in an effort to maintain proper balances (literally and figuratively) that enable standing and moving safely. 

We must be alert to the many medications that can contribute to falling and the many ways that they do so. Medication references rarely list “falls” as a side effect or risk. Instead, they list adverse consequences that reflect fall risk factors, especially when many coexist at once. Many medications can cause multiple adverse consequences, all of which contribute significantly to increased fall risk. 

For example, adverse effects of valproic acid (e.g., depakote) that could cause or contribute to falls are listed in the Medscape online reference as tremor (25%), asthenia (16-20%), somnolence (16-20%), amblyopia (visual disturbance, 11-15%), dizziness (11-15%), abnormal gait and tardive dyskinesia (less than 5%), and other neurological abnormalities. 

All together, these diverse adverse consequences reflect a very significant fall risk. The use of antiepileptics to try to treat pain, behavior or seizures has expanded greatly despite many warnings and limited supporting evidence for their use. 

Looking, seeing and acting

If the above is true, then shouldn’t every licensed healthcare professional and medical practitioner know that medications commonly cause or contribute to repeatedly falling? Shouldn’t they all be looking up all the medications that are given to people who fall repeatedly? 

Yes, they should! Sometimes, review and analysis are done surprisingly well; sometimes, they are done only partially. And all too often, they are not done at all. Instead, nurses and medical practitioners may lean heavily on consultant pharmacists to do the medication reviews. Thus, I would characterize the biggest issues related to falling as follows: looking without seeing, seeing without understanding, and understanding without acting. 

CMS gives consultant pharmacists a prominent role in reviewing medication regimens and warning about drug “irregularities.” Consultant pharmacists can be very helpful, but they are not always in a position to investigate the full picture and pinpoint exact causes of falls among many possibilities. It is everyone’s job, not just that of any one person or discipline.

Everyone has a falls checklist. And almost everyone checks off that drugs were reviewed. But what does that really mean? Eyeballing something does not necessarily mean recognizing, understanding or knowing what to do next. Not infrequently, I have seen patients who fall while on multiple (sometimes, six to eight or more) medications that carry significant fall risks individually and together. 

For example, in one case a 101-year-old woman with repeated falls with injury was receiving clonazepam, lisinopril, nifedipine, escitalopram and quetiapine. Although all five of these are major risk factors for falls, the staff answered “No” to the question, “Is the resident taking any high-risk drugs?” on the facility falls assessment form. This is distressingly common. 

In summary, every facility should consider what they may not know about medications and repeat falls. Don’t wait for CMS to create special fall surveys — they won’t. 

If you think that falls protocols are too complicated and you’re looking for one page’s worth of bullet points, don’t! The body doesn’t operate based on bullet points, so it won’t respond to simplistic notions and more non-skid socks to correct falling. 

Routinely look up all medications in each patient’s regimen and learn to identify findings that indicate increased fall risk. The answers will surprise you and save your residents lots of misery!

Steven Levenson, MD, CMD, has spent 43 years as a physician and medical director in long-term and post-acute care settings in Maryland. He is a pioneer in medical direction, including his groundbreaking book, “Medical Direction in Long-Term Care.” For 25 years (1988-2013), he served as a CMS advisor and consultant, helping develop clinically relevant surveyor guidance and training in many aspects of OBRA.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.