Research Article |
Corresponding author: Yulistiani Yulistiani ( yulistiani@ff.unair.ac.id ) Academic editor: Valentina Petkova
© 2023 Yulistiani Yulistiani, Febriansyah Nur Utomo, Cahyo Wibisono Nugroho, Yasmin N. Izzati.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Yulistiani Y, Utomo FN, Nugroho CW, Izzati YN (2023) Analysis of fall risk increasing drugs on Morse Fall Scale in geriatric patients (a study at geriatric outpatient clinic Airlangga University Teaching Hospital). Pharmacia 70(2): 263-274. https://doi.org/10.3897/pharmacia.70.e101609
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Falls are the geriatric syndromes that become one of the main causes of injury, even death in the elderly. It is known that one of the risk factors for falling is the use of certain drugs that have the effect of orthostatic hypotension, sedation, balance disruptions, and other side effects. This study aims to examine the risk of falling based on Morse scale of geriatric patient that use fall-risk drug. Retrospective data were taken from e-prescriptions for geriatric patients and interviews with the patients to determine the risk of falling based on the Morse scale. The results showed that 115 patients who used the fall-risk drug had an average risk of falling from mild to moderate. The high fall-risk drug used by most patients was gabapentin (43%), the moderate fall-risk drug was candesartan (60%), and the low fall-risk drug was furosemide (9%). Patients with the total of 71% received a combination of two to four fall-risk drugs. Total MFRS of ≥6 was 53% patients, meaning that the patients’ using of drugs needed to be evaluated. From the results of statistical analysis, it was found that the number of fall risk drugs received by patients was not associated to the risk of falling in geriatric patients, while increasing the dose of high fall-risk drugs such as gabapentin, increased the fall risk level in geriatric patients. From the result of this study, it is known that fall-risk drugs are widely used by patients, hence it is necessary to increase the awareness of falling in geriatric patients.
geriatric patients, fall risk increasing drugs, Morse Fall Scale, Medication Fall Risk Score, antihypertension, gabapentin
The number of elderly people in Indonesia is approximately 9.92% of its total population or 26.82 million people. The elderly population is projected in 2045 to reach one-fifth of the total population of Indonesia (
Falls are one of the geriatric syndromes (
Several studies have found various risk factors for falls in elderly patients which include: cognitive impairment, impaired strength or function of the lower extremities, balance disruptions, visual disturbances, nocturia, as well as the amount and effect of drugs taken (
Fall risk increasing drugs generally work by affecting the cardiovascular system or the central nervous system (
In a meta-analysis study, it was reported that antihypertensives are known to increase the risk of falls due to impaired balance, dizziness, and orthostatic hypotension (
Elderly patients tend to have two or more chronic or multi-morbid conditions, such as hypertension, arthritis, heart disease, cancer, diabetes, asthma, chronic bronchitis or emphysema, and stroke, thus requiring many drugs to be used for therapy or prophylaxis (
The risk of falling can be prevented by developing an effective fall prevention strategy. An important component of the prevention strategy is to provide an assessment of the patient’s fall risk. Fall risk assessment can help health professionals to identify patients at high risk of falling so that they can develop prevention strategies for these patients. The fall risk assessment instrument commonly used in hospitals is the St. Thomas’s risk assessment tool in falling elderly inpatients (STRATIFY), Morse Fall Scale (MFS), and Hendrich Fall Risk Model (HFRM II). Of the three instruments, the MFS instrument or Morse Fall Scale is the most widely used by more than 30% of hospitals and has been shown to be effective in assessing patient falls. It was shown that there was an association between MFS scores and the incidence of falls in acute care (
The Agency for Healthcare Research and Quality (AHRQ) provides a recommendation to use the Medication Fall Risk Score (MFRS) as an instrument to assess the risk of drug-induced falls in patients. This MFRS instrument which is used in conjunction with STRATIFY or MFS, can support fall risk assessment and can plan interventions for patients. In the MFRS instrument, fall risk increasing drug are classified according to their level of risk. Analgesic drugs, including opioids, antipsychotics, anticonvulsants, and benzodiazepines, are classified as high-risk drugs for falls. Antihypertensive drugs, cardiac, antiarrhythmic, antidepressants are included in the class of drugs that are at moderate-risk, while diuretic drugs are classified as low-risk drugs causing falls in elderly patients (
Based on the description above, the incidence of falls in geriatric patients has various risk factors, including the use of fall risk increasing drugs. Consequently, this study needs to be carried out in the hope of providing information regarding the use of drugs that increase the risk of falling. With this information, guidelines or fall prevention strategies can be made, thereby providing services to geriatric patients so as to improve the quality of health services.
This study was an observational study and conducted to observe and analyzed the effect of fall risk drugs on the Morse scale. Data were collected in a retrospective, cross-sectional design, by conducting an interview with patients using the Morse scale and observing the retrospective data of e-prescribing for geriatric patients at the Geriatric Outpatient Clinic. Data collection was carried out from April to June 2022. The research instrument used in this study was a data collection sheet in the form of a Morse scale questionnaire and e-prescribing for geriatric patients obtained from the Outpatient Pharmacy. The inclusion criteria in this study were elderly patients (≥60 years old) at the Geriatric Outpatient Clinic, who received and consumed treatment of fall-risk drugs at least for a month prior to the sampling time (April–June 2022), the patients agreed to be a part of this study, and their data were complete. The exclusion criteria in this study were the geriatric patients who just received the fall-risk drugs in the same day within the sampling time. Sampling method in this study was purposive sampling, where the sample was not randomly selected and was chosen because it met the inclusion criteria. The sampling process ended when the total number of samples was met or until the specified time limit. This research was approved by the Research Ethics Commission of the Airlangga University Hospital and was declared to have passed the ethical review with a Certificate of Passing the Ethics Review Number 030/KEP/2022.
Presentation of patient demographic data (age and gender), patient diagnosis results, treatment therapy profile (type, amount, dose, frequency, and duration of drug use), as well as the results of Morse scale calculations and MFRS scores are presented descriptively in the form of frequency (n) and percentage (%). Data analysis using statistics was used to determine the relationship between drug use (amount of drug, drug dose, and MFRS score) with the risk of falling as measured using the Morse scale. The data obtained were tested for normality. If the results of the normality test showed that the data was normally distributed (sig. >0.05), then the data would be tested using the Pearson correlation method. If the results of the normality test showed that the data was not normally distributed (sig. <0.05), then the data would be tested using the Spearman Rho’s method.
Of the 115 patients taken, geriatric patients who received fall-risk drugs were 65 female patients (57%) and male geriatric patients as many as 50 patients (43%). According to a study conducted by Rahmawati in 2019, geriatric patients who use fall risk drug were more female than male (
For age distribution, subjects were divided into three classifications, which are young elderly (60–69 years), middle elderly (70–79 years), and old elderly (≥80 years). From the results obtained, geriatric patients who use fall-risk drugs were dominated by middle-aged patients, as many as 59 patients (51%). In contrast to the research conducted by Rahmawati in 2019, geriatric patients who use fall-risk drugs were dominated by young elderly people, followed by middle and old elderly male (
Subject characteristic | Total n (%) | |
---|---|---|
Gender | Male | 50 (43) |
Female | 65 (57) | |
Age | 60–69 (young elderly) | 42 (37) |
70–79 (middle elderly) | 59 (51) | |
≥80 (old elderly) | 14 (12) | |
Number of diseases | 1 Disease | 13 (11) |
2 Diseases | 66 (57) | |
3 Diseases | 28 (24) | |
4 Diseases | 8 (7) | |
Number of drugs | <5 drugs | 18 (16) |
5–9 drugs (polypharmacy) | 75 (65) | |
10–14 drugs (excessive polypharmacy) | 22 (19) |
In Table
Fall risk | Morse score | Mean | n (%) |
---|---|---|---|
No risk | 0 | 0 | 8 (7) |
Low Risk | <25 | 15±1,4 | 49 (43) |
Moderate Risk | 25–45 | 30±6,8 | 56 (49) |
High Risk | >45 | 50 | 2 (2) |
Fall-risk drugs that are received by geriatric patients at the Geriatric Outpatient Clinic are classified based on the level of the risk of falling according to
Fall-risk drugs that are included in high risk with an MFRS score of three are presented in Table
Fall risk drugs | n | % | Duration of use | n | % |
---|---|---|---|---|---|
Antipsychotic | |||||
Risperidone 1×2 mg | 1 | 1 | >5 years | 1 | 1 |
Quetiapine 1×200 mg | 1 | 1 | >5 years | 1 | 1 |
Anticonvulsant | |||||
Gabapentin | 50 | 43 | |||
1×100 mg | 32 | 27 | <1 year | 11 | 10 |
1–5 years | 12 | 10 | |||
>5 years | 8 | 7 | |||
1×300 mg | 18 | 17 | <1 year | 4 | 3 |
1–5 years | 6 | 5 | |||
>5 years | 9 | 8 | |||
Divalproex 1×250 mg | 1 | 1 | >5 years | 1 | 1 |
Benzodiazepine | |||||
Alprazolam | 6 | 5 | |||
1×0,25 mg | 3 | 3 | <1 year | 1 | 1 |
1–5 years | 1 | 1 | |||
>5 years | 1 | 1 | |||
1×0,5 mg | 3 | 3 | <1 year | 2 | 2 |
1–5 years | 1 | 1 | |||
Diazepam 1×2 mg | 5 | 4 | <1 year | 4 | 3 |
1–5 years | 1 | 1 |
Fall-risk drugs included in moderate risk with an MFRS score of two are presented in Table
Fall risk drugs | n | % | Duration of use | n | % |
---|---|---|---|---|---|
Antihypertension | |||||
Candesartan | 69 | 60 | |||
1×8 mg | 34 | 30 | >5 years | 34 | 30 |
1×16 mg | 35 | 30 | >5 years | 35 | 30 |
Bisoprolol | 59 | 51 | 1 | ||
1×1,25 mg | 1 | 1 | 1–5 years | 1 | 11 |
1×2,5 mg | 51 | 44 | <1 year | 13 | 11 |
1–5 years | 13 | 22 | |||
>5 years | 25 | ||||
1×5 mg | 7 | 6 | <1 year | 1 | 1 |
1–5 years | 2 | 2 | |||
>5 years | 4 | 3 | |||
Nifedipine 1×30 mg | 64 | 56 | <1 year | 12 | 10 |
1–5 years | 19 | 17 | |||
>5 years | 33 | 29 | |||
Amlodipine | 16 | 14 | |||
1×5 mg | 7 | 6 | <1 year | 2 | 2 |
1–5 years | 3 | 3 | |||
>5 years | 2 | 2 | |||
1×10 mg | 9 | 8 | <1 year | 1 | 1 |
1–5 years | 4 | 3 | |||
>5 years | 4 | 3 | |||
Lisinopril | 10 | 9 | |||
1×5 mg | 5 | 4 | <1 year | 1 | 1 |
1–5 years | 2 | 2 | |||
>5 years | 2 | 2 | |||
1×10 mg | 5 | 4 | <1 year | 2 | 2 |
1–5 years | 1 | 1 | |||
>5 years | 2 | 2 | |||
Tamsulosin 1×0,4 mg | 7 | 6 | |||
<1 year | 2 | 2 | |||
1–5 years | 4 | 3 | |||
>5 years | 1 | 1 | |||
Ramipril | 3 | 3 | |||
1×2,5 mg | 1 | 1 | >5 years | 1 | 1 |
1×5 mg | 2 | 2 | >5 years | 2 | 2 |
Nitrates | |||||
Nitro-glycerine 1×2,5 mg | 6 | 5 | 1–5 years | 2 | 2 |
>5 years | 3 | 3 | |||
Isosorbide Dinitrate 1×5 mg | 3 | 3 | <1 year | 1 | 1 |
1–5 years | 2 | 2 | |||
Antiarrhythmic | |||||
Diltiazem 1× 200 mg | 1 | 1 | 1–5 years | 1 | 1 |
Antidepressant | |||||
Amitriptyline 1×25 mg | 3 | 3 | <1 year | 1 | 1 |
1–5 years | 2 | 2 | |||
Fluo×etine 1×20 mg | 1 | 1 | >5 years | 1 | 1 |
Fall-risk drugs that are included in low risk with an MFRS score of one are presented in Table
Fall risk drugs | n | % | Duration of use | n | % |
---|---|---|---|---|---|
Diuretics | |||||
Hydrochlorothiazide 1×25 mg | 1 | 1 | <1 year | 1 | 1 |
Furosemide 1×40 mg | 10 | 9 | <1 year | 3 | 3 |
1–5 years | 3 | 3 | |||
>5 years | 4 | 3 | |||
Spironolactone 1×25 mg | 6 | 5 | <1 year | 2 | 2 |
1–5 years | 1 | 1 | |||
>5 years | 3 | 3 |
In Table
Parameter | MFRS/ drugs combination | Number of patients | Morse fall scale (Number of patients/%b) | |||
---|---|---|---|---|---|---|
No risk | Low risk | Moderate risk | High risk | |||
Number of fall-risk drugs | Single | 21 (18%) | 5 (24) | 6 (29) | 10 (48) | 0 (0) |
2–4 drugs | 82 (71%) | 5 (6) | 38 (46) | 39 (48) | 0 (0) | |
5–7 drugs | 12 (10%) | 0 (0) | 3 (25) | 7 (58) | 2 (17) | |
Medication fall risk score | <6 | 54 (47%) | 7 (6) | 22 (22) | 25 (22) | 0 (0) |
≥6 | 61 (53%) | 1 (1) | 27 (27) | 31 (27) | 2 (2) |
For the sake of determining the correlation between the MFRS score and the risk of falling in geriatric patients, statistical tests were performed. The score data was first tested for normality using the Kolmogorov–Smirnov test to determine if the data were normally or not normally distributed. The result of the significance value of the normality test obtained 0.0 (<0.05), then the data was not normally distributed. In order to find out the correlation between variables, Spearman’s non-parametric correlation test was used. From the results of the Spearman test, the result obtained a significance value of 0.034 (<0.05) so that it was stated that there was a significant correlation between variables. Then from the value of the correlation coefficient, the result is (+) 0.198, namely between variables there was a weak correlation (
In order to determine the correlation between the number of drugs and the risk of falling in geriatric patients, statistical tests were carried out. The score data was first tested for normality using the Kolmogorov-Smirnov test, which was to determine if the data were normally or not normally distributed. The results of the significance value of the normality test obtained 0.0 (<0.05), then the data was not normally distributed. In exchange for finding out the correlation between variables, Spearman’s non-parametric correlation test was used. From the results of the Spearman test, significance value of 0.080 (> 0.05) was obtained, so that it is stated that there was no significant correlation between variables. Then, from the value of the correlation coefficient, the result was (+) 0.161, namely between variables there was a weak correlation (
In order to determine the correlation between drug dose and risk of falls in geriatric patients, a statistical test was conducted between the dose of one drug (which is Gabapentin, the most used of high fall-risk drugs) and Morse score. Gabapentin doses used by patients were 100 mg and 300 mg. The score data was first tested for normality using the Kolmogorov-Smirnov test to determine if the data were normally or not normally distributed. The results of the significance value of the normality test obtained 0.0 or less than 0.05, then the data was not normally distributed. To test the difference in the dose of gabapentin 100 mg and 300 mg, a non-parametric Mann-Whitney U test was carried out. The results of the significance value of the test were 0.008 or <0.05 so that there was a difference in the Morse scale mean in patients with a dose of gabapentin 100 mg and gabapentin. 300 mg.
To determine the correlation between the increase in gabapentin dose and the Morse scale, a non-parametric Spearman Rho’s correlation test was carried out. From the results of the Spearman Rho’s test, the results obtained a significance value of 0.006 (<0.05) so that it is stated that there is a significant correlation between variables. From the correlation coefficient value, the result is (+) 0.380, namely between variables having a moderate correlation (
This study aims to assess the risk of falling of fall-risk drugs in geriatric patients. One of the intrinsic risk factors for falls in elderly patients is the patient’s disease condition (
Table
In Fig.
The second most high fall-risk drugs were benzodiazepines used by eleven patients (Table
Moderate-fall risk drugs are the most common fall-risk drugs used by geriatric patients (Fig.
The second most common moderate-risk drug was bisoprolol. Bisoprolol is a b-blocker antihypertensive. Based on data from the Irish Longitudinal on Aging (TILDA), it was reported that the -blocker group was associated with an increased risk of orthostatic hypotension in elderly patients, thereby increasing the risk of falling. This was due to the negative inotropic and chronotropic effects of b-blocker antihypertensives, thus interfering with the compensatory response to lowering blood pressure when standing. In addition, the inhibition of the juxtaglomerular and b-1 adrenergic presynaptic receptors would reduce RAAS activity and sympathetic outflow resulting in vasodilation (
The third most common moderate-risk drug was nifedipine. Nifedipine is a calcium channel blocker (CCB) antihypertensive. In addition to nifedipine, other CCB classes used by geriatric patients were amlodipine and diltiazem. In a study conducted by
Antihypertensives other than ACE inhibitors, ARBs, CCBs, and b-blocker, in this study geriatric patients received -blocker therapy, namely tamsulosin 1×0.4 mg which was used in patients with a diagnosis of prostatic hyperplasia. a-blocker can increase the risk of falling in geriatric patients because of the inhibition of the a-1 receptor, causing relaxation of vascular smooth muscle and vasodilation (
The nitrate class of drugs which is a moderate-fall risk drug was also found in this study. The nitrates used by geriatric patients were isosorbide dinitrate and nitroglycerin. Nitrates were used as angina therapy with the mechanism of nitric oxide release in smooth muscle so that it activates guanylyl cyclase and increases cGMP so that nitrates have a smooth muscle relaxation effect in vessels and vasodilation of venous return (
Antidepressants are also moderate-fall risk drugs. The antidepressant that was widely used by geriatric patients in this study was amitriptyline at a dose of 1×25 mg. Amitriptyline belongs to the tricyclic antidepressant (TCA) class. Amitriptyline was used to treat depressive disorders, but at low doses it could also be used as abdominal pain, neuropathic pain, and migraine prophylaxis (
Drugs with low risk of falling are diuretics. The most used diuretic is the loop diuretic group, namely furosemide 1×40 mg with a percentage of 9% (Table
Table
In order to determine the relationship between the number of fall-risk drugs and the risk of falling in geriatric patients, a correlation analysis of the fall risk score based on the MFRS and the number of fall risk drugs received by the patient with the patient’s Morse risk scale was carried out. From the results of the analysis, it was found that the total MFRS score was weakly correlated and significant with the Morse score (Table
Variable | Kolmogorov-smirnov Significance | Spearman | |
---|---|---|---|
Coeff. correlation | Sig. | ||
Morse MFRS | 0,000 | (+) 0,198 | 0,034 |
Morse number of fall-risk drugs | 0,000 | (+) 0,161 | 0,085 |
To determine the relationship between the dose of fall-risk drugs and the risk of falling in geriatric patients, a correlation analysis of the dose of gabapentin with the results of the patient’s Morse score was carried out. Gabapentin was used in this analysis because gabapentin is the most common high-fall risk drug used by patients. From the results of the analysis, it was found that there was a difference in the risk of falling in patients with gabapentin at a dose of 100 mg and a dose of 300 mg (Table
Variable | Shapiro-wilk significance | Mann-Whitney U significance | |
---|---|---|---|
100 mg | 0,006 | 0,008 | |
300 mg | 0,03 | ||
Variable | Kolmogorov-Smirnov significance | Spearman | |
Coeff. correlation | Sig. | ||
Morse | 0,001 | (+) 0,380 | 0,006 |
Doses | 0 |
From the results of this study, it is hoped that it can increase awareness for geriatric patients and health workers against the risk of falling due to drug use. It is necessary to develop a good fall prevention strategy by evaluating the use of drugs at risk of falling in geriatric patients. A good fall prevention strategy is to identify the patient’s fall risk. One way is to combine the MFRS with the Morse scale to identify the patient’s risk of falling. In a study conducted by
This study has several limitations, including in assessing the patient’s risk of falling, it is difficult to know whether the fall is a direct result of the drug or the presence of disease factors experienced by the patient. Another limitation of this study is that it did not assess the patient’s compliance in taking the drug at risk of falling so that the drug data was only taken from e-prescribing without knowing whether the patient really took the drug at risk of falling. However, the results of this study can be useful to provide information about drugs at risk of falling so that they can be considered in the selection of drug therapy in elderly patients to prevent falls and increase awareness of elderly patients against the risk of falling due to drugs.
Based on the study on fall-risk drugs in geriatric patients conducted from April to July 2022 at the Geriatric Outpatient Clinic, Airlangga University Teaching Hospital, it can be concluded that the level of risk of falls based on the Morse scale in geriatric patients that used fall-risk drugs are mild to moderate. The most widely used high-fall risk drug was gabapentin at a dose of 1×100 mg with a duration of use of 1–5 years, a moderate-fall risk drugs were candesartan at a dose of 1×8 mg with a duration of use at a dose of >5 years, and a low-fall risk drugs was furosemide at a dose of 1×40 mg, with duration of use >5 years. The number of moderate-fall risk drugs did not increase the level of risk of falls in geriatric patients, while increasing the dose of high-fall risk drugs could increase the chance of falls.