How to Prevent Falls in Older Nursing Home Residents by Reducing CNS
Medication Burden
Created by Joseph T. Hanlon, PharmD, MS, CGP, Professor of Geriatric
Medicine and Shelley Rowe, BS, Systems Analyst, Center for Research on Health
Care (CRHC) Data Center, University of Pittsburgh
Summated Standardized Daily Dose (SDD)
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Falls
- Falls are a major safety problem in older nursing home residents.
- Up to 50% of older nursing home residents fall and 10% are serious.
- High
CNS medication burden significantly increases the risk of falls. High burden
is defined as a summated standardized daily dose (SDD) score of 3 or
greater. CNS medications include antidepressants, antiepileptics,
antipsychotics, benzodiazepines, and opioids.
- The goal is to reduce the 'SDD' to
less than 3 by reducing dosages and/or stopping CNS medications.
How to Calculate CNS Medication Burden
- Determine if the patient is taking any CNS medication from adjoining panels.
- Divide the daily dosage of that drug by the minimum effective geriatric
daily dose.
- Do that for each CNS drug and sum the results; If greater than 3, suggest
discontinuing or reducing the dosage if possible.
EXAMPLE
Patient takes 2 CNS drugs; Tramadol 50 mg twice daily & Amitriptyline 50mg at
bedtime
Tramadol: 100mg per day- 20MME /10MME = 2
PLUS
Amitriptyline 50mg/day/ 10mg/day* = 5.0
*Effective Geriatric Daily Dose (mg)
Result:
SDD = 7.0 (greater than 3 indicating a
high fall risk)
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Calculate the 'CNS Medication Burden' below (Enter daily dosages for any medications
the patient is receiving).
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Opiates
|
|
Codeine (PO) |
(Daily dose in mg) |
|
Fentanyl (Transdermal) |
(mcg/hr) |
|
Hydrocodone (PO) |
(Daily dose in mg) |
|
Hydromorphone (PO) |
(Daily dose in mg) |
|
METHadone (PO) |
(Daily dose in mg) |
|
MORPHine (PO) |
(Daily dose in mg) |
|
Oxycodone (PO) |
(Daily dose in mg) |
|
Tramadol (PO) |
(Daily dose in mg) |
Antidepressants
|
Tricyclic Antidepressants
|
|
Amitrypyline |
(Daily dose in mg) |
|
Clomipramine |
(Daily dose in mg) |
|
Desipramine |
(Daily dose in mg) |
|
Doxepin |
(Daily dose in mg) |
|
Nortriptyline |
(Daily dose in mg) |
Selective Serotonin
Reuptake Inhibitors
|
|
Citalopram |
(Daily dose in mg) |
|
Escitalopram |
(Daily dose in mg) |
|
Fluoxetine |
(Daily dose in mg) |
|
Fluvoxamine |
(Daily dose in mg) |
|
Paroxetine |
(Daily dose in mg) |
|
Sertraline |
(Daily dose in mg) |
Serotonin and
Norepinephrine Reuptake Inhibitors
|
|
Desvenlafaxine |
(Daily dose in mg) |
|
Duloxetine |
(Daily dose in mg) |
|
Milnacipran |
(Daily dose in mg) |
|
Venlafaxine |
(Daily dose in mg) |
Antiepileptics
|
|
Carbamazepine |
(Daily dose in mg) |
|
Gabapentin |
(Daily dose in mg) |
|
Lamotrigine |
(Daily dose in mg) |
|
Levetiracetam |
(Daily dose in mg) |
|
Oxcarbazepine |
(Daily dose in mg) |
|
Phenytoin |
(Daily dose in mg) |
|
Pregabalin |
(Daily dose in mg) |
|
Primidone |
(Daily dose in mg) |
|
Topiramate |
(Daily dose in mg) |
|
Valproic acid |
(Daily dose in mg) |
|
Zonisamide |
(Daily dose in mg) |
Antipsychotics
|
Conventional
|
|
Chlorpromazine |
(Daily dose in mg) |
|
Fluphenazine |
(Daily dose in mg) |
|
Haloperidol |
(Daily dose in mg) |
|
Perphenazine |
(Daily dose in mg) |
|
Thioridazine |
(Daily dose in mg) |
|
Thiothixene |
(Daily dose in mg) |
|
Trifluoperazine |
(Daily dose in mg) |
Atypical
Antipsychotics
|
|
Aripiprazole |
(Daily dose in mg) |
|
Asenapine |
(Daily dose in mg) |
|
Olanzapine |
(Daily dose in mg) |
|
Quetiapine |
(Daily dose in mg) |
|
Risperidone |
(Daily dose in mg) |
|
Ziprasidone |
(Daily dose in mg) |
Benzodiazepine Receptor
Agonists
|
|
Alprazolam |
(Daily dose in mg) |
|
Chlordiazepoxide |
(Daily dose in mg) |
|
Clonazepam |
(Daily dose in mg) |
|
Clorazepate |
(Daily dose in mg) |
|
Diazepam |
(Daily dose in mg) |
|
Estazolam |
(Daily dose in mg) |
|
Eszopiclone |
(Daily dose in mg) |
|
Flurazepam |
(Daily dose in mg) |
|
Lorazepam |
(Daily dose in mg) |
|
Oxazepam |
(Daily dose in mg) |
|
Quazepam |
(Daily dose in mg) |
|
Temazepam |
(Daily dose in mg) |
|
Triazolam |
(Daily dose in mg) |
|
Zaleplon |
(Daily dose in mg) |
|
Zolpidem |
(Daily dose in mg) |
|
Background:
|
CNS Medication Oral Minimum Geriatric Effective
Daily Dose (mg)*
Antidepressants
Tricyclic Antidepressants
Amitriptyline 10
Clomipramine 25
Desipramine 10
Doxepin 10
Nortriptyline
10
Selective Serotonin Reuptake Inhibitors
Citalopram 10
Escitalopram 5
Fluoxetine 10
Fluvoxamine
50
Paroxetine 10
Sertraline 50
Serotonin
and Norepinephrine Reuptake Inhibitors
Desvenlafaxine 75
Duloxetine 40
Milnacipran 50
Venlafaxine 75
Antiepileptics
Carbamazepine 600
Gabapentin 900
Lamotrigine 150
Levetiracetam 1000
Oxcarbazepine 900
Phenytoin 300
Pregabalin 150
Primidone 750
Topiramate
100
Valproic acid 1000
Zonisamide 100
Antipsychotics
Conventional
Chlorpromazine 10
Fluphenazine 0.5
Haloperidol 0.5
Perphenazine 2
Thioridazine 10
Thiothixene 1
Trifluoperazine 1
Atypical Antipsychotics
Aripiprazole 10
Asenapine 10
Olanzapine 5
Quetiapine 50
Risperidone 2
Ziprasidone 20
Benzodiazepine Receptor Agonists
Alprazolam 0.25
Chlordiazepoxide 5
Clonazepam 0.25
Clorazepate 3.75
Diazepam 2
Estazolam 0.5
Eszopiclone 1
Flurazepam 15
Lorazepam 1
Oxazepam 10
Quazepam 7.5
Temazepam 7.5
Triazolam 0.125
Zaleplon 2.5
Zolpidem 2.5
*For
additional agents/dosage forms, please consult Lexicomp’s ®
Geriatric Dosage Handbook or other suitable source.
Converting Oral Opioid Receptor
Agonist Daily Dose to Morphine Milligram Equivalents (MME)
Oral Opioid - MME conversion factor
Codeine 0.15
Fentanyl
(Transdermal) 7.2
Hydrocodone 1.3
Hydromorphone 5.0
Methadone 4.0
Morphine 1.0
Oxycodone 1.5
Tramadol 0.2
* Multiply oral opioid total daily dose times conversion factor
and divide by min. effective geriatric dose of oral morphine
(10mg/day) to calculate the standardized daily dose; Nielson S.
Pharmacoepidemiol Drug Saf. 2016;25:733-7.
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