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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

CNS medication Burden




Summated Standardized Daily Dose (SDD)


Falls

  1. Falls are a major safety problem in older nursing home residents

  2. Up to 50% of older nursing home residents fall and 10% are serious

  3. 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.

  4. Goal is to reduce SDD to <3 by reducing doses and/or stopping CNS medications.

 

How to Calculate CNS Medication Burden

  1. Determine if patient taking any CNS medication from adjoining panels

  2. Divide the daily dosage of that drug by the minimum effective geriatric daily dose

  3. Do that for each CNS drug and sum the results; If 3+ then suggest discontinue or lower dosage.

 

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)


Calculate the 'CNS Medication Burden' below (Enter daily dosages for any medications the patient is receiving).

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.

References

  1. American Pain Society (APS). Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 6th edition. 2008. Glenview, IL 60025.
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  3. Breitbart W, Chandler S, Eagel B, et al. An alternative algorithm for dosing transdermal fentanyl for cancer-related pain. Oncology. 2000;14:695-705.
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  5. Duragesic® Package Insert: https://www.duragesic.com/prescribing-information.html Accessed: October 2010.
  6. Fisch MJ, Cleeland CS: Managing cancer pain. In: Skeel RT, ed.: Handbook of Cancer Chemotherapy. 6th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2003, pp 663.
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  10. Methadone PI (package insert). Dolophine hydrochloride, 5 mg, 10mg tablets. July 2012.
  11. McPherson ML. Demystifying opioid conversion calculations. A guide for effective dosing. Bethesda: American Society of Health System Pharmacists;2010.
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  13. Ripamonti C, Groff L, Brunelli C, Polastri D, Stavrakis A, De Conno F. Switching from morphine to oral methadone in treating cancer pain: what is the equianalgesic dose ratio? J Clin Oncol. 1998;16(10):3216-3221.
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CNS Medication Burden reducing fall risk in elderly patients