Is it okay to discharge a patient with a history of recurring falls who is taking Finasteride (dutasteride)?

Managing Fall Risk in Patients with Recurring Falls Taking Finasteride

Patients with a history of recurring falls should have their medications reviewed and potentially discontinued, including finasteride, as part of a comprehensive fall prevention strategy before discharge.

Fall Risk Assessment and Medication Review

Fall prevention is a critical component of care for patients with a history of recurring falls. According to the American Geriatrics Society guidelines, medication review is an essential part of fall prevention strategies 1.

Medication Considerations:

• Finasteride and Fall Risk: While finasteride is not specifically mentioned in the fall prevention guidelines as a high-risk medication, any medication should be evaluated in patients with recurring falls.
• Medication Review Process: The AGS Panel on Falls Prevention recommends that "patients who have fallen should have their medications reviewed and altered or stopped as appropriate in light of their risk of future falls" 1.
• Polypharmacy Concerns: Particular attention should be given to patients taking four or more medications, as reduction in the number of medications has been shown to be beneficial in fall prevention 1.

Fall Prevention Strategy Before Discharge

For patients with recurring falls, a multifactorial approach is recommended before discharge:

1. Comprehensive Fall Risk Evaluation:

   • Assess balance and mobility using validated tools
   • Evaluate for postural hypotension
   • Review all medications, including finasteride
   • Assess vision and neurological function

2. Medication Management:

   • Review all medications for potential contribution to fall risk
   • Consider discontinuing medications without immediate effect on symptom relief 2
   • Simplify medication regimens to improve adherence

3. Exercise and Physical Therapy:

   • Implement balance and strength training exercises
   • Provide gait training and advice on assistive devices 1
   • Offer long-term exercise and balance training for patients with recurrent falls 1

4. Environmental Assessment:

   • Conduct a facilitated environmental home assessment before discharge 1
   • Implement necessary home modifications to reduce fall hazards

Discharge Planning for Fall Prevention

When discharging a patient with a history of recurring falls:

1. Formal Fall Prevention Program:

   • The American Heart Association/American Stroke Association recommends that "individuals with stroke be provided a formal fall prevention program during hospitalization" 1
   • This recommendation can be applied to all patients with fall risk

2. Patient Education:

   • Provide clear, written instructions about fall prevention strategies
   • Ensure patients understand medication changes and their rationale
   • Research shows that patients often report that "falls are not a priority" during discharge and that information is "not given, or given and not retained" 3

3. Follow-up Care:

   • Schedule follow-up appointments to reassess fall risk
   • Arrange for home health services if needed
   • Consider referral to a falls clinic or specialist

Specific Recommendations Regarding Finasteride

When considering finasteride specifically:

1. Benefit vs. Risk Assessment:

   • Evaluate the necessity of finasteride treatment against the risk of falls
   • Consider the indication for finasteride (BPH vs. androgenic alopecia)
   • For non-essential indications like alopecia, the risk of falls may outweigh the benefits

2. Alternative Treatments:

   • Consider alternative treatments for the condition being treated with finasteride
   • If treating BPH, consider alpha-blockers or surgical interventions as alternatives
   • If treating alopecia, consider topical treatments instead

3. Monitoring Plan:

   • If finasteride must be continued, implement additional fall prevention measures
   • Schedule more frequent follow-ups to assess for adverse effects

Conclusion

For patients with recurring falls, medication review and potential discontinuation of non-essential medications like finasteride should be part of a comprehensive fall prevention strategy before discharge. The evidence strongly supports that medication review and reduction is an effective component of fall prevention interventions 1. While finasteride itself is not specifically identified as a high-risk medication for falls, the principle of minimizing medications in patients with fall risk applies.

Healthcare providers should carefully weigh the benefits of finasteride against the potential risks in patients with a history of falls, and consider alternative treatments when appropriate.