What is the best initial step to prevent falls in an elderly patient with mild dementia and sundowning: raising bed rails, reviewing medications, administering quetiapine at night, or using restraints?

From the Guidelines

The best first step to prevent falls during hospitalization of an 80-year-old man with mild dementia and sundowning is to review the medications. This approach is supported by the most recent and highest quality study, which highlights the importance of medication review in preventing falls in older adults 1. Medication review is essential because many commonly prescribed drugs in elderly patients can increase fall risk, including sedatives, antipsychotics, antidepressants, and certain cardiovascular medications. Polypharmacy is common in older adults and can lead to adverse drug interactions that affect balance and cognition. The review should focus on identifying medications that might cause orthostatic hypotension, sedation, dizziness, or confusion, and consider whether dosage adjustments or medication alternatives are appropriate.

Some key points to consider when reviewing medications include:

• Avoiding anticholinergic medications, such as diphenhydramine and hydroxyzine, which can cause CNS impairment, delirium, and increased fall risk 1
• Being cautious with muscle relaxants, such as cyclobenzaprine and metaxalone, which can increase fall risk 1
• Monitoring the use of opioids, benzodiazepines, and antipsychotics, which can also increase fall risk 1
• Considering alternative medications or dosage adjustments to minimize fall risk

Raising bed rails can actually increase fall risk as confused patients may attempt to climb over them, resulting in falls from greater height. Physical restraints like vests or mitts should be avoided as they can increase agitation, cause physical deconditioning, and are associated with serious injuries. Administering quetiapine (an antipsychotic) at night is not recommended as first-line therapy for sundowning, as antipsychotics can increase fall risk and carry black box warnings for increased mortality in elderly patients with dementia.

Other studies support the importance of multifactorial falls prevention interventions, including exercise, home hazard modification, and clinical education or behavioral counseling 1. However, medication review is a critical first step in preventing falls, as it addresses a root cause of falls rather than simply restricting movement.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Preventing Falls in Older Adults

To prevent falls in an 80-year-old man with mild dementia and sundowning, several strategies can be considered. The options provided include raising the bed rails, reviewing the medications, administering quetiapine at night, or giving the patient soft vest and mitt restraints.

• Reviewing the medications: This is a crucial step as various medicines, sometimes referred to as 'falls risk increasing drugs', can precipitate or contribute to falls 2, 3, 4. A medication review can help identify such drugs and appropriate adjustments can be made to reduce the risk of falls.
• Raising the bed rails: While this can be a part of a multifactorial falls prevention strategy, there is no direct evidence provided in the studies to suggest that this is the best first step.
• Administering quetiapine at night: Quetiapine is associated with an increased risk of falls, especially in older adults with dementia 5. Therefore, administering quetiapine at night may not be the best option.
• Giving the patient soft vest and mitt restraints: There is no evidence provided in the studies to support the use of restraints as a first-line strategy for preventing falls.

Best First Step

Based on the evidence provided, reviewing the medications is the most appropriate first step to prevent falls in this patient 2, 3, 4. This can help identify any medications that may be contributing to the risk of falls and allow for adjustments to be made to reduce this risk.