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Rockwell MS, Oyese EG, Singh E, Vinson M, Yim I, Turner JK, Epling JW. Scoping review of interventions to de-implement potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) in healthcare settings. BMJ Open 2024; 14:e078808. [PMID: 38631836 PMCID: PMC11029194 DOI: 10.1136/bmjopen-2023-078808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 03/12/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVES Potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) utilisation persists at undesirable rates worldwide. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research. DESIGN Scoping review. DATA SOURCES PubMed, CINAHL, Embase, Cochrane Central and Google Scholar (1 January 2000 to 31 May 2022). STUDY SELECTION Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilisation in healthcare settings. DATA EXTRACTION Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilisation. RESULTS From 7818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the USA (35.3%), with randomised controlled trial as the most common design (55.9%). Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%) but were rarely (14.9%) guided by an implementation model, framework or theory. Academic detailing, clinical decision support or electronic medical record interventions, performance reports and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients' age (55.8%), history of gastrointestinal disorders (47.1%), or history of kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter (OTC) NSAIDs in addition to prescription. The majority of studies (76.2%) reported a reduction in the utilisation of potentially harmful NSAIDs. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation. CONCLUSION Many varied interventions to de-implement potentially harmful NSAIDs have been applied in healthcare settings worldwide. Based on these findings and identified knowledge gaps, further efforts to comprehensively evaluate the effectiveness of interventions and the combination of intervention characteristics associated with effective de-implementation are needed. In addition, future work should be guided by de-implementation theory, focus on OTC NSAIDs and incorporate patient-focused strategies and outcomes, including the evaluation of unintended consequences of the intervention.
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Affiliation(s)
- Michelle S Rockwell
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Emma G Oyese
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Eshika Singh
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Matthew Vinson
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Isaiah Yim
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Jamie K Turner
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - John W Epling
- Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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Henry A. Older Adult and Healthcare Provider Beliefs About Fall Prevention Strategies. Am J Lifestyle Med 2024; 18:108-117. [PMID: 39184271 PMCID: PMC11339757 DOI: 10.1177/15598276221100431] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024] Open
Abstract
Introduction: Older adults reported about 36 million falls in 2018. Although effective strategies are available to address risk factors and minimize fall risk, little is known about older adults' and healthcare providers' awareness of these strategies. This study describes and compares healthcare providers' and older adults' beliefs about fall prevention and strategies. Methods: Demographic and fall-related data for older adults were obtained from the 2019 fall cohort of Porter Novelli ConsumerStyles. Similar data from primary care practitioners, nurse practitioners, and physician assistants were gathered from the 2019 cohort of DocStyles. Results: Most providers (91.3%) and older adults (85.1%) believed falls can be prevented. Both providers and older adults were most likely to consider strength and balance exercises (90.7% and 82.8%, respectively) and making homes safer (90.5% and 79.9%, respectively) as strategies that help prevent falls. More providers reported that managing medications (84.2%) and tai chi (45.7%) can prevent falls compared to older adults (24.0% and 21.7%, respectively; P < .0001). Conclusion: More healthcare providers than older adults indicated evidence-based strategies exist to reduce falls. Increased patient and provider communication can increase awareness about the benefits of evidence-based strategies such as tai chi, strength and balance exercises, and medication management.
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Affiliation(s)
- Ankita Henry
- Ankita Henry, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mail-stop S106-9, Chamblee, GA 30341, USA. e-mail:
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Lalor A, Callaway L, Koritsas S, Curran-Bennett A, Wong R, Zannier R, Hill K. Interventions to reduce falls in community-dwelling adults with intellectual disability: a systematic review. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2023; 67:1073-1095. [PMID: 37435852 DOI: 10.1111/jir.13066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/10/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND People with intellectual disability have a high risk of falls and falls-related injuries. Although people with intellectual disability are at increased risk of falls, there is a need to better understand the efficacy of interventions that can help reduce falls and address risk factors in this population. This systematic review aimed to evaluate the type, nature and effectiveness of interventions undertaken to reduce falls with community-dwelling adults with intellectual disability and the quality of this evidence. METHOD Four electronic databases were searched: Ovid MEDLINE, PsycINFO, CINAHL Plus and the Cochrane Library. Studies were included if they involved people aged 18 years or over, at least 50% of study participants had intellectual disability, participants were community-dwelling, and the study evaluated any interventions aiming to reduce falls. Study quality was assessed using the National Institutes of Health study quality assessment tools. Reporting of the review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Seven studies were eligible for review, with a total of 286 participants and mean age of 50.4 years. As only one randomised trial was identified, a narrative synthesis of results was undertaken. Five studies evaluated exercise interventions, one evaluated a falls clinic programme, and one evaluated stretch fabric splinting garments. Methodological quality varied (two studies rated as good, four as fair, and one as poor). Exercise interventions varied in terms of exercise type and dosage, frequency and intensity, and most did not align with recommendations for successful falls prevention exercise interventions reported for older people. While the majority of studies reported reduced falls, they differed in methods of reporting falls, and most did not utilise statistical analyses to evaluate outcomes. CONCLUSION This review identified a small number of falls prevention intervention studies for people with intellectual disability. Although several studies reported improvements in fall outcomes, ability to draw conclusions about intervention effectiveness is limited by small sample sizes and few studies. Further large-scale research is required to implement and evaluate falls prevention interventions specifically for adults with intellectual disability.
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Affiliation(s)
- A Lalor
- Rehabilitation Ageing and Independent Living (RAIL) Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Occupational Therapy, Monash University, Melbourne, Victoria, Australia
| | - L Callaway
- Rehabilitation Ageing and Independent Living (RAIL) Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Occupational Therapy, Monash University, Melbourne, Victoria, Australia
| | - S Koritsas
- Department of Strategy and Transformation, Scope, Melbourne, Australia, Australia
| | - A Curran-Bennett
- Department of Strategy and Transformation, Scope, Melbourne, Australia, Australia
| | - R Wong
- Department of Strategy and Transformation, Scope, Melbourne, Australia, Australia
- IDEAS Therapy Services, Victoria, Australia
| | - R Zannier
- Department of Strategy and Transformation, Scope, Melbourne, Australia, Australia
| | - K Hill
- Rehabilitation Ageing and Independent Living (RAIL) Research Centre, Monash University, Melbourne, Victoria, Australia
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Mullan SM, Evans NJ, Sewell DK, Francis SL, Polgreen LA, Segre AM, Polgreen PM. Predicting use of a gait-stabilizing device using a Wii Balance Board. PLoS One 2023; 18:e0292548. [PMID: 37796884 PMCID: PMC10553233 DOI: 10.1371/journal.pone.0292548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 09/22/2023] [Indexed: 10/07/2023] Open
Abstract
Gait-stabilizing devices (GSDs) are effective at preventing falls, but people are often reluctant to use them until after experiencing a fall. Inexpensive, convenient, and effective methods for predicting which patients need GSDs could help improve adoption. The purpose of this study was to determine if a Wii Balance Board (WBB) can be used to determine whether or not patients use a GSD. We prospectively recruited participants ages 70-100, some who used GSDs and some who did not. Participants first answered questions from the Modified Vulnerable Elders Survey, and then completed a grip-strength test using a handgrip dynamometer. Finally, they were asked to complete a series of four 30-second balance tests on a WBB in random order: (1) eyes open, feet apart; (2) eyes open, feet together; (3) eyes closed, feet apart; and (4) eyes closed, feet together. The four-test series was repeated a second time in the same random order. The resulting data, represented as 25 features extracted from the questionnaires and the grip test, and data from the eight balance tests, were used to predict a subject's GSD use using generalized functional linear models based on the Bernoulli distribution. 268 participants were consented; 62 were missing data elements and were removed from analysis; 109 were not GSD users and 97 were GSD users. The use of velocity and acceleration information from the WBB improved upon predictions based solely on grip strength, demographic, and survey variables. The WBB is a convenient, inexpensive, and easy-to-use device that can be used to recommend whether or not patients should be using a GSD.
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Affiliation(s)
- Sean M. Mullan
- Department of Computer Science, University of Iowa, Iowa City, Iowa, United States of America
| | - Nicholas J. Evans
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Daniel K. Sewell
- Department of Biostatistics, University of Iowa, Iowa City, Iowa, United States of America
| | - Shelby L. Francis
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Linnea A. Polgreen
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City, Iowa, United States of America
| | - Alberto M. Segre
- Department of Computer Science, University of Iowa, Iowa City, Iowa, United States of America
| | - Philip M. Polgreen
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
- Department of Epidemiology, University of Iowa, Iowa City, Iowa, United States of America
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Berry SD, Hecker EJ, McConnell ES, Xue TM, Tsai T, Zullo AR, Colón-Emeric C. Nursing Home PRevention of Injury in DEmentia (NH PRIDE): A pilot study of a remote injury prevention service for NH residents. J Am Geriatr Soc 2023; 71:3267-3277. [PMID: 37596877 PMCID: PMC10592133 DOI: 10.1111/jgs.18564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 07/20/2023] [Accepted: 08/02/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Medication optimization, including prescription of osteoporosis medications and deprescribing medications associated with falls, may reduce injurious falls. Our objective was to describe a remote, injury prevention service (NH PRIDE) designed to optimize medication use in nursing homes (NHs), and to describe its implementation outcomes in a pilot study. METHODS This was a non-randomized trial (pilot study) including NH staff and residents from five facilities. Long-stay residents at high-risk for injurious falls were identified using a validated risk calculator and staff referral. A remote team reviewed the electronic health record (EHR) and provided recommendations as Injury Prevention Plans (IPP). A research nurse served as a care coordinator focused on resident engagement and shared decision-making. Outcomes included implementation measures, as identified in the EHR, and surveys and interviews with staff. RESULTS Across five facilities, 274 residents were screened for eligibility, and 46 residents (16.8%) were enrolled. Most residents were female (73.9%) and had dementia (63.0%). An IPP was completed for 45 residents (97.8%). The nurse made a total of 93 deprescribing recommendations in 36 residents (80% of residents had one or more deprescribing recommendation; mean 2.2 recommendations/resident). Twenty of 45 residents (44.4%) had a recommendation for osteoporosis treatment. Among residents with recommendations, 21/36 (58.3%) had one or more deprescribing orders written and 6/20 (30.0%) had an osteoporosis medication prescribed. At 4 months, most medication changes persisted. Adverse side effects were rare. Staff members identified several areas for program refinement, including aligning recommendations with provider workflow and engaging consultant psychiatrists. CONCLUSIONS A remote injury prevention service is safe and feasible to enhance deprescribing and osteoporosis treatment in long-stay NH residents at risk for injury. Additional investigation is needed to determine if this model could reduce injurious falls when deployed across NH chains.
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Affiliation(s)
- Sarah D. Berry
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, Boston, MA
- Beth Israel Deaconess Medical Center, Department of Medicine & Harvard Medical School, Boston, MA
| | - Emily J. Hecker
- Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, Durham, NC
| | - Eleanor S. McConnell
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC
- Duke University School of Nursing, Durham, NC
| | - Tingzhong-Michelle Xue
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC
- Duke University School of Nursing, Durham, NC
| | - Timothy Tsai
- Hinda and Arthur Marcus Institute for Aging Research and Department of Medicine, Hebrew SeniorLife, Boston, MA
| | - Andrew R. Zullo
- Brown University School of Public Health, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Cathleen Colón-Emeric
- Duke University School of Medicine, Department of Medicine, Division of Geriatric Medicine, Durham, NC
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC
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Rockwell MS, Oyese EG, Singh E, Vinson M, Yim I, Turner JK, Epling JW. A Scoping Review of Interventions to De-implement Potentially Harmful Nonsteroidal Anti-inflammatory Drugs (NSAIDs) in Healthcare Settings. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.29.23293362. [PMID: 37546911 PMCID: PMC10402245 DOI: 10.1101/2023.07.29.23293362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Objectives Potentially harmful nonsteroidal anti-inflammatory drugs (NSAIDs) utilization persists at undesirable rates throughout the world. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in healthcare settings and to suggest directions for future research. Design Scoping review. Data Sources PubMed, CINAHL, Embase, Cochrane Central, and Google Scholar (2000-2022). Study Selection Studies reporting on the effectiveness of interventions to systematically reduce potentially harmful NSAID utilization in healthcare settings. Data Extraction Using Covidence systematic review software, we extracted study and intervention characteristics, including the effectiveness of interventions in reducing NSAID utilization. Results From 7,818 articles initially identified, 68 were included in the review. Most studies took place in European countries (45.6%) or the U.S. (35.3%), with randomized controlled trial as the most common design (55.9%). The majority of studies (76.2%) reported a reduction in the utilization of potentially harmful NSAIDs. Interventions were largely clinician-facing (76.2%) and delivered in primary care (60.2%). Academic detailing, clinical decision support or electronic medical record interventions, performance reports, and pharmacist review were frequent approaches employed. NSAID use was most commonly classified as potentially harmful based on patients' age (55.8%) or history of gastrointestinal disorders (47.1%) or kidney disease (38.2%). Only 7.4% of interventions focused on over-the-counter NSAIDs in addition to prescription. Few studies (5.9%) evaluated pain or quality of life following NSAIDs discontinuation. Conclusion Many varied interventions are effective in de-implementing potentially harmful NSAIDs in healthcare settings. Efforts to adapt, scale, and disseminate these interventions are needed. In addition, future interventions should address over-the-counter NSAIDs, which are broadly available and widely used. Evaluating unintended consequences of interventions, including patient-focused outcomes, is another important priority.
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Affiliation(s)
- Michelle S Rockwell
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Emma G Oyese
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Eshika Singh
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | | | - Isaiah Yim
- Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Jamie K Turner
- Translational Biology, Medicine, and Health Graduate Program, Virginia Tech, Roanoke, VA
| | - John W Epling
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA
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Jensen AD, Taneja K, Ahmad MT, Woreta FA, Rajaii F. Incidence and Characteristics of Orbital Hemorrhages in the United States from 2006 to 2018. Clin Ophthalmol 2022; 16:3369-3380. [PMID: 36237493 PMCID: PMC9553320 DOI: 10.2147/opth.s376447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 09/28/2022] [Indexed: 11/22/2022] Open
Abstract
Purpose To determine the incidence, characteristics, and costs associated with orbital hemorrhages presenting to US EDs. Patients and Methods This was a retrospective, longitudinal study of the Nationwide Emergency Department Sample, 2006 to 2018. Medical records from patients presenting to participating hospital-owned EDs and diagnosed with primary or secondary orbital hemorrhage were examined to determine incidence, demographics, clinical characteristics, mechanism, disposition and related risk factors, and costs. Results From 2006 to 2018, an estimated 20,762 US ED visits included an orbital hemorrhage diagnosis. Most primary diagnosis patients were elderly (35%) and male (51%), and incidence increased from 1.1 (95% CI: 0.8-1.4) to 3.1 per million (95% CI: 2.5-3.7, p < 0.0001). Fall was the most common mechanism (21.6%), particularly among the elderly (39.9%). Fall-related diagnoses increased from 0.03 (95% CI: -0.01-0.07) to 1.0 per million (95% CI: 0.7-1.3, p < 0.0001), while overall falls increased by only 7%. Assault-related orbital hemorrhage increased from 0.1 (95% CI: 0.0-0.2) to 0.6 per million (95% CI: 0.4-0.7, p < 0.0001), while overall assaults decreased by 22%. Annual total ED costs increased from $463,220 (95% CI: 233,993-692,446) to $6,117,320 (95% CI: 4,665,403-7,569,237, p < 0.001). Inpatient admission was uncommon (9.0%), but related costs totaled $18.9 million (95% CI: 13.3-24.5). Odds of admission were lower in fall- and objects-related injuries and higher with certain concurrent injuries. Conclusion Orbital hemorrhages are becoming more frequent and costly. A disproportionately large increase in fall- and assault-related diagnoses highlights the need for targeted injury prevention strategies to reduce cost and morbidity.
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Affiliation(s)
- Adrianna D Jensen
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kamil Taneja
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Meleha T Ahmad
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fatemeh Rajaii
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Seppala LJ, Kamkar N, van Poelgeest EP, Thomsen K, Daams JG, Ryg J, Masud T, Montero-Odasso M, Hartikainen S, Petrovic M, van der Velde N. Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review and meta-analysis. Age Ageing 2022; 51:afac191. [PMID: 36153749 PMCID: PMC9509688 DOI: 10.1093/ageing/afac191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND our aim was to assess the effectiveness of medication review and deprescribing interventions as a single intervention in falls prevention. METHODS DESIGN systematic review and meta-analysis. DATA SOURCES Medline, Embase, Cochrane CENTRAL, PsycINFO until 28 March 2022. ELIGIBILITY CRITERIA randomised controlled trials of older participants comparing any medication review or deprescribing intervention with usual care and reporting falls as an outcome. STUDY RECORDS title/abstract and full-text screening by two reviewers. RISK OF BIAS Cochrane Collaboration revised tool. DATA SYNTHESIS results reported separately for different settings and sufficiently comparable studies meta-analysed. RESULTS forty-nine heterogeneous studies were included. COMMUNITY meta-analyses of medication reviews resulted in a risk ratio (RR) of 1.05 (95% confidence interval, 0.85-1.29, I2 = 0%, 3 studies(s)) for number of fallers, in an RR = 0.95 (0.70-1.27, I2 = 37%, 3 s) for number of injurious fallers and in a rate ratio (RaR) of 0.89 (0.69-1.14, I2 = 0%, 2 s) for injurious falls. HOSPITAL meta-analyses assessing medication reviews resulted in an RR = 0.97 (0.74-1.28, I2 = 15%, 2 s) and in an RR = 0.50 (0.07-3.50, I2 = 72% %, 2 s) for number of fallers after and during admission, respectively. LONG-TERM CARE meta-analyses investigating medication reviews or deprescribing plans resulted in an RR = 0.86 (0.72-1.02, I2 = 0%, 5 s) for number of fallers and in an RaR = 0.93 (0.64-1.35, I2 = 92%, 7 s) for number of falls. CONCLUSIONS the heterogeneity of the interventions precluded us to estimate the exact effect of medication review and deprescribing as a single intervention. For future studies, more comparability is warranted. These interventions should not be implemented as a stand-alone strategy in falls prevention but included in multimodal strategies due to the multifactorial nature of falls.PROSPERO registration number: CRD42020218231.
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Affiliation(s)
- Lotta J Seppala
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Nellie Kamkar
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | - Eveline P van Poelgeest
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Katja Thomsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Joost G Daams
- Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- ODIN (Odense Deprescribing INitiative), Denmark
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Manuel Montero-Odasso
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Schulich School of Medicine and Dentistry, London Ontario, Canada
- Departments of Medicine (Geriatrics) and of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | | | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics (Section of Geriatrics), Ghent University, Ghent, Belgium
| | - Nathalie van der Velde
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Fischer H, Hahn EE, Li BH, Munoz-Plaza CE, Luong TQ, Harrison TN, Slezak JM, Sim JJ, Mittman BS, Lee EA, Singh H, Kanter MH, Reynolds K, Danforth KN. Potentially Harmful Medication Dispenses After a Fall or Hip Fracture: A Mixed Methods Study of a Commonly Used Quality Measure. Jt Comm J Qual Patient Saf 2022; 48:222-232. [PMID: 35190249 DOI: 10.1016/j.jcjq.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 12/16/2021] [Accepted: 01/06/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND High-risk medication dispenses to patients with a prior fall or hip fracture represent a potentially dangerous disease-drug interaction among older adults. The research team quantified the prevalence, identified risk factors, and generated patient and provider insights into high-risk medication dispenses in a large, community-based integrated health system using a commonly used quality measure. METHODS This was a mixed methods study with a convergent design combining a retrospective cohort study using electronic health record (EHR) data, individual interviews of primary care physicians, and a focus group of patient advisors. RESULTS Of 113,809 patients ≥ 65 years with a fall/fracture in 2009-2015, 35.4% had a potentially harmful medication dispensed after their fall/fracture. Most medications were prescribed by primary care providers. Older age, male gender, and race/ethnicity other than non-Hispanic White were associated with a reduced risk of high-risk medication dispenses. Patients with a pre-fall/fracture medication dispense were substantially more likely to have a post-fall/fracture medication dispense (hazard ratio [HR] = 13.26, 95% confidence interval [CI] = 12.91-13.61). Both patients and providers noted that providers may be unaware of patient falls due to inconsistent assessments and patient reluctance to disclose falls. Providers also noted the lack of a standard location to document falls and limited decision support alerts within the EHR. CONCLUSION High-risk medication dispenses are common among older patients with a history of falls/fractures. Future interventions should explore improved assessment and documentation of falls, decision support, clinician training strategies, patient educational resources, building trusting patient-clinician relationships to facilitate long-term medication discontinuation among persistent medication users, and a focus on fall prevention.
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Hart LA, Walker R, Phelan EA, Marcum ZA, Schwartz NR, Crane PK, Larson EB, Gray SL. Change in central nervous system-active medication use following fall-related injury in older adults. J Am Geriatr Soc 2022; 70:168-177. [PMID: 34668191 PMCID: PMC8742750 DOI: 10.1111/jgs.17508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/25/2021] [Accepted: 08/28/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Central nervous system (CNS)-active medication use is an important modifiable risk factor for falls in older adults. A fall-related injury should prompt providers to evaluate and reduce CNS-active medications to prevent recurrent falls. We evaluated change in CNS-active medications up to 12 months following a fall-related injury in community-dwelling older adults compared with a matched cohort without fall-related injury. METHODS Participants were from the Adult Changes in Thought study conducted at Kaiser Permanente Washington. Fall-related injury codes between 1994 and 2014 defined index encounters in participants with no evidence of such injuries in the preceding year. We matched each fall-related injury index encounter with up to five randomly selected clinical encounters from participants without injury. Using automated pharmacy data, we estimated the average change in CNS-active medication use at 3, 6, and 12 months post-index according to the presence or absence of CNS-active medication use before index. RESULTS One thousand five hundred sixteen participants with fall-related injury index encounters (449 CNS-active users, 1067 nonusers) were matched to 7014 index encounters from people without fall-related injuries (1751 users, 5236 nonusers). Among CNS-active users at the index encounter, those with fall-related injury had an average decrease in standard daily doses (SDDs) at 12 months (-0.43; 95% CI: -0.63 to -0.23), and those without injury had a greater (p = 0.047) average decrease (-0.66; 95% CI: -0.78 to -0.55). Among nonusers at index, those with fall-related injury had a smaller increase than those without injury (+0.17, 95% CI: +0.13 to +0.21, vs. +0.24, 95% CI: +0.20 to +0.28, p = 0.005). CONCLUSIONS The differences in CNS-active medication use change over 12 months between those with and without fall-related injury were small and unlikely to be clinically significant. These results suggest that fall risk-increasing drug use is not reduced following a fall-related injury, thus opportunities exist to reduce CNS-active medications, a potentially modifiable risk factor for falls.
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Affiliation(s)
- Laura A. Hart
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA (work completed while a post-doctoral fellow at School of Pharmacy, University of Washington, Seattle, WA)
| | - Rod Walker
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Elizabeth A. Phelan
- Department of Medicine, Division of Gerontology and Geriatric Medicine, School of Medicine, and Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - Zachary A. Marcum
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA
| | - Naomi R.M. Schwartz
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA
| | - Paul K. Crane
- Department of Medicine, Division of General Internal Medicine, School of Medicine; University of Washington, Seattle, WA
| | - Eric B. Larson
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA;,Department of Medicine, Division of General Internal Medicine, School of Medicine; University of Washington, Seattle, WA
| | - Shelly L. Gray
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, WA
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11
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Okpalauwaekwe U, Tzeng HM. Adverse Events and Their Contributors Among Older Adults During Skilled Nursing Stays for Rehabilitation: A Scoping Review. Patient Relat Outcome Meas 2021; 12:323-337. [PMID: 34803416 PMCID: PMC8599876 DOI: 10.2147/prom.s336784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/30/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To identify factors that contribute to adverse events among older adults during short stays at skilled nursing facilities (SNFs) for rehabilitation (ie, up to 100 resident days). Adults aged 65 years and older are at serious risk for adverse events throughout their continuum of care. Over 33% of older adults admitted to SNFs experienced an adverse event (eg, falls) within the first 35 days of their stay. Design A scoping review. Setting and Participants Older adults admitted for short stays in SNFs. Methods Eligibility criteria were peer-reviewed original articles published between 1 January 2015 and 30 May 2021, written in English, and containing any of the following key terms and synonyms: “skilled nursing facilities”, “adverse events”, and “older adults”. These terms were searched in PubMed, MEDLINE, CINAHL, EBSCOHost, and the ProQuest Nursing and Allied Health Database. We summarized the findings using the Joanna Briggs Institute and PRISMA-ScR reporting guidelines. We also used the Capability-Opportunity-Motivation-Behavior (COM-B) model of health behavioral change as a framework to guide the content, thematic, and descriptive analyses of the results. Results Eleven articles were included in this scoping review. Intrinsic and extrinsic contributors to adverse events (ie, falls, medication errors, pressure ulcers, and acute infections) varied for each COM-B domain. The most frequently mentioned capacity-related intrinsic contributors to adverse events were frailty and reduced muscle strength due to advancing age. Inappropriate medication usage and polypharmacy were the most common capacity-related extrinsic factors. Opportunity-related extrinsic factors contributing to adverse events included environmental hazards, poor communication among SNF staff, lack of individualized resident safety plans, and overall poor care quality owing to racial bias and organizational and administrative issues. Conclusion These findings shed light on areas that warrant further research and may aid in developing interventional strategies for adverse events during short SNF stays.
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Affiliation(s)
- Udoka Okpalauwaekwe
- University of Saskatchewan, College of Medicine, Saskatoon, Saskatchewan, Canada
| | - Huey-Ming Tzeng
- The University of Texas Medical Branch at Galveston, School of Nursing, Galveston, TX, USA
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12
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Ming Y, Zecevic AA, Hunter SW, Miao W, Tirona RG. Medication Review in Preventing Older Adults' Fall-Related Injury: a Systematic Review & Meta-Analysis. Can Geriatr J 2021; 24:237-250. [PMID: 34484506 PMCID: PMC8390322 DOI: 10.5770/cgj.24.478] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Medication review is essential in managing adverse drug reactions and improving drug safety in older adults. This systematic review evaluated medication review's role as a single intervention or combined with other interventions in preventing fall-related injuries in older adults. METHODS Electronic databases search was conducted in PubMed, EMBASE, Scopus, and CINAHL. Two reviewers screened titles and abstracts, reviewed full texts, and performed data extraction and risk of bias assessment. Meta-analyses were conducted on studies with similar participants, interventions, outcomes or settings. RESULTS Fourteen randomized, controlled studies were included. The pooled results indicated that medication review as a stand-alone intervention was effective in preventing fall-related injuries in community-dwelling older adults (Risk Difference [RD] = -0.06, 95% CI: [-0.11, -0.00], I2 = 61%, p = .04). Medication review also had a positive impact on decreasing the risk of fall-related fractures (RD = -0.02, 95% CI: [-0.04, -0.01], I2 = 0%, p = .01). DISCUSSION This systematic review and meta-analysis has demonstrated that medication review is effective in preventing fall-related injuries in general, and fractures specifically, in community-dwelling older adults. Future investigations focusing on the process of performing medication review will further inform fall-related injury prevention for older adults.
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Affiliation(s)
- Yu Ming
- Health and Rehabilitation Sciences, School of Health Studies, Western University, London, ON
| | | | | | - Wenxin Miao
- School of Information and Media Studies, Western University, London, ON
| | - Rommel G. Tirona
- School of Physiology and Pharmacology, Western University, London, ON
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13
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Ie K, Aoshima S, Yabuki T, Albert SM. A narrative review of evidence to guide deprescribing among older adults. J Gen Fam Med 2021; 22:182-196. [PMID: 34221792 PMCID: PMC8245739 DOI: 10.1002/jgf2.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/24/2021] [Accepted: 05/09/2021] [Indexed: 11/30/2022] Open
Abstract
Potentially inappropriate prescription and polypharmacy are well‐known risk factors for morbidity and mortality among older adults. However, recent systematic reviews have failed to demonstrate the overall survival benefits of deprescribing. Thus, it is necessary to synthesize the current evidence to provide a practical direction for future research and clinical practice. This review summarizes the existing body of evidence regarding deprescribing to identify useful intervention elements. There is evidence that even simple interventions, such as direct deprescribing targeted at risky medications and explicit criteria‐based approaches, effectively reduce inappropriate prescribing. On the other hand, if the goal is to improve clinical outcomes such as hospitalization and emergency department visits, patient‐centered multimodal interventions such as a combination of medication review, multidisciplinary collaboration, and patient education are likely to be more effective. We also consider the opportunities and challenges for deprescribing within the Japanese healthcare system.
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Affiliation(s)
- Kenya Ie
- Division of General Internal Medicine Department of Internal Medicine St. Marianna University School of Medicine Kawasaki Japan.,Division of General Internal Medicine Department of Internal Medicine Kawasaki Municipal Tama Hospital Kawasaki Japan.,Department of Behavioral and Community Health Sciences University of Pittsburgh Graduate School of Public Health Pittsburgh PA USA
| | | | - Taku Yabuki
- Department of Internal Medicine Tochigi Medical Center Tochigi Japan
| | - Steven M Albert
- Department of Behavioral and Community Health Sciences University of Pittsburgh Graduate School of Public Health Pittsburgh PA USA
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14
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Chen A, Canner JK, Zafar S, Ramulu PY, Shields WC, Iftikhar M, Srikumaran D, Woreta FA. Characteristics of Ophthalmic Trauma in Fall-Related Hospitalizations in the United States from 2000 to 2017. Ophthalmic Epidemiol 2021; 29:206-215. [PMID: 33900147 DOI: 10.1080/09286586.2021.1914668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: Falls is a leading cause of injuries nationally and can lead to serious ophthalmic injuries. The purpose of this study is to examine the incidence and characteristics of ophthalmic trauma in patients with fall-related hospitalizations in the United States.Methods: Retrospective, cross-sectional study. National Inpatient Sample (NIS) was queried to identify all ophthalmic trauma associated with fall-related hospitalizations from 2000 to 2017. Patients were identified using relevant International Classification of Diseases (ICD) codes. National estimates, annual incidences and characteristics were produced from trend weights provided by the NIS sampling frame and population data from the US Census Bureau.Results: There were 21,415,120 fall-related hospitalizations of which 425,725 (2.0%) had ophthalmic trauma. Ophthalmic injury incidence increased from 4.26 to 14.31 per 100,000 population (P < .01) from 2000 to 2017. Mean (±SEM) age was 69.2 ± 20.1 years and 56.9% were females. Of the patients with specified fall mechanism, the most common mechanisms were tripping or stumbling (48.0%), falls related to furniture (18.3%), and falls related to stairs (16.3%). The most common ophthalmic injuries were contusions of the eye and adnexa including hyphema and commotio retinae (50.1%), orbital fractures (20.7%), and eyelid lacerations (14.9%).Conclusions: Incidence of ophthalmic trauma in patients with fall-related hospitalizations has increased and our study provides valuable information for targeting preventive measures particularly for the elderly and falls due to tripping, stairs, and furniture related accidents. The most common associated ophthalmic injuries are contusions, orbital fractures and eyelid lacerations.
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Affiliation(s)
- Ariel Chen
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sidra Zafar
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pradeep Y Ramulu
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wendy C Shields
- Johns Hopkins Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mustafa Iftikhar
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Divya Srikumaran
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fasika A Woreta
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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15
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Lee J, Negm A, Peters R, Wong EKC, Holbrook A. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open 2021; 11:e035978. [PMID: 33568364 PMCID: PMC7878138 DOI: 10.1136/bmjopen-2019-035978] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES Prevention of falls and fall-related injuries is a priority due to the substantial health and financial burden of falls on patients and healthcare systems. Deprescribing medications known as 'fall-risk increasing drugs' (FRIDs) is a common strategy to prevent falls. We conducted a systematic review to determine its efficacy for the prevention of falls and fall-related complications. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and grey literature from inception to 1 August 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials of FRID withdrawal compared with usual care evaluating the rate of falls, incidence of falls, fall-related injuries, fall-related fractures, fall-related hospitalisations or adverse effects related to the intervention in adults aged ≥65 years. DATA EXTRACTION AND SYNTHESIS Two reviewers independently performed citation screening, data abstraction, risk of bias assessment and certainty of evidence grading. Random-effects models were used for meta-analyses. RESULTS Five trials involving 1305 participants met eligibility criteria. Deprescribing FRIDs did not change the rate of falls (rate ratio (RaR) 0.98, 95% CI 0.63 to 1.51), the incidence of falls (risk difference 0.01, 95% CI -0.06 to 0.09; relative risk 1.04, 95% CI 0.86 to 1.26) or rate of fall-related injuries (RaR 0.89, 95% CI 0.57 to 1.39) over a follow-up period of 6-12 months. No trials evaluated the impact of deprescribing FRIDs on fall-related fractures or hospitalisations. CONCLUSION There is a paucity of robust high-quality evidence to support or refute that a FRID deprescribing strategy alone is effective at preventing falls or fall-related injury in older adults. Although there may be other reasons to deprescribe FRIDs, our systematic review found that it may result in little to no difference in the rate or risk of falls as a sole falls reduction strategy. PROSPERO REGISTRATION NUMBER CRD42016040203.
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Affiliation(s)
- Justin Lee
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- GERAS Centre for Aging Research, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ahmed Negm
- GERAS Centre for Aging Research, Hamilton Health Sciences, Hamilton, Ontario, Canada
- School of Rehabilitation Sciences, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Ryan Peters
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Eric K C Wong
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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16
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Ie K, Chou E, Boyce RD, Albert SM. Fall Risk-Increasing Drugs, Polypharmacy, and Falls Among Low-Income Community-Dwelling Older Adults. Innov Aging 2021; 5:igab001. [PMID: 33644415 PMCID: PMC7899132 DOI: 10.1093/geroni/igab001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives Medication exposure is a potential risk factor for falls and subsequent death and functional decline among older adults. However, controversy remains on the best way to assess medication exposure and which approach best predicts falls. The objective of the current study was to examine the association between different measures of medication exposure and falls risk among community-dwelling older adults. Research Design and Methods This retrospective cohort study was conducted using Falls Free PA program data and a linked prescription claims data from Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program. Participants were community-dwelling older adults living in Pennsylvania, United States. Three measures of medication exposure were assessed: (a) total number of regular medications (polypharmacy); (b) counts of potentially inappropriate medications derived from current prescription guidance tools (Fall Risk-Increasing Drugs [FRIDs], Beers Criteria); and (c) medication burden indices based on pharmacologic mechanisms (Anticholinergic Cognitive Burden, Drug Burden Index) all derived from claims data. The associations between the different medication risk measures and self-reported falls incidence were examined with univariate and multivariable negative binomial regression models to estimate incidence rate ratios (IRRs). Results Overall 343 older adults were included and there were 236 months with falls during 2,316 activity-adjusted person-months (10.2 falls per 100 activity-adjusted person-months). Of the 6 measures of medication risk assessed in multivariate models, only the use of 2 or more FRIDs (adjusted IRR 1.67 [95% CI: 1.04-2.68]) independently predicted falls risk. Among the 13 FRID drug classes, the only FRID class associated with an increased fall risk was antidepressants. Discussion and Implications The presence of multiple FRIDs in a prescription is an independent risk factor for falls, even in older adults with few medications. Further investigation is required to examine whether deprescribing focused on FRIDs effectively prevents falls among this population.
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Affiliation(s)
- Kenya Ie
- Division of General Internal Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan.,Division of General Internal Medicine, Department of Internal Medicine, Kawasaki Municipal Tama Hospital, Kanagawa, Japan
| | - Eric Chou
- Department of Biomedical Informatics, University of Pittsburgh, Pennsylvania, USA
| | - Richard D Boyce
- Department of Biomedical Informatics, University of Pittsburgh, Pennsylvania, USA
| | - Steven M Albert
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pennsylvania, USA
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17
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Bloomfield HE, Greer N, Linsky AM, Bolduc J, Naidl T, Vardeny O, MacDonald R, McKenzie L, Wilt TJ. Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:3323-3332. [PMID: 32820421 PMCID: PMC7661661 DOI: 10.1007/s11606-020-06089-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 07/29/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults. METHODS We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes. RESULTS Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes. DISCUSSION In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. REGISTRY INFORMATION PROSPERO - CRD42019132420.
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Affiliation(s)
- Hanna E Bloomfield
- Minneapolis VA Health Care System, Minneapolis, USA.
- University of Minnesota School of Medicine, Minneapolis, USA.
- Minneapolis VA Medical Center (151), 1 Veterans Drive, Minneapolis, MN, 55417, USA.
| | - Nancy Greer
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Amy M Linsky
- VA Boston Healthcare System and Boston University School of Medicine, Boston, USA
| | | | - Todd Naidl
- Minneapolis VA Health Care System, Minneapolis, USA
| | - Orly Vardeny
- Minneapolis VA Health Care System, Minneapolis, USA
- University of Minnesota School of Medicine, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Roderick MacDonald
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Lauren McKenzie
- Minneapolis VA Health Care System, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
| | - Timothy J Wilt
- Minneapolis VA Health Care System, Minneapolis, USA
- University of Minnesota School of Medicine, Minneapolis, USA
- Minneapolis VA Center for Care Delivery and Outcomes Research, Minneapolis, USA
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18
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Hoffman JD, Shayegani R, Spoutz PM, Hillman AD, Smith JP, Wells DL, Popish SJ, Himstreet JE, Manning JM, Bounthavong M, Christopher MLD. Virtual academic detailing (e-Detailing): A vital tool during the COVID-19 pandemic. J Am Pharm Assoc (2003) 2020; 60:e95-e99. [PMID: 32747164 PMCID: PMC7833607 DOI: 10.1016/j.japh.2020.06.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/19/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022]
Abstract
As the coronavirus disease (COVID-19) pandemic continues its course in 2020, telehealth technology provides opportunities to connect patients and providers. Health policies have been amended to allow easy access to virtual health care, highlighting the field's dynamic ability to adapt to a public health crisis. Academic detailing, a peer-to-peer collaborative outreach designed to improve clinical decision-making, has traditionally relied on in-person encounters for effectiveness. A growth in the adoption of telehealth technology translates to increases in academic detailing reach for providers unable to meet with academic detailers in person. The U.S. Department of Veterans Affairs (VA) has used academic detailing to promote and reinforce evidence-based practices and has encouraged more virtual academic detailing (e-Detailing). Moreover, VA academic detailers are primarily clinical pharmacy specialists who provide clinical services and education and have made meaningful contributions to improving health care at VA. Amid the COVID-19 pandemic and physical isolation orders, VA academic detailers have continued to meet with providers to disseminate critical health care information in a timely fashion by using video-based telehealth. When working through the adoption of virtual technology for the delivery of medical care, providers may need time and nontraditional delivery of "evidence" before eliciting signals for change. Academic detailers are well suited for this role and can develop plans to help address provider discomfort surrounding the use of telehealth technology. By using e-Detailing as a method for both familiarizing and normalizing health professionals with video-based telehealth technology, pharmacists are uniquely poised to deliver consultation and direct-care services. Moreover, academic detailing pharmacists are ambassadors of change, serving an important role navigating the evolution of health care in response to emergent public health crises and helping define the norms of care delivery to follow.
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19
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James SL, Lucchesi LR, Bisignano C, Castle CD, Dingels ZV, Fox JT, Hamilton EB, Henry NJ, Krohn KJ, Liu Z, McCracken D, Nixon MR, Roberts NLS, Sylte DO, Adsuar JC, Arora A, Briggs AM, Collado-Mateo D, Cooper C, Dandona L, Dandona R, Ellingsen CL, Fereshtehnejad SM, Gill TK, Haagsma JA, Hendrie D, Jürisson M, Kumar GA, Lopez AD, Miazgowski T, Miller TR, Mini GK, Mirrakhimov EM, Mohamadi E, Olivares PR, Rahim F, Riera LS, Villafaina S, Yano Y, Hay SI, Lim SS, Mokdad AH, Naghavi M, Murray CJL. The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017. Inj Prev 2020; 26:i3-i11. [PMID: 31941758 PMCID: PMC7571347 DOI: 10.1136/injuryprev-2019-043286] [Citation(s) in RCA: 194] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Falls can lead to severe health loss including death. Past research has shown that falls are an important cause of death and disability worldwide. The Global Burden of Disease Study 2017 (GBD 2017) provides a comprehensive assessment of morbidity and mortality from falls. METHODS Estimates for mortality, years of life lost (YLLs), incidence, prevalence, years lived with disability (YLDs) and disability-adjusted life years (DALYs) were produced for 195 countries and territories from 1990 to 2017 for all ages using the GBD 2017 framework. Distributions of the bodily injury (eg, hip fracture) were estimated using hospital records. RESULTS Globally, the age-standardised incidence of falls was 2238 (1990-2532) per 100 000 in 2017, representing a decline of 3.7% (7.4 to 0.3) from 1990 to 2017. Age-standardised prevalence was 5186 (4622-5849) per 100 000 in 2017, representing a decline of 6.5% (7.6 to 5.4) from 1990 to 2017. Age-standardised mortality rate was 9.2 (8.5-9.8) per 100 000 which equated to 695 771 (644 927-741 720) deaths in 2017. Globally, falls resulted in 16 688 088 (15 101 897-17 636 830) YLLs, 19 252 699 (13 725 429-26 140 433) YLDs and 35 940 787 (30 185 695-42 903 289) DALYs across all ages. The most common injury sustained by fall victims is fracture of patella, tibia or fibula, or ankle. Globally, age-specific YLD rates increased with age. CONCLUSIONS This study shows that the burden of falls is substantial. Investing in further research, fall prevention strategies and access to care is critical.
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Affiliation(s)
- Spencer L James
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Lydia R Lucchesi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Catherine Bisignano
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Chris D Castle
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Zachary V Dingels
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Jack T Fox
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Erin B Hamilton
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Nathaniel J Henry
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Kris J Krohn
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Zichen Liu
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Darrah McCracken
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Molly R Nixon
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Nicholas L S Roberts
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Dillon O Sylte
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
| | - Jose C Adsuar
- Sport Science Department, University of Extremadura, Badajoz, Spain
| | - Amit Arora
- School of Science and Health, Western Sydney University, Sydney, NSW, Australia
- Oral Health Services, Sydney Local Health District, Sydney, NSW, Australia
| | - Andrew M Briggs
- School of Physiotherapy and Exercise Science, Curtin University, Bentley, WA, Australia
- Ageing and Life Course, World Health Organization (WHO), Geneva, Switzerland
| | - Daniel Collado-Mateo
- Sport Science Department, University of Extremadura, Cáceres, Spain
- Faculty of Education, Autonomous University of Chile, Talca, Chile
| | - Cyrus Cooper
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
- Department of Rheumatology, University of Oxford, Oxford, United Kingdom
| | - Lalit Dandona
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
- Public Health Foundation of India, Gurugram, India
| | - Rakhi Dandona
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
- Public Health Foundation of India, Gurugram, India
| | - Christian Lycke Ellingsen
- Department of Pathology, Stavanger University Hospital, Stavanger, Norway
- Norwegian Institute of Public Health, Oslo, Norway
| | - Seyed-Mohammad Fereshtehnejad
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Division of Neurology, University of Ottawa, Ottawa, ON, Canada
| | - Tiffany K Gill
- Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Juanita A Haagsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Delia Hendrie
- School of Public health, Curtin University, Perth, Western Australia, Australia
| | - Mikk Jürisson
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - G Anil Kumar
- Public Health Foundation of India, Gurugram, India
| | - Alan D Lopez
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
- University of Melbourne, Melbourne, QLD, Australia
| | - Tomasz Miazgowski
- Department of Hypertension, Pomeranian Medical University, Szczecin, Poland
| | - Ted R Miller
- School of Public health, Curtin University, Perth, Western Australia, Australia
- Pacific Institute for Research and Evaluation, Calverton, Maryland, USA
| | - G K Mini
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
- Global Institute of Public Health (GIPH), Ananthapuri Hospitals and Research Centre, Trivandrum, India
| | - Erkin M Mirrakhimov
- Faculty of General Medicine, Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan
- Department of Atherosclerosis and Coronary Heart Disease, National Center of Cardiology and Internal Disease, Bishkek, Kyrgyzstan
| | - Efat Mohamadi
- Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Pedro R Olivares
- Institute of Physical Activity and Health, Autonomous University of Chile, Talca, Chile
| | - Fakher Rahim
- Thalassemia and Hemoglobinopathy Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Lidia Sanchez Riera
- Department of Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Institute of Bone and Joint Research, University of Sydney, Syndey, NSW, Australia
| | | | - Yuichiro Yano
- Department of Preventive Medicine, Northwestern University, Chicago, IL, United States
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Stephen S Lim
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Ali H Mokdad
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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Mackenzie L, Beavis AM, Tan ACW, Clemson L. Systematic Review and Meta-Analysis of Intervention Studies with General Practitioner Involvement Focused on Falls Prevention for Community-Dwelling Older People. J Aging Health 2020; 32:1562-1578. [PMID: 32912102 DOI: 10.1177/0898264320945168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Objectives: Falls are a significant health problem for the ageing population. This review aimed to identify effective falls prevention interventions with involvement of general practitioners (GPs). Methods: Systematic review of randomised controlled trials conducted from 1999-2019, with meta-analysis. Searches located 2736 articles. A quality assessment was conducted of all included studies. Results: 21 randomised controlled trials met the inclusion criteria and 19 studies could be included in a meta-analysis. Overall, studies were not effective for reducing multiple falls (Relative Risk (RR) 1.16, 95% CI .97-1.39 and p = .10) or reducing one or more falls (RR .91, 95% CI: .82-1.01 and p = .08), but were effective for reducing injurious falls (RR .76, 95% CI: .66-.87 and p = .001). Discussion: Studies involving the GP in an active role and aligned with the primary care context were effective. The fidelity of interventions was limited by independent GP decisions and older participants being required to initiate the intervention.
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Affiliation(s)
- Lynette Mackenzie
- Discipline of Occupational Therapy, School of Health Sciences, 4334The University of Sydney, Australia
| | - Ann-Marie Beavis
- Discipline of Occupational Therapy, School of Health Sciences, 4334The University of Sydney, Australia
| | - Amy C W Tan
- Ageing Work and Health Research Unit, School of Health Sciences, 4334The University of Sydney, Australia
| | - Lindy Clemson
- Ageing Work and Health Research Unit, School of Health Sciences, 4334The University of Sydney, Australia
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Hart LA, Phelan EA, Yi JY, Marcum ZA, Gray SL. Use of Fall Risk-Increasing Drugs Around a Fall-Related Injury in Older Adults: A Systematic Review. J Am Geriatr Soc 2020; 68:1334-1343. [PMID: 32064594 PMCID: PMC7299782 DOI: 10.1111/jgs.16369] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 12/03/2019] [Accepted: 01/14/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine: (1) prevalence of fall risk-increasing drug (FRID) use among older adults with a fall-related injury, (2) which FRIDs were most frequently prescribed, (3) whether FRID use was reduced following the fall-related healthcare episode, and (4) which interventions have reduced falls or FRID use in older adults with a history of falls. DESIGN Systematic review. PARTICIPANTS Observational and intervention studies that assessed (or intervened on) FRID use in participants aged 60 years or older who had experienced a fall. MEASUREMENTS PubMed and EMBASE were searched through June 30, 2019. Two reviewers independently extracted data and evaluated studies for bias. Discrepancies were resolved by consensus. RESULTS Fourteen of 638 articles met selection criteria: 10 observational studies and 4 intervention studies. FRID use prevalence at time of fall-related injury ranged from 65% to 93%. Antidepressants and sedatives-hypnotics were the most commonly prescribed FRIDs. Of the 10 observational studies, only 2 used a design adequate to capture changes in FRID use after a fall-related injury, neither finding a reduction in FRID use. Three randomized controlled studies conducted in various settings (hospital, emergency department, and community pharmacy) with 12-month follow-up did not find a reduction in falls with interventions to reduce FRID use, although the study conducted in the community pharmacy setting was effective in reducing FRID use. In a nonrandomized (pre-post) intervention study conducted in an outpatient geriatrics clinic, falls were reduced in the intervention group. CONCLUSIONS Limited evidence indicates high prevalence of FRID use among older adults who have experienced a fall-related injury and no reduction in overall FRID use following the fall-related healthcare encounter. There is a need for well-designed interventions to reduce FRID use and falls in older adults with a history of falls. Reducing FRID use as a stand-alone intervention may not be effective in reducing recurrent falls. J Am Geriatr Soc 68:1334-1343, 2020.
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Affiliation(s)
- Laura A. Hart
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California
| | - Elizabeth A. Phelan
- Division of Gerontology and Geriatric Medicine, Department of Medicine, and Department of Health Services, School of Public Health, University of Washington, Seattle, Washington
| | - Julia Y. Yi
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, Washington
| | - Zachary A. Marcum
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, Washington
| | - Shelly L. Gray
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, Washington
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22
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Tan ACW, Clemson L, Mackenzie L, Sherrington C, Roberts C, Tiedemann A, Pond CD, White F, Simpson JM. Strategies for recruitment in general practice settings: the iSOLVE fall prevention pragmatic cluster randomised controlled trial. BMC Med Res Methodol 2019; 19:236. [PMID: 31829133 PMCID: PMC6907149 DOI: 10.1186/s12874-019-0869-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 11/14/2019] [Indexed: 01/01/2023] Open
Abstract
Background Falls are common among older people, and General Practitioners (GPs) could play an important role in implementing strategies to manage fall risk. Despite this, fall prevention is not a routine activity in general practice settings. The iSOLVE cluster randomised controlled trial aimed to evaluate implementation of a fall prevention decision tool in general practice. This paper sought to describe the strategies used and reflect on the enablers and barriers relevant to successful recruitment of general practices, GPs and their patients. Methods Recruitment was conducted within the geographical area of a Primary Health Network in Northern Sydney, Australia. General practices and GPs were engaged via online surveys, mailed invitations to participate, educational workshops, practitioner networks and promotional practice visits. Patients 65 years or older were recruited via mailed invitations, incorporating the practice letterhead and the name(s) of participating GP(s). Observations of recruitment strategies, results and enabling factors were recorded in field notes as descriptive and narrative data, and analysed using mixed-methods. Results It took 19 months to complete recruitment of 27 general practices, 75 GPs and 560 patients. The multiple strategies used to engage general practices and GPs were collectively useful in reaching the targeted sample size. Practice visits were valuable in engaging GPs and staff, establishing interest in fall prevention and commitment to the trial. A mix of small, medium and large practices were recruited. While some were recruited as a whole-practice, other practices had few or half of the number of GPs recruited. The importance of preventing falls in older patients, simplicity of research design, provision of resources and logistic facilitation of patient recruitment appealed to GPs. Recruitment of older patients was successfully achieved by mailed invitations which was a strategy that was familiar to practice staff and patients. Patient response rates were above the expected 10% for most practices. Many practices (n = 17) achieved the targeted number of 20 or more patients. Conclusions Recruitment in general practice settings can be successfully achieved through multiple recruitment strategies, effective communication and rapport building, ensuring research topic and design suit general practice needs, and using familiar communication strategies to engage patients. Trial registration The trial was prospectively registered on 29 April 2015 with the Australian New Zealand Clinical Trial Registry www.anzctr.org.au (trial ID: ACTRN12615000401550).
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Affiliation(s)
- Amy C W Tan
- Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia
| | - Lindy Clemson
- Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia.
| | - Lynette Mackenzie
- Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia
| | - Catherine Sherrington
- Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Chris Roberts
- Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Anne Tiedemann
- Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
| | - Constance D Pond
- School of Medicine & Public Health (General Practice), University of Newcastle, Newcastle, New South Wales, Australia
| | - Fiona White
- Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia
| | - Judy M Simpson
- Sydney School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
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23
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de Ruiter SC, Biesheuvel SS, van Haelst IMM, van Marum RJ, Jansen RWMM. To STOPP or to START? Potentially inappropriate prescribing in older patients with falls and syncope. Maturitas 2019; 131:65-71. [PMID: 31787149 DOI: 10.1016/j.maturitas.2019.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 10/18/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To investigate the prevalence of potentially inappropriate prescribing (PIP) according to the revised STOPP/START criteria in older patients with falls and syncope. STUDY DESIGN We included consecutive patients with falls and syncope aged ≥65 years at the day clinic of the Northwest Clinics, the Netherlands, from 2011 to 2016. All medication use before and after the visit was retrospectively investigated using the revised STOPP/START criteria. MAIN OUTCOME MEASURES The prevalence/occurrence of PIP before the visit, persistent PIP after the visit, and unaddressed persistent PIP not explained in the patient's chart. RESULTS PIP was present in 98 % of 374 patients (mean age 80 (SD ± 7) years; 69 % females). 1564 PIP occurrences were identified. 1015 occurrences persisted (in 91 % of patients). 690 occurrences (in 80 % of patients) were not explained in the patient's chart. The most frequent unaddressed persistent forms of PIP were prescriptions of vasodilator drugs for patients with orthostatic hypotension (16 %), and benzodiazepines for >4 weeks (10 %) or in fall patients (8 %), and omission of vitamin D (28 %), antihypertensive drugs (24 %), and antidepressants (17 %). 54 % of all medication changes were initiated for reasons beyond the scope of the STOPP/START criteria. CONCLUSIONS Almost every patient in our study population suffered from PIP. In 80 %, PIP continued after the clinical visit, without an explanation in the patient's chart. The most frequent PIP concerned medication that increased the risk of falls or syncope, specifically vasodilator drugs and benzodiazepines. Physicians should be aware of PIP in older patients with falls and syncope. Further studies should investigate whether a structured medication review may improve clinical outcomes.
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Affiliation(s)
- Susanne C de Ruiter
- Department of Geriatric Medicine, Northwest Clinics Alkmaar, the Netherlands; Currently employed at: Section of Geriatric Medicine, Department of Internal Medicine, St. Antonius Hospital Nieuwegein, Utrecht and Woerden, the Netherlands.
| | - Sophie S Biesheuvel
- Department of Geriatric Medicine, Northwest Clinics Alkmaar, the Netherlands; Department of Pharmacy, Northwest Clinics Alkmaar, the Netherlands
| | | | - Rob J van Marum
- Department of General Medicine and Geriatric Medicine, Free University, Amsterdam, the Netherlands
| | - René W M M Jansen
- Department of Geriatric Medicine, Northwest Clinics Alkmaar, the Netherlands
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Mackenzie L, Clemson L, Irving D. Fall prevention in primary care using chronic disease management plans: A process evaluation of provider and consumer perspectives. Aust Occup Ther J 2019; 67:22-30. [PMID: 31682030 DOI: 10.1111/1440-1630.12618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Falls are an important issue in primary care. General practitioners (GPs) are in a key position to identify older people at risk of falls on their caseload and put preventative plans into action. Chronic Disease Management (CDM) plans allow GPs to refer to allied health practitioners (AHPs) for evidence-based falls interventions. A previous pilot study reduced falls risk factors using CDM pans with older people at risk of falls. This study aimed to conduct a process evaluation of how the intervention worked in the pilot study for providers and consumers. METHODS This process evaluation used qualitative descriptive methods by interviewing the GPs, AHPs and older people involved in the intervention study. An independent researcher conducted interviews. These were audiotaped, transcribed and analysed using thematic analysis. Data were also collected about the implementation of the programme. RESULTS Two GPs, three occupational therapists, three physiotherapists and eight older people were interviewed. Key themes emerged from the perspectives of providers and consumers. The programme was implemented as intended, adherence to the exercise diaries was variable and the falls calendars were fully completed for three months of follow-up. The programme was implemented as intended. CONCLUSION The pilot CDM falls prevention programme did not identify common barriers attributed to GPs. Older people were amenable to the programme and participated freely. Private AHPs needed to make the CDM items work for their business model. This approach can be rolled out in a larger study and integrated pathways are needed to identify and intervene with older people at risk of falls in primary care.
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Affiliation(s)
- Lynette Mackenzie
- Faculty of Health Sciences, Discipline of Occupational Therapy, The University of Sydney, Lidcombe, NSW, Australia
| | - Lindy Clemson
- Faculty of Health Sciences, Physical Activity, Lifestyle, Ageing and Work Research Group, The University of Sydney, Lidcombe, NSW, Australia
| | - Diana Irving
- Faculty of Health Sciences, Discipline of Occupational Therapy, The University of Sydney, Lidcombe, NSW, Australia
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Menant JC, Meinrath D, Sturnieks DL, Hicks C, Lo J, Ratanapongleka M, Turner J, Migliaccio AA, Delbaere K, Titov N, Close JCT, Lord SR. Identifying Key Risk Factors for Dizziness Handicap in Middle-Aged and Older People. J Am Med Dir Assoc 2019; 21:344-350.e2. [PMID: 31631029 DOI: 10.1016/j.jamda.2019.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/13/2019] [Accepted: 08/25/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES More than 10% of people aged 50 years and older report dizziness. Despite available treatments, dizziness remains unresolved for many people due in part to suboptimal assessment. We aimed to identify factors associated with dizziness handicap in middle-aged and older people to identify targets for intervention to address this debilitating problem. A secondary aim was to determine whether factors associated with dizziness differed between middle-aged (<70 years) and older people (≥ 70 years). DESIGN Secondary analysis of baseline and prospective data from a randomized controlled trial. SETTING AND PARTICIPANTS In total, 305 individuals aged 50 to 92 years reporting significant dizziness in the past year were recruited from the community. METHODS Participants were classified as having either mild or no dizziness handicap (score <31) or moderate/severe dizziness handicap (score: 31‒100) based on the Dizziness Handicap Inventory. Participants completed health questionnaires and underwent assessments of psychological well-being, lying and standing blood pressure, vestibular function, strength, vision, proprioception, processing speed, balance, stepping, and gait. Participants reported dizziness episodes in monthly diaries for 6 months following baseline assessment. RESULTS Dizziness Handicap Inventory scores ranged from 0 to 86 with 95 participants (31%) reporting moderate/severe dizziness handicap. Many vestibular, cardiovascular, psychological, balance-related, and medical/medications measures were significantly associated with dizziness handicap severity and dizziness episode frequency. Binary logistic regression identified a positive Dix Hallpike/head-roll test for benign paroxysmal positional vertigo [odds ratio (OR) 2.09, 95% confidence interval (CI) (1.11‒3.97)], cardiovascular medication use [OR 1.90, 95% CI (1.09‒3.32)], high postural sway when standing on the floor with eyes closed (sway path ≥160 mm) [OR 2.97, 95% CI (1.73‒5.10)], and anxiety (Generalized Anxiety Disorder Scale 7-item Scale score ≥8) [OR 3.08, 95% CI (1.36‒6.94)], as significant and independent predictors of moderate/severe dizziness handicap. Participants aged 70 years and over were significantly more likely to report cardiovascular conditions than those aged less than 70 years old. CONCLUSIONS AND IMPLICATIONS Assessments of cardiovascular conditions and cardiovascular medication use, benign paroxysmal positional vertigo, anxiety, and postural sway identify middle-aged and older people with significant dizziness handicap. A multifactorial assessment including these factors may assist in tailoring evidence-based therapies to alleviate dizziness handicap in this group.
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Affiliation(s)
- Jasmine C Menant
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Daniela Meinrath
- Department of Physiotherapy, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Daina L Sturnieks
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Cameron Hicks
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Joanne Lo
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | | | - Jessica Turner
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Americo A Migliaccio
- Neuroscience Research Australia, Sydney, New South Wales, Australia; Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
| | - Kim Delbaere
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Nickolai Titov
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
| | - Jacqueline C T Close
- Neuroscience Research Australia, Sydney, New South Wales, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen R Lord
- Neuroscience Research Australia, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia.
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26
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Lee R, Moreland B. Aging without injury in the United States requires action today. JOURNAL OF SAFETY RESEARCH 2019; 70:272-274. [PMID: 31848005 PMCID: PMC7001090 DOI: 10.1016/j.jsr.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/02/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION In 2017, unintentional injuries were the seventh leading cause of death among older adults (age ≥ 65), resulting in over 55,000 deaths. Falls accounted for more than half of these deaths. Given that older adults are the fastest growing age group in the United States, we can anticipate that injuries will become an even greater health concern in the near future. METHODS Aging without injury is possible. There are evidence-based strategies that can reduce falls. However, older adults may not realize that falls can be prevented or they may be afraid to admit their fear of falling or difficulty with walking as these issues may signal their inability to live independently. RESULTS In this commentary, we will highlight what the Centers for Disease Control and Prevention is doing to prevent older adult falls. We also highlight the importance of broadening older adults' awareness about falls to successfully empower them to begin contemplating and preparing to adopt fall prevention strategies that can help them age in place. CONCLUSIONS Older adult falls are common and can result in severe injury and death but they can be prevented. Broadening older adults' awareness about falls can empower them to take the actions necessary to reduce their fall risk. Practical applications: Increasing awareness about falls can help older adults, healthcare providers, and local and state health departments take steps to reduce fall risk.
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Affiliation(s)
- Robin Lee
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 4770 Buford Highway, Atlanta, GA 30341, United States.
| | - Briana Moreland
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, 4770 Buford Highway, Atlanta, GA 30341, United States; Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830, United States
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27
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Seppala LJ, van der Velde N, Masud T, Blain H, Petrovic M, van der Cammen TJ, Szczerbińska K, Hartikainen S, Kenny RA, Ryg J, Eklund P, Topinková E, Mair A, Laflamme L, Thaler H, Bahat G, Gutiérrez-Valencia M, Caballero-Mora MA, Landi F, Emmelot-Vonk MH, Cherubini A, Baeyens JP, Correa-Pérez A, Gudmundsson A, Marengoni A, O'Mahony D, Parekh N, Pisa FE, Rajkumar C, Wehling M, Ziere G. EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research. Eur Geriatr Med 2019; 10:275-283. [PMID: 34652762 DOI: 10.1007/s41999-019-00162-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.
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Affiliation(s)
- L J Seppala
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - N van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
| | - T Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - H Blain
- Department of Internal Medicine and Geriatrics, University Hospital of Montpellier, Montpellier University, Euromov, France
| | - M Petrovic
- Department of Internal Medicine (Geriatrics), Ghent University, Ghent, Belgium
| | - T J van der Cammen
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
| | - K Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - S Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - R A Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin 2, Ireland.,Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland.,Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland
| | - J Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark.,Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - P Eklund
- Department of Computing Science, Umeå University, Umeå, Sweden
| | - E Topinková
- Department of Geriatrics and Gerontology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic.,Faculty of Health and Social Sciences, South Bohemian University, Česke Budějovice, Czech Republic
| | - A Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
| | - L Laflamme
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Widerströmska huset, 17177, Stockholm, Sweden
| | - H Thaler
- Trauma Center Wien-Meidling, Kundratstrasse 37, 1120, Vienna, Austria
| | - G Bahat
- Istanbul Medical School, Department of Internal Medicine, Division of Geriatrics, Istanbul University, Capa, 34093, Istanbul, Turkey
| | - M Gutiérrez-Valencia
- Department of Health Sciences, Public University of Navarra (UPNA), Avda, Barañain s/n, 31008, Pamplona, Spain
| | - M A Caballero-Mora
- Servicio de Geriatría, Hospital Universitario de Getafe and CIBER de Fragilidad y Envejecimiento Saludable, Getafe, Madrid, Spain
| | - F Landi
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | - M H Emmelot-Vonk
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - A Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'Invecchiamento, Italian National Research Center on Aging (INRCA), Ancona, Italy
| | - J P Baeyens
- University of Luxembourg, Ezch-sur-Alzette, Luxembourg.,AZ Alma, Eeklo, Belgium
| | - A Correa-Pérez
- Servicio de Geriatría, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - A Gudmundsson
- Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - A Marengoni
- Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - D O'Mahony
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland.,Department of Medicine, University College Cork, Cork, Ireland
| | - N Parekh
- Academic Department of Geriatric Medicine, Brighton and Sussex Medical School, Brighton, Sussex, UK
| | - F E Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany.,Institute of Hygiene and Clinical Epidemiology, University Hospital of Udine, Udine, Italy
| | - C Rajkumar
- Department of Elderly Medicine, Brighton and Sussex University Hospitals NHS Trust, Sussex, UK
| | - M Wehling
- Institute of Clinical Pharmacology Mannheim, University of Heidelberg, Heidelberg, Germany
| | - G Ziere
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Seppala LJ, van der Velde N, Masud T, Blain H, Petrovic M, van der Cammen TJ, Szczerbińska K, Hartikainen S, Kenny RA, Ryg J, Eklund P, Topinková E, Mair A, Laflamme L, Thaler H, Bahat G, Gutiérrez-Valencia M, Caballero-Mora MA, Landi F, Emmelot-Vonk MH, Cherubini A, Baeyens JP, Correa-Pérez A, Gudmundsson A, Marengoni A, O'Mahony D, Parekh N, Pisa FE, Rajkumar C, Wehling M, Ziere G. EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research. Drugs Aging 2019; 36:299-307. [PMID: 30741371 PMCID: PMC6435622 DOI: 10.1007/s40266-018-0622-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.
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Affiliation(s)
- L J Seppala
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - N van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
| | - T Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - H Blain
- Department of Internal Medicine and Geriatrics, University Hospital of Montpellier, Montpellier University, Euromov, France
| | - M Petrovic
- Department of Internal Medicine (Geriatrics), Ghent University, Ghent, Belgium
| | - T J van der Cammen
- Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
| | - K Szczerbińska
- Unit for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine Chair, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - S Hartikainen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - R A Kenny
- The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin 2, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin 2, Ireland
- Falls and Syncope Unit, Mercer's Institute for Successful Ageing, St. James's Hospital, Dublin 8, Ireland
| | - J Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - P Eklund
- Department of Computing Science, Umeå University, Umeå, Sweden
| | - E Topinková
- Department of Geriatrics and Gerontology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
- Faculty of Health and Social Sciences, South Bohemian University, Česke Budějovice, Czech Republic
| | - A Mair
- Effective Prescribing and Therapeutics, Health and Social Care Directorate, Scottish Government, Edinburgh, Scotland, UK
| | - L Laflamme
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Widerströmska huset, 17177, Stockholm, Sweden
| | - H Thaler
- Trauma Center Wien-Meidling, Kundratstrasse 37, 1120, Vienna, Austria
| | - G Bahat
- Istanbul Medical School, Department of Internal Medicine, Division of Geriatrics, Istanbul University, Capa, 34093, Istanbul, Turkey
| | - M Gutiérrez-Valencia
- Department of Health Sciences, Public University of Navarra (UPNA), Avda, Barañain s/n, 31008, Pamplona, Spain
| | - M A Caballero-Mora
- Servicio de Geriatría, Hospital Universitario de Getafe and CIBER de Fragilidad y Envejecimiento Saludable, Getafe, Madrid, Spain
| | - F Landi
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of the Sacred Heart, Rome, Italy
| | - M H Emmelot-Vonk
- Department of Geriatrics, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - A Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'Invecchiamento, Italian National Research Center on Aging (INRCA), Ancona, Italy
| | - J P Baeyens
- University of Luxembourg, Ezch-sur-Alzette, Luxembourg
- AZ Alma, Eeklo, Belgium
| | - A Correa-Pérez
- Servicio de Geriatría, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - A Gudmundsson
- Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - A Marengoni
- Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy
| | - D O'Mahony
- Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland
- Department of Medicine, University College Cork, Cork, Ireland
| | - N Parekh
- Academic Department of Geriatric Medicine, Brighton and Sussex Medical School, Brighton, Sussex, UK
| | - F E Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Bremen, Germany
- Institute of Hygiene and Clinical Epidemiology, University Hospital of Udine, Udine, Italy
| | - C Rajkumar
- Department of Elderly Medicine, Brighton and Sussex University Hospitals NHS Trust, Sussex, UK
| | - M Wehling
- Institute of Clinical Pharmacology Mannheim, University of Heidelberg, Heidelberg, Germany
| | - G Ziere
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Mackenzie L, McIntyre A. How Do General Practitioners (GPs) Engage in Falls Prevention With Older People? A Pilot Survey of GPs in NHS England Suggests a Gap in Routine Practice to Address Falls Prevention. Front Public Health 2019; 7:32. [PMID: 30915322 PMCID: PMC6421941 DOI: 10.3389/fpubh.2019.00032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/06/2019] [Indexed: 12/27/2022] Open
Abstract
Falls are highly prevalent amongst older people and have substantial financial and social costs for health services and the community. Prevention of falls is the key to managing this threat to older people. General practitioners can identify older people at risk of falls on their caseloads. Once identified, actions can be taken to reduce the risk of falls by referring to appropriate services available in the community, such as allied health practitioners. However, the level of engagement in evidence based falls prevention by GPs is unknown. This study aimed to explore how British general practitioners (GPs) address falls prevention with older people, and to determine if there are any gaps in practice. As a pilot study, another aim was to test the feasibility of methods to survey GPs, if a larger survey was warranted from the findings. An on-line cross-sectional survey was distributed by email to all the Clinical Commissioning Groups in NHS England (n = 213) and individual general practices listed on the NHS Choices website, supplemented by invitations distributed to CCGs through Twitter and LinkedIn sites. Thirty-seven responses were received. Most GPs were unfamiliar with the 2013 NICE guidelines on assessment and prevention of falls in older people (51.4%, n = 19), and only 29.7% (n = 11) asked older people if they had fallen during consultations. If falls risk was identified, 81.1% (n = 30) frequently made referrals to physiotherapy (PT) and 56.8% (n = 21) to occupational therapy (OT). Most GPs did not identify older people on their caseloads as being at risk of falls unless they presented with a fall, and referral rates to relevant AHPs or falls prevention programs were low. Barriers to implementation of falls prevention best practice were identified. Alternative methods are needed to capture the falls prevention practice of a wider sample of GPs.
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Affiliation(s)
- Lynette Mackenzie
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Anne McIntyre
- Occupational Therapy, College of Health and Life Sciences, Brunel University London, Uxbridge, United Kingdom
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30
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McIntyre A, Mackenzie L, Harvey M. Engagement of general practitioners in falls prevention and referral to occupational therapists. Br J Occup Ther 2018. [DOI: 10.1177/0308022618804752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Anne McIntyre
- Senior Lecturer, Clinical Sciences, Brunel University, London, UK
| | - Lynette Mackenzie
- Associate Professor, Discipline of Occupational Therapy, University of Sydney, Sydney, Australia
| | - Michele Harvey
- Research Assistant, Chelsea Children’s Therapy, London, UK
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Mokhar A, Topp J, Härter M, Schulz H, Kuhn S, Verthein U, Dirmaier J. Patient-centered care interventions to reduce the inappropriate prescription and use of benzodiazepines and z-drugs: a systematic review. PeerJ 2018; 6:e5535. [PMID: 30345166 PMCID: PMC6190800 DOI: 10.7717/peerj.5535] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/08/2018] [Indexed: 12/30/2022] Open
Abstract
Background Benzodiazepines (BZDs) and z-drugs are effective drugs, but they are prescribed excessively worldwide. International guidelines recommend a maximum treatment duration of 4 weeks. Although these drugs are effective in the short-term, long-term BZD therapy is associated with considerable adverse effects, the development of tolerance and, finally, addiction. However, there are different interventions in terms of patient-centered care that aim to reduce the use of BZDs and z-drugs as well as assist health care professionals (HCPs) in preventing the inappropriate prescription of BZDs. Aim The aim of this systematic review was to identify interventions that promote patient-centered treatments for inappropriate BZD and z-drug use and to analyze their effectiveness in reducing the inappropriate use of these drugs. Methods To identify relevant studies, the PubMed, EMBASE, PsycINFO, Psyndex, and Cochrane Library databases were searched. Studies with controlled designs focusing on adult patients were included. Trials with chronically or mentally ill patients were excluded if long-term BZD and z-drug use was indicated. Study extraction was performed based on the Cochrane Form for study extraction. To assess the quality of the studies, we used a tool based on the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials. Results We identified 7,068 studies and selected 20 for systematic review. Nine interventions focused on patients, nine on HCPs, and two on both patients and HCPs. Intervention types ranged from simple to multifaceted. Patient-centered interventions that provided patient information effectively increased the appropriate use of BZDs. The educational approaches for HCPs that aimed to achieve appropriate prescription reported inconsistent results. The methods that combined informing patients and HCPs led to a significant reduction in BZD use. Conclusions This is the first review of studies focused on patient-centered approaches to reducing the inappropriate prescription and use of BZDs and z-drugs. The patient-centered dimension of patient information was responsible for a decrease in BZD and z-drug consumption. Further, in some studies, the patient-centered dimensions responsible for reducing the prescription and use of BZDs and z-drugs were the clinician’s essential characteristics and clinician-patient communication.
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Affiliation(s)
- Aliaksandra Mokhar
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Janine Topp
- Department of Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Schulz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Silke Kuhn
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Verthein
- Department of Psychiatry and Psychotherapy, Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Dirmaier
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Rankin A, Cadogan CA, Patterson SM, Kerse N, Cardwell CR, Bradley MC, Ryan C, Hughes C. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2018; 9:CD008165. [PMID: 30175841 PMCID: PMC6513645 DOI: 10.1002/14651858.cd008165.pub4] [Citation(s) in RCA: 202] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review. OBJECTIVES To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies. SELECTION CRITERIA We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people). DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. AUTHORS' CONCLUSIONS It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.
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Affiliation(s)
- Audrey Rankin
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
| | - Cathal A Cadogan
- Royal College of Surgeons in IrelandSchool of PharmacyDublinIreland
| | - Susan M Patterson
- No affiliationIntegrated Care40 Dunmore RoadBallynahinchNorthern IrelandUKBT24 8PR
| | - Ngaire Kerse
- University of AucklandDepartment of General Practice and Primary Health CarePrivate Bag 92019AucklandNew Zealand
| | - Chris R Cardwell
- Queen's University BelfastCentre for Public HealthSchool of MedicineDentistry and Biomedical SciencesBelfastNorthern IrelandUKBT12 6BJ
| | - Marie C Bradley
- National Cancer Institute9609 Medical Center DriveRockvilleMDUSA20850
| | - Cristin Ryan
- Trinity College DublinSchool of Pharmacy and Pharmaceutical Sciences111 St Stephen’s GreenDublin 2Ireland
| | - Carmel Hughes
- Queen's University BelfastSchool of Pharmacy97 Lisburn RoadBelfastNorthern IrelandUKBT9 7BL
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Stevens JA, Lee R. The Potential to Reduce Falls and Avert Costs by Clinically Managing Fall Risk. Am J Prev Med 2018; 55:290-297. [PMID: 30122212 PMCID: PMC6103639 DOI: 10.1016/j.amepre.2018.04.035] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 04/04/2018] [Accepted: 04/25/2018] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Falls often cause severe injuries and are one of the most costly health conditions among older adults. Yet, many falls are preventable. The number of preventable medically treated falls and associated costs averted were estimated by applying evidence-based fall interventions in clinical settings. METHODS A review of peer-reviewed literature was conducted in 2017 using literature published between 1994 and 2017, the authors estimated the prevalence of seven fall risk factors and the effectiveness of seven evidence-based fall interventions. Then authors estimated the number of older adults (aged ≥65 years) who would be eligible to receive one of seven fall interventions (e.g., Tai Chi, Otago, medication management, vitamin D supplementation, expedited first eye cataract surgery, single-vision distance lenses for outdoor activities, and home modifications led by an occupational therapist). Using the reported effectiveness of each intervention, the number of medically treated falls that could be prevented and the associated direct medical costs averted were calculated. RESULTS Depending on the size of the eligible population, implementing a single intervention could prevent between 9,563 and 45,164 medically treated falls and avert $94-$442 million in direct medical costs annually. The interventions with the potential to help the greatest number of older adults were those that provided home modification delivered by an occupational therapist (38.2 million), and recommended daily vitamin D supplements (16.7 million). CONCLUSIONS This report is the first to estimate the number of medically treated falls that could be prevented and the direct medical costs that could be adverted. Preventing falls can benefit older adults substantially by improving their health, independence, and quality of life.
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Affiliation(s)
- Judy A Stevens
- Advanced Technology Logistics Inc., Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, Georgia
| | - Robin Lee
- Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, Georgia.
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de Vries M, Seppala LJ, Daams JG, van de Glind EMM, Masud T, van der Velde N. Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: I. Cardiovascular Drugs. J Am Med Dir Assoc 2018; 19:371.e1-371.e9. [PMID: 29396189 DOI: 10.1016/j.jamda.2017.12.013] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Use of certain medications is recognized as a major and modifiable risk factor for falls. Although the literature on psychotropic drugs is compelling, the literature on cardiovascular drugs as potential fall-risk-increasing drugs is conflicting. The aim of this systematic review and meta-analysis is to provide a comprehensive overview of the associations between cardiovascular medications and fall risk in older adults. METHODS Design: A systematic review and meta-analysis. DATA SOURCES Medline, Embase, and PsycINFO. Key search concepts were "fall," "aged," "causality," and "medication." Studies that investigated cardiovascular medications as risk factors for falls in participants ≥60 years old or participants with a mean age of 70 or older were included. A meta-analysis was performed using the generic inverse variance method, pooling unadjusted and adjusted odds ratios (ORs) separately. RESULTS In total, 131 studies were included in the qualitative synthesis. Meta-analysis using adjusted ORs showed significant results (pooled OR [95% confidence interval]) for loop diuretics, OR 1.36 (1.17, 1.57), and beta-blocking agents, OR 0.88 (0.80, 0.97). Meta-analysis using unadjusted ORs showed significant results for digitalis, OR 1.60 (1.08, 2.36); digoxin, OR 2.06 (1.56, 2.74); and statins, OR 0.80 (0.65, 0.98). Most of the meta-analyses resulted in substantial heterogeneity that mostly did not disappear after stratification for population and setting. In a descriptive synthesis, consistent associations were not observed. CONCLUSION Loop diuretics were significantly associated with increased fall risk, whereas beta-blockers were significantly associated with decreased fall risk. Digitalis and digoxin may increase the risk of falling, and statins may reduce it. For the majority of cardiovascular medication groups, outcomes were inconsistent. Furthermore, recent studies indicate that specific drug properties, such as selectivity of beta-blockers, may affect fall risk, and drug-disease interaction also may play a role. Thus, studies addressing these issues are warranted to obtain a better understanding of drug-related falls.
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Affiliation(s)
- Max de Vries
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Lotta J Seppala
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Joost G Daams
- Medical library, Academic Medical Center, Amsterdam, The Netherlands
| | - Esther M M van de Glind
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam, The Netherlands.
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Kielich K, Mackenzie L, Lovarini M, Clemson L. Urban Australian general practitioners' perceptions of falls risk screening, falls risk assessment, and referral practices for falls prevention: an exploratory cross-sectional survey study. AUST HEALTH REV 2018; 41:111-119. [PMID: 27096324 DOI: 10.1071/ah15152] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 02/09/2016] [Indexed: 11/23/2022]
Abstract
Objective The study aimed to explore Australian general practitioners' (GPs) perceptions of falls risk screening, assessment and their referral practices with older people living in the community, and to identify any barriers or facilitators to implementing evidence-based falls prevention practice. Methods Hardcopy surveys and a link to an online survey were distributed to 508 GPs working at one Medicare Local (now part of a Primary Care Network) located in Sydney, Australia. Data were analysed using descriptive statistics and key themes were identified from open text responses. Results A total of 37 GPs returned the survey. Only 10 (27%) GPs routinely asked older people about falls, and five (13.5%) asked about fear of falls during clinical consultations. Barriers to managing falls risk were identified. GPs estimated that they made few referrals to allied health professionals for falls interventions. Conclusions GPs were knowledgeable about falls risk factors but this did not result in consistent falls risk screening, assessment or referral practices. Due to the small sample, further research is needed with a larger sample to augment these results. What is known about the topic? Falls are a common and serious health issue for older people and fall prevention is vital, especially in the primary care setting. General practitioners (GPs) are key health professionals to identify older people at risk of falls and refer them to appropriate health professionals for intervention. Evidence-based falls prevention interventions exist but are not easily or routinely accessed by older people. What does this paper add? GPs believe that previous falls are an important falls risk factor but they do not routinely ask about falls or fear of falls in clinical practice with older people. GP referral rates to allied health professionals for falls prevention are low, despite evidence-based falls prevention interventions being provided by allied health professionals. There are several barriers to GPs providing falls prevention assessment and intervention referrals, particularly using the current primary health systems. What are the implications for practitioners? GPs need to recognise their potential significant contribution to falls prevention in the community and may require tailored training. Sustainable evidence-based referral pathways need to be developed so that older people can be referred to allied health professionals for falls prevention interventions in the primary care setting, and better local networks need to be developed to allow this to occur. Policy makers may have to address the identified barriers to multidisciplinary practice and funding of services to facilitate effective falls prevention programs in primary care.
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Affiliation(s)
- Kajtek Kielich
- Ageing Work and Health Research Unit, Faculty of Health Sciences, 75 East Street, University of Sydney, Lidcombe, NSW 2141, Australia.
| | - Lynette Mackenzie
- Ageing Work and Health Research Unit, Faculty of Health Sciences, 75 East Street, University of Sydney, Lidcombe, NSW 2141, Australia.
| | - Meryl Lovarini
- Ageing Work and Health Research Unit, Faculty of Health Sciences, 75 East Street, University of Sydney, Lidcombe, NSW 2141, Australia.
| | - Lindy Clemson
- Ageing Work and Health Research Unit, Faculty of Health Sciences, 75 East Street, University of Sydney, Lidcombe, NSW 2141, Australia.
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Donoghue OA, Setti A, O'Leary N, Kenny RA. Self-Reported Unsteadiness Predicts Fear of Falling, Activity Restriction, Falls, and Disability. J Am Med Dir Assoc 2017. [DOI: 10.1016/j.jamda.2017.01.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Impact of a medication therapy management intervention targeting medications associated with falling: Results of a pilot study. J Am Pharm Assoc (2003) 2017; 56:22-8. [PMID: 26802916 DOI: 10.1016/j.japh.2015.11.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 07/19/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND The use of fall risk-increasing drugs (FRIDs) by older adults is one factor associated with falling, and FRID use is common among older adults. A targeted medication therapy management intervention focused on FRID use that included prescription and over-the-counter (OTC) medications, along with follow-up telephone calls was designed. OBJECTIVE The purpose of this pilot study was to examine preliminary effects of a medication therapy management (MTM) intervention focused on FRIDs provided by a community pharmacist to older adults. DESIGN Randomized, controlled trial. SETTING One community pharmacy. PARTICIPANTS Eighty older adults who completed a fall prevention workshop. MAIN OUTCOME MEASURES The main outcome measures were the rate of discontinuing FRIDs, the proportion of older adults falling, and the number of falls. A secondary outcome was the acceptance rate of medication recommendations by patients and prescribers. RESULTS Thirty-eight older adults received the targeted MTM intervention. Of the 31 older adults using a FRID, a larger proportion in the intervention group had FRID use modified relative to controls (77% and 28%, respectively; P < 0.05). There were no significant changes between the study groups in the risk and rate of falling. Medication recommendations in the intervention group had a 75% acceptance rate by patients and prescribers. CONCLUSION A targeted MTM intervention provided by a community pharmacist and focused on FRID use among older adults was effective in modifying FRID use. This result supports the preliminary conclusion that community pharmacists can play an important role in modifying FRID use among older adults.
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Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, Holmberg JM, Mahoney K, Hollingsworth DB, Roberts R, Seidman MD, Steiner RWP, Do BT, Voelker CCJ, Waguespack RW, Corrigan MD. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg 2017; 156:S1-S47. [DOI: 10.1177/0194599816689667] [Citation(s) in RCA: 363] [Impact Index Per Article: 51.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Objective This update of a 2008 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV. Purpose The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV. Action Statements The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.
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Affiliation(s)
- Neil Bhattacharyya
- Department of Otolaryngology, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Samuel P. Gubbels
- Department of Otolaryngology, School of Medicine and Public Health, University of Colorado, Aurora, Colorado, USA
| | - Seth R. Schwartz
- Department of Otolaryngology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jonathan A. Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Hussam El-Kashlan
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Terry Fife
- Barrow Neurological Institute and College of Medicine, University of Arizona, Phoenix, Arizona, USA
| | | | | | | | - Richard Roberts
- Alabama Hearing and Balance Associates, Inc, Birmingham, Alabama, USA
| | - Michael D. Seidman
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Robert W. Prasaad Steiner
- Department of Health Management and Systems Science and Department of Family and Geriatric Medicine, School of Public Health and Information Science, University of Louisville, Louisville, Kentucky, USA
| | - Betty Tsai Do
- Department of Otorhinolaryngology, Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Courtney C. J. Voelker
- Department of Otolaryngology–Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Richard W. Waguespack
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maureen D. Corrigan
- American Academy of Otolaryngology–Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Clemson L, Mackenzie L, Roberts C, Poulos R, Tan A, Lovarini M, Sherrington C, Simpson JM, Willis K, Lam M, Tiedemann A, Pond D, Peiris D, Hilmer S, Pit SW, Howard K, Lovitt L, White F. Integrated solutions for sustainable fall prevention in primary care, the iSOLVE project: a type 2 hybrid effectiveness-implementation design. Implement Sci 2017; 12:12. [PMID: 28173827 PMCID: PMC5296956 DOI: 10.1186/s13012-016-0529-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/01/2016] [Indexed: 12/30/2022] Open
Abstract
Background Despite strong evidence giving guidance for effective fall prevention interventions in community-residing older people, there is currently no clear model for engaging general medical practitioners in fall prevention and routine use of allied health professionals in fall prevention has been slow, limiting widespread dissemination. This protocol paper outlines an implementation-effectiveness study of the Integrated Solutions for Sustainable Fall Prevention (iSOLVE) intervention which has developed integrated processes and pathways to identify older people at risk of falls and engage a whole of primary care approach to fall prevention. Methods/design This protocol paper presents the iSOLVE implementation processes and change strategies and outlines the study design of a blended type 2 hybrid design. The study consists of a two-arm cluster randomized controlled trial in 28 general practices and recruiting 560 patients in Sydney, Australia, to evaluate effectiveness of the iSOLVE intervention in changing general practitioner fall management practices and reducing patient falls and the cost effectiveness from a healthcare funder perspective. Secondary outcomes include change in medications known to increase fall risk. We will simultaneously conduct a multi-methodology evaluation to investigate the workability and utility of the implementation intervention. The implementation evaluation includes in-depth interviews and surveys with general practitioners and allied health professionals to explore acceptability and uptake of the intervention, the coherence of the proposed changes for those in the work setting, and how to facilitate the collective action needed to implement changes in practice; social network mapping will explore professional relationships and influences on referral patterns; and, a survey of GPs in the geographical intervention zone will test diffusion of evidence-based fall prevention practices. The project works in partnership with a primary care health network, state fall prevention leaders, and a community of practice of fall prevention advocates. Discussion The design is aimed at providing clear direction for sustainability and informing decisions about generalization of the iSOLVE intervention processes and change strategies. While challenges exist in hybrid designs, there is a potential for significant outcomes as the iSOLVE pathways project brings together practice and research to collectively solve a major national problem with implications for policy service delivery. Trial registration Australian New Zealand Clinial Trials Registry ACTRN12615000401550
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Affiliation(s)
- Lindy Clemson
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia. .,Centre of Excellence in Population Ageing Research, Sydney, Australia.
| | - Lynette Mackenzie
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
| | - Chris Roberts
- Sydney Medical School - Northern, The University of Sydney, Sydney, Australia
| | - Roslyn Poulos
- School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
| | - Amy Tan
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
| | - Meryl Lovarini
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
| | - Cathie Sherrington
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Judy M Simpson
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Karen Willis
- Faculty of Health Sciences, Australian Catholic University, Melbourne, Australia
| | - Mary Lam
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
| | - Anne Tiedemann
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Dimity Pond
- School of Medicine & Public Health, University of Newcastle, Newcastle, Australia
| | - David Peiris
- The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Sarah Hilmer
- Sydney Medical School - Northern, The University of Sydney, Sydney, Australia.,Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Sabrina Winona Pit
- University Centre for Rural Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | | | - Fiona White
- Faculty of Health Sciences, The University of Sydney, Lidcombe, Australia
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Beuscart JB, Pont LG, Thevelin S, Boland B, Dalleur O, Rutjes AWS, Westbrook JI, Spinewine A. A systematic review of the outcomes reported in trials of medication review in older patients: the need for a core outcome set. Br J Clin Pharmacol 2017; 83:942-952. [PMID: 27891666 DOI: 10.1111/bcp.13197] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/22/2016] [Accepted: 11/22/2016] [Indexed: 11/27/2022] Open
Abstract
AIM Medication review has been advocated as one of the measures to tackle the challenge of polypharmacy in older patients, yet there is no consensus on how best to evaluate its efficacy. This study aimed to assess outcome reporting in trials of medication review in older patients. METHODS Randomized controlled trials (RCTs), prospective studies and RCT protocols involving medication review performed in patients aged 65 years or older in any setting of care were identified from: (1) a recent systematic review; (2) RCT registries of ongoing studies; (3) the Cochrane library. The type, definition, and frequency of all outcomes reported were extracted independently by two researchers. RESULTS Forty-seven RCTs or prospective published studies and 32 RCT protocols were identified. A total of 327 distinct outcomes were identified in the 47 published studies. Only one fifth (21%) of the studies evaluated the impact of medication reviews on adverse events such as drug reactions or drug-related hospital admissions. Most of the outcomes were related to medication use (n = 114, 35%) and healthcare use (n = 74, 23%). Very few outcomes were patient-related (n = 24, 7%). A total of 248 distinct outcomes were identified in the 32 RCT protocols. Overall, the number of outcomes and the number and type of health domains covered by the outcomes varied largely. CONCLUSION Outcome reporting from RCTs concerning medication review in older patients is heterogeneous. This review highlights the need for a standardized core outcome set for medication review in older patients, to improve outcome reporting and evidence synthesis.
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Affiliation(s)
- Jean-Baptiste Beuscart
- Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium
| | - Lisa G Pont
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Stefanie Thevelin
- Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium
| | - Benoit Boland
- Geriatric Medicine, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.,Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | - Olivia Dalleur
- Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium.,Pharmacy department, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Anne W S Rutjes
- CTU Bern, Department of Clinical Research, University of Bern, Switzerland.,Institute of Social and Preventive Medicine (ISPM), University of Bern, Switzerland
| | - Johanna I Westbrook
- Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia
| | - Anne Spinewine
- Louvain Drug Research Institute (LDRI), Université catholique de Louvain, Brussels, Belgium.,Pharmacy department, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
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Huiskes VJB, Burger DM, van den Ende CHM, van den Bemt BJF. Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials. BMC FAMILY PRACTICE 2017; 18:5. [PMID: 28095780 PMCID: PMC5240219 DOI: 10.1186/s12875-016-0577-x] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 12/26/2016] [Indexed: 12/02/2022]
Abstract
BACKGROUND Medication review is often recommended to optimize medication use. In clinical practice it is mostly operationalized as an intervention without co-interventions during a short term intervention period. However, most systematic reviews also included co-interventions and prolonged medication optimization interventions. Furthermore, most systematic reviews focused on specific patient groups (e.g. polypharmacy, elderly, hospitalized) and/or on specific outcome measures (e.g. hospital admissions and mortality). Therefore, the objective of this study is to assess the effectiveness of medication review as an isolated short-term intervention, irrespective of the patient population and the outcome measures used. METHODS A literature search was performed in MEDLINE, EMBASE and Web of Science from their inception through September 2015. Randomized controlled trials (RCTs) with medication review as isolated short term intervention (<3 months) were included. There were no restrictions with regard to patient characteristics and outcome measures. One reviewer extracted and a second checked data. The risk of bias of studies was evaluated independently by two reviewers. A best evidence synthesis was conducted for every outcome measure used in more than one trial. In case of binary variables a meta-analysis was performed in addition to the best evidence synthesis, to quantify the effect. RESULTS Thirty-one RCTs were included in this systematic review (55% low risk of bias). A best evidence synthesis was conducted for 22 outcome measures. No effect of medication review was found on clinical outcomes (mortality, hospital admissions/healthcare use, the number of patients falling, physical and cognitive functioning), except a decrease in the number of falls per patient. However, in a sensitivity analysis using a more stringent threshold for risk of bias, the conclusion for the effect on the number of falls changed to inconclusive. Furthermore no effect was found on quality of life and evidence was inconclusive about the effect on economical outcome measures. However, an effect was found on most drug-related problems: medication review resulted in a decrease in the number of drug-related problems, more changes in medication, more drugs with dosage decrease and a greater decrease or smaller increase of the number of drugs. CONCLUSIONS An isolated medication review during a short term intervention period has an effect on most drug-related outcomes, minimal effect on clinical outcomes and no effect on quality of life. No conclusion can be drawn about the effect on economical outcome measures. Therefore, it should be considered to stop performing cross-sectional medication reviews as standard care.
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Affiliation(s)
| | - David Marinus Burger
- Department of Pharmacy, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands
| | | | - Bartholomeus Johannes Fredericus van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Hengstdal 3, 6574 NA Ubbergen, The Netherlands
- Department of Pharmacy, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center +, Maastricht, Peter Debyelaan 15, 6229 HX Maastricht, The Netherlands
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42
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Boyé NDA, van der Velde N, de Vries OJ, van Lieshout EMM, Hartholt KA, Mattace-Raso FUS, Lips P, Patka P, van Beeck EF, van der Cammen TJM. Effectiveness of medication withdrawal in older fallers: results from the Improving Medication Prescribing to reduce Risk Of FALLs (IMPROveFALL) trial. Age Ageing 2017; 46:142-146. [PMID: 28181639 DOI: 10.1093/ageing/afw161] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/15/2016] [Indexed: 11/14/2022] Open
Abstract
Objectives To investigate the effect of withdrawal of fall-risk-increasing-drugs (FRIDs) versus ‘care as usual’ on reducing falls in community-dwelling older fallers. Design Randomised multicentre trial Participants Six hundred and twelve older adults who visited an Emergency Department (ED) because of a fall. Interventions Withdrawal of FRIDs. Main Outcomes and Measures Primary outcome was time to the first self-reported fall. Secondary outcomes were time to the second self-reported fall and to falls requiring a general practitioner (GP)-consultation or ED-visit. Intention-to-treat (primary) and a per-protocol (secondary) analysis were conducted. The hazard ratios (HRs) for time-to-fall were calculated using a Cox-regression model. Differences in cumulative incidence of falls were analysed using Poisson regression. Results During 12 months follow-up, 91 (34%) control and 115 (37%) intervention participants experienced a fall; 35% of all attempted interventions were unsuccessful, either due to recurrence of the initial indication for prescribing, additional medication for newly diagnosed conditions or non-compliance. Compared to baseline, the overall percentage of users of ≥3 FRIDs at 12 months did not change in either the intervention or the control group. Our intervention did not have a significant effect on time to first fall (HR 1.17; 95% confidence interval 0.89–1.54), time to second fall (1.19; 0.78–1.82), time to first fall-related GP-consultation (0.66; 0.42–1.06) or time to first fall-related ED-visit (0.85; 0.43–1.68). Conclusion In this population of complex multimorbid patients visiting an ED because of a fall, our single intervention of FRIDs-withdrawal was not effective in reducing falls. Trial Registration Netherlands Trial Register NTR1593.
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Affiliation(s)
- Nicole D A Boyé
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nathalie van der Velde
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Oscar J de Vries
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Esther M M van Lieshout
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Klaas A Hartholt
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul Lips
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ed F van Beeck
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tischa J M van der Cammen
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Karani MV, Haddad Y, Lee R. The Role of Pharmacists in Preventing Falls among America's Older Adults. Front Public Health 2016; 4:250. [PMID: 27882314 PMCID: PMC5101193 DOI: 10.3389/fpubh.2016.00250] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/25/2016] [Indexed: 11/13/2022] Open
Abstract
Falls are the leading cause of both fatal and non-fatal injuries in people aged 65 years and older and can lead to significant costs, injuries, functional decline, and reduced quality of life. While certain medications are known to increase fall risk, medication use is a modifiable risk factor. Pharmacists have specialized training in medication management and can play an important role in fall prevention. Working in a patient-centered team-based approach, pharmacists can collaborate with the primary care providers to reduce fall risk. They can screen for fall risk, review and optimize medication therapy, recommend vitamin D, and educate patients and caregivers about ways to prevent falls. To help health-care providers implement fall prevention, the Centers for Disease Control and Prevention developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative. Based on the established clinical guidelines, STEADI provides members of the health-care team, including pharmacists, with the tools and resources they need to manage their older patients’ fall risk. These tools are being adapted to specifically advance the roles of pharmacists in reviewing medications, identifying those that increase fall risk, and communicating those risks with patients’ primary care providers. Through a multidisciplinary approach, pharmacists along with other members of the health-care team can better meet the needs of America’s growing older adult population and reduce falls.
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Affiliation(s)
- Mamta V Karani
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA , USA
| | - Yara Haddad
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA , USA
| | - Robin Lee
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention , Atlanta, GA , USA
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Polinder S, Boyé NDA, Mattace-Raso FUS, Van der Velde N, Hartholt KA, De Vries OJ, Lips P, Van der Cammen TJM, Patka P, Van Beeck EF, Van Lieshout EMM. Cost-utility of medication withdrawal in older fallers: results from the improving medication prescribing to reduce risk of FALLs (IMPROveFALL) trial. BMC Geriatr 2016; 16:179. [PMID: 27809792 PMCID: PMC5096283 DOI: 10.1186/s12877-016-0354-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/25/2016] [Indexed: 11/13/2022] Open
Abstract
Background The use of Fall-Risk-Increasing-Drugs (FRIDs) has been associated with increased risk of falls and associated injuries. This study investigates the effect of withdrawal of FRIDs versus ‘care as usual’ on health-related quality of life (HRQoL), costs, and cost-utility in community-dwelling older fallers. Methods In a prospective multicenter randomized controlled trial FRIDs assessment combined with FRIDs-withdrawal or modification was compared with ‘care as usual’ in older persons, who visited the emergency department after experiencing a fall. For the calculation of costs the direct medical costs (intramural and extramural) and indirect costs (travel costs) were collected for a 12 month period. HRQoL was measured at baseline and at 12 months follow-up using the EuroQol-5D and Short Form-12 version 2. The change in EuroQol-5D and Short Form-12 scores over 12 months follow-up within the control and intervention groups was compared using the Wilcoxon Signed Rank test for continuous variables and the McNemar test for dichotomous variables. The change in scores between the control and intervention groups were compared using a two-way analysis of variance. Results We included 612 older persons who visited an emergency department because of a fall. The mean cost of the FRIDs intervention was €120 per patient. The total fall-related healthcare costs (without the intervention costs) did not differ significantly between the intervention group and the control group (€2204 versus €2285). However, the withdrawal of FRIDs reduced medication costs with a mean of €38 per participant. Furthermore, the control group had a greater decline in EuroQol-5D utility score during the 12-months follow-up than the intervention group (p = 0.02). The change in the Short Form-12 Physical Component Summary and Mental Component Summary scores did not differ significantly between the two groups. Conclusions Withdrawal of FRID’s in older persons who visited an emergency department due to a fall, did not lead to reduction of total health-care costs. However, the withdrawal of FRIDs reduced medication costs with a mean of €38 per participant in combination with less decline in HRQoL is an important result. Trial registration The trial is registered in the Netherlands Trial Register (NTR1593 – October 1st 2008). Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0354-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Nicole D A Boyé
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nathalie Van der Velde
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Klaas A Hartholt
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Oscar J De Vries
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Paul Lips
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - Tischa J M Van der Cammen
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Peter Patka
- Department of Emergency Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ed F Van Beeck
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Wang X, Ma Y, Wang J, Han P, Dong R, Kang L, Zhang W, Shen S, Wang J, Li D, Zhou M, Wang L, Niu K, Guo Q. Mobility and Muscle Strength Together are More Strongly Correlated with Falls in Suburb-Dwelling Older Chinese. Sci Rep 2016; 6:25420. [PMID: 27146721 PMCID: PMC4857074 DOI: 10.1038/srep25420] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 04/15/2016] [Indexed: 12/22/2022] Open
Abstract
Falls are common in older adults and result in adverse outcomes. Impaired mobility and poor muscle strength have been consistently identified as the main contributors to falls. We choose three easy-to-perform tests (i.e. Timed Up and Go test (TUGT), walking speed (WS) and grip strength (GS)) in order to assess mobility and muscle strength to further define their relationship with falls. This study is cross-sectional, consisting of 1092 residents over 60-year-old; 589 were female. 204 (18.68%) participants reported falling at least once in the past year. It was found that, of the three tests evaluated independently, a TUGT < 9.1750 s had the strongest association with fewer falls. When evaluating these tests as pairs, the combination of a TUGT < 9.1750 s and a WS < 0.9963 m/s was the best protective indicator of falls after adjusting for age, sex and other variables. When evaluating all three tests in conjunction with each other, the combination of a TUGT < 9.1750 s, a WS < 0.9963 m/s, and a GS > 0.3816 was most correlated with less possibility of falls. The combination of a better TUGT performance, a stronger GS, and a slower WS is the most strongly correlated with less possibility of falls.
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Affiliation(s)
- Xiuyang Wang
- Department of Rehabilitation Medicine, TEDA International Cardiovascular Hospital, Cardiovascular Clinical College of Tianjin Medical University, Tianjin, China.,Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Yixuan Ma
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Jiazhong Wang
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Peipei Han
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Renwei Dong
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Li Kang
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Wen Zhang
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Suxing Shen
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Jing Wang
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Dongfang Li
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Maoran Zhou
- Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
| | - Liancheng Wang
- Department of Rehabilitation Medicine, Tianjin Hospital, Tianjin, China
| | - Kaijun Niu
- Nutritional Epidemiology Institute, Tianjin Medical University, Tianjin, China.,School of Public Health, Tianjin Medical University, Tianjin, China
| | - Qi Guo
- Department of Rehabilitation Medicine, TEDA International Cardiovascular Hospital, Cardiovascular Clinical College of Tianjin Medical University, Tianjin, China.,Department of Rehabilitation and Sports Medicine, Tianjin Medical University, Tianjin, China
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Naples JG, Hanlon JT, Schmader KE, Semla TP. Recent Literature on Medication Errors and Adverse Drug Events in Older Adults. J Am Geriatr Soc 2016; 64:401-8. [PMID: 26804210 DOI: 10.1111/jgs.13922] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medication errors and adverse drug events are common in older adults, but locating literature addressing these issues is often challenging. The objective of this article is to summarize recent studies addressing medication errors and adverse drug events in a single location to improve accessibility for individuals working with older adults. A comprehensive literature search for studies published in 2014 was conducted, and 51 potential articles were identified. After critical review, 17 studies were selected for inclusion based on innovation; rigorous observational or experimental study designs; and use of reliable, valid measures. Four articles characterizing potentially inappropriate prescribing and interventions to optimize medication regimens were annotated and critiqued in detail. The authors hope that health policy-makers and clinicians find this information helpful in improving the quality of care for older adults.
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Affiliation(s)
- Jennifer G Naples
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, School of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Todd P Semla
- Department of Veterans Affairs, Pharmacy Benefits Management Services, Hines, Illinois.,Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Department of Psychiatry and Behavioral Science, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Albert SM, Edelstein O, King J, Flatt J, Lin CJ, Boudreau R, Newman AB. Assessing the quality of a non-randomized pragmatic trial for primary prevention of falls among older adults. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2015; 16:31-40. [PMID: 24488533 DOI: 10.1007/s11121-014-0466-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Current approaches to falls prevention mostly rely on secondary and tertiary prevention and target individuals at high risk of falls. An alternative is primary prevention, in which all seniors are screened, referred as appropriate, and educated regarding falls risk. Little information is available on research designs that allow investigation of this approach in the setting of aging services delivery, where randomization may not be possible. Healthy Steps for Older Adults, a statewide program of the Pennsylvania (PA) Department of Aging, involves a combination of education about falls and screening for balance problems, with referral to personal physicians and home safety assessments. We developed a non-randomized statewide trial, Falls Free PA, to assess its effectiveness in reducing falls incidence over 12 months. We recruited 814 seniors who completed the program (503 first-time participants, 311 people repeating the program) and 1,020 who did not participate in the program, from the same sites. We assessed the quality of this non-randomized design by examining recruitment, follow-up across study groups, and comparability at baseline. Of older adults approached in senior centers, 90.5 % (n = 2,219) signed informed consent, and 1,834 (82.4 %) completed baseline assessments and were eligible for follow-up. Attrition in the three groups over 12 months was low and non-differential (<10 % for withdrawal and <2 % for other loss to follow-up). Median follow-up, which involved standardized monthly assessment of falls, was 10 months in all study groups. At baseline, the groups did not differ in measures of health or falls risk factors. Comparable status at baseline, recruitment from common sites, and similar experience with retention suggest that the non-randomized design will be effective for assessment of this approach to primary prevention of falls.
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Affiliation(s)
- Steven M Albert
- Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, 208 Parran Hall, 130 Desoto Street, Pittsburgh, PA, 15261, USA,
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Rojas-Fernandez C, Dadfar F, Wong A, Brown SG. Use of fall risk increasing drugs in residents of retirement villages: a pilot study of long term care and retirement home residents in Ontario, Canada. BMC Res Notes 2015; 8:568. [PMID: 26467915 PMCID: PMC4606840 DOI: 10.1186/s13104-015-1557-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Falls continue to be a problem for older people in long-term care (LTC) and retirement home (RH) settings and are associated with significant morbidity and health care use. Fall-risk increasing drugs (FRIDs) are known to increase fall risk and represent modifiable risk factors. There are limited data regarding the use of FRIDs in contemporary LTC and RH settings, and it has not been well documented to what extent medication regimens are reviewed and modified for those who have sustained falls. The objective of this study is to characterize medication related fall risk factors in LTC and RH residents and on-going use of medications known to increase fall risk. METHODS Retrospective chart review of residents aged >65 who sustained one or more falls living in LTC or RH settings. RESULTS 105 residents who fell one or more times during 2009-2010 were identified with a mean age of 89 years, a mean of nine scheduled medications and seven diagnoses, and 83% were women. Residents in LTC were ostensibly at higher risk for falls relative to those in RH settings as suggested by higher proportion of residents with multiple falls, multiple comorbidities, comorbidities that increase fall risk and visual impairment. Post fall injuries were sustained by 42% of residents, and residents in RH sustained more injuries relative to LTC residents (47 vs 34%). Use of FRIDs such as benzodiazepines, antipsychotic, antidepressant and various antihypertensive drugs was common in the present sample. No medication regimen changes were noted in the 6-month post fall period. CONCLUSIONS The present study documented common use FRIDs by LTC and RH residents with multiple falls. These potentially modifiable falls risk factors are not being adequately addressed in contemporary practice, demonstrating that there is much room for improvement with regards to the safe and appropriate use of medications in LTC and RH residents.
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Affiliation(s)
- Carlos Rojas-Fernandez
- Schlegel Research Chair in Geriatric Pharmacotherapy, Schlegel-UW Research Institute for Ageing, School of Pharmacy, University of Waterloo, 10 Victoria St S, Room 7004, Kitchener, ON, N2G 1C5, Canada. .,, .
| | - Farzan Dadfar
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada.
| | - Andrea Wong
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada.
| | - Susan G Brown
- Schlegel-University of Waterloo Research Institute for Aging, 325 Max Becker Drive, Suite 202, Kitchener, ON, N2E 4H5, Canada.
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49
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Hedna K, Hakkarainen KM, Gyllensten H, Jönsson AK, Petzold M, Hägg S. Potentially inappropriate prescribing and adverse drug reactions in the elderly: a population-based study. Eur J Clin Pharmacol 2015; 71:1525-33. [PMID: 26407684 PMCID: PMC4643104 DOI: 10.1007/s00228-015-1950-8] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 09/15/2015] [Indexed: 12/04/2022]
Abstract
Purpose Potentially inappropriate prescriptions (PIPs) criteria are widely used for evaluating the quality of prescribing in elderly. However, there is limited evidence on their association with adverse drug reactions (ADRs) across healthcare settings. The study aimed to determine the prevalence of PIPs, defined by the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria, in the Swedish elderly general population and to investigate the association between PIPs and occurrence of ADRs. Method Persons ≥65 years old were identified from a random sample of 5025 adults drawn from the Swedish Total Population Register. A retrospective cohort study was conducted among 813 elderly with healthcare encounters in primary and specialised healthcare settings during a 3-month period in 2008. PIPs were identified from the Swedish Prescribed Drug Register, medical records and health administrative data. ADRs were independently identified by expert reviewers in a stepwise manner using the Howard criteria. Multivariable logistic regression examined the association between PIPs and ADRs. Results Overall, 374 (46.0 %) persons had ≥1 PIPs and 159 (19.5 %) experienced ≥1 ADRs during the study period. In total, 29.8 % of all ADRs was considered caused by PIPs. Persons prescribed with PIPs had more than twofold increased odds of experiencing ADRs (OR 2.47; 95 % CI 1.65–3.69). PIPs were considered the cause of 60 % of ADRs affecting the vascular system, 50 % of ADRs affecting the nervous system and 62.5 % of ADRs resulting in falls. Conclusion PIPs are common among the Swedish elderly and are associated with increased odds of experiencing ADRs. Thus, interventions to decrease PIPs may contribute to preventing ADRs, in particular ADRs associated with nervous and vascular disorders and falls. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1950-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Khedidja Hedna
- Division of Drug Research, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden. .,Nordic School of Public Health NHV, Gothenburg, Sweden.
| | - Katja M Hakkarainen
- Nordic School of Public Health NHV, Gothenburg, Sweden.,EPID Research, Espoo, Finland
| | - Hanna Gyllensten
- Nordic School of Public Health NHV, Gothenburg, Sweden.,Division of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Anna K Jönsson
- Department of Clinical Pharmacology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Max Petzold
- Centre for Applied Biostatistics, University of Gothenburg, Gothenburg, Sweden
| | - Staffan Hägg
- Division of Drug Research, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden.,Futurum, Jönköping County Council, Jönköping, Sweden
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