Medical conditions and medications as risk factors of falls in the inpatient older people: a case-control study

A novel multistep approach to standardize the reported risk factors for in-hospital falls: a proof-of-concept study

Background

Uncertainty and inconsistency in terminology regarding the risk factors (RFs) for in-hospital falls are present in the literature.

Objective

(1) To perform a literature review to identify the fall RFs among hospitalized adults; (2) to link the found RFs to the corresponding categories of international health classifications to reduce the heterogeneity of their definitions; (3) to perform a meta-analysis on the risk categories to identify the significant RFs; (4) to refine the final list of significant categories to avoid redundancies.

Methods

Four databases were investigated. We included observational studies assessing patients who had experienced in-hospital falls. Two independent reviewers performed the inclusion and extrapolation process and evaluated the methodological quality of the included studies. RFs were grouped into categories according to three health classifications (ICF, ICD-10, and ATC). Meta-analyses were performed to obtain an overall pooled odds ratio for each RF. Finally, protective RFs or redundant RFs across different classifications were excluded.

Results

Thirty-six articles were included in the meta-analysis. One thousand one hundred and eleven RFs were identified; 616 were linked to ICF classification, 450 to ICD-10, and 260 to ATC. The meta-analyses and subsequent refinement of the categories yielded 53 significant RFs. Overall, the initial number of RFs was reduced by about 21 times.

Conclusion

We identified 53 significant RF categories for in-hospital falls. These results provide proof of concept of the feasibility and validity of the proposed methodology. The list of significant RFs can be used as a template to build more accurate measurement instruments to predict in-hospital falls.

Strategies and Tools for Supporting the Appropriateness of Drug Use in Older People

Through this structured review of the published literature, we aimed to provide an up-to-date description of strategies (human-related) and tools (mainly from the digital field) facilitating the appropriateness of drug use in older adults. The evidence of each strategy and tool's effectiveness and sustainability largely derives from local and heterogeneous experiences, with contrasting results. As a general framework, three main steps should be considered in implementing measures to improve appropriateness: prescription, acceptance by the patient, and continuous monitoring of adherence and risk-benefit profile. Each step needs efforts from specific actors (physicians, patients, caregivers, healthcare professionals) and dedicated supporting tools. Moreover, how to support the appropriateness also strictly depends on the particular setting of care (hospital, ambulatory or primary care, nursing home, long-term care) and available economic resources. Therefore, it is urgent assigning to each approach proposed in the literature the following characteristics: level of effectiveness, strength of evidence, setting of implementation, needed resources, and issues for its sustainability.

Efficacy and safety of Z-substances in the management of insomnia in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing

BACKGROUND

Z-drugs are usually prescribed as first line pharmacological therapy for insomnia. However, the benefits and risks of Z-drugs may differ for older adults. This systematic review investigated the available evidence on the efficacy and safety of Z-drugs in the management of insomnia in older adults.

METHODS

The Cochrane database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE were searched for systematic reviews, meta-analyses, controlled interventional and observational studies using a pre-formulated search term. The target population was older adults (≥65 years old) with insomnia. Studies were included if they reported efficacy and/or safety outcomes of the use of Z-drugs for the management of insomnia compared to placebo, usual or no treatment, or other pharmacological agents.

RESULTS

Eighteen studies were included (8 interventional and 10 observational studies). In short-term interventional studies, Z-drugs were similarly or better efficacious in improving both sleep and daytime parameters than placebo or other pharmacological treatments, while showing good results on measures of safety. However, in longer-term observational studies, Z-drugs significantly increased the risk for falls and fractures in comparison to no treatment or melatonin agonists.

CONCLUSIONS

Analyzing the evidence from short-term interventional studies, Z-drugs appear effective and safe for treatment of insomnia in older adults, but they may have unfavorable side effects when used for longer periods of time. We, therefore, recommend discontinuing Z-drugs, principally because of the high risk for falls and fractures. Nonetheless, quality and quantity of evidence are low. Due to the scarcity of data, especially concerning drug dependence after longer periods of treatment and due to the significantly increased risk for falls and fractures, further studies are needed to evaluate the benefit-risk profile of Z-drugs use in older patients, particularly for long-term use.

Effects of Prescription Opioid Use on Traumatic Brain Injury Risk in Older Adults

OBJECTIVE

The objective of this study was to estimate the risk of traumatic brain injury (TBI) associated with opioid use among older adult Medicare beneficiaries.

SETTING

Five percent sample of Medicare administrative claims obtained for years 2011-2015.

PARTICIPANTS

A total of 50 873 community-dwelling beneficiaries 65 years and older who sustained TBI.

DESIGN

Case-crossover study comparing opioid use in the 7 days prior to TBI with the control periods of 3, 6, and 9 months prior to TBI.

MAIN MEASURES

TBI cases were identified using ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Classification of Diseases, Tenth Revision) codes. Prescription opioid exposure and concomitant nonopioid fall risk-increasing drug (FRID) use were determined by examining the prescription drug event file.

RESULTS

The 8257 opioid users (16.2%) were significantly younger (mean age 79.0 vs 80.8 years, P < .001). Relative to nonusers, opioid users were more likely to be women (77.0% vs 70.0%, P < .001) with a Charlson Comorbidity Index of 2 or more (43.7% vs 30.9%, P < .001) and higher concomitant FRID use (94.0% vs 82.7%, P < .001). Prescription opioid use independently increased the risk of TBI compared with nonusers (OR = 1.34; 95% CI, 1.28-1.40). In direct comparisons, we did not observe evidence of a significant difference in adjusted TBI risk between high- (≥90 morphine milligram equivalents) and standard-dose opioid prescriptions (OR = 1.01; 95% CI, 0.90-1.14) or between acute and chronic (≥90 days) opioid prescriptions (OR = 0.93; 95% CI, 0.84-1.02).

CONCLUSIONS

Among older adult Medicare beneficiaries, prescription opioid use independently increased risk for TBI compared with nonusers after adjusting for concomitant FRID use. We found no significant difference in adjusted TBI risk between high-dose and standard-dose opioid use, nor did we find a significant difference in adjusted TBI risk between acute and chronic opioid use. This analysis can inform prescribing of opioids to community-dwelling older adults for pain management.

Risk of In-Hospital Falls among Medications Commonly Used for Insomnia in Hospitalized Patients

STUDY OBJECTIVES

To investigate the risk of in-hospital falls among patients receiving medications commonly used for insomnia in the hospital setting.

METHODS

Retrospective cohort study of all adult hospitalizations to a large academic medical center from 1/2007 to 7/2013. We excluded patients admitted for a primary psychiatric disorder. Medication exposures of interest, defined by pharmacy charges, included benzodiazepines, non-benzodiazepine benzodiazepine receptor agonists (BZRAs), trazodone, atypical antipsychotics, and diphenhydramine. In-hospital falls were ascertained from an online patient safety reporting system.

RESULTS

Among the 225,498 hospitalizations (median age = 57 years; 57.9% female) in our cohort, 84,911 (37.7%) had exposure to at least one of the five medication classes of interest; benzodiazepines were the most commonly used (23.5%), followed by diphenydramine (8.3%), trazodone (6.6%), BZRAs (6.4%), and atypical antipsychotics (6.3%). A fall occurred in 2,427 hospitalizations (1.1%). The rate of falls per 1,000 hospital days was greater among hospitalizations with exposure to each of the medications of interest, compared to unexposed: 3.6 versus 1.7 for benzodiazepines (adjusted hazard ratio [aHR] 1.8, 95%CI 1.6-1.9); 5.4 versus 1.8 for atypical antipsychotics (aHR 1.6, 95%CI 1.4-1.8); 3.0 versus 2.0 for BZRAs (aHR 1.5, 95%CI 1.3-1.8); 3.3 versus 2.0 for trazodone (aHR 1.2, 95%CI 1.1-1.5); and 2.5 versus 2.0 for diphenhydramine (aHR 1.2, 95%CI 1.03-1.5).

CONCLUSIONS

In this large cohort of hospitalizations at an academic medical center, we found an association between each of the sedating medications examined and in-hospital falls. Benzodiazepines, BZRAs, and atypical antipsychotics had the strongest associations.

Opioid Use and the Risk of Falls, Fall Injuries and Fractures among Older Adults: A Systematic Review and Meta-Analysis

BACKGROUND

There is increasing concern about opioid use as a pain treatment option among older adults. Existing literature implies an association between opioid use and fracture, increasing the risk of death and disabilities; yet, this relationship with other fall-related outcomes has not been fully explored. We performed a meta-analysis to evaluate the associations between opioid use and adverse health outcomes of falls, fall injuries, and fractures among older adults.

METHODS

A systematic literature search was conducted using nine databases: Medline, Embase, CINAHL, PsycInfo, Global Health, Northern Light Sciences Conference Abstracts, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We log-transformed effect sizes (relative risk [RR], odds ratio [OR], and hazard ratio [HR]) to compute pooled risk estimates comparable across the studies. The random-effects model was applied to calculate the pooled risk estimates due to heterogeneity. Meta-regressions explored differences in risk estimates by analysis method, study design, setting, and study quality.

RESULTS

Thirty studies, providing 34 relevant effect sizes, met the inclusion criteria for this meta-analysis. Overall, opioid use was significantly associated with falls, fall injuries, and fractures, with effect sizes ranging from 0.15 to 0.71. In meta-regressions, no selected factors explained heterogeneity.

CONCLUSION

While heterogeneity is present, results suggest an increased risk of falls, fall injuries, and fractures among older adults who used opioids. Findings highlight the need for opioid education and nonopioid-related pain management interventions among older adults to decrease fall-related risk.

Factors Associated With Falls Among Urban-Dwellers Aged 55 Years and Over in the Malaysian Elders Longitudinal Research (MELoR) Study

Falls are major issues affecting the older population with potentially serious complications, including fractures, head injury, institutionalization, fear of falling and depression. While risk factors for falls have been established across Western Europe and North America, geographical differences in falls risk have not been well researched. We aim to examine the clinical and physical risk factors for falls in a middle-income South East Asian country. Cross-sectional data from the Malaysian Elders Longitudinal Research (MELoR) study involving 1,362 community dwelling individuals aged 55 years and above was utilized. Information on sociodemographic and medical history was obtained by computer-assisted questionnaires completed during home visits and hospital-based detailed health checks. Univariate and multivariate analyses compared non-fallers and fallers in the previous 12 months. Urinary incontinence, hearing impairment, depression, arthritis and cognitive impairment were risk factors for falls in the past 12 months after adjustment for age in our study population. Awareness about the risk factors in a population helps the design of fall prevention strategies that target specific or multiple risk factors.

[Association Suvorexant and Ramelteon Use with the Risk of Falling: A Retrospective Case-control Study]

Sedative hypnotics are among the classes of drugs reported to influence falls. However, the effects of the sedative hypnotic drugs, suvorexant and ramelteon, on falls are not well known. Therefore, we conducted this retrospective case-control study to examine the association of the use of these two sedative hypnotics with the risk of falls. Conducted at the Sapporo Medical University Hospital in Japan, our study included 360 patients with fall incidents and 819 randomly selected control patients. Patients in the fall group were significantly older with a lower body mass index, and had a history of falls, disabilities in activities of daily living, cognitive impairment, and delirium. Monovariate analysis revealed that patients in the fall group frequently used ramelteon [odds ratio (OR) 2.38, 95% confidence interval (CI): 1.49-3.81, p<0.001], but rarely used suvorexant (OR 0.66, 95% CI: 0.29-1.39, p=0.317), compared with control patients. Furthermore, multivariate analysis revealed that ramelteon use did not increase the risk of falls (adjusted OR 1.43, 95% CI: 0.82-2.48, p=0.207), whereas suvorexant use significantly decreased the risk of falls (adjusted OR 0.32, 95% CI: 0.13-0.76, p=0.009). Although ramelteon tends to be used in patients at a high risk of falls, it may not increase the risk of falls. In contrast, the use of suvorexant may reduce the risk of falls.

How smart medication systems are used to support older people's drug regimens: A systematic literature review

Smart medication systems are used to help older people, and the professionals and family who care for them, to organize and manage their daily drug regimes. However, synthetized knowledge on previous studies about how these improve everyday life is needed. We searched the PubMed, Scopus, CINAHL, PsycINFO, SocINDEX and Cochrane library databases from 2005 to 2019 and this review focused on nine of the 2,424 papers we identified. According to our analysis, smart medication systems make it possible to regulate medication times and doses and detect medication errors. With further development, smart medication systems could be more be effective at preventing medication errors, improving medication adherence by older people and freeing up healthcare professional, so that they can focus on other tasks. However, more research on different systems is needed to improve existing solutions and to understand how they can make older people more independent when it comes to their daily medication.

Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: II. Psychotropics

BACKGROUND AND OBJECTIVE

Falls are a major public health problem in older adults. Earlier studies showed that psychotropic medication use increases the risk of falls. The aim of this study is to update the current knowledge by providing a comprehensive systematic review and meta-analysis on psychotropic medication use and falls in older adults.

METHODS AND DESIGN

This study is a systematic review and meta-analysis. A search was conducted in Medline, PsycINFO, and Embase. Key search concepts were "falls," "aged," "medication," and "causality." Studies were included that investigated psychotropics (antipsychotics, antidepressants, anxiolytics, sedatives, and hypnotics) as risk factors for falls in participants ≥60 years of age or participants with a mean age of ≥70 years. Meta-analyses were performed using generic inverse variance method pooling unadjusted and adjusted odds ratio (OR) estimates separately.

RESULTS

In total, 248 studies met the inclusion criteria for qualitative synthesis. Meta-analyses using adjusted data showed the following pooled ORs: antipsychotics 1.54 [95% confidence interval (CI) 1.28-1.85], antidepressants 1.57 (95% Cl 1.43-1.74), tricyclic antidepressants 1.41 (95% CI 1.07-1.86), selective serotonin reuptake inhibitors 2.02 (95% CI 1.85-2.20), benzodiazepines 1.42 (95%, CI 1.22-1.65), long-acting benzodiazepines 1.81 (95%, CI 1.05-3.16), and short-acting benzodiazepines 1.27 (95%, CI 1.04-1.56) Most of the meta-analyses resulted in substantial heterogeneity that did not disappear after stratification for population and healthcare setting.

CONCLUSIONS

Antipsychotics, antidepressants, and benzodiazepines are consistently associated with a higher risk of falls. It is unclear whether specific subgroups such as short-acting benzodiazepines and selective serotonin reuptake inhibitors are safer in terms of fall risk. Prescription bias could not be accounted for. Future studies need to address pharmacologic subgroups as fall risk may differ depending on specific medication properties. Precise and uniform classification of target medication (Anatomical Therapeutic Chemical Classification) is essential for valid comparisons between studies.

Hospitalized burn injury risk associated with benzodiazepines and Z-drugs in elders: A population-based case-control study

OBJECTIVE

To examine the association between benzodiazepines (BZDs) and Z-drugs treatment and risk of burn injury in elders.

METHODS

We designed a nested case-control study. All subjects were aged 65 and older and enrolled in the National Health Insurance program in Taiwan, 2003 to 2012; 813 cases were identified with burn injury for the first time in their inpatient claims, and they were individually matched to 4879 controls based on age, gender, and index year. Benzodiazepines and Z-drugs usage (doses, duration, half-life) and the other covariates including comorbidities, health care utilization, and psychotropic medications used in the 365 days before index events were examined.

RESULTS

A significant increased risk of burn injury hospitalization in elders was observed among current Z-drugs users compared with nonusers (adjusted odds ratio [AOR] = 1.59, 95% confidence interval [CI] [1.23, 2.07]). BZDs at high (AOR = 1.81, 95% CI [1.12, 2.94] and medium dosage (AOR = 1.53, 95% CI [1.15, 2.04] and Z-drugs at medium dosage (AOR = 1.60, 95% CI [1.20, 2.12]) were all significantly increased the burn-related injury requiring hospitalization. Polypharmacy of anxiolytic and hypnotic BZDs, long- and short-acting BZDs, and more than one BZD with or without Z-drugs also increased the risk.

CONCLUSIONS

BZDs and Z-drugs prescriptions in elders may be associated with increased risk of burn injury hospitalization. When prescribing BZDs and Z-drugs, clinicians should exercise caution with the elderly to minimize risks.

Influences of Age, Obesity, and Adverse Drug Effects on Balance and Mobility Testing Scores in Ambulatory Older Adults

BACKGROUND AND PURPOSE

The adverse effects of drugs may influence results on tests of mobility and balance, but the drug-specific impact is not identified when using these tests. We propose that a quantitative drug index (QDI) will assist in assessing fall risk based on these tests, when combined with other fall risk variables.

METHODS

Fifty-seven community-dwelling older adults who could walk independently on a treadmill and had Mini-Mental State Examination (MMSE) scores equal to or greater than 24 participated. Mobility and balance outcome measures included the Balance Evaluation Systems Test (BESTest), Berg Balance Scale (BBS), Timed Up and Go (TUG) and cognitive dual task TUG (TUGc). Fall history, current drug list, and Activity-Specific Balance Confidence (ABC) scale scores were also collected. Body mass index (BMI) was calculated. The QDI was derived from the drug list for each individual, and based on fall-related drug adverse effects. Multiple linear regression analyses were conducted using age, BMI, and QDI as predictor variables for determining mobility and balance test scores, and ABC scale scores. Subsequently, participants were divided into (QDI = 0) low-impact drug group (LIDG) and (QDI > 0) high-impact drug group (HIDG) for Mann-Whitney 2-group comparisons.

RESULTS

Age, BMI, and QDI were all significant (P < .001) independent variables in multiple regression analyses for mobility and balance test scores, but not for the ABC scale. Separately, the 2 group comparisons for the BESTest, BBS, TUG, and TUGc demonstrated that HIDG scored significantly (P < .05) worse on these tests compared with the LIDG. Drug counts were also significantly higher for the HIDG than for the LIDG. In contrast, age, BMI, MMSE, and reported falls in the last 12 months were not significantly different between groups.

CONCLUSION

Age, BMI, and QDI-all contributed independently to the mobility and balance test scores examined, and may provide health care professionals a screening tool to determine whether additional mobility and balance testing is required. In addition, the QDI is a more precise marker of adverse effects of drugs compared with drug counts, as the latter does not quantitate the influence of drugs on physiologic function.

The relation between falls and medication use among elderly in assisted living facilities

PURPOSE

Many elderly are concerned about falling transfer to assisted living facilities (ALF). Previous literatures studied the medication use and falls in the community, hospitals, or nursing homes, with scanty data about ALF. Therefore, the aim of the current case-control study was to assess the relation between medication use and falls among elderly in ALF.

METHODS

A matched case-control study was conducted. The study was conducted in ALF in Cairo, Egypt. The study participants were 188 individuals; they were subdivided into two groups: fallers and nonfallers; timed up and go test (TUGT) was performed by all subjects. Medication data were collected according to the fall risk-increasing drugs list and the list of drugs that cause or worsen orthostatism. Other fall risk factors, as suggested by American Geriatric Society, were assessed.

RESULTS

The use of vasodilators, diuretics, alpha blockers, opioids, antipsychotics, and sedative hypnotics were more common in fallers than in nonfallers (P < 0.001, P = 0.03, P < 0.001, P = 0.013, P < 0.001, and P < 0.001, respectively). Vasodilators, alpha blockers, and antipsychotics were significant predictors of falls even after adjustment for the possible confounding factors. Vasodilators, alpha blockers, opioids, sedative hypnotics, and recent dose changes in oral hypoglycemics were significant predictors of higher TUGT after adjustment for the possible confounding factors.

CONCLUSION

The current study supported the risk of psychotropic and cardiovascular medications, with especial emphasis on vasodilators, alpha blockers, and antipsychotics, with raising concern about opioids, sedative hypnotics, and recent dose change in oral hypoglycemics.

[Association between Elimination Half-life of Benzodiazepines and Falls in the Elderly: A Meta-analysis of Observational Studies]

Benzodiazepine receptor agonists (BZDRAs) have been associated with an increased risk of falls in the elderly. However, the association between the elimination half-life (t_1/2) of BZDRAs and the difference between benzodiazepines (BZDs) and non-benzodiazepines (Z-drugs) has not been clarified. By conducting a meta-analysis of observational studies, we compared the risk of falls with respect to 1) short-acting BZDRAs (t_1/2<12 h) vs. long-acting BZDRAs (t_1/2≥12 h) and 2) BZDs vs. Z-drugs in elderly patients. Data were retrieved from MEDLINE, the Cochrane Library, and Igaku Chuo Zasshi. In total, 13 observational studies from 12 articles were included in our study (short-acting BZDRAs, n=12; long-acting BZDRAs, n=9; BZDs, n=13; Z-drugs, n=7). The risk of falls was significantly increased by the use of short-acting BZDRAs [Odds ratio (OR) (95% Confidence interval (CI)): 2.00 (1.46-2.73)], long-acting BZDRAs [OR (95%CI): 2.16 (1.61-2.89)], BZDs [OR (95%CI): 1.67 (1.31-2.13)], and Z-drugs [OR (95%CI): 2.42 (1.35-4.34)] compared to the risk in BZDRAs non-users. The increased risk of falls in elderly patients was similar in each group and unrelated to t_1/2. This study suggested that all BZDRAs including Z-drugs should be avoided in elderly patients.

The prevalence of benzodiazepines utilization and its association with falls among Saudi older adults; results from the Saudi national survey for elderly Health (SNSEH)

PURPOSE

First, to determine benzodiazepines prevalence (BDZs) among Saudi older adults (SOA); Second, to quantify the association between BDZs use and falls among SOA. Third, to determine falls effect on all-cause mortality among SOA.

METHODS

This is a cross-sectional study that used the Saudi National Survey for Elderly Health; a nationally-representative, population-based survey. Participants were asked about BDZs use and falls history during the 12 months prior to the interview. Demographics, medications, comorbidities and housing conditions were used as covariates. Multiple imputation was used to impute missing data. Modified poisson multivariable regression was used to study the association between BDZs and falls. Cox- proportional hazard regression was used to determine falls effect on mortality over nine years period.

RESULTS

Among 2946 SOA, BDZs prevalence was 4%. Around 13% reported falls. In the multivariable regression, relative risk (RR) of falls was 2 comparing BDZs users to non-users (95CI%: 1.02-3.99). Antidepressants (RR = 1.72; 95%CI: 1.10-2.74), laxatives (RR = 1.38; 95%CI: 1.11-1.7), low body mass index (RR = 1.94; 95%CI: 1.33-2.84), mild cognitive impairment (RR = 1.56; 95%CI: 1.21-2.03), high door steps (RR = 1.54; 95%CI: 1.23-1.93) and insufficient illumination (RR = 1.38; 95%CI: 1.11-1.71) increased falls risk. Lastly, the hazard ratio of falls on death was 1.48 (95%CI: 1.17, 1.89) over nine years.

CONCLUSION

Despite the recommendation against BDZs use among older adults, still there were subjects who were prescribed these drugs. falls are common among SOA. Preventive strategies such medication therapy management, nutrition improvement, elderly-friendly housing structures can reduce the prevalence of falls and consequent increase in mortality among SOA.

A predictive model for fall risk in hospitalized adults: A case-control study

AIM

To develop and validate a predictive model for falls in hospitalized adult clinical and surgical patients, assessing intrinsic (i.e. patient-related) and extrinsic factors (i.e. care process-related).

BACKGROUND

To identify factors predictive of falls and enable appropriate management of fall risk it is necessary to understand patient and environmental factors, along with care delivery processes.

DESIGN

A matched case-control study.

METHODS

This study was conducted in the medical and surgical wards of a Brazilian teaching hospital. The sample included 536 patients, with data collected in 2013-2014. Data analysis included descriptive statistics and conditional logistic regression. Cases of patients aged 18 years or older who fell while hospitalized were included. One patient who did not fall during hospitalization, matched by sex, ward and admission date, was selected as a control for each included case.

RESULTS

The SAK Fall Scale (Severo-Almeida-Kuchenbecker) was developed and validated. The scale includes seven variables: disorientation/confusion, frequent urination, walking limitations, lack of caregiver, postoperative status, previous falls and number of medications administered within 72 hr prior to the fall. This scale showed acceptable predictive accuracy.

CONCLUSIONS

The newly developed SAK Fall Scale includes five intrinsic and two extrinsic variables and differs from other predictive scales for falls. The findings of this study are broad and the scale, which is easy to apply, can be used worldwide by nurses in health services. In advanced practice, the testing of a new model for fall risk contributes to preventive interventions and thus has an impact on patient safety.

Antihistamine use and the risk of injurious falls or fracture in elderly patients: a systematic review and meta-analysis

Despite their anticholinergic side effects, first-generation antihistamines are widely prescribed to elderly patients. A systematic review was conducted to synthesize real-world evidence. First-generation antihistamine use is considerably associated with an increased risk of injurious falls or fracture among the elderly.

INTRODUCTION

First-generation antihistamines are considered potentially inappropriate for elderly patients owing to anticholinergic side effects. We aimed to determine whether elderly patients taking antihistamines are at increased risk of injurious falls or fracture.

METHODS

We identified studies in MEDLINE, EMBASE, and several local databases through November 2016. Observational studies on the association between antihistamine use and the risk of injurious falls or fracture were selected. Quality of the studies and the level of evidence were assessed. The random-effects model was employed for meta-analysis, and heterogeneity was examined based on I-square and Cochrane's Q test. Subgroup analyses were performed when the heterogeneity among studies could not be explained.

RESULTS

From 473 identified studies, five (three case-control studies, one cohort study, and one case-crossover study) were included in our analysis based on eligibility criteria. First-generation antihistamine use showed significantly increased risk of injurious falls or fracture (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.49-2.76, heterogeneity: p = 0.41, I² = 0%). Studies including antihistamines of all generations or containing no generation information were dealing with falls during hospitalization. Among these studies, the association was statistically significant without heterogeneity (OR 2.89, 95% CI 1.71-4.89, heterogeneity: p = 0.42, I² = 0%). Due to the small number of studies included and unadjusted results, meaningful interpretation based on subgroup analysis was limited.

CONCLUSIONS

First-generation antihistamine use is considerably associated with increased risk of injurious falls or fracture among the elderly. Clinicians need to exercise caution when prescribing first-generation antihistamines to elderly patients.

Risk factors for fall occurrence in hospitalized adult patients: a case-control study

OBJECTIVE

to identify risk factors for falls in hospitalized adult patients.

METHODS

a matched case-control study (one control for each case). A quantitative study conducted in clinical and surgical units of a teaching hospital in Southern Brazil. The sample comprised 358 patients. Data were collected over 18 months between 2013-2014. Data analysis was performed with descriptive statistics and conditional logistic regression using Microsoft Excel and SPSS version 18.0.

RESULTS

risk factors identified were: disorientation/confusion [OR 4.25 (1.99 to 9.08), p<0.001]; frequent urination [OR 4.50 (1.86 to 10.87), p=0.001]; walking limitation [OR 4.34 (2.05 to 9.14), p<0.001]; absence of caregiver [OR 0.37 (0.22 to 0.63), p<0.001]; postoperative period [OR 0.50 (0.26 to 0.94), p=0.03]; and number of medications administered within 72 hours prior the fall [OR 1.20 (1.04 to 1.39) p=0.01].

CONCLUSION

risk for falls is multifactorial. However, understanding these factors provides support to clinical decision-making and positively influences patient safety.

Safety of brotizolam in hospitalized patients

PURPOSE

The objective of this study was to evaluate the safety of brotizolam in hospitalized patients.

METHODS

A single-center, comparative retrospective cohort analysis of patients hospitalized in internal medicine wards. Patients treated with brotizolam were compared to patients not treated with any benzodiazepines during hospitalization. Primary outcome was any of the following safety events: mechanical ventilation, delirium, and falls.

RESULTS

Six hundred patients were included after exclusion in the final analysis; 300 treated with brotizolam (treatment) and 300 not treated with any benzodiazepines (comparator). The brotizolam-treated patients were older with more comorbidities and psychotropic medications. After adjustment using multivariate logistic regression analysis with propensity score, the primary outcomes occurred at significantly higher rates in treated patients than in untreated patients (17 vs. 2 events; OR = 7.33). Any psychotropic medication administered during hospitalization was found by logistic regression to be the main independent risk factor for the studied safety outcomes while age, comorbidities, and the cause of hospitalization were not.

CONCLUSIONS

Treatment with brotizolam during hospitalization in internal medicine wards is linked to a higher risk of respiratory deterioration, delirium, and falls. Use of psychotropic medications during hospitalization is the main independent risk factor of safety outcomes. Further research is needed to fully evaluate the risks and benefits of sleep induction medications in hospitals.

Fall-Risk-Increasing Drugs: A Systematic Review and Meta-analysis: III. Others

BACKGROUND AND OBJECTIVE

The use of psychotropic medication and cardiovascular medication has been associated with an increased risk of falling. However, other frequently prescribed medication classes are still under debate as potential risk factors for falls in the older population. The aim of this systematic review and meta-analysis is to evaluate the associations between fall risk and nonpsychotropic and noncardiovascular medications.

METHODS AND DESIGN

A systematic review and meta-analysis. A search was conducted in Medline, PsycINFO, and Embase. Key search concepts were "falls," "aged," "medication," and "causality." Studies were included that investigated nonpsychotropic and noncardiovascular medications as risk factors for falls in participants ≥60 years or participants with a mean age ≥70 years. A meta-analysis was performed using the generic inverse variance method, pooling unadjusted and adjusted odds ratio (OR) estimates separately.

RESULTS

In a qualitative synthesis, 281 studies were included. The results of meta-analysis using adjusted data were as follows (a pooled OR [95% confidence interval]): analgesics, 1.42 (0.91-2.23); nonsteroidal anti-inflammatory drugs (NSAIDs), 1.09 (0.96-1.23); opioids, 1.60 (1.35-1.91); anti-Parkinson drugs, 1.54 (0.99-2.39); antiepileptics, 1.55 (1.25-1.92); and polypharmacy, 1.75 (1.27-2.41). Most of the meta-analyses resulted in substantial heterogeneity that did not disappear after stratification for population and setting in most cases. In a descriptive synthesis, consistent associations with falls were observed for long-term proton pump inhibitor use and opioid initiation. Laxatives showed inconsistent associations with falls (7/20 studies showing a positive association).

CONCLUSION

Opioid and antiepileptic use and polypharmacy were significantly associated with increased risk of falling in the meta-analyses. Long-term use of proton pump inhibitors and opioid initiation might increase the fall risk. Future research is necessary because the causal role of some medication classes as fall-risk-increasing drugs remains unclear, and the existing literature contains significant limitations.

Association between anxious symptoms and sleeping medication use among US older adults

OBJECTIVE

To investigate the relationship between anxiety symptoms and sleeping medication use among a nationally representative sample of US older adults.

DESIGN

Cross-sectional design using data from the 2011 National Health and Aging Trends Study to examine the relationship between anxiety symptoms as rated by the Generalized Anxiety Disorder-2 and self-reported sleeping medication use. Survey weights were applied to account for complex survey design. Logistic regression was used to measure the association between anxiety symptoms and sleeping medication use after adjusting for sociodemographic factors, physical health, and other sleep-related issues.

RESULTS

In 2011, 13.1% of respondents experienced high anxiety symptoms and 29.0% reported taking a sleeping medication at least once a week during the last 30 days. Results estimate that approximately 4 million US older adults have clinically significant anxiety symptoms and approximately 10 million US older adults used a sleeping medication in the last 30 days. Adjusted results revealed that high anxiety symptoms are significantly associated with sleeping medication use compared to low anxiety symptoms (AOR = 1.57; 95% CI, 1.29-1.91). Depression symptoms were also associated with sleeping medication (AOR = 1.29; 95% CI, 1.08-1.55).

CONCLUSIONS

Results demonstrated that anxiety symptoms are significantly associated with sleeping medication use among US older adults. We also found that depressive symptoms, chronic conditions, and worse self-rated health are associated with sleeping medication use. As sleeping medications are associated with adverse health events, these results have clinical implications for treating anxiety symptoms among older patients.

Can clinical practice indicator relating to long-acting benzodiazepine use in the elderly be easily generated in a hospital setting?

BACKGROUND

To improve the appropriate use of long-acting benzodiazepine (la.bzd) prescriptions in the elderly, the Haute Autorité de Santé (HAS) has developed clinical practice indicators (CPI). The alert indicator (AI) evaluates the prevalence of la.bzd prescription among older people. The mastering indicator (MI) corresponds to the prevalence of elderly with a justified, i.e., appropriate, la.bzd prescription among all the elderly with la.bzd prescriptions.

OBJECTIVE

The objective of this study was to test the feasibility of routine generation of CPI regarding la.bzd prescriptions among the elderly in the hospital setting.

DESIGN

This was a retrospective study.

SETTING

The study was conducted in two university hospitals located in Paris.

SUBJECT

Eligible cases were patients aged 65 years and older who were hospitalized in acute care units from January to June 2014.

METHOD

The AI calculation was based on information extracted from medical databases from these hospitals. The appropriateness of la.bzd prescription was assessed by a physician and a pharmacist and was based on review of computerized patient records and prescriptions, using an ad hoc algorithm. The MI was then calculated. Variation in the level of indicators was explored according to the characteristics of patients and of their hospitalization using chi² test. Factors associated with a potentially inappropriate prescription (PIP) of la.bzd were studied using univariate and multivariate logistic regression.

RESULT

Among the 4167 patients included in the study, 362 had la.bzd prescriptions, i.e., the AI was 9%. Prescriptions were found to be appropriate for 83 patients, i.e., the MI was 23% and PIP was 77%. The MI varied between 13 and 31% according to characteristics of patients and of hospitalization. In multivariate analysis, factors associated with PIP were age, number of comorbidities, type of care unit, and concurrent prescription of a neuroleptic or hypnotic.

CONCLUSION

Generation of the AI was routinely possible but only for acute care units with computerized prescriptions, corresponding to 78% of patients. Production of the MI has required medical record review for all patients with a la.bzd prescription and cannot be automated. However, difficulties in generating the MI have identified areas for significant improvement. Moreover, strategies to improve the care of older people with a la.bzd prescription could be targeted using characteristics of patients and of hospitalization associated with PIP. The future deployment of a single electronic medical record in all care departments would make it easier to mine the data and make possible automated production of CPI.

Use of antiepileptic drugs and risk of falls in old age: A systematic review

OBJECTIVE

The aim of this study is to systematically review the scientific literature to investigate if use of antiepileptic drugs (AEDs) is associated with falls and/or recurrent falls in old age.

METHOD

We searched the literature for relevant articles in PubMed and Embase published up until 3rd December 2015. Studies on people aged 60 years and over with an observational design assessing the risk of fall in people exposed to AEDs compared to people not exposed to AED were included.

RESULTS

We found 744 studies by searching Medline and Embase and an additional 9 studies by reviewing relevant reference lists. Of these studies, 13 fulfilled our predefined criteria. The articles were of various study design, sizes and follow-up times, and presented the results in different ways. Also, confounder adjustment varied considerably between the studies. Ten studies presented results for the association between use of any AED and any fall/injurious fall. Of these studies, 6 presented adjusted estimates, of which all but one showed statistically significant associations between use of any AED and any fall/injurious fall. Six studies investigated the association between use of any AED and recurrent falls. Of these, only 3 studies presented adjusted effect estimates of which 2 reached statistical significance for the association between use of AEDs and recurrent falls in elderly people.

CONCLUSION

Our results indicate an association between use of AEDs and risk of falls and recurrent falls in older people. This finding may be clinically important given that a substantial amount of older people use these drugs. However, further research is needed to increase the knowledge about the actual risk of falls when using these drugs in old age.

Association of benzodiazepine and Z-drug use with the risk of hospitalisation for fall-related injuries among older people: a nationwide nested case-control study in Taiwan

Background

Non-benzodiazepine hypnotics (Z-drugs) are advocated to be safer than benzodiazepines (BZDs). This study comprehensively investigated the association of BZD and Z-drug usage with the risk of hospitalisation for fall-related injuries in older people.

Methods

This study used the Taiwan National Health Insurance Database with a nested matched case-control design. We identified 2238 elderly patients who had been hospitalised for fall-related injuries between 2003 and 2012. They were individually matched (1:4) with a comparison group by age, sex, and index year. Conditional logistic regression was used to determine independent effects of drug characteristics (type of exposure, dosage, half-life, and polypharmacy) on older people.

Results

Older people hospitalisation for fall-related injuries were significantly associated with current use of BZDs (adjusted odds ratio [AOR] = 1.32, 95% confidential interval [CI] = 1.17–1.50) and Z-drugs (AOR = 1.24, 95%CI = 1.05–1.48). At all dose levels of BZDs, high dose levels of Z-drugs, long-acting BZD, and short-acting BZD use were all significantly increased the risk of fall-related injuries requiring hospitalisation. Polypharmacy, the use of two or more kinds of BZDs, one kind of BZD plus Z-drugs and two or more kinds of BZDs plus Z-drugs, also significantly increased the risk (AOR = 1.61, 95% CI = 1.38–1.89; AOR = 1.65, 95% CI = 1.08–2.50, and AOR = 1.58, 95% CI = 1.21–2.07).

Conclusions

Different dose levels and half-lives of BZDs, a high dose of Z-drugs, and polypharmacy with BZDs and Z-drugs were associated with an increased risk of fall-related injury requiring hospitalisation in older people. Physicians should balance the risks and benefits when prescribing these drug regimens to older people considering the risk of falls.

Analysis of National Pharmacovigilance Data Associated with Statin Use in Korea

The aim of this study was to evaluate clinical manifestations, age distribution and risk factors of adverse drug reactions (ADRs) of statins. Korean Adverse Event Reporting System (KAERS) database records (July 2009-June 2014) on statin-treated adults were used. ADRs classified as 'certain', 'probable' and 'possible' based on the WHO-Uppsala Monitoring Centre criteria were analysed. The frequency of ADRs was compared between adults (18-64 years) and older people (age ≥65 years) groups. In total, 2161 ADRs from 1690 patients (579, 34.3% older people) were included for analysis. Mean patient age and ADRs per patient were 60.46 ± 12.72 years and 1.28, respectively. ADRs were reported with atorvastatin (48.4%), rosuvastatin (23.0%), pitavastatin (10.4%) and simvastatin (9.1%). The frequent ADRs were gastrointestinal (421 events, 19.5%), musculoskeletal (331, 15.3%), skin (312, 14.4%) and hepatobiliary disorders (286, 13.2%). Skin disorders were significantly more frequent in adults compared to those in older patients (16.3% versus 12.4%, p = 0.021). Common clinical symptoms were myalgia (263 events, 12.2%), dyspepsia (133, 6.2%) and pruritus (103, 4.8%). Myalgia was more frequently reported in adults (12.7% versus 9.5%, p = 0.039) and dizziness was more frequent in older people (3.4% versus 5.8%, p = 0.015). According to KAERS data, leading statin ADRs were gastrointestinal and musculoskeletal disorders. Myalgia and dyspepsia were the common clinical symptoms.

Discrepancies between home medication and patient documentation in primary care

BACKGROUND

Medication Reconciliation leads to quick detection of drug-related problems, studies in ambulatory care are scarce. The recently introduced Medication Plan in Germany serves as an ideal basis for Medication Reconciliation.

OBJECTIVE

The study aim was to provide accurate data on the magnitude of discrepancy between the prescription and the actually taken medicine. Clinical relevance of discrepancies was assessed to estimate the impact on medication safety.

METHODS

Patients were assessed at home, data was reconciled with the physician's documentation. Discrepancies were analyzed and stratified. Risk for hospitalization, risk for falls and the potential for drug-drug interactions was estimated based on literature. Drugs were tested for its origin and grouped to indication clusters. Detected DRPs at a Medication Review were linked to the results at Medication Reconciliation.

RESULTS

Medication of 142 elderly patients from 12 practices was reconciled. 1498 drugs were found at the home assessment, 1099 (73.4%) of which were detected in the physician's documentation. 94.4% of the patients were affected by discrepancies. A total of 2.8 ± 2.4 drugs was undocumented per patient. 26.6% of missing drugs were prescribed by medical specialists, 42.5% of drugs of unknown origin were prescription drugs. 53.9% of the patients used a undocumented drug, which carried a high risk for hospitalization. 23.1% of the drugs not covered were used for treatment of cardiovascular diseases. 65.8% of the differing drugs caused at least one DRP.

CONCLUSION

A high discrepancy between the drugs used by the patient and the medication documented by the primary care physician could be found. Relating drugs had a profound systemic effect and were particular relevant to medication safety. Many drugs were prescription drugs. The majority of differing drugs caused DRPs. A collaborative Medication Reconciliation as part of a Medication Management could compile the entire medication and increase patient safety.

Who falls in an adult emergency department and why-A retrospective review

INTRODUCTION

Falls are a significant source of healthcare related morbidity and mortality of patients in hospitals and residential healthcare settings. Commonly falls are thought of as an affliction of the elderly and the frail. The emergency department (ED) is a unique healthcare setting that sees patients in the acute and hyper acute stages of physical and mental illness and intoxication. Falls occur in this setting, however there is little knowledge about the factors that influence falls in the emergency department.

METHODS

This study was conducted in a large inner city, tertiary ED. Data was collected from the electronic incident management system for the period of time 2011-2015 and additional information was extracted from the patient's medical record.

RESULTS

During the study period a total of 190 fall incidents at a fall rate of 0.63 falls per 1000 presentations. 95.7% of these falls resulted in no or minimal harm to the patient. Patients who fell in the emergency department were younger them previously identified in other settings. The use of high-risk medications, recreational substances and alcohol was prevalent throughout the ED falls population. The most likely time for a patient to fall was during mobilisation, especially to the bathroom.

CONCLUSION

Falls occur in all healthcare settings, which include the ED. The cohort that falls in the ED is younger then in other settings and is more likely to have ingested recreational substances such as alcohol. A rethinking of falls risk specific to the emergency department needs to occur, along with further research into ED related falls.

Benzodiazepine Initiation and Dose Escalation

BACKGROUND

Benzodiazepines (BZDs) place patients at a significant risk of falling. The current literature does not address if this risk is increased during initiation or dose escalations of BZDs.

OBJECTIVE

To determine if initiation or dose escalations of BZD regimens are associated with an increased risk of falls in hospitalized patients compared with patients maintained on their home dose or who had their dose decreased from baseline.

METHODS

This retrospective case-control study evaluated hospitalized patients aged 45 years or older who received a BZD. Patients who did not fall were collected in a 3:1 ratio to patients who fell. Comparisons were made between BZD regimens prior to admission and those 48 hours prior to the index date. The date of fall served as the index date for patients who fell, and the median time-to-fall served as the index date for all other patients.

RESULTS

A total of 132 patients were included in the study (33 falls and 99 without a fall). No significant differences were noted in demographics, baseline mobility, or past medical history. Patients who fell had a significantly longer median length of stay (15 vs 10 days; P = 0.025). Additionally, patients who fell were more likely to have had their BZD regimen initiated or dose escalated compared with patients who did not fall (63.6% vs 41.4%; P = 0.043).

CONCLUSIONS

The risk of falling while on a BZD is increased on initiation and dose escalations. Hospitals should ensure judicious use of BZDs in inpatients to reduce the risk of falls.

Risk factors for recurrent injurious falls that require hospitalization for older adults with dementia: a population based study

Background

Older adults with dementia are at an increased risk of falls, however, little is known about risk factors for recurrent injurious falls (a subsequent fall after the first fall has occurred) among this group. This study aimed to identify risk factors for recurrent injurious falls requiring hospitalization among adults aged 60+ years with dementia.

Methods

This retrospective, whole-population cohort study was conducted using the Western Australian Hospital Morbidity Data System and Western Australian Death Registrations from 2001 to 2013. Survival analysis using a stratified conditional Cox model (type 1) was undertaken to identify risk factors for recurrent injurious falls requiring hospitalization.

Results

There were 32,519 participants with an index hospital admission with dementia during the study period. Over 27 % (n = 8970) of the cohort experienced a total of 11,073 injurious falls requiring hospitalization during follow up with 7297 individuals experiencing a single fall, 1330 experiencing two falls and 343 experiencing three or more falls. The median follow-up time for each individual was 2.49 years. Females were at a significantly increased risk of 7 % for recurrent injurious falls resulting in hospitalization (adjusted hazard ratio 1.07, 95 % CI 1.01–1.12), compared to males. Increasing age, living in rural areas, and having an injurious fall in the year prior to the index hospital admission with dementia also increased the risk of recurrent injurious falls resulting in hospitalization.

Conclusions

Screening those with dementia for injurious falls history could help to identify those most at risk of recurrent injurious falls. Improvement of heath care and falls prevention services for those with dementia who live in rural areas may also reduce recurrent injurious falls.

Comorbidities and concurrent medications increasing the risk of adverse drug reactions: prevalence in French benzodiazepine users

PURPOSE

To estimate benzodiazepine prevalence of use and to quantify, in benzodiazepine users, the prevalence of comorbidities and concurrent medications increasing the risk of adverse drug reactions (ADRs).

METHODS

Cross-sectional study performed using data from the French national healthcare insurance system. The prevalence of use was estimated by considering as users, patients who had at least one benzodiazepine reimbursement during the year 2013. Patients at increased risk for benzodiazepine ADRs were those who had (i) drug-drug interactions at risk for central nervous system and respiratory depression and (ii) comorbidities at risk for adverse respiratory effects, or for falls or fractures.

RESULTS

Overall, the prevalence of benzodiazepine use in 2013 was estimated to be 13.8 %; it was higher among women and increased with age. This prevalence was 10.6 % for anxiolytic benzodiazepines, and 6.1 % for hypnotic benzodiazepines. Approximately half of the benzodiazepine users (48.1 %) were at increased risk for benzodiazepine ADRs; this proportion increased with age. Drug-drug interactions represented the most prevalent condition (39.3 % of benzodiazepine users). The drugs most frequently involved were opioids: analgesics (15.9 %) and antitussives (6.8 %). Overall, 11.3 % of benzodiazepine users had comorbidities at increased risk for adverse respiratory effects (13.9 % in those aged 65-79), and 7.0 % comorbidities at increased risk for falls or fractures (13.4 % in those aged ≥80).

CONCLUSIONS

This study found that benzodiazepine use remained high in France, and that roughly half of the users presented with comorbidities and concurrent medications increasing the risk of ADRs. These findings are of concern, given that benzodiazepines are frequently used, and especially among the elderly.

Medications associated with falls in older people: systematic review of publications from a recent 5-year period

PURPOSE

Falls are an important public health problem in older people. Medication use is considered a risk factor for falls. This study systematically reviewed recent studies to determine the medications that might be associated with the risk of falling in older people.

METHODS

We conducted a systematic review of prospective and retrospective studies identified through the MEDLINE and CINAHL databases that quantitatively assessed the contribution of medications to falls risk in participants ≥60 years old published in English between May 2008 and April 2013.

RESULTS

The search identified 1,895 articles; 36 articles met the inclusion criteria. Of the 19 studies that investigated the effect of polypharmacy on the risk of falling, six studies reported that the risk of falling increased with polypharmacy. Data on the use of antihypertensive medications including calcium channel blockers, beta-blockers, and angiotensin system blocking medications were collected in 14 studies, with mixed results. Twenty-nine studies reported an association between the risk of falls and psychotropic medications including sedatives and hypnotics, antidepressants, and benzodiazepines.

CONCLUSIONS

The use of sedatives and hypnotics and antidepressants including tricyclic antidepressants, selective serotonin reuptake inhibitors, and serotonin norepinephrine reuptake inhibitors appears to be related with an increased risk of falls. It is not clear if the use of antihypertensive medications is associated with the risk of falls in older people.

Care needs and clinical outcomes of older people with dementia: a population-based propensity score-matched cohort study

Objective

To explore the healthcare resource utilization, psychotropic drug use and mortality of older people with dementia.

Design

A nationwide propensity score-matched cohort study.

Setting

National Health Insurance Research database.

Participants

A total of 32,649 elderly people with dementia and their propensity-score matched controls (n=32,649).

Measurements

Outpatient visits, inpatient care, psychotropic drug use, in-hospital mortality and all-cause mortality at 90 and 365 days.

Results

Compared to the non-dementia group, a higher proportion of patients with dementia used inpatient services (1 year after index date: 20.91% vs. 9.55%), and the dementia group had more outpatient visits (median [standard deviation]: 7.00 [8.87] vs. 3.00 [8.30]). Furthermore, dementia cases with acute admission had the highest psychotropic drug utilization both at baseline and at the post-index dates (difference-in-differences: all <0.001). Dementia was associated with an increased risk of all-cause mortality (90 days, Odds ratio (OR)=1.85 [95%CI 1.67-2.05], p<0.001; 365 days, OR=1.59 [1.50-1.69], p<0.001) and in-hospital mortality (90 days, OR=1.97 [1.71-2.27], p<0.001; 365 days, OR=1.82 [1.61-2.05], p<0.001) compared to matched controls.

Conclusions

When older people with dementia are admitted for acute illnesses, they may increase their use of psychotropic agents and their risk of death, particularly in-hospital mortality.

Update on managing generalized anxiety disorder in older adults

With the recent updates to the Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-5), there are many questions on how to care for older adults with generalized anxiety disorder (GAD) and other psychiatric conditions. The current article reviews the new changes to the DSM-5 for diagnosis of GAD, discusses new anxiety assessment scales that are validated in older adults, evaluates pharmacological agents that have been studied in older adults for GAD treatment, and provides monitoring recommendations to help those who provide care to older adults experiencing GAD.

Use of benzodiazepines and association with falls in older people admitted to hospital: a prospective cohort study

BACKGROUND

Hypnosedatives are commonly prescribed for anxiety and sleep problems. Changes in pharmacokinetics and pharmacodynamics of benzodiazepines (BZDs) during ageing may increase their potential to cause adverse outcomes.

OBJECTIVE

This study aimed to investigate the use of BZDs in acute care settings and explore their association with falls.

METHODS

A prospective cohort study was undertaken of patients aged over 70 years consecutively admitted to 11 acute care hospitals in Australia. Data were collected using the interRAI Acute Care assessment tool. Falls were recorded prospectively (in hospital) and retrospectively (in the 90 days prior to admission).

RESULTS

Of 1,412 patients, 146 (10.3 %) were taking BZDs at admission and 155 (11.3 %) at discharge. Incidence rates of in-hospital fallers for users and non-users of BZDs were not statistically different [incidence rate ratio 1.03, 95 % confidence interval (CI) 0.58-1.82]. There was also no significant association between benzodiazepine use at admission and history of falls in the previous 90 days compared with non-users. However, patients on diazepam were significantly more likely to have a history of falls than all other benzodiazepine users (70.8 vs. 36.1 %; p = 0.002), particularly when compared with oxazepam users (70.8 vs. 25.0 %; p < 0.001). Adjusting for confounders, use of diazepam at admission was positively associated with a history of falls compared with all other benzodiazepine users (odds ratio 3.0; 95 % CI 1.1-8.5; p = 0.036).

CONCLUSIONS

Different BZDs may vary in their propensity to predispose to falls, with diazepam having the strongest association. The selection of particular BZDs for older patients should be carefully evaluated.

Exposure to anticholinergic and sedative drugs, risk of falls, and mortality: an elderly inpatient, multicenter cohort

This study aimed to assess whether exposure to anticholinergic and sedative medications and its evolution was associated with increased risk of in-hospital falls and all-cause mortality. Furthermore, results were compared with 2 definitions of drug burden index (DBI) against the outcomes.This observational, multicentric, and longitudinal study was conducted among patients aged 65 years or older, in 3 geriatric hospitals, in Francheville, Lyon, and Villeurbanne, France (duration of follow-up, 11.6 months). The exposure to anticholinergic and sedative medications was quantified using a DBI, at admission and at the end of observation for 337 patients. The evolution of exposure was the absolute difference between the index at admission and at the end of observation. The outcomes were in-hospital falls and all-cause mortality.Overall, 5.9% of patients experienced a fall. The risk of fall was nearly 3-fold in patients whose DBI increased during hospital stay compared to those with stable or decreased DBI (hazard ratio, 2.9 [1.14-7.12]; P = 0.03), after adjustment for comorbidities.The overall proportion of mortality was 6.5%. The evolution of DBI during hospital stay was not related to the risk of mortality (hazard ratio, 1.9 [0.8-4.4]; P = 0.14). Results were similar with the 2 definitions of DBI.Increased exposure to anticholinergic and sedative medications during hospital stay is associated with a higher risk of in-hospital falls but not with mortality. The DBI could be implemented in hospital, to guide prescription and reduce anticholinergic and sedative drug exposure.

Why is your patient sedated?

PURPOSE

The purpose of this paper is to examine the recording of clinical indication for prescribed sedative/hypnotic (SH) medications in a large, acute tertiary referral hospital.

DESIGN/METHODOLOGY/APPROACH

All hospital inpatients' medications (n = 367) were audited for prescription details regarding SH medications. Medical notes were then examined for evidence of a recorded indication for such medications.

FINDINGS

SH medications were prescribed to many hospital inpatients (42.5 per cent) during admission. An indication was documented in the nursing or medical records for 24.4 per cent of patients who were prescribed such medications. Nurses rather than by doctors prescribed most SH medications (74 vs 26 per cent, respectively, p = 0.003). Some patients receiving SH medications were both over 65 and impaired in their mobility (19.2 per cent). The treatment indication was documented in 47 per cent.

PRACTICAL IMPLICATIONS

Most patients prescribed SH medications have nothing in their medical record explaining why these drugs are being used, including half of the elderly, less mobile patients. All health professionals dealing with SH medications and doctors in particular need to justify the use of such medications in the medical record. For the particularly high-risk groups where SH medications are potentially more dangerous, explicit guidance on why and how such medications are to be used must be provided by prescribers.

ORIGINALITY/VALUE

For the first time, data are presented on documentation rates for clinical indication of prescribed SH medications across a large acute hospital, and highlights significant shortcomings in practice. This study should inform other organisations of the need to be mindful of facilitating greater compliance with good prescribing practice.

Effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and relevant pharmacological interventions on fall risk in elderly patients

BACKGROUND

Falls among the elderly are an issue internationally and a public health problem that brings substantial economic and quality-of-life burdens to individuals and society. Falls prevention is an important measure of nursing quality and patient safety. Numerous studies have evaluated the association of medication use with fall risk in elderly patients. However, an up-to-date review has not been available to summarize the multifaceted pharmaceutical concerns in the prevention of medication-related falls.

MATERIALS AND METHODS

Relevant literature was identified by performing searches in PubMed, Web of Science, and the Cochrane Library, covering the period until February 2014. We included studies that described an association between medications and falls, and effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and pharmacological interventions on fall risk in elderly patients. The full text of each included article was critically reviewed, and data interpretation was performed.

RESULTS

Fall-risk-increasing drugs (FRIDs) include central nervous system-acting agents, cough preparations, nonsteroidal anti-inflammatory drugs, anti-Alzheimer's agents, antiplatelet agents, calcium antagonists, diuretics, α-blockers, digoxin, hypoglycemic drugs, neurotoxic chemotherapeutic agents, nasal preparations, and antiglaucoma ophthalmic preparations. The degree of medication-related fall risk was dependent on one or some of the following factors: drug pharmacokinetic/pharmacodynamic properties (eg, elimination half-life, metabolic pathway, genetic polymorphism, risk rating of medications despite belonging to the same therapeutic class) and/or characteristics of medication use (eg, number of medications and drug-drug interactions, dose strength, duration of medication use and time since stopping, medication change, prescribing appropriateness, and medication adherence). Pharmacological interventions, including withdrawal of FRIDs, pharmacist-conducted clinical medication review, and computerized drug alerts, were effective in reducing fall risk.

CONCLUSION

Based on the literature review, clear practical recommendations for clinicians to prevent falls in the elderly included making a list of FRIDs, establishing a computerized alert system for when to e-prescribe FRIDs, seeking an alternative drug with lower fall risk, withdrawing FRIDs if clinically indicated, taking pertinent cautions when the use of FRIDs cannot be avoidable, paying attention to prescribing appropriateness, simplifying the medication regimen, strengthening pharmacist-conducted clinical medication review, ensuring the label of each FRID dispensed contains a corresponding warning sign, being careful when medication change occurs, enhancing medication adherence, and mandating for periodic reassessment of potential risk associated with the patient's medication regimen. Further studies should be conducted in this area, such as investigating whether medication reconciliation and improving medication adherence could decrease the rate of falls.

Risk factors for falls in hospitalized adult patients: an integrative review

Objective: Identifying risk factors for the occurrence of falls in hospitalized adult patients. Method: Integrative review carried out in the databases of LILACS, SciELO, MEDLINE and Web of Science, including articles published between 1989 and 2012. Results: Seventy-one articles were included in the final sample. Risk factors for falls presented in this review were related to patients (intrinsic), the hospital setting and the working process of health professionals, especially in nursing (extrinsic). Conclusion: The systematic screening of risk factors for falls was identified as a contributing factor to the reduction of this injury, helping the non-occurrence of this event that, despite being preventable, can have serious consequences including death.


The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study

BACKGROUND

cataract is a leading cause of reversible vision impairment and may increase falls in older adults.

OBJECTIVE

to assess the risk of an injury due to a fall among adults aged 60+, 2 years before first-eye cataract surgery, between first-eye surgery and second-eye surgery and 2 years after second-eye surgery.

DESIGN

a retrospective cohort study.

SETTING

Western Australian Hospital Morbidity Data System and the Western Australian Death Registry.

SUBJECTS

there were 28,396 individuals aged 60+ years who underwent bilateral cataract surgery in Western Australia between 2001 and 2008.

METHODS

Poisson regression analysis based on generalised estimating equations compared the frequency of falls 2 years before first-eye cataract surgery, between first- and second-eye surgery and 2 years after second-eye cataract surgery after accounting for potential confounders.

RESULTS

the risk of an injurious fall that required hospitalisation doubled (risk ratio: 2.14, 95% confidence interval: 1.82 to 2.51) between first- and second-eye cataract surgery compared with the 2 years before first-eye surgery. There was a 34% increase in the number of injurious falls that required hospitalisation in the 2 years after second-eye cataract surgery compared with the 2 years before first-eye surgery (risk ratio: 1.34, 95% confidence interval: 1.16-1.55).

CONCLUSIONS

there was an increased risk of injurious falls after first- and second-eye cataract surgery which has implications for the timely provision of second-eye surgery as well as appropriate refractive management between surgeries.

Inpatient falls: defining the problem and identifying possible solutions. Part I: an evidence-based review

In this 2 part series, analysis of the risk stratification tools that are available, definition for the scope of the problem, and potential solutions through a review of the literature are presented. A systematic review was used to identify articles for risk stratification and interventions. Three risk stratification systems are discussed, St Thomas's Risk Assessment Tool in Falling Elderly Inpatients, Morse Fall Scale, and the Hendrich Fall Risk Model. Of these scoring systems, the Hendrich Fall Risk Model is the easiest to use and score. Predominantly, multifactorial interventions are used to prevent patient falls. Education and rehabilitation are common themes in studies with statistically significant results. The second article presents a guide to implementing a quality improvement project around hospital falls. A 10-step approach to Plan-Do-Study-Act (PDSA) cycles is described. Specific examples of problems and analysis are easily applicable to any institution. Furthermore, the sustainability of interventions and targeting new areas for improvement is discussed. Although specific to falls in the hospitalized patient, the goal is to present a stepwise approach which is broadly applicable to other areas requiring quality improvement.