Exploring the relationship between fall risk-increasing drugs and fall-related fractures

Effects of medication management in geriatric patients who have fallen: results of the EMMA mixed-methods study

BACKGROUND

comprehensive medication management (CMM) can reduce medication-related risks of falling. However, knowledge about inter-individual treatment effects and patient-related barriers remains scarce.

OBJECTIVE

to gain in-depth insights into how geriatric patients who have fallen view their medication-related risks of falling and to identify effects and barriers of a CMM in preventing falls.

DESIGN

complementary mixed-methods pre-post study, based on an embedded quasi-experimental model.

SETTING

geriatric fracture centre.

METHODS

qualitative, semi-structured interviews framed the CMM intervention, including a follow-up period of 12 weeks. Interviews explored themes of falling, medication-related risks, post-discharge acceptability and sustainability of interventions using qualitative content analysis. Optimisation of pharmacotherapy was assessed via changes in the weighted and summated Medication Appropriateness Index (MAI) score, number of fall-risk-increasing drugs (FRID) and potentially inappropriate medications (PIM) according to the Fit fOR The Aged and PRISCUS lists using parametric testing.

RESULTS

thirty community-dwelling patients aged ≥65 years, taking ≥5 drugs and admitted after an injurious fall were recruited. The MAI was significantly reduced, but number of FRID and PIM remained largely unchanged. Many patients were open to medication reduction/discontinuation, but expressed fear when it came to their personal medication. Psychosocial issues and pain increased the number of indications. Safe alternatives for FRID were frequently not available. Psychosocial burden of living alone, fear, lack of supportive care and insomnia increased after discharge.

CONCLUSION

as patients' individual attitudes towards trauma and medication were not predictable, an individual and longitudinal CMM is required. A standardised approach is not helpful in this population.

Development and validation of a machine learning-based fall-related injury risk prediction model using nationwide claims database in Korean community-dwelling older population

BACKGROUND

Falls impact over 25% of older adults annually, making fall prevention a critical public health focus. We aimed to develop and validate a machine learning-based prediction model for serious fall-related injuries (FRIs) among community-dwelling older adults, incorporating various medication factors.

METHODS

Utilizing annual national patient sample data, we segmented outpatient older adults without FRIs in the preceding three months into development and validation cohorts based on data from 2018 and 2019, respectively. The outcome of interest was serious FRIs, which we defined operationally as incidents necessitating an emergency department visit or hospital admission, identified by the diagnostic codes of injuries that are likely associated with falls. We developed four machine-learning models (light gradient boosting machine, Catboost, eXtreme Gradient Boosting, and Random forest), along with a logistic regression model as a reference.

RESULTS

In both cohorts, FRIs leading to hospitalization/emergency department visits occurred in approximately 2% of patients. After selecting features from initial set of 187, we retained 26, with 15 of them being medication-related. Catboost emerged as the top model, with area under the receiver operating characteristic of 0.700, along with sensitivity and specificity rates around 65%. The high-risk group showed more than threefold greater risk of FRIs than the low-risk group, and model interpretations aligned with clinical intuition.

CONCLUSION

We developed and validated an explainable machine-learning model for predicting serious FRIs in community-dwelling older adults. With prospective validation, this model could facilitate targeted fall prevention strategies in primary care or community-pharmacy settings.

Medication Prescribed Within One Year Preceding Fall-Related Injuries in Ontario Older Adults

Background

Serious injuries secondary to falls are becoming more prevalent due to the worldwide ageing of societies. Several medication classes have been associated with falls and fall-related injuries. The purpose of this study was to describe medication classes and the number of medication classes prescribed to older adults prior to the fall-related injury.

Methods

This population-based descriptive study used secondary administrative health-care data in Ontario, Canada for 2010-2014. Descriptive statistics were reported for Anatomic Therapeutic Chemical 4^th level medication classes. Frequency of medications prescribed to older adults was calculated on different sex, age groups, types of medications, and injures.

Results

Over five years (2010-2014), 288,251 older adults (63.2% females) were admitted to an emergency department for a fall-related injury (40.0% fractures, 12.1% brain injury). In the year before the injury, 48.5% were prescribed statins, 27.2% antidepressants, 25.0% opioids, and 16.6% anxiolytics. Females were prescribed more diuretics, antidepressants, and anxiolytics than males; and people aged 85 years and older had a higher percentage of diuretics, antidepressants, and antipsychotics. There were 36.4% of older adults prescribed 5-9 different medication classes and 41.2% were prescribed 10 or more medication classes.

Discussion

Older adults experiencing fall-related injuries were prescribed more opioids, benzodiazepines, and antidepressants than previously reported for the general population of older adults in Ontario. Higher percentage of females and more 85+ older adults were prescribed with psychotropic drugs, and they were also found to be at higher risk of fall-related injuries. Further associations between medications and fall-related injuries need to be explored in well-defined cohort studies.

Development of an algorithm for assessing fall risk in a Japanese inpatient population

Falling is a representative incident in hospitalization and can cause serious complications. In this study, we constructed an algorithm that nurses can use to easily recognize essential fall risk factors and appropriately perform an assessment. A total of 56,911 inpatients (non-fall, 56,673; fall; 238) hospitalized between October 2017 and September 2018 were used for the training dataset. Correlation coefficients, multivariable logistic regression analysis, and decision tree analysis were performed using 36 fall risk factors identified from inpatients. An algorithm was generated combining nine essential fall risk factors (delirium, fall history, use of a walking aid, stagger, impaired judgment/comprehension, muscle weakness of the lower limbs, night urination, use of sleeping drug, and presence of infusion route/tube). Moreover, fall risk level was conveniently classified into four groups (extra-high, high, moderate, and low) according to the priority of fall risk. Finally, we confirmed the reliability of the algorithm using a validation dataset that comprised 57,929 inpatients (non-fall, 57,695; fall, 234) hospitalized between October 2018 and September 2019. Using the newly created algorithm, clinical staff including nurses may be able to appropriately evaluate fall risk level and provide preventive interventions for individual inpatients.

Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review)

Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.

Medications and the risk of falls among older people in a geriatric centre in Nigeria: a cross-sectional study

Background Falls are a major cause of morbidity and hospitalization in older people. Many drugs have been shown to increase the risk of falls in this population. Few empirical data exist on the use of fall-risk-increasing drugs among older people of sub-Saharan Africa countries. Objective This study aimed to assess the prevalence and predictors of falls, and the association between FRIDs, drugs causing orthostatic hypotension and falls. Setting Geriatric center, University College Hospital, Ibadan, Nigeria. Methods A cross-sectional study of 400 older patients aged ≥ 60 years selected consecutively at the geriatric centre, between September and November 2019, were interviewed using a semi-structured questionnaire. Socio-demographic information, medication utilization, and history of falls were obtained. Bivariate and multivariate analyses were carried out using SPSS 23. Alpha was set at 0.05. Main outcome measure Prevalence and predictors of falls among ambulatory older patients. Results The mean age of the older patients was 72.4 ± 7.3 years and 255 (63.7%) were females. The total number of FRIDs and ODs used by older patients was 578 (35.2%). The prevalence of fall was 181 (45.3%) which was significantly higher among the females compared with the males (51.8% vs 33.8%) p = 0.01. Classes of medications such as anti-Parkinson's (p = 0.027), sedatives (p = 0.033), antipsychotics (p = 0.011) and anticholinergic (p = 0.027) were significantly associated with fall. Predictive factors for falls on logistic regression were female [OR = 2.375; 95% CI 0.274-3.704, p = 0.001] and use of antipsychotics [OR = 5.132; 95% CI 1.352-19.480, p = 0.016]. Conclusion The prevalence of falls was high and being a woman ≥ 60 years is a major risk factor for falling. Interventions to decrease falls in older patients by drug modification and deprescribing of FRIDs and ODs might reduce fall-related injuries. Thus, a multidisciplinary approach is essential for intervention to reduce the risk of falls and improve therapeutic outcomes among older patients.

Risk factors associated with in-hospital falls reported to the Patient Safety Commitee of a teaching hospital

OBJECTIVE

To investigate the use of fall-risk-increasing drugs among patients with falls reported to the Patient Safety Office of a hospital, and to identify the factors associated with high risk for fall.

METHODS

A cross-sectional study, carried out in a teaching hospital. The study population was the universe of fall reports received by the Patient Safety Office. The dependent variable was a high risk for falls. The Medication Fall Risk Score was used to measure fall risk. Descriptive, univariate and multivariate analyses were performed.

RESULTS

Of the 125 fall reports in the study, 38 (30.4%) were in 2014, 26 (20.8%) in 2015, and 61 (48.8%) in 2016. Half of the patients (63; 50.4%) were classified as high fall risk and 74 (59.2%) had two or more risk factors for the event. The most frequently used drug classes were opioids (25%), anxiolytics (19.7%), beta-blockers (9.9%), angiotensin II antagonists (7%) and vascular-selective calcium channel blockers (7%). After the adjusted analysis, the factors associated with falls were amputation (odds ratio: 14.17), female sex (odds ratio: 2.98) and severe pain (odds ratio: 5.47).

CONCLUSION

Medications are an important contributor to in-hospital falls, and the Medication Fall Risk Score can help identify patients at a high risk for falls.

Study of fall risk-increasing drugs in elderly patients before and after a bone fracture

BACKGROUND

Accidental falls have a significant economic and human impact. The use of certain drugs is one of the modifiable risk factors associated with these events.

OBJECTIVE

The aim of this study was to determine the prevalence of use and to explore changes in treatment with fall-related drugs in patients over 65 years of age admitted as a result of a fall-related fracture.

METHODS

Observational and prospective study performed in a tertiary level hospital. A list of fall risk-increasing drugs (FRIDs) was drawn up. The main study variables were number and type of FRIDs prescribed at admission and 1 month after the fracture and number, type, treating physician and place where changes in FRIDs were implemented.

RESULTS

In total, 252 patients were included. At admission, 91.3% were receiving at least one FRID, mean daily use was 3.1 FRIDs and the most frequently prescribed FRIDs were diuretics (18%), renin-angiotensin system-acting agents (15.8%) and antidepressants (15%). One month later, mean daily use was 3.4 FRIDs (p=0.099) and a significant increase was detected in the use of hypnotics (p=0.003) and antidepressants (p=0.042). A total of 327 changes in treatment were recorded (1.3 changes/patient). Of the changes, 52.6% were new prescriptions, 72.2% occurred at discharge and 56.6% were ordered by a geriatrician.

CONCLUSIONS

The use of FRIDs among patients with a fall-related fracture is very high. This use rises 1 month after the fracture, significantly in the case of hypnotics and antidepressants.