Medication-related fall incidents in an older, ambulant population: the B-PROOF study

The effect of statins on falls and physical activity in people aged 65 and older: A systematic review

PURPOSE

Statins are commonly prescribed medications with recognised side effects including muscle weakness. Despite this, little is known about their effect on the physical activity and falls risk in the older population. This paper aims to explore the relationship between statin use and the physical activity and falls risk in adults aged 65 and older.

METHODS

MEDLINE, Embase, CINAHL and PsycINFO were searched on 21/11/2022 to obtain relevant articles. Data considered appropriate included that relating to muscle strength, grip strength, gait speed, balance and falls incidence. Reference and citation searches were performed to identify further relevant papers, and all eligible articles were subject to a Critical Appraisal Skills Programme (CASP) to assess potential bias. With the data being highly heterogeneous, no attempt to measure effect size was made and a narrative synthesis approach was used. The review proposal was registered with PROSPERO: CRD42022366159.

RESULTS

Twenty articles were included. Data were inconsistent throughout, with the overall trend suggesting no significant negative effects of statins on the parameters of physical activity, or on falls risk. This was especially true in matched and adjusted cohorts, where potential confounders had been accounted for.

CONCLUSION

This review did not identify a relationship between statin use and physical activity and falls risk in people aged 65 years and older. Ultimately, the risks and benefits of every medication should be considered in the context of each individual.

The role of plasma concentrations and drug characteristics of beta-blockers in fall risk of older persons

Beta-blocker usage is inconsistently associated with increased fall risk in the literature. However, due to age-related changes and interindividual heterogeneity in pharmacokinetics and dynamics, it is difficult to predict which older adults are more at risk for falls. Therefore, we wanted to explore whether elevated plasma concentrations of selective and nonselective beta-blockers are associated with an increased risk of falls in older beta-blocker users. To answer our research question, we analyzed samples of selective (metoprolol, n = 316) and nonselective beta-blockers (sotalol, timolol, propranolol, and carvedilol, n = 179) users from the B-PROOF cohort. The associations between the beta-blocker concentration and time to first fall were assessed using Cox proportional hazard models. Change of concentration over time in relation to fall risk was assessed with logistic regression models. Models were adjusted for potential confounders. Our results showed that above the median concentration of metoprolol was associated with an increased fall risk (HR 1.55 [1.11-2.16], p = .01). No association was found for nonselective beta-blocker concentrations. Also, changes in concentration over time were not associated with increased fall risk. To conclude, metoprolol plasma concentrations were associated with an increased risk of falls in metoprolol users while no associations were found for nonselective beta-blockers users. This might be caused by a decreased β1-selectivity in high plasma concentrations. In the future, beta-blocker concentrations could potentially help clinicians estimate fall risk in older beta-blockers users and personalize treatment.

Medications influencing the risk of fall-related injuries in older adults: case-control and case-crossover design studies

BACKGROUND

Medications influencing the risk of fall-related injuries (FRIs) in older adults have been inconsistent in previous guidelines. This study employed case-control design to assess the association between FRIs and medications, and an additional case-crossover design was conducted to examine the consistency of the associations and the transient effects of the medications on FRIs.

METHODS

This study was conducted using a national claims database (2002-2015) in Korea. Older adults (≥ 65 years) who had their first FRI between 2007 and 2015 were matched with non-cases in 1:2 ratio. Drug exposure was examined for 60 days prior to the date of the first FRI (index date) in the case-control design. The hazard period (1-60 days) and two control periods (121-180 and 181-240 days prior to the index date) were investigated in the case-crossover design. The risk of FRIs with 32 medications was examined using conditional logistic regression after adjusting for other medications that were significant in the univariate analysis. In the case-crossover study, the same conditional model was applied.

RESULTS

In the case-control design, the five medications associated with the highest risk of FRIs were muscle relaxants (adjusted odd ratio(AOR) = 1.35, 95% confidence interval (CI) = 1.31-1.39), anti-Parkinson agents (AOR = 1.30, 95%CI = 1.19-1.40), opioids (AOR = 1.23, 95%CI = 1.19-1.27), antiepileptics (AOR = 1.19, 95%CI = 1.12-1.26), and antipsychotics (AOR = 1.16, 95%CI = 1.06-1.27). In the case-crossover design, the five medications associated with the highest risk of FRIs were angiotensin II antagonists (AOR = 1.87, 95%CI = 1.77-1.97), antipsychotics (AOR = 1.63, 95%CI = 1.42-1.83), anti-Parkinson agents (AOR = 1.58, 95%CI = 1.32-1.85), muscle relaxants (AOR = 1.42, 95%CI = 1.35-1.48), and opioids (AOR = 1.35, 95%CI = 1.30-1.39).

CONCLUSIONS

Anti-Parkinson agents, opioids, antiepileptics, antipsychotics, antidepressants, hypnotics and sedatives, anxiolytics, muscle relaxants, and NSAIDs/antirheumatic agents increased the risk of FRIs in both designs among older adults. Medications with a significant risk only in the case-crossover analysis, such as antithrombotic agents, calcium channel blockers, angiotensin II antagonists, lipid modifying agents, and benign prostatic hypertrophy agents, may have transient effects on FRIs at the time of initiation. Corticosteroids, which were only associated with risk of FRIs in the case-control analysis, had more of cumulative than transient effects on FRIs.

Associations between polypharmacy and potentially inappropriate medications with risk of falls among the elderly in Saudi Arabia

BACKGROUND

Falls are dangerous to the health of older adults and can impact their functional status leading to frailty. The use of potentially inappropriate medications (PIMs) among older adults may lead to adverse health outcomes and increase the risk of falls. Polypharmacy increases the incidence of falls. Beers criteria by the American Geriatric Society is one of the many criteria used to detect PIMs. It assesses the appropriateness of drug prescriptions (i.e., correct dose, duration, and indications) to ensure the safety of these drugs, reducing drug interactions and decreasing the hazards of side effects. This epidemiological study aims to explore the association between polypharmacy and Beers criteria with the risk of falls in the elderly.

METHOD

A total of 387 outpatients aged 60 or older were interviewed in person. The patients were recruited from the University Hospital and the Family and Community Medicine Center in Khobar city, Saudi Arabia, between the period of November 2021 to March 2022. All patients were able to walk independently. The survey began by collecting patients' demographics, gathering medication history, and asking three key questions to detect the risk of falls which was developed by the Center of Disease Control (CDC). Polypharmacy (defined as concurrent use of five or more medications) and PIMs (defined as use of one or more medications in the Beers list) were examined against risk of falls in the elderly. Multiple logistic regression analyses were used to estimate adjusted Odds Ratios (ORs).

RESULT

A total of 387 patients participated in the study; 62% were male, and most participants belonged to the 60 < 65 years age category (47.80%). Among all patients, 55% had a high risk of falling, and 21% of patients had fell during the past year. Polypharmacy applied to 50.90% of all patients, while Beers criteria positive group applied to 51.42%. Risk of falls and prior falls were associated with polypharmacy both before and after adjustment.

CONCLUSION

The results showed a significant association between risk of falls with polypharmacy and PIMs, and more than half of our study population had a high risk of falls. Of those at a higher risk, one out of five had indeed experienced a fall in the last 12 months. Higher rates of falls were associated with older aged patients, lower educational levels, female gender, and cardiovascular medications.

Theoretically derived interventions aimed at improving appropriate polypharmacy in primary care: A systematic review

Background

Polypharmacy (the use of multiple medications) is common in older patients and achieving a balance between appropriate and inappropriate polypharmacy is a challenge routinely faced by prescribers. It is recommended to incorporate the use of theory when developing complex interventions, but it is not known if theoretically derived interventions aimed at improving appropriate polypharmacy are effective.

Objective

This systematic review aimed to establish the overall effectiveness of theoretically derived interventions on improving appropriate polypharmacy and to investigate the degree to which theory informed intervention design.

Methods

Seven electronic databases were searched from inception to August 2021 including hand-searching of reference lists. Interventions developed using a theory, involving the use of a validated tool to assess prescribing, delivered in primary care to participants with a mean age of ≥65 years and prescribed ≥four medications, were included. Data was extracted independently by two reviewers. The Theory Coding Scheme (TCS) was applied to evaluate the use of theory; Risk of Bias (RoB) was assessed using the Cochrane RoB 2.0 tool.

Results

Two studies, one feasibility study and one randomised controlled trial (RCT) were included, and therefore overall effectiveness of the theoretically derived intervention could not be assessed. Theory used in development included the Theoretical Domains Framework and Reason's system-based risk management theory. The RCT was rated to have a high RoB. Based on the TCS, neither study used theory completely.

Conclusion

The effectiveness of theoretically derived interventions to improve appropriate polypharmacy in primary care could not be determined due to the small number of studies and their heterogeneity. Further incorporation of theory into intervention development is required to understand the effectiveness of this approach.

Prospero registration: CRD42020157175.

Community-Based Support and Social Services and Their Association with Frailty Factors in Older People with Intellectual Disability and Affective and Anxiety Disorders: A Swedish National Population-Based Register Study

Affective and anxiety diagnoses are common in older people with intellectual disability (ID). The aim was to describe support and social services for older people with ID and affective and/or anxiety diagnoses, also to investigate in this study group the association between support and social services and frailty factors in terms of specialist healthcare utilisation, multimorbidity, polypharmacy, level of ID and behavioural impairment. Data was selected from four population-based Swedish national registries, on 871 identified persons with affective and/or anxiety diagnoses and ID. Multivariate regression analysis was used to investigate associations between frailty factors during 2002-2012 and social services in 2012. People with multimorbidity who frequently utilised specialist healthcare were less likely to utilise residential arrangements. Those with polypharmacy were more likely utilise residential arrangements, and receive personal contact. People with moderate, severe/profound levels of ID were more likely to utilise residential arrangements and to pursue daily activities.

Hospital-wide surveillance of fracture risk assessment by both FRAX and medication patterns in acute care hospital

To identify patients at a high risk for primary and secondary osteoporotic fractures using fracture risk assessments performed using the current method and the proposed method, in an acute care hospital and to identify departments where high-risk patients are admitted. This retrospective study included patients aged 40-90 years who were hospitalized at Fujita Health University Hospital. We collated the clinical data and prescriptions of all study participants. We also gathered data pertaining to risk factors according to Fracture Risk Assessment Tool (FRAX). Of the 1,595 patients, the mean number of major osteoporotic fracture risk predicted using FRAX was 11.73%. The department of rheumatology showed the highest fracture risk (18.55 ± 16.81) and had the highest number of patients on medications that resulted in reduced bone mineral density (1.07 ± 0.98 medication). Based on the FRAX, the proportion of patients in the high-risk group in this department was significantly higher compared with those in the remaining departments with respect to glucocorticoid administration, rheumatoid arthritis, and secondary osteoporosis. However, the departments included in the high-risk group were not necessarily the same as the departments included in the top group, based on the administered medications. FRAX score is calculated based on various risk factors; however, only glucocorticoid corresponds to medications. We should focus on medication prescription patterns in addition to FRAX to improve fracture risk assessment in hospital-wide surveillance. Therefore, we recommend the use of FRAX along with the prescribed medications to identify departments that admit high-risk patients.

Candidate genetic variants and antidepressant-related fall risk in middle-aged and older adults

BACKGROUND

Antidepressant use has been associated with increased fall risk. Antidepressant-related adverse drug reactions (e.g. orthostatic hypotension) depend partly on genetic variation. We hypothesized that candidate genetic polymorphisms are associated with fall risk in older antidepressant users.

METHODS

The association between antidepressant use and falls was cross-sectionally investigated in a cohort of Dutch older adults by logistic regression analyses. In case of significant interaction product term of antidepressant use and candidate polymorphism, the association between the variant genotype and fall risk was assessed within antidepressant users and the association between antidepressant use and fall risk was investigated stratified per genotype. Secondly, a look-up of the candidate genes was performed in an existing genome-wide association study on drug-related falls in antidepressant users within the UK Biobank. In antidepressant users, genetic associations for our candidate polymorphisms for fall history were investigated.

RESULTS

In antidepressant users(n = 566), for rs28371725 (CYP2D6*41) fall risk was decreased in TC/variant allele carriers compared to CC/non-variant allele carriers (OR = 0.45, 95% CI 0.26-0.80). Concerning rs1057910 (CYP2C9*3), fall risk was increased in CA/variant allele carriers compared to AA/non-variant allele carriers (OR = 1.95, 95% CI 1.17-3.27). Regarding, rs1045642 (ABCB1), fall risk was increased in AG/variant allele carriers compared to GG/non-variant allele carriers (OR = 1.69, 95% CI 1.07-2.69). Concerning the ABCB1-haplotype (rs1045642/rs1128503), fall risk was increased in AA-AA/variant allele carriers compared to GG-GG/non-variant allele carriers (OR = 1.86, 95% CI 1.05-3.29). In the UK Biobank, in antidepressant users(n = 34,000) T/variant-allele of rs28371725 (CYP2D*41) was associated with increased fall risk (OR = 1.06, 95% CI 1.01-1.12). G/non-variant-allele of rs4244285 (CY2C19*2) was associated with decreased risk (OR = 0.96, 95% CI 0.92-1.00).

CONCLUSION

This is the first study showing that certain genetic variants modify antidepressant-related fall risk. The results were not always consistent across the studies and should be validated in a study with a prospective design. However, pharmacogenetics might have value in antidepressant (de)prescribing in falls prevention.

Association of orexin receptor antagonists with falls during hospitalization

WHAT IS KNOWN AND OBJECTIVE

The use of hypnotics, especially benzodiazepines (BZs), increases the risk of falls. Regarding the association of orexin receptor antagonists with fall risk, consistent results have not been obtained for suvorexant, and studies of lemborexant have not been reported. Therefore, this study investigated whether orexin receptor antagonists, including lemborexant, increase the risk of falls.

METHODS

Data were obtained from the medical records of patients hospitalized at Saga University Hospital in Japan between July 2020 and April 2021. Patients were retrospectively divided into the fall and non-fall groups, and the groups were compared for medication usage.

RESULTS AND DISCUSSION

The fall and non-fall groups included 132 and 6857 patients respectively. A significantly higher proportion of patients in the fall group used hypnotics (40.2% vs. 21.7%; p < 0.0001). Hypnotics remained significantly associated with a higher risk of falls after adjusting for confounders (adjusted odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.13-2.48, p = 0.01). In particular, the use of benzodiazepines was associated with a significantly higher risk of falls (adjusted OR = 2.08, 95% CI = 1.38-3.15, p = 0.0005). Meanwhile, suvorexant use was not linked to the risk of falls, and lemborexant use was associated with a significantly lower risk of falls (adjusted OR = 0.27, 95% CI = 0.09-0.84, p = 0.02).

WHAT IS NEW AND CONCLUSION

The use of hypnotics is a risk factor for falls, but orexin receptor antagonists may represent a safe option for patients requiring hypnotics. Our results provide evidence supporting the safety of these drugs.

Osteoporosis referral and treatment among people with severe mental illness: A ten-year data linkage study

INTRODUCTION

People with severe mental illness (SMI) are at increased risk of osteoporosis but minimal information is available on their treatment and referral. We investigated differences in these outcomes between patients with/without SMI in linked primary and specialist care data.

METHODS

People with SMI aged 18+ at diagnosis with both primary and mental healthcare records between 1st May 2009 and 31st May 2019 from a south London catchment were matched 1:4 to randomly selected controls on gender, age and duration of primary care follow-up. Outcomes included prescription of osteoporosis medications and referrals for osteoporosis, analysed using multivariable logistic regression analyses.

RESULTS

The study included 2269 people with SMI and 9069 matched non-SMI controls. People with SMI were more likely to have a recorded prescription of osteoporosis medications (odds ratio [OR] = 3.54, 95% confidence interval [CI] 2.87, 4.35) and be referred for osteoporosis (OR = 1.51, 95% CI 1.09, 2.08) within 2 years after the date of first SMI diagnosis after adjusting for ethnicity, deprivation and Charlson Comorbidity Index. Factors including older age (osteoporosis medications: OR = 1.04, 95% CI 1.03, 1.05; osteoporosis referral: OR = 1.05, 95% CI 1.04, 1.07) and being prescribed with Class A analgesics (osteoporosis medications: OR = 1.91, 95% CI 1.31, 2.77; osteoporosis referral: OR = 1.77, 95% CI 1.02, 3.07) are significant predictors for osteoporosis management pathways within SMI patients.

CONCLUSION

People with SMI are more frequently prescribed medications for osteoporosis and referred to osteoporosis screening than the general population. Given the many risk factors for osteoporosis in this group, this increased rate of referrals may well be warranted, and there is need to pay more attention to this at-risk group. Screening studies are needed to determine whether the rate of referral is proportional to the need.

Health in Men Study: is frailty a predictor of medication-related hospitalization?

BACKGROUND

Older adults are at high risk of medication-related hospitalizations. Frailty is a phenotype commonly observed in older people due to declining physiological functions.

AIM

To examine the association of frailty with medication-related hospitalization among community dwelling older men.

METHODS

A prospective observational cohort study was conducted among community dwelling older men (mean age 75.6 years SD 5.9) from Western Australia (4324) who participated in the Health in Men Study. Participants were followed-up at 12 and 24 months to determine adverse drug event-related hospitalization, hospitalizations for other causes and mortality.

RESULTS AND DISCUSSION

The prevalence of frailty was 13.2%. At baseline, frailty was associated with exposure to polypharmacy, potentially inappropriate medication use and potential adverse drug-drug interactions with unadjusted odds ratios; [4.13 (3.48-4.89) P < 0.001], [2.46 (1.91-3.17) P < 0.001], [3.85 (3.03-4.90) P < 0.001], respectively. In unadjusted models, frail men were more likely to have non-accidental falls [OR 3.16 (2.51-3.99) P < 0.001], acute kidney injury [OR 3.37 (2.35-4.82) P < 0.001], ADE-related hospitalizations at 12 months [OR 6.83 (4.91-9.51)] and non-ADE-related hospitalizations [OR 2.63 (2.01-3.45)], or to be dead at 12 months [OR 2.97 (1.79-4.92)] and at 24 months [OR 3.14 (2.28-4.33)] when compared with non-frail men. After adjusting for age, living alone, cognitive decline, smoking status and comorbidity, frailty remained associated with ADE-related hospitalization [OR 3.60 (2.41-5.37)], non-ADE-related hospitalizations [OR 1.74 (1.29-2.36)] and death [OR 1.67 (1.15-2.41)].

CONCLUSION

The study suggests that frailty is a predictor of medication-related harm with poorer clinical outcomes including mortality.

Predictors of poor medication adherence of older people with hypertension

Aims

To explore the risk factors for poor medication adherence in older people with hypertension.

Design

A cross‐sectional study.

Methods

Participants were administered with a self‐report questionnaire about their demographic characteristics; additionally, their four‐item Morisky Medication Adherence Scale scores were calculated. The STROBE checklist was applied as the reporting guideline for this study (File S1).

Results

Univariate analysis indicated that the following five factors were statistically significantly associated with medication adherence: education level (χ² = 8.073, p = .045), co‐living (χ² = 11.364, p = .010), hypertension complications (χ² = 10.968, p = .001), admission blood pressure (χ² = 8.876, p = .003), and falls (χ² = 6.703, p = .010). Multivariable binary logistic regression analysis showed that there were four statistically significant predictors, such as people who lived with spouses and offspring (OR = 3.004, p = .017), and those who had high admission blood pressure (OR = 1.910, p = .003) had a greater risk of poor medication adherence, whereas those without hypertension complications (OR = 0.591, p = .026) and those without falls (OR = 0.530, p = .046) had a lower risk.

Relevance to clinical practice

We believe that these findings contribute to the identification of high‐risk people with poor adherence, allowing nurses to identify people with poor adherence in a timely manner, and pay attention to the people's medication.

Research on Beers Criteria and STOPP/START Criteria based on the FDA FAERS database

PURPOSE

Inappropriate medication criteria for the elderly have played an important role in ensuring the safety of medications for the elderly. Too few drugs included in the criteria cannot guarantee the safety of medication for the elderly. Too many drugs included in the criteria will result in less selective medication for the elderly. This paper uses real-world data to evaluate the relationship between antihypertensive drugs and falls, so as to provide references for experts and scholars to revise the criteria of potentially inappropriate medications for the elderly and clinical safe medication.

METHOD

We use the US Food and Drug Administration Adverse Event Reporting System (FDA FAERS) to evaluate the association between specific antihypertensive drugs in six categories (alpha-1 receptor blockers (α-1 blockers), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-receptor blockers (β-blockers), and diuretics) and falls by data mining algorithms, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), Medicines and Healthcare Products Regulatory Agency (MHRA), and the empirical Bayes geometric mean (EBGM) and compared with the relevant drugs included in the Beers Criteria and STOPP/START Criteria.

RESULT

There are a total of 5,157,172 co-occurrences found in 973,447 reports aged 65 years or older from 2016 to 2019 in the FDA FAERS database, and the number of co-occurrences of falls is 5917 for the six categories of 51 antihypertensive drugs. Four kinds of mining methods overlap detection of 12 kinds of positive signal drugs, none of which are not included in the Beers Criteria and 7 drugs are included in the STOPP/START Criteria; 1-3 kinds of mining methods overlap detection of positive signal drugs, a total of 12 kinds, and one drug is included in the Beers Criteria and 5 drugs are included in the STOPP/START Criteria; 22 drugs have fall adverse events, but no positive signal is detected, and 13 drugs are included in STOPP/START Criteria; and 5 drugs have no fall adverse events and 3 drugs are included in the STOPP/START Criteria.

CONCLUSION

The FAERS database was used to confirm the potential connection between some antihypertensive drugs and fall adverse events through data mining algorithms. The Beers Criteria did not clearly indicate the antihypertensive drugs that caused falls, and the antihypertensive drugs included in the STOPP/START Criteria were too extensive and did not include β-blockers and diuretics. It is recommended that experts and scholars use real-world data (such as FAERS, EudraVigilance, WHO VigiBase, and so on) to further explore the relationship between specific antihypertensive drugs and falls in the elderly, so as to revise and improve the criteria for inappropriate medications for the elderly.

Fall incidents in nursing home residents: development of a predictive clinical rule (FINDER)

OBJECTIVES

To develop (part I) and validate (part II) an electronic fall risk clinical rule (CR) to identify nursing home residents (NH-residents) at risk for a fall incident.

DESIGN

Observational, retrospective case-control study.

SETTING

Nursing homes.

PARTICIPANTS

A total of 1668 (824 in part I, 844 in part II) NH-residents from the Netherlands were included. Data of participants from part I were excluded in part II.

PRIMARY AND SECONDARY OUTCOME MEASURES

Development and validation of a fall risk CR in NH-residents. Logistic regression analysis was conducted to identify the fall risk-variables in part I. With these, three CRs were developed (ie, at the day of the fall incident and 3 days and 5 days prior to the fall incident). The overall prediction quality of the CRs were assessed using the area under the receiver operating characteristics (AUROC), and a cut-off value was determined for the predicted risk ensuring a sensitivity ≥0.85. Finally, one CR was chosen and validated in part II using a new retrospective data set.

RESULTS

Eleven fall risk-variables were identified in part I. The AUROCs of the three CRs form part I were similar: the AUROC for models I, II and III were 0.714 (95% CI: 0.679 to 0.748), 0.715 (95% CI: 0.680 to 0.750) and 0.709 (95% CI: 0.674 to 0.744), respectively. Model III (ie, 5 days prior to the fall incident) was chosen for validation in part II. The validated AUROC of the CR, obtained in part II, was 0.603 (95% CI: 0.565 to 0.641) with a sensitivity of 83.41% (95% CI: 79.44% to 86.76%) and a specificity of 27.25% (95% CI 23.11% to 31.81%).

CONCLUSION

Medication data and resident characteristics alone are not sufficient enough to develop a successful CR with a high sensitivity and specificity to predict fall risk in NH-residents.

TRIAL REGISTRATION NUMBER

Not available.

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.

Rationale and design of the Novel Uses of adaptive Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) pragmatic adaptive randomized trial: a trial protocol

BACKGROUND

The prescribing of high-risk medications to older adults remains extremely common and results in potentially avoidable health consequences. Efforts to reduce prescribing have had limited success, in part because they have been sub-optimally timed, poorly designed, or not provided actionable information. Electronic health record (EHR)-based tools are commonly used but have had limited application in facilitating deprescribing in older adults. The objective is to determine whether designing EHR tools using behavioral science principles reduces inappropriate prescribing and clinical outcomes in older adults.

METHODS

The Novel Uses of Designs to Guide provider Engagement in Electronic Health Records (NUDGE-EHR) project uses a two-stage, 16-arm adaptive randomized pragmatic trial with a "pick-the-winner" design to identify the most effective of many potential EHR tools among primary care providers and their patients ≥ 65 years chronically using benzodiazepines, sedative hypnotic ("Z-drugs"), or anticholinergics in a large integrated delivery system. In stage 1, we randomized providers and their patients to usual care (n = 81 providers) or one of 15 EHR tools (n = 8 providers per arm) designed using behavioral principles including salience, choice architecture, or defaulting. After 6 months of follow-up, we will rank order the arms based upon their impact on the trial's primary outcome (for both stages): reduction in inappropriate prescribing (via discontinuation or tapering). In stage 2, we will randomize (a) stage 1 usual care providers in a 1:1 ratio to one of the up to 5 most promising stage 1 interventions or continue usual care and (b) stage 1 providers in the unselected arms in a 1:1 ratio to one of the 5 most promising interventions or usual care. Secondary and tertiary outcomes include quantities of medication prescribed and utilized and clinically significant adverse outcomes.

DISCUSSION

Stage 1 launched in October 2020. We plan to complete stage 2 follow-up in December 2021. These results will advance understanding about how behavioral science can optimize EHR decision support to improve prescribing and health outcomes. Adaptive trials have rarely been used in implementation science, so these findings also provide insight into how trials in this field could be more efficiently conducted.

TRIAL REGISTRATION

Clinicaltrials.gov ( NCT04284553 , registered: February 26, 2020).

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.

Association between Statin Use and Balance in Older Adults

Background: Several medications have been associated with an increased risk of balance deficits and greater likelihood to sustain a fall, representing a large health and economic issue. Statins are regularly prescribed to prevent strokes and heart attacks, but their impact on balance is unknown. The aim of this paper was to determine whether statin use is associated with poorer balance performances in older adults. Methods: All participants, one group taking statins (n = 34), and the other group not taking statins (n = 31), completed a balance assessment with their eyes closed and their eyes opened on a MatScan Pressure Sensing Mat. Center of Pressure (CoP) velocity, peak-to-peak distance, and standard deviation were collected in both anteroposterior (AP) and mediolateral (ML) directions. Multiple linear regression analyses were performed for each balance outcome, testing the statin use status as a predictor and controlling for appropriate factors including participants characteristics, lipid profile, and cardiovascular disease. Results: After controlling for confounding factors, statin use significantly predicted both CoP ML-Amplitude (β = 0.638, p = 0.004) and ML-Velocity (β = 0.653, p = 0.002) in the eyes-opened condition. Conclusions: The present study detected a negative association between statin use and balance control in the ML direction, suggesting that caution should be taken when prescribing statins in older adults, as this could decrease ML stability and ultimately increase fall and fracture risks.

Psychotropic drug use in residents with dementia living in small-scaled special care facilities; a longitudinal study

Objectives: Over the past decade, a trend has been noticed in the Netherlands to replace large-scaled special care units (SCUs) caring for 20-30 residents with dementia by small-scaled SCUs caring for up to 8 residents. Systematic evaluations, however, have yielded a differentiated picture of the effects. As the impact on psychotropic drug use has hardly been addressed thus far, we examined the (potential) impact of psychotropic drug use when moving residents with dementia from large-scaled to small-scaled SCUs.Methods: We conducted a non-randomized, controlled study with a six-month follow-up. Among 145 residents with dementia living a large-scaled SCUs for dementia caring for 20-30 residents per unit, a total of 77 residents were moved to small-scaled SCUs caring for up to 8 residents per unit. Psychotropic drug use, classified according to the Anatomical Therapeutic Chemical Classification (ATC) system was monitored at 2 months before replacement, as well as at 3 and 6 months thereafter. Repeated measures ANOVAs were conducted for the mean Defined Daily Doses (DDDs) of both groups.Results: No significant differences between both groups in psychotropic medication use were found over a period of 8 months.Conclusion: Prescription of psychotropic drugs does not change after a transfer from a large-scaled SCU to a small-scaled SCU of patients with moderate to severe dementia.Current Controlled Trials: ISRCTN11151241.

Association of Antidepressants With Recurrent, Injurious and Unexplained Falls is Not Explained by Reduced Gait Speed

OBJECTIVE

To examine if antidepressants at baseline are associated with falls and syncope over 4 years follow-up and if any observed associations are explained by baseline gait speed.

DESIGN

Longitudinal study (three waves).

SETTING

The Irish Longitudinal Study on Ageing (TILDA), a nationally representative cohort study.

PARTICIPANTS

Two thousand ninety-three community-dwelling adults aged ≥60 years.

MEASUREMENTS

Antidepressants (ATC code "N06A") were identified. Recurrent falls (≥2 falls), injurious falls (requiring medical attention), unexplained falls, and syncope were reported at either Wave 2 or 3. Usual gait speed was the mean of two walks on a 4.88 m GAITRite walkway. Poisson regression analysis was used to examine associations between baseline antidepressant use and future falls adjusting for sociodemographics, physical, cognitive and mental health, and finally, gait speed.

RESULTS

Compared to non-antidepressant users, those on antidepressants at baseline were more likely to report all types of falls (24.8-40.7% versus 9.8-18%) at follow-up. Antidepressants at baseline were independently associated with injurious falls (incidence risk ratio: 1.58, 95% confidence interval: 1.21, 2.06, z = 3.38, p = 0.001, df = 32) and unexplained falls (incidence risk ratio: 1.49, 95% confidence interval: 1.04, 2.15, z = 2.17, p = 0.030, df = 32) independent of all covariates including gait speed.

CONCLUSION

There was little evidence to support the hypothesis that gait would (partly) explain any observed associations between baseline use of antidepressants and future falls. The underlying mechanisms of the observed relationships may be related to depression, vascular pathology, or direct effects of antidepressants. Clinicians should identify the best treatment option for an individual based on existing risk factors for outcomes such as falls.

Effects of benzodiazepines on orthostatic blood pressure in older people

BACKGROUND

Older people taking benzodiazepines (BDZs) have higher risk of falling, which is mainly attributed to cognitive and psychomotor effects. BDZs may also have hypotensive effects. We investigated the association between BDZs and orthostatic blood pressure behaviour in older people.

METHODS

We retrospectively analysed data from an outpatient clinic where people aged 60 or older underwent a geriatric assessment. Non-invasive beat-to-beat orthostatic systolic blood pressure (SBP) was assessed at regular time intervals before and after an active stand test. We compared clinical characteristics between BDZs users and non-users and also investigated if BDZs use was an independent predictor of baseline SBP. Factors associated with SBP change were investigated using a repeated measures general linear model.

RESULTS

Of 538 participants (67.7% female, mean age 72.7), 33 (6.1%) reported regular BDZs use. BDZ users had lower baseline SBP (149 versus 161 mmHg, P < 0.05). Multiple linear regression confirmed BDZs use as independent predictor of baseline SBP in N = =538. At 10 s post-stand, the SBP difference between BDZs use groups became maximum (21 mmHg); at this point, SBP still seemed to be decreasing in BDZ-users, whereas in controls it seemed to be recovering. After adjustment (age, sex, hypertension, frailty, comorbidity, antihypertensives), BDZs were associated with greater SBP reduction between baseline and 10 s post-stand (P < 0.05).

CONCLUSION

Older people taking BDZs may have a higher risk of orthostatic hypotension, perhaps due to an exaggerated immediate BP drop. This adds to other BDZ-related falls risks. BDZs should be avoided in older people at risk of falling.

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.

Hypoglycemia and hyperglycemia are risk factors for falls in the hospital population

OBJECTIVE

To determine the role of hypoglycemia, hyperglycemia or the combination of both as independent risk factors for falls in a hospital population. Secondary objectives included evaluation of other risk factors for falling and their relationships with glucose levels.

RESEARCH DESIGN AND METHODS

Retrospective cohort study over 2 years on hospitalized subjects (N = 57411) analyzing in-hospital-falls and capillary glucose values. Bivariate analysis (χ² test) and multivariate analysis (logistic regression) were performed to test for correlation of glucose values, age, sex, Charlson index, service of care, diagnosis at discharge and diabetes treatment with risk of in-hospital-falls.

RESULTS

The comparison of patients who experienced a fall (fall population) with the non-fall population suggested that: glucose determinations were significantly more frequent in the fall population (OR 3.45; CI 2.98-3.99; p < 0.0001); values of glucose below 70 mg/dl and over 200 mg/dl were significantly associated to falls during hospitalization (OR 1.76; CI 1.42-2.19; p < 0.001) as compared to glycemic values between 70 and 200 mg/dl; diabetes treatment was significantly correlated to risk of fall (OR 2.97; CI 2.54-3.49; p < 0.001); the frequency of glycemia measurements below 70 mg/dl and over 200 mg/dl in the same subject was significantly associated to falls during hospitalization (OR 1.01; CI 1.01-1.02; p < 0.001).

CONCLUSION

Hypoglycemia and hyperglycemia during hospital stays are correlated with an increased risk for falls in the hospitalized population. Presence of diabetes, use of insulin or glucose variability could potentially constitute risk factors for falls inside the hospital as well.

Risk factors for fall in elderly with diabetes mellitus type 2

AIMS

Diabetes mellitus type 2 (DMT2) is a major chronic condition that also common in older people, and associated with an increased risk of falling. This study aimed to determine the risk factor of fall in elderly with DMT2.

METHODS

In this cross-sectional study, 220 elderly diabetic patients who had referred to diabetes center in Kerman were chosen via convenience sampling method. To collect data, Semi-structured Fall Risk questionnaire and the Pittsburgh Sleep Quality Index (PSQI) were used.

FINDINGS

The mean age was estimated to be 69.82 (SD: 9.9) years. Among the participants, 38.5% suffered falls in the past one year. Good sleep quality (OR = 0.45, 95% CI = 0.1-0.85) and appropriate environment (OR = 0.6, 95% CI = 0.1-0.77) were significantly associated with a lesser odd of having recurrent falls. Gait problem (OR = 1.8, 95% CI = 1.1-4.9), balance difficulties (OR = 2.1, 95% CI = 1.24-7.12), hypotension (OR = 1.7, 95% CI = 1.2-5.6), and medication above three medicine (OR = 1.55, 95% CI = 1.12-6.34) were significantly associated with a greater odd of having recurrent falls.

CONCLUSION

It would therefore appear that older diabetic patients would be a suitable target group for a strategy aimed at preventing falls. Early recognition of the multiple causes of falls in the older diabetic patient and prompt referral of this group of patients to a specialist falls clinic is recommend.

The occurrence of comorbidities with affective and anxiety disorders among older people with intellectual disability compared with the general population: a register study

BACKGROUND

Little is known regarding the burden of comorbidities among older people with intellectual disability (ID) who have affective and anxiety disorders. Therefore, we aimed to investigate the occurrence and risk of psychiatric and somatic comorbidities with affective and/or anxiety disorders in older people with ID compared to the general population.

METHODS

This population study was based on three Swedish national registers over 11 years (2002-2012). The ID group was identified in the LSS register, which comprises of data on measures in accordance with the Act Concerning Support and Service for Persons with Certain Functional Impairments (n = 7936), and a same-sized reference cohort from the Total Population Register was matched by sex and year of birth. The study groups consisted of those with affective (n = 918) and anxiety (n = 825) disorder diagnoses. The information about diagnoses were collected from the National Patient Register based on ICD-10 codes.

RESULTS

The rate of psychiatric comorbidities with affective and anxiety disorders was approximately 11 times higher for people with ID compared to the general reference group. The two most common psychiatric comorbidities occurred with affective and anxiety disorders were Unspecified non-organic psychosis and Other mental disorders due to brain damage and dysfunction and to physical disease (8% for each with affective disorders and 7 and 6% with anxiety disorders, respectively). In contrast, somatic comorbidity comparisons showed that the general reference group was 20% less likely than the ID cohort to have comorbid somatic diagnoses. The most commonly occurring somatic comorbidities were Injury, poisoning and certain other consequences of external causes (49 and 47% with affective and anxiety disorders, respectively) and Signs and symptoms and abnormal clinical and laboratory findings not elsewhere classified (44 and 50% with affective and anxiety disorders, respectively).

CONCLUSION

Older people with ID and with affective and anxiety diagnoses are more likely to be diagnosed with psychiatric comorbidities that are unspecified, which reflects the difficulty of diagnosis, and there is a need for further research to understand this vulnerable group. The low occurrence rate of somatic diagnoses may be a result of those conditions being overshadowed by the high degree of psychiatric comorbidities.

Geriatric Polypharmacy: Pharmacist as Key Facilitator in Assessing for Falls Risk: 2019 Update

This article highlights the significant health impact of falls among older adults. An emphasis is placed on the vital role of the pharmacist, regardless of practice setting, in assessing and reducing falls risk for this growing population. In addition, the importance of a stepwise comprehensive approach to falls assessment by pharmacists in collaboration with other clinicians is elucidated.

Association between gaps in antihypertensive medication adherence and injurious falls in older community-dwelling adults: a prospective cohort study

OBJECTIVE

Growing evidence suggests that older adults are at an increased risk of injurious falls when initiating antihypertensive medication, while the evidence regarding long-term use of antihypertensive medication and the risk of falling is mixed. However, long-term users who stop and start these medications may have a similar risk of falling to initial users of antihypertensive medication. Our aim was to evaluate the association between gaps in antihypertensive medication adherence and injurious falls in older (≥65 years) community-dwelling, long-term (≥≥1 year) antihypertensive users.

DESIGN

Prospective cohort study.

SETTING

Irish Community Pharmacy.

PARTICIPANTS

Consecutive participants presenting a prescription for antihypertensive medication to 106 community pharmacies nationwide, community-dwelling, ≥65 years, with no evidence of cognitive impairment, taking antihypertensive medication for ≥1 year (n=938).

MEASURES

Gaps in antihypertensive medication adherence were evaluated from linked dispensing records as the number of 5-day gaps between sequential supplies over the 12-month period prior to baseline. Injurious falls during follow-up were recorded via questionnaire during structured telephone interviews at 12 months.

RESULTS

At 12 months, 8.1% (n=76) of participants reported an injurious fall requiring medical attention. The mean number of 5-day gaps in medication refill behaviour was 1.47 (SD 1.58). In adjusted, modified Poisson models, 5-day medication refill gaps at baseline were associated with a higher risk of an injurious fall during follow-up (aRR 1.18, 95% CI 1.02 to 1.37, p=0.024).

CONCLUSION

Each 5-day gap in antihypertensive refill adherence increased the risk of self-reported injurious falls by 18%. Gaps in antihypertensive adherence may be a marker for increased risk of injurious falls. It is unknown whether adherence-interventions will reduce subsequent risk. This finding is hypothesis generating and should be replicated in similar populations.

Evaluation of pregabalin-induced adverse events related to falls using the FDA adverse event reporting system and Japanese Adverse Drug Event Report databases

WHAT IS KNOWN AND OBJECTIVE

Pregabalin is used for neuropathic and postherpetic pain and generalized anxiety. The aim of this study was to obtain the onset profiles of adverse events (AE) related to falls (AEFs) such as "somnolence," "dizziness," "loss of consciousness" and "fall" onset and several clinical factor combinations such as age and administered dose, using spontaneous reporting system (SRS) analysis such as the US Food and Drug Administration Adverse Event Reporting System (FAERS) database and the Japanese Adverse Drug Event Report (JADER) database.

METHODS

We used the reporting odds ratio (ROR) to analyse the association between pregabalin and AEFs. Additionally, we used the time-to-onset analysis.

RESULTS AND DISCUSSION

The crude RORs of AEFs such as somnolence and dizziness were higher than one for both the databases. The adjusted RORs for AEFs in the ≥60 years age group compared to those in the <60 years age group for the FAERS and JADER databases were 1.46 (95% CI = 1.39-1.53; P < 0.0001) and 2.58 (95% CI = 2.06-3.27; P < 0.0001), respectively. In the JADER database, the median and quartile range for AEFs with pregabalin, at ≤75 and ≥100 mg/d, were 2.0 (0.0-5.0) and 2.0 (1.0-4.3) days, respectively. Additionally, 57.2% of AEFs (four preferred terms) were observed within 2 days after administration.

WHAT IS NEW AND CONCLUSIONS

This study is the first to evaluate the relationship between pregabalin and AEFs using the SRS analysis strategy. The risk of AEFs in the ≥60 years age group might increase compared to that in the <60 years age group. AEFs occurred almost within 1 week after pregabalin administration, and the median for AEF onset was 2 days. Our results show that patients should be closely monitored for AEFs for 1 week from the start of pregabalin administration.

Analysis of fall-related adverse events among older adults using the Japanese Adverse Drug Event Report (JADER) database

Background

Falls are a common but serious problem in older adults, and may lead to fractures and bleeding. As many factors, such as medication, aging, and comorbid diseases may simultaneously affect fall-related adverse events (AEs) in older adults, we evaluated the association between fall-related AEs and the use of medication, aging, and comorbid diseases using the Japanese Adverse Drug Event Report (JADER) database.

Methods

We analyzed reports of fall-related AEs associated with α-blockers, diuretics, calcium channel blockers, central nervous system (CNS)-active drugs (opioids, benzodiazepines, hypnotics and sedatives, non-selective monoamine reuptake inhibitors, and selective serotonin reuptake inhibitors (SSRI)) in the JADER database using the reporting odds ratio (ROR). For the definition of falls, we used the Preferred Terms of The Medical Dictionary for Regulatory Activities (MedDRA). We used the association rule mining technique to discover undetected associations, such as potential risk factors.

Results

The JADER database comprised 430,587 reports between April 2004 and November 2016. The RORs (95% CI) of α-blockers, diuretics, calcium channel blockers, opioids, benzodiazepines, hypnotics and sedatives, non-selective monoamine reuptake inhibitors, and SSRIs were 1.63 (1.27–2.09), 0.74 (0.63–0.86), 1.26 (1.15–1.38), 0.93 (0.80–1.07), 1.83 (1.68–2.01), 1.55 (1.12–2.14), 2.31 (1.82–2.95), and 2.86 (2.49–3.29), respectively. From the lift value in the association rule mining, the number of administered CNS-active drugs and patient age were associated with fall-related AEs. Furthermore, the scores of lift for patients with herpes zoster administered calcium channel blockers or benzodiazepines and patients with dementia administered benzodiazepines were high.

Conclusion

Our results suggest that the number of administered CNS-active drugs and patient age are both associated with fall-related AEs. We recommend that patients with herpes zoster treated with calcium channel blockers and benzodiazepines be closely monitored for fall-related AEs.

Fall-risk-increasing drugs and falls requiring health care among older people with intellectual disability in comparison with the general population: A register study

Background

Falls are the most common cause of injury for older people in the general population as well as among those with intellectual disability. There are many risk factors for falls, including a range of drugs which are considered to be fall-risk-increasing (FRIDs). The aim of the present study was to describe prescription patterns of FRIDs in itself as well as in relation to falls requiring health care among older people with intellectual disability and their age-peers in the general population. Moreover, to investigate possible differences between the two groups.

Methods

A cohort of people with intellectual disability and a referent cohort, one-to-one-matched by sex and year of birth, were established. Each cohort comprised 7936 people aged 55+ years at the end of 2012. Register data were collected for 2006–2012 on prescription of antidepressants, anxiolytics, hypnotics and sedatives, opioids, and antipsychotics, as well as for fall-related health care contacts. Analyses were performed on yearly data, using repeated measures models.

Results

People with intellectual disability were more likely to be prescribed at least one FRID (Relative Risk [RR] 2.31). The increase was highest for antipsychotics (RR 25.0), followed by anxiolytics (RR 4.18), antidepressants (RR 2.72), and hypnotics and sedatives (RR 1.42). For opioids, however, a lower prevalence (RR 0.74) was found. In both cohorts, those with prescription of at least one FRID were more likely to have a fall-related injury that required health care. The increased risk was higher in the referent cohort (RR 3.98) than among people with intellectual disability (RR 2.27), although people with intellectual disability and prescription still had a higher risk of falls than those with prescription in the referent cohort (RR 1.27). A similar pattern was found for all drug groups, except for opioids, where prescription carried the same risk of having a fall-related injury that required health care in both cohorts.

Conclusions

With or without prescription of FRIDs, older people with ID have a higher risk of falls requiring health care than their age-peers in the general population. It is important to be aware of this when prescribing drugs that further increase the risk of falls.

A predictive model of isolated and recurrent falls in functionally independent community-dwelling older adults

BACKGROUND

Aging is associated with an increased risk of accidental falls. Falls in older people have been widely studied in nursing homes and in the elderly with poor functionality, but there have been few investigations into functionally independent community-dwelling older adults.

OBJECTIVE

To determine the predictive factors for falls in functionally independent community-dwelling older adults.

METHODS

A cohort trial-nested case-control study was carried out. The participants were community-dwelling people aged 70 and over who were treated in primary care centers from December 2012 to May 2014 in la Ribera (Valencia, Spain).

RESULTS

There were a total of 374 participants, with a mean age of 76.1 (SD 3.4) years (63.8% females). The subjects presented high functionality scores: Barthel 96.5 (SD 9.4), Lawton 7.2 (SD1.2), Tinetti 25.6 (SD 3.3). The mean number of prescribed drugs was 4.7 (SD 2.9). The cumulative incidence of falls was 39.2%, and 24.1% of these older adults suffered falls. The number of falls in the previous 12 months (OR=1.3; 95%CI: 1.11-1.53; p<0.001) and alpha-blockers (OR=6.72; 95%CI: 1.62-27.79; p=0.009) were predictors of falls. The presence of previous fractures (OR=9.55; 95%CI: 4.1-22.25; p<0.001), a body mass index of ≥30kg/m² (OR=1.09; 95%CI: 1.01-1.19; p=0.035), and who are using benzodiazepines and beta-blockers (OR=2.77; 95%CI: 1.53-5.02; p<0.001), were predictors of recurrent fallers.

CONCLUSIONS

Older people who use alpha-blockers, benzodiazepines and beta-blockers, had previous fractures, with increased body mass index are more likely to fall.

Association Between Chronic or Acute Use of Antihypertensive Class of Medications and Falls in Older Adults. A Systematic Review and Meta-Analysis

BACKGROUND

Evaluating effect of acute or chronic use of antihypertensives on risk of falls in older adults.

METHODS

Data sources: Systematic search of primary research articles in CINAHL, Cochrane, EBM, EMBASE, and MEDLINE databases from January 1 2007 to June 1 2017. Study selection: Research studies of cohort, case-control, case-crossover, cross-sectional, or randomized controlled trial (RCT) design examining association between antihypertensives and falls in people older than 60 years were evaluated. Data synthesis: Twenty-nine studies (N = 1,234,667 participants) were included. Study quality was assessed using the Newcastle-Ottawa Scale (NOS). PRISMA and MOOSE guidelines were used for abstracting data and random-effects inverse-variance meta-analysis was conducted on 26 articles examining chronic antihypertensive use, with odds ratios (ORs) and hazards ratios (HRs) analyzed separately. Time-risk analysis was performed on 5 articles examining acute use of antihypertensives. Outcomes: Pooled ORs and HRs were calculated to determine the association between chronic antihypertensive use and falls. For time-risk analysis, OR was plotted with respect to number of days since antihypertensive commencement, change, or dose increase.

RESULTS

There was no significant association between risk of falling and chronic antihypertensive medication use (OR = 0.97, 95% confidence interval [CI] 0.93-1.01, I2 = 64.1%, P = 0.000; and HR = 0.96, 95% CI 0.92-1.00, I2 = 0.0%, P = 0.706). The time-risk analysis demonstrated a significantly elevated risk of falling 0-24 hours after antihypertensive initiation, change, or dose increase. When diuretics were used, the risk remained significantly elevated till day 21.

CONCLUSIONS

There is no significant association between chronic use of antihypertensives and falls in older adults. Risk of falls is highest on day zero for all antihypertensive medications.

Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: I. Cardiovascular Drugs

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.

Comorbidities and medication use in patients with a recent clinical fracture at the Fracture Liaison Service

In this cross-sectional study, two-thirds of Fracture Liaison Service (FLS) patients had comorbidities and medications associated with increased bone- or fall-related fracture risk. Bone-related and fall-related fracture risk (BRR and FRR) were associated with age and fracture type, but not with gender or BMD. Systematic evaluation of these factors leads to a more profound assessment in FLS care.

INTRODUCTION

This study is a systematic evaluation of comorbidities and medications associated with increased fracture risk in patients aged 50-90 years with a recent fracture visiting the FLS.

METHODS

In this cross-sectional cohort study, comorbidities were classified according to ICD-10 and medications according to the Anatomic Therapeutic Chemical (ATC) classification and further categorized into those associated BRR and FRR.

RESULTS

Of 1282 patients (72% women; 65 ± 9 years), 53% had at least one BRR, 46% had at least one FRR, and 66% at least one BRR and/or FRR. At least one BRR, as well as at least one FRR were associated with age, BMI, and fracture type, but not with gender or BMD. The proportion of patients with only BRR (± 20%) or only FRR (± 10%) was similar among ages, gender, BMI, fracture type, and BMD. The combination of at least one BRR and at least one FRR was significantly associated with age, BMI, and major fractures, but not with gender or BMD.

CONCLUSION

Comorbidities and medications associated with increased fracture risk are present in two-thirds of patients visiting the FLS. In addition, the proportion of patients having a combination of BRR and FRR increased significantly with age, BMI, and fracture severity. This indicates that systematic evaluation of these factors is important for a more profound assessment of subsequent fracture risk in FLS care.

[Statin and risk of falls in the elderly: A sytematic review of the literature]

BACKGROUND

With the high incidence of cardiovascular events in the elderly population the effectiveness of statins in reducing mortality from coronary events has been demonstrated. However, there have been adverse effects, such as myalgia, myopathy, myonecrosis, not to mention the falls as a result of muscle damage with statin use.

OBJECTIVE

The purpose of this study is to conduct a systematic review to assess the literature on the association between statin use and the risk of falls.

METHODS

The databases that were included PUBMED AND SCOPUS, with articles published from January 2000 to May 2016. The MESH terms used for the search were "FALLS" AND "STATIN". Selected studies included cohort populations from the community (>50 years old), and analysed using the Scottish Intercollegiate (SIGN) methodology guidelines, as no randomised controlled study was found.

RESULTS

In the study by Ham et al., statin use was shown to be a protective factor for presence of falls. In the second study by Scott et al., there was an increased risk of falls (P=.029) and an impairment in muscle strength and quality muscle (P=.033 and P=.046, respectively). In the third study Haerer et al., found an increased risk of falls (P=.63).

CONCLUSIONS

The association between use of statins and risk of falls could not be determined with the available evidence, although an association with the involvement of some determinants of muscular function was found.

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.

Falls-Related Drug Use and Risk of Falls Among Older Adults: A Study in a US Medicare Population

Background

Approximately one-third of community-dwelling older adults fall each year, and approximately 10% have falls requiring medical services. Among other factors, research studies have linked certain medications with an increased risk of falls.

Objective

The aim of this study was to examine the risk of falls relative to use patterns among new and continuing falls-related drug (FRD) users.

Methods

A 10% random sample, insured in AARP^® Medicare Supplement and AARP Medicare Part D Rx plans, was utilized to define new and continuing FRD users. New users had a 12-month pre-period without FRD use, whereas continuing users had at least one FRD in the pre-period. Both groups had 12-month follow-up after initiating or continuing FRD use. Characteristics associated with the risk of falls for new and continuing users were determined using multivariate logistic regression models.

Results

Among insureds, 44% used at least one of the FRD classes. Of these, 29% were new users (N = 35,340) and 71% were continuing users (N = 121,488). Fall rates for the two subgroups were similar at 7 and 8%, respectively. Characteristics associated with the risk of falls were previous injurious fall, use of two or more classes of FRDs, older age, poorer health, and being female. New users were at higher risk than continuing users.

Conclusion

New users of FRDs were at highest risk of falls, and continuing users were at increased risk, especially with higher numbers of FRD classes. Both groups could benefit from falls awareness and prevention programs.

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.

Trends in patterns of antidepressant use in older general population between 2006 and 2012 following publication of practice guidelines

OBJECTIVE

The French regulatory agency published in 2006 practice guidelines related to the management of depressive and anxiety disorders. The main objective of the study was to assess their impact regarding use and monitoring of antidepressant drug treatment in older patients. The secondary objective was to identify factors associated with compliance with practice guidelines.

METHODS

A historical fixed cohort study with dynamic follow-up time was conducted in 16,144 subjects aged 65 years and over, initiating antidepressant treatment and registered in the National Health Insurance Database between 2006 and 2012. Compliance with guidelines was assessed from year to year using segmented regression analysis. Multiple logistic regressions were used to identify factors associated with compliance with guidelines.

RESULTS

Duration of antidepressant treatment was compliant with guidelines in 13.0% of patients aged 65-74 years and 18.5% of patients aged 75 years and over. Biological monitoring was performed in 12.6% of patients aged 65-74 years and 18.5% of patients aged 75 years and over. No significant change of rate of compliance with guidelines was observed over the study period. Compliance of prescriptions with guidelines was associated with patient's age, specialty of the prescriber, presence of chronic disease, year of treatment initiation, and presence of a university hospital in the area of residence.

CONCLUSION

While treatment duration and biological monitoring were often inadequate in older patients, the publication of guidelines by the French health regulatory authorities did not lead to any significant and sustained improvement in their patterns of antidepressant use. Copyright © 2016 John Wiley & Sons, Ltd.

Beta-blocker use and fall risk in older individuals: Original results from two studies with meta-analysis

AIMS

To investigate the association between use of β-blockers and β-blocker characteristics - selectivity, lipid solubility, intrinsic sympathetic activity (ISA) and CYP2D6 enzyme metabolism - and fall risk.

METHODS

Data from two prospective studies were used, including community-dwelling individuals, n = 7662 (the Rotterdam Study) and 2407 (B-PROOF), all aged ≥55 years. Fall incidents were recorded prospectively. Time-varying β-blocker use was determined using pharmacy dispensing records. Cox proportional hazard models adjusted for age and sex were applied to determine the association between β-blocker use, their characteristics - selectivity, lipid solubility, ISA and CYP2D6 enzyme metabolism - and fall risk. The results of the studies were combined using meta-analyses.

RESULTS

In total 2917 participants encountered a fall during a total follow-up time of 89 529 years. Meta-analysis indicated no association between use of any β-blocker, compared to nonuse, and fall risk, hazard ratio (HR) = 0.97 [95% confidence interval (CI) 0.88-1.06]. Use of a selective β-blocker was also not associated with fall risk, HR = 0.92 (95%CI 0.83-1.01). Use of a nonselective β-blocker was associated with an increased fall risk, HR = 1.22 (95%CI 1.01-1.48). Other β-blocker characteristics including lipid solubility and CYP2D6 enzyme metabolism were not associated with fall risk.

CONCLUSION

Our study suggests that use of a nonselective β-blocker, contrary to selective β-blockers, is associated with an increased fall risk in an older population. In clinical practice, β-blockers have been shown effective for a variety of cardiovascular indications. However, fall risk should be considered when prescribing a β-blocker in this age group, and the pros and cons for β-blocker classes should be taken into consideration.

Geriatric Polypharmacy: Pharmacist as Key Facilitator in Assessing for Falls Risk

This article highlights the significant health impact of falls among older adults. An emphasis is placed on the vital role of the pharmacist, regardless of practice setting, in assessing and reducing falls risk for this growing population. In addition, the importance of a stepwise comprehensive approach to falls assessment by pharmacists in collaboration with other clinicians is elucidated.