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Sogawa R, Emoto A, Monji A, Miyamoto Y, Yukawa M, Murakawa-Hirachi T, Tagomori Y, Kawasaki M, Kimura S, Shimanoe C. Association of orexin receptor antagonists with falls during hospitalization. J Clin Pharm Ther 2022; 47:809-813. [PMID: 35229895 DOI: 10.1111/jcpt.13619] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/11/2022] [Accepted: 01/21/2022] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Rintaro Sogawa
- Department of Pharmacy, Saga University Hospital, Saga, Japan
| | - Akiko Emoto
- Department of Pharmacy, Saga University Hospital, Saga, Japan.,Safety Management Section, Saga University Hospital, Saga, Japan
| | - Akira Monji
- Department of Psychiatry, Faculty of Medicine, Saga University, Saga, Japan
| | - Yuki Miyamoto
- Department of Pharmacy, Saga University Hospital, Saga, Japan
| | - Misako Yukawa
- Department of Pharmacy, Saga University Hospital, Saga, Japan
| | | | | | - Mikiko Kawasaki
- Department of Nursing, Saga University Hospital, Saga, Japan
| | - Shinya Kimura
- Safety Management Section, Saga University Hospital, Saga, Japan
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Cardinali DP, Brown GM, Pandi-Perumal SR. Melatonin's Benefits and Risks as a Therapy for Sleep Disturbances in the Elderly: Current Insights. Nat Sci Sleep 2022; 14:1843-1855. [PMID: 36267165 PMCID: PMC9578490 DOI: 10.2147/nss.s380465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/03/2022] [Indexed: 01/19/2023] Open
Abstract
Aging is accompanied by circadian changes, including disruptive alterations in the sleep/wake cycle, as well as the beginning of low-degree inflammation ("inflammaging"), a scenario that leads to several chronic illnesses, including cancer, and metabolic, cardiovascular, and neurological dysfunctions. As a result, any effective approach to healthy aging must consider both the correction of circadian disturbance and the control of low-grade inflammation. One of the most important prerequisites for healthy aging is the preservation of robust circadian rhythmicity (particularly of the sleep/wake cycle). Sleep disturbance disrupts various activities in the central nervous system, including waste molecule elimination. Melatonin is a chemical with extraordinary phylogenetic conservation found in all known aerobic creatures whose alteration plays an important role in sleep changes with aging. Every day, the late afternoon/nocturnal surge in pineal melatonin helps to synchronize both the central circadian pacemaker found in the hypothalamic suprachiasmatic nuclei (SCN) and a plethora of peripheral cellular circadian clocks. Melatonin is an example of an endogenous chronobiotic substance that can influence the timing and amplitude of circadian rhythms. Moreover, melatonin is also an excellent anti-inflammatory agent, buffering free radicals, down-regulating proinflammatory cytokines, and reducing insulin resistance, among other things. We present both scientific and clinical evidence that melatonin is a safe drug for treating sleep disturbances in the elderly.
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Affiliation(s)
- Daniel P Cardinali
- Faculty of Medical Sciences, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
| | - Gregory M Brown
- Molecular Brain Science Research Department, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Mohamed Ibrahim O, Al Mazrouei N, Al Meslamani AZ, Kassem AB, El-Bassiouny NA, Mohammed Ebaed SB, Ibrahim RM. Assessment of a new strategy for catalyzing deprescribing in community pharmacies. J Am Pharm Assoc (2003) 2021; 62:125-133. [PMID: 34580032 DOI: 10.1016/j.japh.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/03/2021] [Accepted: 09/03/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although community pharmacists have been actively engaged in patient care, their role in deprescribing is still restricted. OBJECTIVES This study aimed to assess the effectiveness of a new educational approach designed to catalyze deprescribing in community pharmacies. METHODS In this 4-month, randomized, controlled trial, 108 community pharmacies in Egypt were randomly and equally distributed to either the active or the control groups. Participants from the active group pharmacies received 31 deprescribing-related clinical case scenarios, designed according to the available deprescribing guideline and clinical experiences of an expert panel members, and delivered through WhatsApp. Then participants from both groups reported the incidence of potentially inappropriate medicines (PIMs), the frequency of deprescribing opportunities, and related pharmacist interventions. RESULTS Pharmacists from the active group reported a considerably higher incidence of PIMs (20.87%) than that reported by pharmacists from the control group (5.03%). In addition, they made 1326 deprescribing-related interventions, of which 1022 (77.07%) were accepted and 641 (48.34%) were significant interventions. The proportions of cessation of drug therapy, reducing the dose, and persuasion of patients to accept deprescribing pharmacist interventions in the active group were 37.85%, 22.09%, and 10.63%, respectively. In contrast, 150 of 268 deprescribing-related interventions (55.97%) in the active group were accepted. The clinical value and type of deprescribing decision were statistically significant determinants for the acceptance of deprescribing decisions. The mean time needed to persuade the patient about deprescribing and the cost saved per patient across the active and the control groups were 5.09 ± 3.54 minutes versus 10.03 ± 6.19 minutes and 17.88 ± 9.60 U.S. dollars versus 4.49 ± 2.44 U.S. dollars, respectively. CONCLUSION The intervention proposed improved the frequency and clinical value of deprescribing decisions.
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CYP2D6-inhibiting drugs and risk of fall injuries after newly initiated antidepressant and antipsychotic therapy in a Swedish, register-based case-crossover study. Sci Rep 2021; 11:5796. [PMID: 33707555 PMCID: PMC7970948 DOI: 10.1038/s41598-021-85022-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/23/2021] [Indexed: 11/25/2022] Open
Abstract
Drug-drug interactions have been shown to affect the risk of fall injuries when opioids are used concomitantly with drugs inhibiting the cytochrome P450 2D6 (CYP2D6) enzyme in a previous pharmacoepidemiological study. The aim of this study was to determine whether CYP2D6-inhibiting drugs reinforce the risk of fall injuries when used concomitantly with antidepressants or antipsychotics. We identified all 252,704 adults with a first fall injury leading to hospitalisation from the National Patient Register in Sweden 2006–2013. Data on dispensed drugs was linked from the Swedish Prescribed Drug Register. We applied a case-crossover design to analyse newly dispensed (28 days preceding the fall injury, preceded by a 12-week washout period) antidepressants and antipsychotics, respectively, in relation to risk of a fall injury and according to concomitant use of CYP2D6-inhibiting drugs. Newly dispensed drugs were assessed correspondingly in a control period of equal length, 28 days prior to the 12-week washout period. Overall, the risk of fall injury was increased after newly initiated antidepressant and antipsychotic treatment. For antidepressants, concomitant CYP2D6 inhibitor use further elevated the risk estimates compared to non-use, most pronounced for the groups selective serotonin reuptake inhibitors (sertraline excluded) [OR = 1.47 (95% CI 1.19–1.80) vs. OR = 1.19 (95% CI 1.13–1.26)], and tricyclic antidepressants [OR = 1.71 (95% CI 1.17–2.51) vs. 1.27 (95% CI 1.11–1.47)] as well as for sertraline [OR = 1.61 (95% CI 1.05–2.38) vs. 1.12 (95% CI 1.00–1.26)]. For antipsychotics, the risk of fall injury was not altered by concomitant use of CYP2D6-inhibiting drugs. In conclusion, concomitant use of CYP2D6 inhibiting drugs tends to further increase the risk of fall injury in newly initiated antidepressant treatment, but not in antipsychotic treatment.
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Cojocariu SA, Maștaleru A, Sascău RA, Stătescu C, Mitu F, Leon-Constantin MM. Neuropsychiatric Consequences of Lipophilic Beta-Blockers. ACTA ACUST UNITED AC 2021; 57:medicina57020155. [PMID: 33572109 PMCID: PMC7914867 DOI: 10.3390/medicina57020155] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 12/21/2022]
Abstract
Beta-blockers are a class of drugs with important benefits in cardiovascular pathology. In this paper, we aim to highlight their adverse and therapeutic effects in the neuropsychiatric field. With respect to permeability, we would like to mention that most beta-blockers are lipophilic and can cross the blood–brain barrier. Observational studies show the presence of neuropsychiatric side effects when taking beta-blockers, and is the reason for which caution is recommended in their use in patients with depressive syndrome. From a therapeutic point of view, most current evidence is for the use of beta-blockers in migraine attacks, essential tremor, and akathisia. Beta-blockers appear to be effective in the treatment of aggressive behavior, beneficial in the prevention of posttraumatic stress syndrome and may play a role in the adjuvant treatment of obsessive–compulsive disorder, which is refractory to standard therapy. In conclusion, the relationship between beta-blockers and the central nervous system appears as a two-sided coin. Summarizing the neuropsychiatric side effects of beta-blockers, we suggest that clinicians pay special attention to the pharmacological properties of different beta-blockers.
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Affiliation(s)
- Sabina Alexandra Cojocariu
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
| | - Alexandra Maștaleru
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Clinical Rehabilitation Hospital–Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania
- Correspondence:
| | - Radu Andy Sascău
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Institute of Cardiovascular Disease “Prof. Dr. George. I.M. Georgescu”, Carol I Boulevard nr 50, 700503 Iasi, Romania
| | - Cristian Stătescu
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Institute of Cardiovascular Disease “Prof. Dr. George. I.M. Georgescu”, Carol I Boulevard nr 50, 700503 Iasi, Romania
| | - Florin Mitu
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Clinical Rehabilitation Hospital–Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania
| | - Maria Magdalena Leon-Constantin
- Department of Medical Specialties (I), Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy, University Street nr 16, 700115 Iasi, Romania; (S.A.C.); (R.A.S.); (C.S.); (F.M.); (M.M.L.-C.)
- Clinical Rehabilitation Hospital–Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania
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O'Donovan A, Leech M. Personalised treatment for older adults with cancer: The role of frailty assessment. Tech Innov Patient Support Radiat Oncol 2020; 16:30-38. [PMID: 33102819 PMCID: PMC7568178 DOI: 10.1016/j.tipsro.2020.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022] Open
Abstract
It is widely accepted in clinical practice that chronological age is a poor predictor of treatment tolerance and outcomes in older adults with cancer. Intrinsic vulnerability is more a function of underlying frailty, rather than chronological age. Frailty is a state of increased vulnerability to stressors, such as cancer and its treatment, which can lead to adverse health outcomes for patients. Capturing this heterogeneity in reserve capacity is the cornerstone of management in geriatricmedicine, but remains poorly understood or adopted in radiation oncology. A two-step approach, using a shorter screening tool, followed by full assessment for those who need it, is the mostresourceful way of implementing frailty assessment in radiotherapy departments. It is important for radiation oncology professionals to identify frailty and to use this information in multidisciplinary decision making in order to develop a personalised radiotherapy approach for the older person. There are many ways we can effectively use this information, such as considering treatment fractionation schedules that would limit the burden of travel for those with social frailty, or reviewing the range of modalities at our disposal, which might limit toxicity in the older person at high risk of deterioration during treatment. Frailty assessment is not carried out in many radiotherapy departments presently, but there are many international models to use as exemplars as to how it may be implemented in clinical practice. There are many opportunities for further research and role development in this field at the current time.
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Ohara E, Bando Y, Yoshida T, Ohara M, Kirino Y, Iihara N. Fracture risk increased by concurrent use of central nervous system agents in older people: Nationwide case-crossover study. Res Social Adm Pharm 2020; 17:1181-1197. [PMID: 32980237 DOI: 10.1016/j.sapharm.2020.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/25/2020] [Accepted: 09/08/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Multiple medication use among older patients is reported to increase fracture risk. But this association is unclear in different subgroups and has not been confirmed by a case-crossover study, which can eliminate measurable and unmeasurable time-invariant confounders. OBJECTIVE To estimate the fragility fracture risk associated with concurrent use of multiple central nervous system (CNS) agents in older patients using a case-crossover design. METHODS This study targeted almost all patients aged ≥65 years in Japan who incurred fragility fractures from May 2013 to September 2014, based on the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB Japan). Conditional logistic regression analysis estimated the risk of fragility fracture associated with the daily number of CNS agents, including subgroup analyses stratified by sex, age, and fracture location. RESULTS For 446,101 patients, the adjusted odds ratios (ORs) of fragility fracture increased almost linearly with number of CNS agents; 0, 0-1, 1-2, 2-3, 3-4, 4-5, and >5: OR reference, 1.21 (95% confidence interval, 1.18-1.23), 1.40 (1.35-1.46), 1.58 (1.49-1.67), 1.89 (1.74-2.05), 1.80 (1.60-2.03), and 1.90 (1.61-2.23; trend p < 0.001), respectively. A similar trend was observed for several subgroups, especially in males and those aged ≥85 years, showing marked linearity. CONCLUSIONS The increased risk of fragility fracture associated with the use of multiple CNS agents was robust in older people in Japan.
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Affiliation(s)
- Eri Ohara
- Kagawa School of Pharmaceutical Sciences, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
| | - Yoshinori Bando
- Faculty of Health and Welfare, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
| | - Tomoji Yoshida
- Faculty of Health and Welfare, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
| | - Masaki Ohara
- Ayagawa National Health Insurance Sue Hospital, 1720-1 Ayagawa-cho, Ayauta-gun, Kagawa, 761-2103, Japan.
| | - Yutaka Kirino
- Kagawa School of Pharmaceutical Sciences, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
| | - Naomi Iihara
- Kagawa School of Pharmaceutical Sciences, Tokushima Bunri University, 1314-1 Shido, Sanuki-City, Kagawa, 769-2193, Japan.
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Ernst R, Fischer K, de Godoi Rezende Costa Molino C, Orav EJ, Theiler R, Meyer U, Fischler M, Gagesch M, Ambühl PM, Freystätter G, Egli A, Bischoff-Ferrari HA. Polypharmacy and Kidney Function in Community-Dwelling Adults Age 60 Years and Older: A Prospective Observational Study. J Am Med Dir Assoc 2019; 21:254-259.e1. [PMID: 31501003 DOI: 10.1016/j.jamda.2019.07.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Information on the impact of polypharmacy on kidney function in older adults is limited. We prospectively investigated the association between intake of total number of drugs or nonsteroidal anti-inflammatory drugs (NSAIDs) and kidney function. DESIGN Our study is a prospective observational analysis of the 2-year Zurich Multiple Endpoint Vitamin D Trial in Knee Osteoarthritis Patients. SETTING AND PARTICIPANTS Of the 273 participants of the original trial, 270 participants (mean age 70.3 ± 6.4 years, 53% women) were included in this observational analysis. METHODS The associations between (1) total number of drugs (or NSAIDs) at baseline or (2) cumulative number of drugs (or NASAIDs) repeatedly measured over 24 months and kidney function repeatedly measured over 24 months as estimated glomerular filtration rate (eGFR) were investigated using multivariable-adjusted repeated-measures analysis. RESULTS Per drug at baseline, kidney function decreased by 0.64 mL/min/1.73 m2 eGFR (Beta = -0.64; 95% CI -1.19 to -0.08; P = .024) over 24 months. With every additional drug taken cumulatively over 24 months, kidney function decreased by 0.39 mL/min/1.73 m2 eGFR (Beta = -0.39; 95% CI -0.63 to -0.15; P = .002). In a high-risk subgroup, per NSAID taken cumulatively over 24 months, kidney function declined by 1.21 mL/min/1.73 m2 eGFR (Beta = -1.21; 95% CI -2.35 to -0.07; P = .021). CONCLUSIONS AND IMPLICATIONS For every additional drug prescribed among older adults, our study supports an independent and immediate harmful impact on kidney function. This negative impact seems to be about 3 times greater for NSAIDs compared with an additional average drug.
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Affiliation(s)
- Rahel Ernst
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Center on Aging and Mobility, University Hospital Zurich, City Hospital Waid Zurich, Zurich, Switzerland; Internal Medicine Clinic, City Hospital Waid, Zurich, Switzerland
| | - Karina Fischer
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Center on Aging and Mobility, University Hospital Zurich, City Hospital Waid Zurich, Zurich, Switzerland
| | - Caroline de Godoi Rezende Costa Molino
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Center on Aging and Mobility, University Hospital Zurich, City Hospital Waid Zurich, Zurich, Switzerland
| | - Endel J Orav
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Robert Theiler
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Center on Aging and Mobility, University Hospital Zurich, City Hospital Waid Zurich, Zurich, Switzerland
| | - Ursina Meyer
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Center on Aging and Mobility, University Hospital Zurich, City Hospital Waid Zurich, Zurich, Switzerland
| | - Manuel Fischler
- Internal Medicine Clinic, City Hospital Waid, Zurich, Switzerland
| | - Michael Gagesch
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Center on Aging and Mobility, University Hospital Zurich, City Hospital Waid Zurich, Zurich, Switzerland
| | - Patrice M Ambühl
- Institute of Nephrology, City Hospital Waid, Zurich, Switzerland
| | - Gregor Freystätter
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Center on Aging and Mobility, University Hospital Zurich, City Hospital Waid Zurich, Zurich, Switzerland
| | - Andreas Egli
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Center on Aging and Mobility, University Hospital Zurich, City Hospital Waid Zurich, Zurich, Switzerland
| | - Heike A Bischoff-Ferrari
- Department of Geriatrics and Aging Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Center on Aging and Mobility, University Hospital Zurich, City Hospital Waid Zurich, Zurich, Switzerland; University Clinic for Acute Geriatric Care, City Hospital Waid, Zurich, Switzerland.
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Trevisan C, Di Gregorio P, Debiasi E, Pedrotti M, La Guardia M, Manzato E, Sergi G, March A. Decision tree for ward admissions of older patients at the emergency department after a fall. Geriatr Gerontol Int 2018; 18:1388-1392. [PMID: 30088330 DOI: 10.1111/ggi.13497] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 05/09/2018] [Accepted: 07/02/2018] [Indexed: 11/28/2022]
Abstract
AIM Falls are a prevalent issue for the older population, and for the healthcare system in terms of emergency department (ED) access and hospitalizations. There is still a lack of knowledge and guidelines, however, regarding the need to hospitalize older patients accessing the ED after a fall. In the present study, we aimed to analyze the factors and the decisional process that led to older patients accessing the ED after a fall being admitted to hospital or discharged. METHODS The study sample included 2144 older people who accessed the ED after a fall. For each patient, we obtained information on the nature of the fall and the related injuries, previous falls, dementia and ongoing medical therapies. As the outcome variable, we considered the indication for ward admission after the ED visit. RESULTS Of the 2144 individuals who accessed the ED after a fall, 38% had at least one fracture, and 40.1% were admitted to a ward. The decision tree obtained using the chi-squared automatic interaction detection algorithm showed that the indication for ward admission could be accurately predicted (risk estimate 0.205) by just five factors, namely: presence and severity of fall-related injuries, reportedly suspicious fall dynamics, use of anticoagulants, polypharmacy, and dementia. CONCLUSIONS The need for ward admission in older patients who access the ED after a fall seems to be determined not only by the severity of fall-related injuries, but also by the fall dynamics and the individual's clinical complexity. Geriatr Gerontol Int 2018; 18: 1388-1392.
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Affiliation(s)
- Caterina Trevisan
- Department of Medicine (DIMED), Geriatrics Division, University of Padova, Padova, Italy
| | | | - Eugenio Debiasi
- Emergency Department, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Martina Pedrotti
- Department of Geriatrics, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Mario La Guardia
- Emergency Department, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Enzo Manzato
- Department of Medicine (DIMED), Geriatrics Division, University of Padova, Padova, Italy.,National Research Council, Institute of Neuroscience, Padova, Italy
| | - Giuseppe Sergi
- Department of Medicine (DIMED), Geriatrics Division, University of Padova, Padova, Italy
| | - Albert March
- Department of Geriatrics, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
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Ribeiro TB, Melo DOD, Maia FDOM, Ribeiro E. Medication-related inpatient falls: a critical review. BRAZ J PHARM SCI 2018. [DOI: 10.1590/s2175-97902018000117355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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11
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Martinez-Cengotitabengoa M, Diaz-Gutierrez MJ, Besga A, Bermúdez-Ampudia C, López P, Rondon MB, Stewart DE, Perez P, Gutierrez M, Gonzalez-Pinto A. Prescripción de benzodiacepinas y caídas en mujeres y hombres ancianos. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2018; 11:12-18. [DOI: 10.1016/j.rpsm.2017.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/15/2016] [Accepted: 01/09/2017] [Indexed: 11/15/2022]
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12
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Ham AC, van Dijk SC, Swart KMA, Enneman AW, van der Zwaluw NL, Brouwer-Brolsma EM, van Schoor NM, Zillikens MC, Lips P, de Groot LCPGM, Hofman A, Witkamp RF, Uitterlinden AG, Stricker BH, van der Velde N. Beta-blocker use and fall risk in older individuals: Original results from two studies with meta-analysis. Br J Clin Pharmacol 2017; 83:2292-2302. [PMID: 28589543 DOI: 10.1111/bcp.13328] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 04/24/2017] [Accepted: 04/27/2017] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Annelies C Ham
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Suzanne C van Dijk
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Karin M A Swart
- Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
| | - Anke W Enneman
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | | | | | - Natasja M van Schoor
- Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
| | - M Carola Zillikens
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Paul Lips
- Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands.,Department of Endocrinology, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - Albert Hofman
- Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Epidemiology, Harvard H.T. Chan School of Public Health, Boston, MA, USA
| | - Renger F Witkamp
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
| | - André G Uitterlinden
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Bruno H Stricker
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Epidemiology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Inspectorate of Health Care, Utrecht, The Netherlands
| | - Nathalie van der Velde
- Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Centre, P.O. Box 22700, 1100 DD, Amsterdam, The Netherlands
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Nakagawa HB, Ferraresi JR, Prata MG, Scheicher ME. Postural balance and functional independence of elderly people according to gender and age: cross-sectional study. SAO PAULO MED J 2017; 135:260-265. [PMID: 28746661 PMCID: PMC10019839 DOI: 10.1590/1516-3180.2016.0325280217] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 02/28/2017] [Indexed: 11/21/2022] Open
Abstract
CONTEXT AND OBJECTIVE: Aging causes changes in men and women. Studies have shown that women have worse postural balance and greater functional dependence than men, but there is no consensus regarding this. The aim of this study was to compare the balance and functional independence of elderly people according to sex and age, and to evaluate the association between postural balance and the number of drugs taken. DESIGN AND SETTING: Cross-sectional at a state university. METHODS: 202 elderly people were evaluated regarding balance (Berg Scale), independence (Barthel Index), age, sex, number of medications and physical activity. RESULTS: The subjects comprised 117 women (70.2 ± 5.6 years old) and 85 men (71.1 ± 6.9 years old). For balance, there was no significant difference regarding sex, but there was a difference regarding age (P < 0.0001). For functional independence, there was a difference regarding sex (P = 0.003), but not regarding age. The variables of age, medications and physical activity were significant for predicting the Berg score. For the Barthel index, only age and sex were significant. Elderly people who took three or more medications/day showed higher risk of falling than those who took up two drugs/day (odds ratio = 5.53, P < 0.0001, 95% confidence interval, 2.3-13.0). CONCLUSIONS: There was no sexual difference in relation to postural balance. However, people who were more elderly presented a high risk of falling. Functional dependence was worse among females. There was an association between the number of medication drugs and risk of falling.
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Affiliation(s)
- Helen Benincasa Nakagawa
- PT. Physiotherapist, Department of Physiotherapy and Occupational Therapy, Universidade Estadual Paulista “Júlio de Mesquita Filho” (Unesp), Campus de Marília, Marília (SP), Brazil.
| | | | - Melina Galetti Prata
- PT, Msc. Physiotherapist, Hospital das Clínicas, Faculdade de Medicina de Marília, Marília (SP), Brazil.
| | - Marcos Eduardo Scheicher
- PT, PhD. Adjunct Professor, Department of Physiotherapy and Occupational Therapy, Universidade Estadual Paulista “Júlio de Mesquita Filho” (Unesp), Campus de Marília, Marília (SP), Brazil.
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14
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Mirelman A, Rochester L, Maidan I, Del Din S, Alcock L, Nieuwhof F, Rikkert MO, Bloem BR, Pelosin E, Avanzino L, Abbruzzese G, Dockx K, Bekkers E, Giladi N, Nieuwboer A, Hausdorff JM. Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial. Lancet 2016; 388:1170-82. [PMID: 27524393 DOI: 10.1016/s0140-6736(16)31325-3] [Citation(s) in RCA: 257] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 07/27/2016] [Accepted: 07/28/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Age-associated motor and cognitive deficits increase the risk of falls, a major cause of morbidity and mortality. Because of the significant ramifications of falls, many interventions have been proposed, but few have aimed to prevent falls via an integrated approach targeting both motor and cognitive function. We aimed to test the hypothesis that an intervention combining treadmill training with non-immersive virtual reality (VR) to target both cognitive aspects of safe ambulation and mobility would lead to fewer falls than would treadmill training alone. METHODS We carried out this randomised controlled trial at five clinical centres across five countries (Belgium, Israel, Italy, the Netherlands, and the UK). Adults aged 60-90 years with a high risk of falls based on a history of two or more falls in the 6 months before the study and with varied motor and cognitive deficits were randomly assigned by use of computer-based allocation to receive 6 weeks of either treadmill training plus VR or treadmill training alone. Randomisation was stratified by subgroups of patients (those with a history of idiopathic falls, those with mild cognitive impairment, and those with Parkinson's disease) and sex, with stratification per clinical site. Group allocation was done by a third party not involved in onsite study procedures. Both groups aimed to train three times per week for 6 weeks, with each session lasting about 45 min and structured training progression individualised to the participant's level of performance. The VR system consisted of a motion-capture camera and a computer-generated simulation projected on to a large screen, which was specifically designed to reduce fall risk in older adults by including real-life challenges such as obstacles, multiple pathways, and distracters that required continual adjustment of steps. The primary outcome was the incident rate of falls during the 6 months after the end of training, which was assessed in a modified intention-to-treat population. Safety was assessed in all patients who were assigned a treatment. This study is registered with ClinicalTrials.gov, NCT01732653. FINDINGS Between Jan 6, 2013, and April 3, 2015, 302 adults were randomly assigned to either the treadmill training plus VR group (n=154) or treadmill training alone group (n=148). Data from 282 (93%) participants were included in the prespecified, modified intention-to-treat analysis. Before training, the incident rate of falls was similar in both groups (10·7 [SD 35·6] falls per 6 months for treadmill training alone vs 11·9 [39·5] falls per 6 months for treadmill training plus VR). In the 6 months after training, the incident rate was significantly lower in the treadmill training plus VR group than it had been before training (6·00 [95% CI 4·36-8·25] falls per 6 months; p<0·0001 vs before training), whereas the incident rate did not decrease significantly in the treadmill training alone group (8·27 [5·55-12·31] falls per 6 months; p=0·49). 6 months after the end of training, the incident rate of falls was also significantly lower in the treadmill training plus VR group than in the treadmill training group (incident rate ratio 0·58, 95% CI 0·36-0·96; p=0·033). No serious training-related adverse events occurred. INTERPRETATION In a diverse group of older adults at high risk for falls, treadmill training plus VR led to reduced fall rates compared with treadmill training alone. FUNDING European Commission.
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Affiliation(s)
- Anat Mirelman
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Neurology, Tel Aviv University, Tel Aviv, Israel.
| | - Lynn Rochester
- Institute of Neuroscience, Newcastle University, Newcastle, UK
| | - Inbal Maidan
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Silvia Del Din
- Institute of Neuroscience, Newcastle University, Newcastle, UK
| | - Lisa Alcock
- Institute of Neuroscience, Newcastle University, Newcastle, UK
| | - Freek Nieuwhof
- Department of Geriatrics Medicine, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands; Radboud Alzheimers Center, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands; Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands
| | - Marcel Olde Rikkert
- Department of Geriatrics Medicine, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands; Radboud Alzheimers Center, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands
| | - Bastiaan R Bloem
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, Netherlands
| | - Elisa Pelosin
- Department of Neurosciences, University of Genoa, Genoa, Italy
| | - Laura Avanzino
- Department of Neurosciences, University of Genoa, Genoa, Italy; Department of Experimental Medicine, University of Genoa, Genoa, Italy
| | | | - Kim Dockx
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Esther Bekkers
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Nir Giladi
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Neurology, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Alice Nieuwboer
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jeffrey M Hausdorff
- Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Physical Therapy, Tel Aviv University, Tel Aviv, Israel; Sackler Faculty of Medicine, and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
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15
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Burns ER, Stevens JA, Lee R. The direct costs of fatal and non-fatal falls among older adults - United States. JOURNAL OF SAFETY RESEARCH 2016; 58:99-103. [PMID: 27620939 PMCID: PMC6823838 DOI: 10.1016/j.jsr.2016.05.001] [Citation(s) in RCA: 505] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 05/12/2016] [Indexed: 05/10/2023]
Abstract
INTRODUCTION This study sought to estimate the incidence, average cost, and total direct medical costs for fatal and non-fatal fall injuries in hospital, ED, and out-patient settings among U.S. adults aged 65 or older in 2012, by sex and age group and to report total direct medical costs for falls inflated to 2015 dollars. METHOD Incidence data came from the 2012 National Vital Statistics System, 2012 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, 2012 Health Care Utilization Program National Emergency Department Sample, and 2007 Medical Expenditure Panel Survey. Costs for fatal falls were derived from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System; costs for non-fatal falls were based on claims from the 1998/1999 Medicare fee-for-service 5% Standard Analytical Files. Costs were inflated to 2015 estimates using the health care component of the Personal Consumption Expenditure index. RESULTS In 2012, there were 24,190 fatal and 3.2 million medically treated non-fatal fall related injuries. Direct medical costs totaled $616.5 million for fatal and $30.3 billion for non-fatal injuries in 2012 and rose to $637.5 million and $31.3 billion, respectively, in 2015. Fall incidence as well as total cost increased with age and were higher among women. CONCLUSION Medically treated falls among older adults, especially among older women, are associated with substantial economic costs. PRACTICAL APPLICATION Widely implementing evidence-based interventions for fall prevention is essential to decrease the incidence and healthcare costs associated with these injuries.
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Affiliation(s)
- Elizabeth R Burns
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Judy A Stevens
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Robin Lee
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Cardinali DP, Golombek DA, Rosenstein RE, Brusco LI, Vigo DE. Assessing the efficacy of melatonin to curtail benzodiazepine/Z drug abuse. Pharmacol Res 2016; 109:12-23. [DOI: 10.1016/j.phrs.2015.08.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 08/17/2015] [Accepted: 08/19/2015] [Indexed: 12/15/2022]
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Nishtala PS, Salahudeen MS, Hilmer SN. Anticholinergics: theoretical and clinical overview. Expert Opin Drug Saf 2016; 15:753-68. [DOI: 10.1517/14740338.2016.1165664] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - Sarah N. Hilmer
- Sydney Medical School, Royal North Shore Hospital and Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia
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18
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Iihara N, Bando Y, Ohara M, Yoshida T, Nishio T, Okada T, Kirino Y. Polypharmacy of medications and fall-related fractures in older people in Japan: a comparison between driving-prohibited and driving-cautioned medications. J Clin Pharm Ther 2016; 41:273-8. [DOI: 10.1111/jcpt.12381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 02/22/2016] [Indexed: 12/12/2022]
Affiliation(s)
- N. Iihara
- Kagawa School of Pharmaceutical Sciences; Tokushima Bunri University; Sanuki-City Kagawa Japan
| | - Y. Bando
- Faculty of Health and Welfare; Tokushima Bunri University; Sanuki-City Kagawa Japan
| | - M. Ohara
- Ayagawa National Health Insurance Sue Hospital; Ayauta-gun Kagawa Japan
| | - T. Yoshida
- Faculty of Health and Welfare; Tokushima Bunri University; Sanuki-City Kagawa Japan
| | - T. Nishio
- Graduate School of Pharmaceutical Sciences; Tokushima Bunri University; Sanuki-City Kagawa Japan
- Department of Pharmacy; Sanuki City Hospital; Sanuki-City Kagawa Japan
| | - T. Okada
- Kagawa School of Pharmaceutical Sciences; Tokushima Bunri University; Sanuki-City Kagawa Japan
| | - Y. Kirino
- Kagawa School of Pharmaceutical Sciences; Tokushima Bunri University; Sanuki-City Kagawa Japan
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Nimmons D, Limdi JK. Elderly patients and inflammatory bowel disease. World J Gastrointest Pharmacol Ther 2016; 7:51-65. [PMID: 26855812 PMCID: PMC4734955 DOI: 10.4292/wjgpt.v7.i1.51] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 09/13/2015] [Accepted: 12/14/2015] [Indexed: 02/06/2023] Open
Abstract
The incidence and prevalence of inflammatory bowel disease (IBD) is increasing globally. Coupled with an ageing population, the number of older patients with IBD is set to increase. The clinical features and therapeutic options in young and elderly patients are comparable but there are some significant differences. The wide differential diagnosis of IBD in elderly patients may result in a delay in diagnosis. The relative dearth of data specific to elderly IBD patients often resulting from their exclusion from pivotal clinical trials and the lack of consensus guidelines have made clinical decisions somewhat challenging. In addition, age specific concerns such as co-morbidity; loco-motor and cognitive function, poly-pharmacy and its consequences need to be taken into account. In applying modern treatment paradigms to the elderly, the clinician must consider the potential for more pronounced adverse effects in this vulnerable group and set appropriate boundaries maximising benefit and minimising harm. Meanwhile, clinicians need to make personalised decisions but as evidence based as possible in the holistic, considered and optimal management of IBD in elderly patients. In this review we will cover the clinical features and therapeutic options of IBD in the elderly; as well as addressing common questions and challenges posed by its management.
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20
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Fonad E, Robins Wahlin TB, Rydholm Hedman AM. Associations between falls and general health, nutrition, dental health and medication use in Swedish home-dwelling people aged 75 years and over. HEALTH & SOCIAL CARE IN THE COMMUNITY 2015; 23:594-604. [PMID: 25676026 DOI: 10.1111/hsc.12182] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/15/2014] [Indexed: 06/04/2023]
Abstract
The vast majority of elderly people in Sweden live in private homes in their communities for as long as possible. Poor health and a high risk of falls are very common among this group. This cross-sectional study investigates the association between falls and general health, appetite, dental health, and the use of multiple medications among home-dwelling men and women aged ≥ 75 years. Data were collected between October 2008 and March 2009 using a postal questionnaire. A total of 1243 people participated in the questionnaire survey (74% response rate), of which 1193 were included in the analysis. The majority of participants were women (n = 738, 62%). Falls in the previous 12-month period were reported by 434 (36%) participants. Most fallers (n = 276, 64%) were women. The majority of the fallers lived in a flat (n = 250, 58%). Poor health (aOR: 1.61; CI: 1.34-1.95), poor dental health (aOR: 1.22; CI: 1.07-1.39) and the use of four or more types of medication daily (aOR: 1.13; CI: 1.03-1.25) were significantly associated with falls in all participants. Poor dental health was found irrespectively of living in a flat (aOR: 1.23; CI: 1.04-1.46) or living in a house (aOR: 1.28; CI: 1.02-1.61), and both were significantly associated with falls. The use of more than four different types of medication daily (aOR: 1.25; CI: 1.11-1.41) was associated with falls for those living in a flat. The results highlight that falls are associated with poor general health, poor dental health and the use of four or more types of medication daily. Health professionals should provide health promotion education and investigate dental health and risk factors for oral disease. Likewise, medical and clinical practices of physicians and community care nurses should include assessing the risk of falling, and treatment that predisposes falls.
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Affiliation(s)
- Edit Fonad
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Tarja-Brita Robins Wahlin
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Discipline of Psychiatry, The University of Queensland School of Medicine, Brisbane, Queensland, Australia
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Rojas-Fernandez C, Dadfar F, Wong A, Brown SG. Use of fall risk increasing drugs in residents of retirement villages: a pilot study of long term care and retirement home residents in Ontario, Canada. BMC Res Notes 2015; 8:568. [PMID: 26467915 PMCID: PMC4606840 DOI: 10.1186/s13104-015-1557-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Falls continue to be a problem for older people in long-term care (LTC) and retirement home (RH) settings and are associated with significant morbidity and health care use. Fall-risk increasing drugs (FRIDs) are known to increase fall risk and represent modifiable risk factors. There are limited data regarding the use of FRIDs in contemporary LTC and RH settings, and it has not been well documented to what extent medication regimens are reviewed and modified for those who have sustained falls. The objective of this study is to characterize medication related fall risk factors in LTC and RH residents and on-going use of medications known to increase fall risk. METHODS Retrospective chart review of residents aged >65 who sustained one or more falls living in LTC or RH settings. RESULTS 105 residents who fell one or more times during 2009-2010 were identified with a mean age of 89 years, a mean of nine scheduled medications and seven diagnoses, and 83% were women. Residents in LTC were ostensibly at higher risk for falls relative to those in RH settings as suggested by higher proportion of residents with multiple falls, multiple comorbidities, comorbidities that increase fall risk and visual impairment. Post fall injuries were sustained by 42% of residents, and residents in RH sustained more injuries relative to LTC residents (47 vs 34%). Use of FRIDs such as benzodiazepines, antipsychotic, antidepressant and various antihypertensive drugs was common in the present sample. No medication regimen changes were noted in the 6-month post fall period. CONCLUSIONS The present study documented common use FRIDs by LTC and RH residents with multiple falls. These potentially modifiable falls risk factors are not being adequately addressed in contemporary practice, demonstrating that there is much room for improvement with regards to the safe and appropriate use of medications in LTC and RH residents.
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Affiliation(s)
- Carlos Rojas-Fernandez
- Schlegel Research Chair in Geriatric Pharmacotherapy, Schlegel-UW Research Institute for Ageing, School of Pharmacy, University of Waterloo, 10 Victoria St S, Room 7004, Kitchener, ON, N2G 1C5, Canada. .,, .
| | - Farzan Dadfar
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada.
| | - Andrea Wong
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada.
| | - Susan G Brown
- Schlegel-University of Waterloo Research Institute for Aging, 325 Max Becker Drive, Suite 202, Kitchener, ON, N2E 4H5, Canada.
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23
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Golombek DA, Pandi-Perumal SR, Brown GM, Cardinali DP. Some implications of melatonin use in chronopharmacology of insomnia. Eur J Pharmacol 2015; 762:42-8. [DOI: 10.1016/j.ejphar.2015.05.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 04/10/2015] [Accepted: 05/11/2015] [Indexed: 12/20/2022]
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Houry D, Florence C, Baldwin G, Stevens J, McClure R. The CDC Injury Center's response to the growing public health problem of falls among older adults. Am J Lifestyle Med 2015; 10. [PMID: 26688674 DOI: 10.1177/1559827615600137] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Older adult falls are a significant cause of morbidity and mortality in the United States. This leading cause of injury in adults aged 65 and older results in $35 billion in direct medical costs. OBJECTIVE To project the number of older adult falls by 2030 and the associated lifetime medical cost. A secondary objective is to review what clinicians can do to incorporate falls screening and prevention into their practice for community-dwelling older adults. METHODS Using the CDC's Web-based Injury Statistics Query and Reporting System and the US Census Bureau data, the number of older adults in 2030, fatal falls, and medical costs associated with fall injuries was projected. In addition, evidence-based interventions that can be integrated into clinical practice were reviewed. RESULTS The number of older adult fatal falls is projected to reach 100,000 per year by 2030 with an associated cost of $100 billion. By integrating screening for falls risk into clinical practice, reviewing and modifying medications, and recommending Vitamin D supplementation, physicians can reduce future falls by nearly 25%. CONCLUSION Falls in older adults will continue to rise substantially and become a significant cost to our health care system if we do not begin to focus on prevention in the clinical setting.
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Affiliation(s)
- Debra Houry
- , National Center for Injury Prevention and Control, CDC
| | - Curtis Florence
- , Division of Analysis, Research, and Practice Integration; National Center for Injury Prevention and Control, CDC
| | - Grant Baldwin
- , Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC
| | - Judy Stevens
- , Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC
| | - Rod McClure
- , Division of Analysis, Research, and Practice Integration; National Center for Injury Prevention and Control, CDC
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Prospective observational study to evaluate risk factors for falls in institutionalized elderly people: the role of cystatin C. Aging Clin Exp Res 2015; 27:419-24. [PMID: 25528300 DOI: 10.1007/s40520-014-0304-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
Abstract
AIM To evaluate the role of balance and gait disorders, comorbidities and laboratory abnormalities in the occurrence of falls in an institutionalized elderly population. METHODS We made a non-interventional, prospective, observational study in elderly institutionalized people. Comorbidities and information on treatments were obtained. Function and cognition were measured using the Katz Index, the Tinetti Balance and Gait, lower extremity function tests and the Mini-Mental test. At the inclusion, the analytical was made including cystatin C. Falls were recorded for 20 months after inclusion. RESULTS Patients with falls were older (85 ± 7 vs. 82 ± 8, p = 0.04) and more often female (88 vs. 12 %, p = 0.01). Dyslipidemia, hypertension and antihypertensive treatment were associated with an increased risk of falls. Cystatin C was higher in patients with falls (0.96 ± 0.21 vs. 1.12 ± 0.29, p = 0.02). Functional tests showed differences in the Tinetti balance test (15 ± 2 vs. 13 ± 3, p = 0.04) and lower extremity function balance test (2.8 ± 1.2 vs. 2.2 ± 1.2, p = 0.05). The Mini-Mental State Examination (MMSE) scores were worse in patients with falls (22 ± 4 vs. 25 ± 4, p = 0.01). Only female status (6.2, p = 0.03), the MMSE scores (1.2, p = 0.02) and cystatin C (5.3, p = 0.02) were independent risk factors for falls after logistic regression. CONCLUSIONS Female sex, cognitive impairment and cystatin C were risk factors for falls in non-dependent institutionalized elderly people.
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Abstract
BACKGROUND Medication use is a potentially modifiable risk factor for falling; psychotropic and cardiovascular drugs have been indicated as main drug groups that increase fall risk. However, evidence is mainly based on studies that recorded falls retrospectively and/or did not determine medication use at the time of the fall. Therefore, we investigated the associations indicated in the literature between medication use and falls, using prospectively recorded falls and medication use determined at the time of the fall. METHODS Data from the B-PROOF (B-vitamins for the prevention of osteoporotic fractures) study were used, concerning community-dwelling elderly aged ≥65 years. We included 2,407 participants with pharmacy dispensing records. During the 2- to 3-year follow-up, participants recorded falls using a fall calendar. Cox proportional hazard models were applied, adjusting for potential confounders including age, sex, health status variables and concomitant medication use. RESULTS During follow-up, 1,147 participants experienced at least one fall. Users of anti-arrhythmic medication had an increased fall risk (hazard ratio [HR] 1.61; 95% confidence interval [CI] 1.12-2.32) compared with non-users. Similarly, non-selective beta-blocker use was associated with an increased fall risk (HR 1.41 [95% CI 1.12-1.78]), while statin use was associated with a lower risk (HR 0.81 [95% CI 0.71-0.94]). Benzodiazepine use (HR 1.32 [95% CI 1.02-1.71]), and antidepressant use (HR 1.40 [95% CI 1.07-1.82]) were associated with an increased fall risk. Use of other cardiovascular and psychotropic medication was not associated with fall risk. CONCLUSION Our results strengthen the evidence for an increased fall risk in community-dwelling elderly during the use of anti-arrhythmics, non-selective beta-blockers, benzodiazepines, and antidepressant medication. Clinicians should prescribe these drugs cautiously and if possible choose safer alternatives for older patients.
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Laflamme L, Monárrez-Espino J, Johnell K, Elling B, Möller J. Type, number or both? A population-based matched case-control study on the risk of fall injuries among older people and number of medications beyond fall-inducing drugs. PLoS One 2015; 10:e0123390. [PMID: 25815483 PMCID: PMC4376700 DOI: 10.1371/journal.pone.0123390] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 02/18/2015] [Indexed: 01/22/2023] Open
Abstract
Objectives Drug use is a modifiable risk factor for fall-related injuries in older people. Whereas the injurious effect of polypharmacy is established, that of low numbers of medications has not been fully ascertained. Neither do we know whether it is the number per se or the type of medications that actually matters. We assessed this question for fall injuries leading to hospitalization. Design National register-based, population-based, matched case-control study. Setting Community dwellers aged 65+ years living in Sweden between March 2006 and December 2009. Methods Cases (n = 64,399) were identified in the national inpatient register and four controls per case were randomly matched by gender, date of birth and residential area. The association between number of prescribed medications, assessed through linkage with the Swedish prescribed drug register, and the risk of injurious falls was estimated with odds ratios with 95% confidence intervals using conditional logistic regression, adjusted for demographic and health status. Results The number of medications was associated with an increased risk of fall injury in a dose-response fashion, even after adjustment for marital status, comorbidity and number of fall-risk-inducing drugs (FRIDs). Using ten or more medications was associated with an almost two-fold higher risk (adjusted OR: 1.76, 95% CI: 1.66 to 1.88). When stratified by use (or not) of at least one FRID, the association weakened slightly among both non-users (adjusted OR: 1.50, 95% CI: 1.34 to 1.67) and users (adjusted OR: 1.67, 95% CI: 1.58 to 1.77). Conclusion In older people, not only large but also small numbers of medications may affect the risk for them to sustain injurious falls. Although the mechanisms lying behind this are complex, the finding challenges the prevention strategies targeting either specific types of medications (FRIDs) or high numbers of them.
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Affiliation(s)
- Lucie Laflamme
- Karolinska Institutet, Department of Public Health Sciences, Stockholm, Sweden
- * E-mail:
| | | | - Kristina Johnell
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Berty Elling
- Karolinska Institutet, Department of Public Health Sciences, Stockholm, Sweden
| | - Jette Möller
- Karolinska Institutet, Department of Public Health Sciences, Stockholm, Sweden
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Runganga M, Peel NM, Hubbard RE. Multiple medication use in older patients in post-acute transitional care: a prospective cohort study. Clin Interv Aging 2014; 9:1453-62. [PMID: 25214773 PMCID: PMC4158998 DOI: 10.2147/cia.s64105] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background Older adults with a range of comorbidities are often prescribed multiple medications, which may impact on their function and cognition and increase the potential for drug interactions and adverse events. Aims This study investigated the extent of polypharmacy and potentially inappropriate medications in patients receiving post-discharge transitional home care and explored the associations of polypharmacy with patient characteristics, functional outcomes, and frailty. Methods A prospective observational study was conducted of 351 patients discharged home from hospital with support from six Transition Care Program (TCP) sites in two states of Australia. A comprehensive geriatric assessment was conducted at TCP admission and discharge using the interRAI Home Care assessment tool, with frailty measured using an index of 57 accumulated deficits. Medications from hospital discharge summaries were coded using the World Health Organization Anatomical Therapeutic Chemical Classification System. Results Polypharmacy (5–9 drugs) was observed in 46.7% and hyperpolypharmacy (≥10 drugs) in 39.2% of patients. Increasing numbers of medications were associated with greater number of comorbid conditions, a higher prevalence of diabetes mellitus, coronary heart disease, chronic obstructive pulmonary disease, dizziness, and dyspnea and increased frailty. At discharge from the program, the non-polypharmacy group (<5 drugs) had improved outcomes in Activities of Daily Living, Instrumental Activities of Daily Living and fewer falls, which was mediated because of lower levels of frailty. The commonest drugs were analgesics (56.8%) and antiulcer drugs (52.7%). The commonest potentially inappropriate medications were tertiary tricyclic antidepressants. Conclusion Polypharmacy is common in older patients discharged from hospital. It is associated with frailty, falls, and poor functional outcomes. Efforts should be made to encourage regular medication reviews and rationalization of medications as part of discharge planning. Whether careful deprescribing improves outcomes in frail patients should be the focus of randomized trials.
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Affiliation(s)
- Maureen Runganga
- The Prince Charles Hospital, Chermside, QLD, Australia ; Centre for Research in Geriatric Medicine, The University of Queensland School of Medicine, QLD, Australia
| | - Nancye M Peel
- Centre for Research in Geriatric Medicine, The University of Queensland School of Medicine, QLD, Australia
| | - Ruth E Hubbard
- Centre for Research in Geriatric Medicine, The University of Queensland School of Medicine, QLD, Australia ; Princess Alexandra Hospital, Woolloongabba, QLD, Australia
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Möller J, Laflamme L, Söderberg Löfdal K. CYP2D6-Inhibiting Drugs and the Increased Risk of Fall-Related Injuries Due to Newly Initiated Opioid Treatment - A Swedish, Register-Based Case-Crossover Study. Basic Clin Pharmacol Toxicol 2014; 116:134-9. [DOI: 10.1111/bcpt.12289] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/11/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Jette Möller
- Department of Public Health Sciences; Karolinska Institutet; Stockholm Sweden
| | - Lucie Laflamme
- Department of Public Health Sciences; Karolinska Institutet; Stockholm Sweden
| | - Karin Söderberg Löfdal
- Department of Clinical Pharmacology; Karolinska University Hospital Huddinge; Stockholm Sweden
- Division of Clinical Pharmacology; Department of Laboratory Medicine; Karolinska Institutet; Stockholm Sweden
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Kauppi M, Stenholm S, Impivaara O, Mäki J, Heliövaara M, Jula A. Fall-related risk factors and heel quantitative ultrasound in the assessment of hip fracture risk: a 10-year follow-up of a nationally representative adult population sample. Osteoporos Int 2014; 25:1685-95. [PMID: 24658297 DOI: 10.1007/s00198-014-2674-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 02/22/2014] [Indexed: 12/22/2022]
Abstract
UNLABELLED Maximal walking speed and quantitative ultrasound index (QUI) were significant and independent predictors of hip fracture among subjects aged ≥ 55 years. A model including readily available variables along with simple fall-related factors may be clinically useful in the assessment of hip fracture risk even without a QUI measurement. INTRODUCTION This study assessed fall-related risk factors along with heel bone quantitative ultrasound (QUS) measurements for the prediction of hip fracture during a mean follow-up of 9.8 years in a nationally representative population sample. METHODS The study population consisted of 2,300 subjects (1,331 women and 969 men) aged 55 years or over, who had participated in a comprehensive health survey in 2000-2001. Information on the subjects’ health and fall-related risk factors was obtained with interviews, questionnaires and tests carried out by specially trained professionals. QUS measurements were made by means of the Hologic Sahara device. First emerging cases of hip fracture were identified from the National Hospital Discharge Register. RESULTS During the follow-up, 96 subjects sustained a hip fracture. Slow maximal walking speed, low quantitative ultrasound index (QUI), high age, tallness, short waist circumference, Parkinson's disease and the number of central nervous system active medication were significant and independent predictors of hip fracture. The model including all of these risk factors explained 68 % of the variation in hip fracture risk. Excluding QUI from this model reduced the percentage to 66%. CONCLUSIONS Maximal walking speed and QUI were significant and independent predictors of hip fracture. A model including readily available variables such as age, gender, height and waist circumference along with simple fall-related factors may be of clinical use in the assessment of hip fracture risk even without a QUS measurement.
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Day L, Trotter MJ, Hill KD, Haines TP, Thompson C. Implementation of evidence-based falls prevention in clinical services for high-risk clients. J Eval Clin Pract 2014; 20:255-9. [PMID: 24661470 DOI: 10.1111/jep.12119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2014] [Indexed: 11/26/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The extent to which best practice for falls prevention is being routinely delivered by health care providers for community-dwelling older adults is unclear. We investigated falls prevention practice among Hospital Admission Risk Programs (HARP) that provide and coordinate specialized health care for people at high risk of hospitalization. METHOD Cross-sectional survey of all HARP services in Victoria, excluding one paediatric programme (n = 34). The questionnaire focused upon medication review and exercise prescription, as these are the evidence-based falls interventions with a good fit with HARP services. RESULTS Completed questionnaires were received from 24 programmes (70.6%) that service 15,250 older clients (60+ years). All except one programme screened for medicine use; however, a lower proportion (65% of those that screen) target falls risk medications. Among the 17 programmes responding to the exercise prescription question, all routinely include strengthening exercises, and almost all (n = 15) include flexibility, endurance training and movement of the centre of gravity. A lesser proportion (71%) includes reducing the need for upper limb support. The majority of services (88%) undertake falls risk assessments, and all of these either make referral appointments for clients or refer to other services that make referral appointments for clients. Follow-up of appointments and the resulting recommendations was high. CONCLUSION Screening for falls risk medications could be improved and staff training in exercise prescription for balance challenge in this high-risk group may be needed. Although evidence-based falls prevention practice within Victorian HARP services appears strong, the effect on falls risk may not be as high as that achieved in randomized trials.
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Affiliation(s)
- Lesley Day
- Falls Prevention Research Unit, Monash Injury Research Institute, Monash University, Australia
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Ding J, Heller DA, Ahern FM, Brown TV. The relationship between proton pump inhibitor adherence and fracture risk in the elderly. Calcif Tissue Int 2014; 94:597-607. [PMID: 24706060 DOI: 10.1007/s00223-014-9855-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 03/19/2014] [Indexed: 12/14/2022]
Abstract
Studies suggest that long-term use of proton pump inhibitors (PPIs) may be associated with an increased risk of fracture. However, the role of medication adherence in this association is not fully understood. A retrospective cohort study was conducted to examine the relationship between PPI use/adherence and fracture risk among elderly subjects by combining administrative pharmacy claims data, survey data, and Medicare data. The study cohort included 1,604 PPI users and 23,672 nonusers who were enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program. PPI adherence was measured by the proportion of days covered (PDC). Time-dependent Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) of PPI use/adherence for fracture risk while controlling for demographics, comorbidity, body mass index, smoking, and non-PPI medication use. The overall incidence of any fracture per 100 person-years was 8.7 for PPI users and 5.0 for nonusers. A gradient in fracture risk according to PPI adherence was observed. Relative to nonusers, fracture HRs associated with the highest (PDC ≥ 0.80), intermediate (PDC 0.40-0.79), and lowest (PDC <0.40) adherence levels were 1.46 (p < 0.0001), 1.30 (p = 0.02), and 0.95 (p = 0.75), respectively. In addition, the fracture risk of PPI use was significant for hip (HR = 1.32, p = 0.04) and vertebral (HR = 1.69, p = 0.0005) fractures, and risk was similar between major osteoporotic and other fractures. These results provide further evidence that PPI use may increase fracture risk in the elderly and highlight the need for clinicians to periodically reassess elderly patients' individualized needs for ongoing PPI therapy, while weighing potential risks and benefits.
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Affiliation(s)
- Jian Ding
- Magellan Health Services/PACE, 4000 Crums Mill Road, Suite 301, Harrisburg, PA, 17112, USA,
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Rojas-Fernandez CH, Seymour N, Brown SG. Helping pharmacists to reduce fall risk in long-term care: A clinical tool to facilitate the medication review process. Can Pharm J (Ott) 2014; 147:171-8. [PMID: 24847370 DOI: 10.1177/1715163514529706] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND One-third to one-half of adults older than 65 fall at least once per year. Fall prevention through medication management requires little effort and has consistently been shown to reduce risk of falls. The objective of this study was to further develop and perform preliminary pilot testing of an algorithm designed to assist consultant pharmacists in systematically identifying medications that might be modifiable, in order to reduce the risk of falls in older adults. We hypothesized that algorithm use would increase the number of fall-related medication change recommendations made to physicians. METHODS Four consultant pharmacists were trained to use the algorithm during their routine medication reviews over a 3-week period. An informal survey was administered at the end of the study period to assess the algorithm. RESULTS Overall, 51% of residents of long-term facilities had 1 or more recommendations for medication changes related to reducing fall risk (range 0-3 recommendations per resident), with an average 0.675 recommendations made per resident. There were more recommendations for men compared with women and for residents receiving more medications, but the number of recommendations did not correspond with age. All 4 pharmacists agreed that the algorithm was useful and worthwhile. DISCUSSION The absolute 20% increase in recommendations related to falls supports the study hypothesis. Time was cited as a barrier to using the algorithm, but this should decrease with continued use of this tool. CONCLUSION This preliminary study furthered the development of and confirmed the possible utility and acceptability of a fall risk-reducing algorithm that may be used in practice.
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Affiliation(s)
- Carlos H Rojas-Fernandez
- Schlegel-University of Waterloo Research Institute for Aging (Rojas-Fernandez, Brown), University of Waterloo, Waterloo, Ontario
| | - Nicole Seymour
- Schlegel-University of Waterloo Research Institute for Aging (Rojas-Fernandez, Brown), University of Waterloo, Waterloo, Ontario
| | - Susan G Brown
- Schlegel-University of Waterloo Research Institute for Aging (Rojas-Fernandez, Brown), University of Waterloo, Waterloo, Ontario
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Factors Leading to Falls in Elderly Patients With Hip Fractures. TOPICS IN GERIATRIC REHABILITATION 2013. [DOI: 10.1097/tgr.0b013e3182940ce2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Neumann L, Hoffmann V, Klugmann B, Golgert S, Hasford J, von Renteln-Kruse W. In-hospital falls and potentially inappropriate medication (PIM). Eur Geriatr Med 2013. [DOI: 10.1016/j.eurger.2013.07.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
The aging U.S. population will approach 20% of the total population by 2030. The number of older patients with inflammatory bowel disease is anticipated to increase accordingly bringing the burden of multiple comorbidities, polypharmacy with drug interactions, the aging immune system, and extended social and financial issues to overall management of an already challenging management of these patients. Each of these concerns is measured by the metric of distinguishing the "fit versus frail" elderly and will be discussed in this review with an emphasis on a practical guide to therapy.
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Salvi F, Marchetti A, D'Angelo F, Boemi M, Lattanzio F, Cherubini A. Adverse drug events as a cause of hospitalization in older adults. Drug Saf 2013; 35 Suppl 1:29-45. [PMID: 23446784 DOI: 10.1007/bf03319101] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Older adults are about four to seven times more likely than younger persons to experience adverse drug events (ADEs) that cause hospitalization, especially if they are women and take multiple medications. The prevalence of drug-related hospitalizations has been reported to be as high as 31%, with large heterogeneity between different studies, depending on study setting (all hospital admissions or only acute hospital admissions), study population (entire hospital, specific wards, selected population and/or age groups), type of drug-related problem measured (adverse drug reaction or ADE), method of data collection (chart review, spontaneous reporting or database research) and method and definition used to detect ADEs. The higher risk of drug-related hospitalizations in older adults is mainly caused by age-related pharmacokinetic and pharmacodynamic changes, a higher number of chronic conditions and polypharmacy, which is often associated with the use of potentially inappropriate drugs. Other factors that have been involved are errors related to prescription or administration of drugs, medication non-adherence and inadequate monitoring of pharmacological therapies. A few commonly used drugs are responsible for the majority of emergency hospitalizations in older subjects, i.e. warfarin, oral antiplatelet agents, insulin and oral hypoglycaemic agents, central nervous system agents. The aims of the present review are to summarize recent evidence concerning drug-related hospitalization in older adults, to assess the contribution of specific medications, and to identify potential interventions able to reduce the occurrence of these drug-related events, as they are, at least partly, potentially preventable.
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Affiliation(s)
- Fabio Salvi
- Geriatrics and Geriatric Emergency Care, Italian National Research Centres on Aging (INRCA), Via della Montagnola n. 81, 60127, Ancona, Italy
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Accidental falls in home care hematological patients. Support Care Cancer 2013; 21:2087-9. [PMID: 23640299 DOI: 10.1007/s00520-013-1828-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 04/21/2013] [Indexed: 10/26/2022]
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Lowry E, Woodman RJ, Soiza RL, Hilmer SN, Mangoni AA. Drug Burden Index, Physical Function, and Adverse Outcomes in Older Hospitalized Patients. J Clin Pharmacol 2013; 52:1584-91. [DOI: 10.1177/0091270011421489] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Heppner HJ, Christ M, Gosch M, Mühlberg W, Bahrmann P, Bertsch T, Sieber C, Singler K. Polypharmacy in the elderly from the clinical toxicologist perspective. Z Gerontol Geriatr 2013; 45:473-8. [PMID: 22915001 DOI: 10.1007/s00391-012-0383-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Polypharmacy is closely associated with multimorbidity in the elderly and can lead to problems and drug interactions. AIM This study assessed polypharmacy in the elderly, tracking inquiries to the Poison Information Centre Nuremberg (PICN) and patients needing toxicological intensive care therapy. METHODS From 2006-2009, all PICN inquiries involving individuals > 70 years were tracked, as were cases at the Toxicological Intensive Care Unit (T-ICU) regarding adverse drug reactions (ADRs) and drug poisoning. RESULTS Of 11,683 PICN calls about pharmaceuticals, 175 (1.5%) were from people > 70 years; 156 (4.8%) of 3,272 T-ICU patients were > 70 years. Calls about psychopharmaceuticals (46.9%) and analgesics (25.7%) were most frequent. Among the T-ICU patients, psychopharmaceuticals like sedatives and hypnotics were frequently involved (20.5%), as were tricyclic antidepressants (17.9%) and analgesics (29.5%). Ethanol was co-ingested by 18.3%. CONCLUSION Population-specific poison prevention strategies are needed to reduce toxic exposures. Such strategies could include pharmacist intervention, improved prescriber communication and education regarding the geriatric population, and computerized drug databases.
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Affiliation(s)
- H J Heppner
- Department of Emergency and Intensive Care Medicine, Klinikum Nuremberg, Prof.-E.-Nathan-Str. 1, 90419, Nuremberg, Germany.
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Geller AI, Nopkhun W, Dows-Martinez MN, Strasser DC. Polypharmacy and the role of physical medicine and rehabilitation. PM R 2012; 4:198-219. [PMID: 22443958 DOI: 10.1016/j.pmrj.2012.02.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 02/08/2012] [Accepted: 02/10/2012] [Indexed: 02/07/2023]
Abstract
Polypharmacy and inappropriate prescribing practices lead to higher rates of mortality and morbidity, particularly in vulnerable populations, such as the elderly and those with complex medical conditions. Physical medicine and physiatrists face particular challenges given the array of symptoms treated across a spectrum of conditions. This clinical review focuses on polypharmacy and the associated issue of potentially inappropriate prescribing. The article begins with a review of polypharmacy along with relevant aspects of pharmacokinetics and pharmacodynamics in the elderly. The adverse effects and potential hazards of selected medications commonly initiated and managed by rehabilitation specialists are then discussed with specific attention to pain medications, neurostimulants, antipsychotics, antidepressants, antispasmodics, sleep medications, and antiepileptics. Of particular concern is the notion that an adverse effect of one medication can mimic an indication for another and lead to a prescribing cascade and further adverse medication events. Appropriate prescribing practices mandate an accurate, current medication list, yet errors and inaccuracies often plague such lists. The evidence to support explicit (medications to avoid) and implicit (how to evaluate) criteria is presented along with the role of physicians and patients in prescribing medications. A brief discussion of "medication debridement" or de-prescribing strategies follows. In the last section, we draw on the essence of physiatry as a team-based endeavor to discuss the potential benefits of collaboration. In working to optimize medication prescribing, efforts should be made to collaborate not only with pharmacists and other medical specialties but with members of inpatient rehabilitation teams as well.
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Affiliation(s)
- Andrew I Geller
- Department of Rehabilitation Medicine, Emory University, Atlanta, GA, USA
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Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem. Drugs Aging 2012; 29:15-30. [PMID: 22191720 DOI: 10.2165/11598420-000000000-00000] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Falls are a common health problem for older people, and psychotropic medications have been identified as an important independent fall risk factor. The objective of this paper was to review the literature relating to the effect of psychotropic medications on falls in older people, with a particular focus on evidence supporting minimization of their use to reduce risk of falls. A literature search identified 18 randomized trials meeting the inclusion criteria for the review of effectiveness of psychotropic medication withdrawal studies, including four with falls outcomes. One of these, which targeted reduced psychotropic medication use in the community, reported a 66% reduction in falls, while the other studies demonstrated some success in reducing psychotropic medication use but with mixed effects on falls. Other randomized trials evaluated various approaches to reducing psychotropic medications generally or specific classes of psychotropic medications (e.g. benzodiazepines), but did not report fall-related outcomes. Overall, these studies reported moderate success in reducing psychotropic medication use, and a number reported no or limited worsening of key outcomes such as sleep quality or behavioural difficulties associated with withdrawal of psychotropic medication use. Reduced prescription of psychotropic medications (e.g. seeking non-pharmacological alternatives to their use in place of prescription in the first place or, for those patients for whom these medications are deemed necessary, regular monitoring and efforts to cease use or wean off use over time) needs to be a strong focus in clinical practice for three reasons. Firstly, psychotropic medications are commonly prescribed for older people, both in the community and especially in the residential care setting, and their effectiveness in a number of clinical groups has been questioned. Secondly, there is strong evidence of an association between substantially increased risk of falls and use of a number of psychotropic medications, including benzodiazepines (particularly, the long-acting agents), antidepressants and antipsychotic drugs. Finally, the largest effect of any randomized trial of falls prevention to date was achieved with a single intervention consisting of weaning psychotropic drug users off their medications.
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Affiliation(s)
- Keith D Hill
- Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Bundoora, VIC, Australia.
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Abstract
The elderly are at risk for polypharmacy, which is associated with significant consequences such as adverse effects, medication nonadherence, drug-drug and drug-disease interactions, and increased risk of geriatric syndromes. Providers should evaluate all existing medications at each patient visit for appropriateness and weigh the risks and benefits of starting new medications to minimize polypharmacy.
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Affiliation(s)
- Bhavik M Shah
- Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Abstract
The prevalence of gait disturbances and falls increases dramatically with age, but these problems are not universal in the elderly. They should trigger a systematic search for underlying disease states, many of which can be treated medically or surgically, or significantly ameliorated through provision of physical therapy focused on gait training and aids to ambulation, removal of safety hazards in the environment, and the elimination of polypharmacy. While cardiovascular, orthopedic, and rheumatologic diseases account for the majority of gait disturbances in the elderly, the aim here is to outline an approach to the diagnosis and treatment of a broad array of neurologic conditions causing gait disturbance in the elderly.
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Affiliation(s)
- Frederick J Marshall
- Geriatric Neurology Unit, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Quinlan J, Carter K. Acute pain management in patients with persistent pain. Curr Opin Support Palliat Care 2012; 6:188-93. [DOI: 10.1097/spc.0b013e3283520fb6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Gray-Miceli D, Ratcliffe SJ, Liu S, Wantland D, Johnson J. Orthostatic Hypotension in Older Nursing Home Residents Who Fall. Clin Nurs Res 2012; 21:64-78. [DOI: 10.1177/1054773811434045] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Orthostatic hypotension (OH) and dizziness have been linked to older adult falls. As a treatable condition, the detection of OH is of clinical importance to falls prevention. Gaps in the literature about symptoms associated with OH among older adult fallers, such as dizziness led to this secondary analysis of blood pressure data and reported symptoms. Of the 194 Registered Nurse (RN) documented falls, most ( n = 91; 46.9%) failed to meet the prevailing diagnostic criteria for OH; 18 (9.2%) met criteria; and 8 (4%) nearly met the OH criteria. OH determinations were incomplete or absent in 41% ( n = 77). Of the 18 residents with OH, none reported dizziness, instead half reported loss of balance. We conclude, older residents did not report symptoms of dizziness prior to OH drops in blood pressure and falls. Further study is warranted to identify other predictive symptoms of OH and to evaluate nursing staff’s understanding of OH.
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Affiliation(s)
| | | | - Sizhu Liu
- Rutgers College of Nursing, Rutgers University, Newark, NJ, USA
| | - Dean Wantland
- Rutgers College of Nursing, Rutgers University, Newark, NJ, USA
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Abstract
Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.
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Affiliation(s)
- Roschelle Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt Pleasant, Michigan 48859, USA.
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Prata MG, Scheicher ME. Correlation between balance and the level of functional independence among elderly people. SAO PAULO MED J 2012; 130:97-101. [PMID: 22481755 PMCID: PMC10896569 DOI: 10.1590/s1516-31802012000200005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 03/01/2011] [Accepted: 08/23/2011] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE As the overall number of elderly people increases there is a corresponding rise in the number of older persons with disabilities. In order to examine whether there is any relationship between balance and activities of daily living, we evaluated balance and daily activities among elderly people living in the community. DESIGN AND SETTING Cross-sectional study at Universidade Estadual Paulista (Unesp), Marília, São Paulo, Brazil. METHODS The study included 70 community-dwelling elderly people aged 65 and over. Balance was evaluated using the Berg Balance Scale (BBS) and physical independence in daily activities was evaluated using the Barthel Index (BI). The Spearman correlation coefficient was used to examine the relationship between the parameters evaluated. Significance was set at the level of 5% (P < 0.05). RESULTS The population's mean age was 70.5 ± 5 years. The mean BBS score was 50.9 ± 4.1, whereas the mean BI score was 98.1 ± 2.8. Statistically significant relationships were found between the BBS and BI (r = 0.41; P = 0.0004); between age and BI (r = -0.24; P = 0.04); and between age and BBS (r = -0.57; P = 0.0001). CONCLUSIONS The results showed that among elderly people, there are correlations between age, balance and independence level.
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Affiliation(s)
- Melina Galetti Prata
- Physiotherapist, Department of Physical Education, Universidade Estadual Paulista (Unesp), Rio Claro, São Paulo, Brazil.
| | - Marcos Eduardo Scheicher
- PhD. Physiotherapist and Assistant Professor, Department of Special Education, Universidade Estadual Paulista (Unesp), Marília, São Paulo, Brazil.
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Nobili A, Garattini S, Mannucci PM. Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium. JOURNAL OF COMORBIDITY 2011; 1:28-44. [PMID: 29090134 PMCID: PMC5556419 DOI: 10.15256/joc.2011.1.4] [Citation(s) in RCA: 152] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 11/16/2011] [Indexed: 12/13/2022]
Abstract
The pattern of patients admitted to internal medicine wards has dramatically changed in the last 20-30 years. Elderly people are now the most rapidly growing proportion of the patient population in the majority of Western countries, and aging seldom comes alone, often being accompanied by chronic diseases, comorbidity, disability, frailty, and social isolation. Multiple diseases and multimorbidity inevitably lead to the use of multiple drugs, a condition known as polypharmacy. Over the last 20-30 years, problems related to aging, multimorbidity, and polypharmacy have become a prominent issue in global healthcare. This review discusses how internists might tackle these new challenges of the aging population. They are called to play a primary role in promoting a new, integrated, and comprehensive approach to the care of elderly people, which should incorporate age-related issues into routine clinical practice and decisions. The development of new approaches in the frame of undergraduate and postgraduate training and of clinical research is essential to improve and implement suitable strategies meant to evaluate and manage frail elderly patients with chronic diseases, comorbidity, and polypharmacy. Journal of Comorbidity 2011;1:28-44.
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Affiliation(s)
| | | | - Pier Mannuccio Mannucci
- Scientific Direction, IRCCS Cà Granda Foundation Maggiore Policlinico Hospital, Milan, Italy
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Bourgeois J, Elseviers MM, Azermai M, Van Bortel L, Petrovic M, Vander Stichele RR. Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages. Eur J Clin Pharmacol 2011; 68:833-44. [PMID: 22189673 DOI: 10.1007/s00228-011-1188-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 11/24/2011] [Indexed: 11/30/2022]
Abstract
AIM (1) To describe the prevalence of benzodiazepine use in Belgian nursing homes, with specific attention to indications and dosages. (2) To compare actual and recommended dosages of benzodiazepines for anxiety and insomnia. (3) To explore the risk profile for chronic benzodiazepine use in institutionalised older adults. METHODS Medication charts of 1,730 residents from 76 nursing homes in Belgium were collected and analysed, using the ATC classification. Drug name, indication and daily dosage were recorded. From authoritative international sources, we extracted for each drug and each indication a daily dosage recommended not to be exceeded in older adults for comparison with observed actual dosages. RESULTS Among the chronic benzodiazepine or z-drug (BZD/Z) users (50% of the residents), the leading indication was 'insomnia' (59% of the users) followed by 'anxiety' (17%) and 'unrest' (10%). In the chronic prescriptions of BZD/Zs indicated for insomnia, the actual daily dose exceeded the geriatric upper limit in 95% of lormetazepam prescriptions, 82% of zolpidem, 78% of zopiclone and 35% of lorazepam prescriptions. For anxiety, daily doses also exceeded the limit but not to the same extent. Multivariate analysis showed BZD/Z use was positively associated with pain (OR 1.58, 95% CI 1.27-1.97), constipation (OR 1.43, 95% CI 1.16-1.76) and depression (OR 1.68, 95% CI 1.35-2.08). Residents with dementia were less likely to receive a BZD/Z (OR 0.60, 95% CI 0.48-0.74). CONCLUSION Efforts to reduce the use of BZD/Zs in nursing homes should concentrate on insomnia, with interventions aimed at reducing too high prevalence of chronic use and too high daily dosages in this indication.
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Affiliation(s)
- Jolyce Bourgeois
- Heymans Institute of Pharmacology, Ghent University, De Pintelaan 185 (1 blok B), 9000 Ghent, Belgium.
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