The impact of combined use of fall-risk medications and antithrombotics on injury severity and intracranial hemorrhage among older trauma patients

Pharmacist intervention is associated with fewer serious falls over 3 months among older fallers at a day hospital: A quasi-experimental study

OBJECTIVES

Some drugs increase the risk of falls, including serious falls. The objective of this quasi-experimental study was to determine whether the intervention of a clinical pharmacist among older outpatients receiving a multifactorial fall prevention program at a geriatric day hospital dedicated to older patients with a recent history of falls was effective in preventing serious falls over a 3-month follow-up, compared with usual care.

STUDY DESIGN

Quasi-experimental study in 296 consecutive older outpatients, including 85 with pharmacist intervention (the intervention group) and 148 without (the control group).

MAIN OUTCOME MEASURES

The main outcome was the occurrence of at least one serious fall within 3 months of follow-up. Covariates included age, sex, body mass index, grip strength, history of falls, Mini-Mental State Examination score, use of ≥3 drugs associated with risk of falls, frailty, and disability.

RESULTS

Fewer participants in the intervention group experienced at least one serious fall than in the control group (5 (5.9 %) versus 23 (15.5 %), P = 0.029), which persisted after adjustment for potential confounding factors (OR = 0.30 [95CI:0.11-0.84], P = 0.022). No significant effect was found on the indicence of all falls. Pharmacist intervention allowed more frequent therapeutic optimizations of antithrombotics (OR = 3.69 [95CI: 1.66-8.20]), proton pump inhibitors (OR = 3.34 [95CI: 1.31-8.50]), benzodiazepines (OR = 3.15 [95CI: 1.06-9.36]) and antidepressants (OR = 3.87 [95CI: 1.21-12.35]).

CONCLUSIONS

Among older fallers receiving a multifactorial fall prevention program at a day hospital, a clinical pharmacist intervention was associated with fewer incident serious falls over 3 months of follow-up.

Antithrombotic therapy in patients undergoing transcatheter aortic valve replacement: the complexity of the elderly

Along with epidemiologic transitions of the global population, the burden of aortic stenosis (AS) is rapidly increasing and transcatheter aortic valve replacement (TAVR) has quickly spread; indeed, it is nowadays also employed in treating patients with AS at intermediate operative risk. Nonetheless, the less invasive interventional strategy still carries relevant issues concerning post-procedural optimal antithrombotic strategy, given the current indications provided by guidelines are not completely supported by evidence-based data. Geriatric patients suffer from high bleeding and thromboembolic risks, whose balance is particularly subtle due to the presence of concomitant conditions, such as atrial fibrillation and chronic kidney disease, that make the post-TAVR antithrombotic management particularly insidious. This scenario is further complicated by the lack of specific evidence regarding the 'real-life' complex conditions typical of the geriatric syndromes, thus, the management of such a heterogeneous population, ranging from healthy ageing to frailty, is far from being defined. The aim of the present review is to summarize the critical points and the most updated evidence regarding the post-TAVR antithrombotic approach in the geriatric population, with a specific focus on the most frequent clinical settings.

Adult and elderly population access to trauma centers: an ecological analysis evaluating the relationship between injury-related mortality and geographic proximity in the United States in 2010

Background

Ongoing development and expansion of trauma centers in the United States necessitates empirical analysis of the effect of investment in such resources on population-level health outcomes.

Methods

Multiple linear regressions were performed to predict state-level trauma-related mortality among adults and the elderly across 50 US states in 2010. The number of trauma centers per capita in each state and the percentage of each state’s population living within 45-min of a trauma center served as the key independent variables and injury-related mortality served as the dependent variable. All analyses were stratified by age (adult versus elderly; elderly ≥ 65 years old) and were performed in SPSS.

Results

The proportion of a population with geographic proximity to a trauma center demonstrates a consistent inverse linear relationship to injury-related mortality. The relationship reliably retains its significance in models including demographic covariates. Interestingly, access to Levels I and II trauma centers demonstrates a stronger correlation with mortality than was observed with Level III centers.

Conclusion

Trauma center access is associated with reduced trauma-related mortality among both adults and the elderly as measured by state reported mortality rates. Ongoing efforts to designate and verify new trauma centers, particularly in poorly-served ‘trauma deserts’, could lead to lower mortality for large populations.

After rescue: the importance of Beers Criteria for medication assessment in older adults

Critical care units serve the vital function of patient rescue through life-saving and life-preserving treatments. When an older patient's life hangs in the balance, preserving life takes priority over potential serious adverse drug events. There may be a tendency to consider transfer out of the unit as a less serious event; therefore, less attention is given to medication assessment. Often thought of by nurses as an almost clerical level task, the professional nurse plays a key role in identifying potentially harmful medications or medication combinations. If older patients remain on medications considered to be potentially dangerous, then patients are at risk for adverse drug events. Once the emergent nature of critical care interventions has passed, it is important to judiciously appraise patient status and conduct a medication assessment to discontinue or change the medication regimen to safer alternatives for older adults. Nurses can be instrumental in further research, education, and awareness for practitioners, patients, and families regarding the role of medications for older adults. Beers Criteria are not intended to be a clinical mandate, rather a designated as a clinical guideline with a clinical recommendation to support a provider's clinical judgment.