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

Detection of ethanol, cannabinoids, benzodiazepines, and opioids in older adults evaluated for serious injuries from falls

BACKGROUND

In 2020, there were 36.7 million reported falls among older adults (65+) in the United States. Ethanol and other sedating substances may increase fall risk among older adults due to their effect on cognitive and physical function. We estimate the prevalence of these substances in blood specimens of older adults presenting with a fall injury at selected trauma centers.

METHODS

The initial study collected blood specimens from May 2020 through July 2021 from adults undergoing a trauma team evaluation at selected United States Level 1 trauma centers. We limited our study to older adults evaluated after a fall (n = 1,365) and selected a random sample (n = 300) based on age, sex, and trauma-center quotas. Medical health records and blood specimens obtained at trauma center presentation were analyzed. We estimated the prevalence of ethanol, benzodiazepines, cannabinoids, and opioids in the blood specimens. Two-sample tests of binomial proportions and Chi-square two-tailed tests were used to compare prevalence estimates of substances by demographic characteristics.

RESULTS

At least one substance was detected among 31.3% of samples analyzed. Prevalences of specific substances detected were 9.3% (95% CI: 6.0-12.6%) for benzodiazepines, 4.3% (95% CI: 2.0-6.7%) for cannabinoids, 8.0% (95% CI: 5.2-11.7%) for ethanol, and 15.0% (95% CI: 10.9-19.1%) for opioids. There were 18 deaths (6%; 95% CI: 3.6-9.3%). One-third of decedents had at least one substance detected in their blood.

DISCUSSION

Opioids were the most frequently detected substance, followed by benzodiazepines, ethanol, and cannabinoids. Substance use prevalence was not uniform across demographics, with differences observed by sex and age.

CONCLUSIONS

This study provides insight into the frequency of the presence of substances that may contribute to fall risk and serious injury among older adults. Screening older adults for substances that impair cognitive and physical function can enhance clinical fall prevention efforts.

High rate of potentially inappropriate medication use in older people: a case-control study

Annually, 172 million fall events cause temporary or permanent impairment in older adults, and this number is increasing. Contributing factors that increase the risk for falls include age, polypharmacy, and malnutrition. This study evaluated medications mainly included in the EU(7)-PIM (potentially inappropriate medication) list. From March 21, 2022, to July 6, 2022, 945 patients who experienced a fall and visited the Department of Emergency Medicine at the Albert Szent-Györgyi Health Centre of the University of Szeged in Hungary. Data from 886 patients were collected (study group). The control group included 1364 patient data collected from three general practice in Hungary. The use of ≥ 2 EU(7)-PIM drugs was found to be associated with increased risk for falls (adjusted odds ratio [AOR], 1.38; 95% confidence interval [CI] 1.01-1.88). Piracetam (AOR, 1.81; 95% CI, 1.28-2.57) and trimetazidine (AOR, 1.62; 95% CI, 1.17-2.24) were associated with increased risk for falls. Doxazosin was associated with a low risk for falls (AOR, 0.59; 95% CI, 0.41-0.86). Tiapride (AOR, 3.54; 95% CI, 1.75-7.17), gliclazide (AOR, 1.57; 95% CI, 1.02-2.43), and vinpocetine (AOR, 1.95; 95% CI, 1.29-2.95) are not included in the EU(7)-PIM list; however, they are associated with increased risk for falls. Long-acting benzodiazepines (AOR, 1.79; 95% CI, 1.20-2.68), antidepressants (AOR, 1.89; 95% 95% CI, 1.37-2.61), serotonin-norepinephrine reuptake inhibitor (AOR, 2.82; 95% CI, 1.41-5.67; p < 0.01), and selective serotonin reuptake inhibitor (AOR, 1.88; 95% CI, 1.24-2.85) were also associated with increased risk for falls. However, Z-drugs were associated with a low risk for falls (AOR, 0.57; 95% CI, 0.36-0.92). With the help of this tool, trimetazidine and piracetam are filtered as EU(7)-PIM drugs associated with increased risk for falls.

Development of the ADFICE_IT clinical decision support system to assist deprescribing of fall-risk increasing drugs: A user-centered design approach

INTRODUCTION

Deprescribing fall-risk increasing drugs (FRIDs) is promising for reducing the risk of falling in older adults. Applying appropriate deprescribing in practice can be difficult due to the outcome uncertainties associated with stopping FRIDs. The ADFICE_IT intervention addresses this complexity with a clinical decision support system (CDSS) that facilitates optimum deprescribing of FRIDs by using a fall-risk prediction model, aggregation of deprescribing guidelines, and joint medication management.

METHODS

The development process of the CDSS is described in this paper. Development followed a user-centered design approach in which users and experts were involved throughout each phase. In phase I, a prototype of the CDSS was developed which involved a literature and systematic review, European survey (n = 581), and semi-structured interviews with clinicians (n = 19), as well as the aggregation and testing of deprescribing guidelines and the development of the fall-risk prediction model. In phase II, the feasibility of the CDSS was tested by means of two usability testing rounds with users (n = 11).

RESULTS

The final CDSS consists of five web pages. A connection between the Electronic Health Record allows for the retrieval of patient data into the CDSS. Key design requirements for the CDSS include easy-to-use features for fast-paced clinical environments, actionable deprescribing recommendations, information transparency, and visualization of the patient's fall-risk estimation. Key elements for the software include a modular architecture, open source, and good security.

CONCLUSION

The ADFICE_IT CDSS supports physicians in deprescribing FRIDs optimally to prevent falls in older patients. Due to continuous user and expert involvement, each new feedback round led to an improved version of the system. Currently, a cluster-randomized controlled trial with process evaluation at hospitals in the Netherlands is being conducted to test the effect of the CDSS on falls. The trial is registered with ClinicalTrials.gov (date; 7-7-2022, identifier: NCT05449470).

Identification of medication-related fall risk in adults and older adults admitted to hospital: A machine learning approach

The study aimed to develop and validate, through machine learning, a fall risk prediction model related to prescribed medications specific to adults and older adults admitted to hospital. A case-control study was carried out in a tertiary hospital, involving 9,037 adults and older adults admitted to hospital in 2016. The variables were analyzed using the algorithms: logistic regression, naive bayes, random forest and gradient boosting. The best model presented an area under the curve = 0.628 in the older adult subgroup, compared to an area under the curve (AUC) = 0.776 in the adult subgroup. A specific model was developed for this sample. The gradient boosting model presented the best performance in the sample of older adults (AUC = 0.71). Models developed to predict the risk of falls based on medications specifically aimed at older adults presented better performance in relation to models developed in the total population studied.

Polypharmacy and potentially inappropriate medications in older adults who use long-term care services: a cross-sectional study

BACKGROUND

Older adults requiring care often have multiple morbidities that lead to polypharmacy, including the use of potentially inappropriate medications (PIMs), leading to increased medical costs and adverse drug effects. We conducted a cross-sectional study to clarify the actual state of drug prescriptions and the background of polypharmacy and PIMs.

METHODS

Using long-term care (LTC) and medical insurance claims data in the Ibaraki Prefecture from April 2018 to March 2019, we included individuals aged ≥ 65 who used LTC services. The number of drugs prescribed for ≥ 14 days and the number of PIMs were counted. A generalized linear model was used to analyze the association between the backgrounds of individuals and the number of drugs; logistic regression analysis was used for the presence of PIMs. PIMs were defined by STOPP-J and Beers Criteria.

RESULTS

Herein, 67,531 older adults who received LTC services were included. The median number of total prescribed medications and PIMs was 7(IQR 5-9) and 1(IQR 0-1), respectively. The main PIMs were loop diuretics/aldosterone antagonists (STOPP-J), long-term use of proton pump inhibitors (Beers Criteria), benzodiazepines/similar hypnotics (STOPP-J and Beers Criteria), and nonsteroidal anti-inflammatory drugs (STOPP-J and Beers Criteria). Multivariate analysis revealed that the number of medications and presence of PIMs were significantly higher in patients with comorbidities and in those visiting multiple medical institutions. However, patients requiring care level ≥1, nursing home residents, users of short-stay service, and senior daycare were negatively associated with polypharmacy and PIMs.

CONCLUSIONS

Polypharmacy and PIMs are frequently observed in older adults who require LTC. This was prominent among individuals with comorbidities and at multiple consulting institutions. Utilization of nursing care facilities may contribute to reducing polypharmacy and PIMs.

Drug burden index in people living with HIV over 50 years of age in a real clinical practice cohort

OBJECTIVES

To determine DBI and its relationship with polypharmacy and pharmacotherapeutic complexity (PC) in a cohort of PLWH over 50 years of age at follow-up of pharmacotherapy in a tertiary hospital.

METHODS

Observational and retrospective study that included PLWH in active antiretroviral treatment over 50 years of age who have been followed up in outpatient pharmacy services. Pharmacotherapeutic complexity was estimated through Medication Regimen Complexity Index (MRCI). Collected variables included comorbidities, current prescriptions and its classification according to anticholinergic and sedative activity and associated risk of falls.

RESULTS

Studied population included 251 patients (85.7% men; median age: 58 years, interquartile range: 54-61). There was a high prevalence of high DBI scores (49.2%). High DBI was significantly correlated with a high PC, polypharmacy, psychiatric comorbidity and substances abuse (p<0.05). Among sedative drugs, the most prescribed were anxiolytic drugs (N05B) (n=85), antidepressant drugs (N06A) (n=41) and antiepileptic drugs (N03A) (n=29). For anticholinergic drugs, alpha-adrenergic antagonist drugs (G04C) were the most prescribed (n=18). Most frequent drugs associated with risk of falls were anxiolytics (N05B) (n=85), angiotensin-converting enzyme inhibitors (C09A) (n=61) and antidepressants (N06A) (n=41).

CONCLUSION

The DBI score in older PLWH is high and it is related to PC, polypharmacy, mental diseases and substance abuse as is the prevalence of fall-related drugs. Control of these parameters as well as the reduction of the sedative and anticholinergic load should be included in the lines of work in the pharmaceutical care of people living with HIV+.

A Longitudinal Study of the Use and Effects of Fall-Risk-Increasing Drugs in Residential Aged Care

OBJECTIVES

Fall-risk-increasing drugs (FRIDs)-psychotropics and cardiovascular disease (CVD) drugs-may elevate the risk of falling, with strong evidence observed in psychotropic FRIDs, whereas findings from cardiovascular disease (CVD) FRIDs remain inconclusive. Existing studies on FRIDs and falls are often hampered by methodologic limitations. Leveraging longitudinal observational data, we aimed to determine the long-term patterns of FRID use and their association with falls in residential aged care (RAC) homes.

DESIGN

A retrospective longitudinal cohort study.

SETTING AND PARTICIPANTS

A total of 4207 permanent residents newly admitted to 27 RAC homes in Sydney, Australia.

METHOD

The outcomes were incidence of all and injurious falls. We measured exposure to each FRID over 60 months using the Proportion of Days Covered (PDC) metric. We used group-based multitrajectory modeling to determine concurrent usage patterns of psychotropics and CVD FRIDs and applied negative binomial regression to assess their associations with the outcomes.

RESULTS

A total of 83.6% (n = 3516) and 77.3% (n = 3254) residents used psychotropic and CVD FRIDs, respectively. The PDC values ranged from 67.3% (opioids) to 86.9% (antidepressants) for specific psychotropics and 79.0% (α-adrenoceptor antagonists) to 89.6% (β blockers) for CVD FRIDs. We identified 4 groups: group 1, low psychotropics-low CVDs use (16.7%, n = 701); group 2, low psychotropics-high CVDs (25.0%, n = 1054); group 3, high psychotropics-high CVDs (41.0%, n = 1723); and group 4, high psychotropics-low CVDs (17.3%, n = 729). Group 4 had a significantly higher rate of falls than the other groups for both outcomes, including relative to group 3, in which exposure to both FRID classes was high.

CONCLUSIONS AND IMPLICATIONS

Our findings reveal concerningly high FRID use in RAC homes and highlight a critical difference in the impact of the 2 major FRID classes on falls. Psychotropics were strongly associated with falls, whereas the studied CVD FRIDs did not elevate risk of falling.

A quantitative study on the impact of a community falls pharmacist role, on medicines optimisation in older people at risk of falls

BACKGROUND

The World Falls guidance includes medication review as part of its recommended multifactorial risk assessment for those at high risk of falling. Use of Falls Risk Increasing Drugs (FRIDs) along with polypharmacy and anticholinergic burden (ACB) are known to increase the risk of falls in older people.

METHOD

The impact of a community falls pharmacist within a hospital Trust, working as part of a multi-professional community falls prevention service, was evaluated in 92 people aged 65 years or older, by analysing data before and after pharmacist review, namely: number and type of FRIDs prescribed; anticholinergic burden score using ACBcalc®; appropriateness of medicines prescribed; bone health review using an approved too; significance of clinical intervention; cost avoidance, drug cost savings and environmental impact.

RESULTS

Following pharmacist review, there was a reduction in polypharmacy (mean number of medicines prescribed per patient reduced by 8%; p < 0.05) and anticholinergic burden score (average score per patient reduced by 33%; p < 0.05). Medicines appropriateness improved (Medicines Appropriateness Index score decreased by 56%; p < 0.05). There were 317 clinically significant interventions by the community falls pharmacist. One hundred and one FRIDs were deprescribed. Annual cost avoidance and drug cost savings were £40,689-£82,642 and avoidable carbon dioxide (CO2) emissions from reducing inappropriate prescribing amounted to 941 kg CO2.

CONCLUSION

The community falls pharmacist role increases prescribing appropriateness in the older population at risk of falls, and is an effective and cost-efficient means to optimise medicines in this population, as well as having a positive impact on the environment.

Risk Factors for Falls Among Hospitalized Medical Patients - A Systematic Review and Meta-analysis

OBJECTIVE

To identify and quantify risk factors for in-hospital falls in medical patients.

DATA SOURCES

Six databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar) were systematically screened until April 11, 2023, to identify relevant articles.

STUDY SELECTION

All titles and abstracts of the retrieved articles were independently screened by 2 researchers who also read the full texts of the remaining articles. Quantitative studies that assessed risk factors for falls among adult patients acutely hospitalized were included in the review. Publications that did not capture internal medicine patients or focused on other specific populations were excluded.

DATA EXTRACTION

Information on study characteristics and potential risk factors were systematically extracted. Risk of bias was assessed using the Quality in Prognosis Studies tool. Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analyses of Observational Studies in Epidemiology guidelines were followed for reporting.

DATA SYNTHESIS

The main outcome was any in-hospital falls. Using a random-effects meta-analysis model, association measures for each risk factor reported in 5 or more studies were pooled. Separate analyses according to effect measure and studies adjusted for sex and age at least were performed. Of 5067 records retrieved, 119 original publications from 25 countries were included. In conclusion, 23 potential risk factors were meta-analyzed. Strong evidence with large effect sizes was found for a history of falls (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.63-3.96; I2, 91%), antidepressants (pooled OR, 2.25; 95% CI, 1.92-2.65; I2, 0%), benzodiazepines (OR, 1.97; 95% CI, 1.68-2.31; I2, 0%), hypnotics-sedatives (OR, 1.90; 95% CI, 1.53-2.36; I2, 46%), and antipsychotics (OR, 1.61; 95% CI, 1.33-1.95; I2, 0%). Furthermore, evidence of associations with male sex (OR, 1.22, 95% CI, 0.99-1.50; I2, 65%) and age (OR, 1.17, 95% CI, 1.02-1.35; I2, 72%) were found, but effect sizes were small.

CONCLUSIONS

The comprehensive list of risk factors, which specifies the strength of evidence and effect sizes, could assist in the prioritization of preventive measures and interventions.

A systematic review of fall prediction models for community-dwelling older adults: comparison between models based on research cohorts and models based on routinely collected data

BACKGROUND

Prediction models can identify fall-prone individuals. Prediction models can be based on either data from research cohorts (cohort-based) or routinely collected data (RCD-based). We review and compare cohort-based and RCD-based studies describing the development and/or validation of fall prediction models for community-dwelling older adults.

METHODS

Medline and Embase were searched via Ovid until January 2023. We included studies describing the development or validation of multivariable prediction models of falls in older adults (60+). Both risk of bias and reporting quality were assessed using the PROBAST and TRIPOD, respectively.

RESULTS

We included and reviewed 28 relevant studies, describing 30 prediction models (23 cohort-based and 7 RCD-based), and external validation of two existing models (one cohort-based and one RCD-based). The median sample sizes for cohort-based and RCD-based studies were 1365 [interquartile range (IQR) 426-2766] versus 90 441 (IQR 56 442-128 157), and the ranges of fall rates were 5.4% to 60.4% versus 1.6% to 13.1%, respectively. Discrimination performance was comparable between cohort-based and RCD-based models, with the respective area under the receiver operating characteristic curves ranging from 0.65 to 0.88 versus 0.71 to 0.81. The median number of predictors in cohort-based final models was 6 (IQR 5-11); for RCD-based models, it was 16 (IQR 11-26). All but one cohort-based model had high bias risks, primarily due to deficiencies in statistical analysis and outcome determination.

CONCLUSIONS

Cohort-based models to predict falls in older adults in the community are plentiful. RCD-based models are yet in their infancy but provide comparable predictive performance with no additional data collection efforts. Future studies should focus on methodological and reporting quality.

Statin use and fall risk in adults: a cross-sectional survey and mendelian randomization analysis

Background and Objective

The issue of falls poses a significant threat to the health of the elderly population. Although statins can cause myopathy, which implies that they may cause balance problems and increase the risk of falling, this has not been tested. Our objective was to assess whether the use of statins is linked to a higher risk of falls.

Methods

A cross-sectional survey study and Mendelian randomization (MR) study were conducted to examine whether the use of statins was associated with an increased risk of falling and balance problems. The cross-sectional study included 2,656 participants from the US population (NHANES) who reported information on balance and falling problems in the past year and their use of statins. Univariate and multivariate logistic regression models were used to investigate the association between statin use and the likelihood of falling or experiencing balance problems. The MR study identified five Single Nucleotide Polymorphisms (SNPs) that predict statin use across five ancestry groups: Admixed African or African, East Asian, European, Hispanic, and South Asian. Additionally, SNPs predicting the risk of falls were acquired from the UK Biobank population. A two-sample MR analysis was performed to examine whether genetically predicted statin use increased the risk of falls.

Results

The use of statins was found to be associated with an increased likelihood of balance and falling problems (balance problem, OR 1.25, 95%CI 1.02 to 1.55; falling problem, OR 1.27, 95%CI 1.03-1.27). Subgroup analysis revealed that patients under the age of 65 were more susceptible to these issues when taking statins (balance problem, OR 3.42, 95%CI 1.40 to 9.30; falling problem, OR 5.58, 95%CI 2.04-15.40). The MR analysis indicated that the use of statins, as genetically proxied, resulted in an increased risk of falling problems (OR 1.21, 95% CI 1.1-1.33).

Conclusion

Our study found an association between the use of statins and an increased risk of balance problems and falls in adults over 40 years old, and the MR study result suggested statin use increased risk of falls. The risk was higher in participants under 65 years old compared to those over 65 years old.

Assessing the Efficacy of the ARMOR Tool-Based Deprescribing Intervention for Fall Risk Reduction in Older Patients Taking Fall Risk-Increasing Drugs (DeFRID Trial): Protocol for a Randomized Controlled Trial

BACKGROUND

Falls in older patients can lead to serious health complications and increased health care costs. Fall risk-increasing drugs (FRIDs) are a group of drugs that may induce falls or increase the tendency to fall (ie, fall risk). Deprescribing is the process of withdrawal from an inappropriate medication, supervised by a health care professional, with the goal of managing polypharmacy and improving outcomes.

OBJECTIVE

This study aims to assess the effectiveness of a deprescribing intervention based on the Assess, Review, Minimize, Optimize, and Reassess (ARMOR) tool in reducing the risk of falls in older patients and evaluate the cost-effectiveness of deprescribing FRIDs.

METHODS

This is an open-label, parallel-group randomized controlled academic trial. Individuals aged 60-80 years who are currently taking 5 or more prescribed drugs, including at least 1 FRID, will be recruited. Demographic data, medical conditions, medication lists, orthostatic hypotension, and fall history details will be collected. Fall concern will be assessed using the Fall Efficacy Scale, and fall risk will be assessed by the Timed Up and Go test and Tinetti Performance-Oriented Mobility Assessment tool. In this study, all treating physicians will be randomized using a stratified randomization method based on seniority. Randomized physicians will do deprescribing with the ARMOR tool for patients on FRIDs. Participants will maintain diaries, and monthly phone follow-ups will be undertaken to monitor falls and adverse events. Physical assessments will be performed to evaluate fall risk every 3 months for a year. The rationality of prescription drugs will be evaluated using the World Health Organization's core indicators.

RESULTS

The study received a grant from the Indian Council of Medical Research-Safe and Rational Use of Medicine in October 2023. The study is scheduled to commence in April 2024 and conclude by 2026. Efficacy will be measured by fall frequency and changes in fall risk scores. Cost-effectiveness analysis will also include the incremental cost-effectiveness ratio calculation. Adverse events related to deprescription will be recorded.

CONCLUSIONS

This trial will provide essential insights into the efficacy of the ARMOR tool in reducing falls among the geriatric population who are taking FRIDs. Additionally, it will provide valuable information on the cost-effectiveness of deprescribing practices, offering significant implications for improving the well-being of older patients and optimizing health care resource allocation. The findings from this study will be pertinent for health care professionals, policy makers, and researchers focused on geriatric care and fall prevention strategies.

TRIAL REGISTRATION

Clinical Trials Registry - India CTRI/2023/12/060516; https://ctri.nic.in/Clinicaltrials/pubview2.php.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/55638.

A European survey of older peoples' preferences, and perceived barriers and facilitators to inform development of a medication-related fall-prevention patient portal

PURPOSE

Falls are a major and growing health care problem in older adults. A patient portal has the potential to provide older adults with fall-prevention advice to reduce fall-risk. However, to date, the needs and preferences regarding a patient portal in older people who have experienced falls have not been explored. This study assesses content preferences, potential barriers and facilitators with regard to using a patient portal, as perceived by older people who have experienced falls, and explores regional differences between European participants.

METHODS

We conducted a survey of older adults attending an outpatient clinic due to a fall or fall-related injury, to explore their content preferences, perceived barriers, and facilitators with respect to a fall-prevention patient portal. Older adults (N = 121, 69.4% female, mean age: 77.9) were recruited from seven European countries.

RESULTS

Almost two-thirds of respondents indicated they would use a fall-prevention patient portal. The portal would preferably include information on Fall-Risk-Increasing Drugs (FRIDs), and ways to manage other related/relevant medical conditions. Facilitators included a user-friendly portal, with easily accessible information and physician recommendations to use the portal. The most-commonly-selected barriers were privacy issues and usage fees. A family member's recommendation to use the portal was seemingly more important for Southern and Eastern European participants compared to the other regions.

CONCLUSION

The majority of older people with lived falls experience expressed an interest in a fall-prevention patient portal providing personalized treatment advice to prevent further falls. The results will be used to inform the development of a fall-prevention patient portal. The fall-prevention patient portal is intended to be used in addition to a consultation with a physician. Future research is needed to explore how to prevent falls in older patients who are not interested in a fall-prevention patient portal.

Polypharmacy and Bleeding Outcomes After Percutaneous Coronary Intervention

BACKGROUND

Polypharmacy was reported to be associated with major bleeding in various populations. However, there are no data on polypharmacy and its association with bleeding in patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Among 12,291 patients in the CREDO-Kyoto PCI Registry Cohort-3, we evaluated the number of medications at discharge and compared major bleeding, defined as Bleeding Academic Research Consortium Type 3 or 5 bleeding, across tertiles (T1-3) of the number of medications. The median number of medications was 6, and 88.0% of patients were on ≥5 medications. The cumulative 5-year incidence of major bleeding increased incrementally with increasing number of medications (T1 [≤5 medications] 12.5%, T2 [6-7] 16.5%, and T3 [≥8] 20.4%; log-rank P<0.001). After adjusting for confounders, the risks for major bleeding of T2 (hazard ratio [HR] 1.21; 95% confidence interval [CI] 1.08-1.36; P=0.001) and T3 (HR 1.27; 95% CI 1.12-1.45; P<0.001) relative to T1 remained significant. The adjusted risks of T2 and T3 relative to T1 were not significant for a composite of myocardial infarction or ischemic stroke (HR 0.95 [95% CI 0.83-1.09; P=0.47] and HR 1.06 [95% CI 0.91-1.23; P=0.48], respectively).

CONCLUSIONS

In a real-world population of patients undergoing PCI, approximately 90% were on ≥5 medications. Increasing number of medications was associated with a higher adjusted risk for major bleeding, but not ischemic events.

Factors Impacting Fall Severity in Hospitalized Patients: A Retrospective Cohort Study

Objectives: This retrospective case-controlled study aimed to evaluate the association between the severity of fall-related injuries and fall-risk-increasing drugs (FRIDs) in hospitalized patients. Methods: Data were collected from Changhua Christian Hospital, Taiwan, of all adult inpatients who experienced falls between January 2017 and December 2021, and were divided into two groups based on whether they sustained severe fall-related injuries. Retrospective data that may affect the severity of fall-related injuries and the use of FRIDs were investigated. Results: Among 1231 documented cases of falls, 26 patients sustained severe fall-related injuries. Older patients and those with osteoporosis were more susceptible to more severe injuries from a fall. The use of mobility aids and osteoporosis medications showed protective effects against fall injuries. No significant association was observed between fall-related injuries and comorbidities or FRIDs. Multivariate analysis confirmed the inverse correlation between the use of mobility aids, osteoporosis medications, and fall severity. Patients with osteoporosis exhibited significantly higher odds of sustaining more severe injuries with a fall (odds ratio = 3.02, 95% confidence interval: 1.21-7.53). Conclusions: This study highlights the importance of addressing risk factors associated with fall severity among hospitalized patients. Providing mobility aids to persons at greater risk.

Factors affecting outcomes among older trauma patients in Singapore: A retrospective observational study

Singapore faces a rapidly ageing population with its median age projected to be above 45 years by 2030. Our greying demographics is accompanied by a rise in chronic diseases and medication use, including polypharmacy. Longer life expectancy and increased activity levels have contributed to higher incidence of geriatric trauma locally, with a three-fold rise between 2004 and 2015. Older patients are at greater risk of poorer outcomes following trauma.3 However, the impact of comorbidities and medication use on post-trauma outcomes in Singapore’s ageing population remains unclear.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Drug therapy for arterial hypertension and atrial fibrillation in frail patients : Are there any new insights and recommendations?]

The frail and elderly are considered to be at particular risk of suffering an adverse drug reaction. Empirical studies confirm the increased rate of adverse drug reactions. Whether frailty per se impairs drug metabolism or the underlying organ ageing processes and multimorbidity cannot be answered with certainty based on current data. Cardiovascular diseases exhibit a considerable interdependence with frailty. For example, there is a disproportionate syndromal interdependence between heart failure and frailty, and the typical ageing processes of the sinus node can be interpreted as heartbeat frailty. Multimorbidity in the elderly often includes a cluster of chronic cardiovascular diseases, often leading to the use of several cardiovascular medications as required. More recent definitions of polypharmacy assess the appropriateness of drugs rather than their number. The Fit-fOR-The-Aged (FORTA) list, the PRISCUS 2.0 list and the "Cochrane Library Special Collection on deprescribing", for example, offer a practice-oriented assessment aid. In the treatment of arterial hypertension, the target values for older people have also been set ever lower in recent years. In the case of frail elderly people, on the other hand, the guidelines do not specify a strict blood pressure target corridor; tolerability is the crucial factor here. When initiating antihypertensive therapy in frail individuals, one can consider monotherapy-in a departure from the standard case of dual combination therapy. The OPTIMISE study showed that discontinuation of one blood pressure medication did not lead to better tolerability of the drug therapy. Current studies come to differing conclusions regarding the risk-benefit assessment of new oral anticoagulants compared to vitamin K antagonists in the anticoagulation of frail elderly people with atrial fibrillation. Shared decision-making, which could improve adherence particularly in older people, is recommended.

Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review

Importance

Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures.

Observations

Falls result from age-related physiologic changes compounded by multiple intrinsic and extrinsic risk factors. Major modifiable risk factors among community-dwelling older adults include gait and balance disorders, orthostatic hypotension, sensory impairment, medications, and environmental hazards. Guidelines recommend that individuals who report a fall in the prior year, have concerns about falling, or have gait speed less than 0.8 to 1 m/s should receive fall prevention interventions. In a meta-analysis of 59 randomized clinical trials (RCTs) in average-risk to high-risk populations, exercise interventions to reduce falls were associated with 655 falls per 1000 patient-years in intervention groups vs 850 falls per 1000 patient-years in nonexercise control groups (rate ratio [RR] for falls, 0.77; 95% CI, 0.71-0.83; risk ratio for number of people who fall, 0.85; 95% CI, 0.81-0.89; risk difference, 7.2%; 95% CI, 5.2%-9.1%), with most trials assessing balance and functional exercises. In a meta-analysis of 43 RCTs of interventions that systematically assessed and addressed multiple risk factors among individuals at high risk, multifactorial interventions were associated with 1784 falls per 1000 patient-years in intervention groups vs 2317 falls per 1000 patient-years in control groups (RR, 0.77; 95% CI, 0.67-0.87) without a significant difference in the number of individuals who fell. Other interventions associated with decreased falls in meta-analysis of RCTs and quasi-randomized trials include surgery to remove cataracts (8 studies with 1834 patients; risk ratio [RR], 0.68; 95% CI, 0.48-0.96), multicomponent podiatry interventions (3 studies with 1358 patients; RR, 0.77; 95% CI, 0.61-0.99), and environmental modifications for individuals at high risk (12 studies with 5293 patients; RR, 0.74; 95% CI, 0.61-0.91). Meta-analysis of RCTs of programs to stop medications associated with falls have not found a significant reduction, although deprescribing is a component of many successful multifactorial interventions.

Conclusions and Relevance

More than 25% of older adults fall each year, and falls are the leading cause of injury-related death in persons aged 65 years or older. Functional exercises to improve leg strength and balance are recommended for fall prevention in average-risk to high-risk populations. Multifactorial risk reduction based on a systematic clinical assessment for modifiable risk factors may reduce fall rates among those at high risk.

Development and internal validation of a dynamic fall risk prediction and monitoring tool in aged care using routinely collected electronic health data: a landmarking approach

OBJECTIVES

Falls pose a significant challenge in residential aged care facilities (RACFs). Existing falls prediction tools perform poorly and fail to capture evolving risk factors. We aimed to develop and internally validate dynamic fall risk prediction models and create point-based scoring systems for residents with and without dementia.

MATERIALS AND METHODS

A longitudinal cohort study using electronic data from 27 RACFs in Sydney, Australia. The study included 5492 permanent residents, with a 70%-30% split for training and validation. The outcome measure was the incidence of falls. We tracked residents for 60 months, using monthly landmarks with 1-month prediction windows. We employed landmarking dynamic prediction for model development, a time-dependent area under receiver operating characteristics curve (AUROCC) for model evaluations, and a regression coefficient approach to create point-based scoring systems.

RESULTS

The model identified 15 independent predictors of falls in dementia and 12 in nondementia cohorts. Falls history was the key predictor of subsequent falls in both dementia (HR 4.75, 95% CI, 4.45-5.06) and nondementia cohorts (HR 4.20, 95% CI, 3.87-4.57). The AUROCC across landmarks ranged from 0.67 to 0.87 for dementia and from 0.66 to 0.86 for nondementia cohorts but generally remained between 0.75 and 0.85 in both cohorts. The total point risk score ranged from -2 to 57 for dementia and 0 to 52 for nondementia cohorts.

DISCUSSION

Our novel risk prediction models and scoring systems provide timely person-centered information for continuous monitoring of fall risk in RACFs.

CONCLUSION

Embedding these tools within electronic health records could facilitate the implementation of targeted proactive interventions to prevent falls.

Fall risk factors among poly-medicated older Lebanese patients in primary care settings: a secondary cross-sectional analysis of the "MGPIDP-L project"

BACKGROUND

Falling is a major concern for the health of older adults and significantly affects their quality of life. Identifying the various risk factors and the differences between older patients can be challenging. The objective of this study was to identify the risk factors for falls among polymedicated community-dwelling older Lebanese patients following a medication review.

METHODS

In this analytical cross-sectional study, we examined the risk factors for falls in 850 patients aged ≥ 65 years who were taking ≥ 5 medications daily. The study involved conducting a medication review over the course of a year in primary care settings and using multivariate logistic regression analysis to analyze the data.

RESULTS

Our results showed that 106 (19.5%) of the 850 included patients had fallen at least once in the three months prior to the medication review. Loss of appetite and functional dependence were identified as the most significant predictors of falls ORa = 3.020, CI [2.074-4.397] and ORa = 2.877, CI [1.787-4.632], respectively. Other risk factors for falls included drowsiness ORa = 2.172, CI [1.499-3.145], and the use of beta-blockers ORa = 1.943, CI [1.339-2.820].

CONCLUSION

Our study highlights the importance of addressing multiple risk factors for falls among Lebanese older adults and emphasizes the need for customized interventions and ongoing monitoring to prevent falls and improve health outcomes. This study sheds light on a critical issue in the Lebanese older population and provides valuable insight into the complex nature of falls among poly-medicated Lebanese community-dwelling older adults.

TRIAL REGISTRATION

2021REC-001- INSPECT -09-04.

Enhancing knowledge, attitude, and perceptions towards fall prevention among older adults: a pharmacist-led intervention in a primary healthcare clinic, Gemas, Malaysia

BACKGROUND

Falls and fall-related injuries are very common among older adults, and the risk of falls increases with the aging process. The lack of awareness of falls and fall-related injuries among older adults can contribute to an increasing risk of falls. Hence, a study was carried out to improve the knowledge, attitude, and perception of falls and fractures among older adults in a primary care setting in Gemas, a rural area of the Selangor state of Malaysia.

METHOD

A structured educational intervention was provided to older adults who visited the primary care setting in Gemas and provided written informed consent to participate in the study. A total of 310 older adult patients was included in the study using a convenience sampling technique.

RESULTS

Before the intervention, 74.84% of the respondents (n = 232) agreed that falls and related fractures are the leading causes of hospital admission among older adults. In post-intervention, the number of respondents who agreed with this statement increased to 257 (82.91%). At baseline, 28 respondents (9.03%) had poor knowledge, 160 respondents (51.61%) had average knowledge levels, and 122 respondents (39.35%) had good knowledge. In post-intervention, respondents with poor and average knowledge reduced to 1.93% (n = 6) and 29.35% (n = 91) respectively. A majority of respondents' knowledge levels improved significantly after the intervention (n = 213; 68.71%). About eight respondents (2.58%) had a negative perception of falls. In post-intervention, the percentage reduced to 0.65% as only two respondents had a negative perception. A total of 32 types of fall-risk-increasing drugs (FRIDs) have been prescribed to the respondents. A strong correlation (r = 0.89) between pre- and post-intervention knowledge was shown among the respondents. Paired t-test analysis showed a statistically significant difference.

CONCLUSION

The pharmacist-led educational intervention significantly improved the knowledge, attitude, and perception of falls among older adults. More structured and periodical intervention programmes are warranted to reduce the risk of falls and fractures among older adults.

Age-Related Risk of Serious Fall Events and Opioid Analgesic Use

Importance

Opioid analgesics may be associated with increased risk of falls, particularly among older adults.

Objective

To quantify the age-related risk of serious fall events among adults prescribed opioids by opioid exposure, time from initiation, and daily dose.

Design, Setting, and Participants

This population-based cohort study conducted in New South Wales, Australia, used data linking national pharmaceutical claims to national and state datasets, including information on sociodemographic characteristics, clinical characteristics, medicines use, health services utilization, and mortality (POPPY II study). It included adults (18 years or older) who initiated prescription opioid treatment, which was defined as no prior dispensing during the preceding 365 days, between January 1, 2005, and December 31, 2018. Data were analyzed from February to June 2023.

Exposure

Time-dependent periods of opioid exposure were evaluated from dispensing records.

Main Outcome and Measures

Serious fall events identified from emergency department, hospitalization, and mortality records. Negative binomial models were used to assess associations between time-dependent opioid exposure (overall, by time from initiation, and by dose), age, and risk of fall events. Models were adjusted for known fall risk factors, including other fall risk-increasing drugs, frailty risk, and prior serious fall events.

Results

The cohort comprised 3 212 369 individuals who initiated prescription opioid treatment (1 702 332 women [53%]; median [IQR] age at initiation, 49 [32-65] years). Overall, 506 573 serious fall events were identified, including 5210 fatal falls. During exposure to opioids, the risk of serious fall events was elevated among all age groups; compared with the group aged 18 to 44 years, this risk was highest among those 85 years or older (adjusted incident rate ratio, 6.35; 95% CI, 6.20-6.51). Across all age groups, the first 28 days following opioid initiation was a time of increased serious fall risk; this risk increased with age. Among individuals aged 18 to 84 years, associations were identified between higher daily opioid doses and serious fall events.

Conclusions and Relevance

The results of this cohort study suggest that prescription opioids were associated with increased risk of serious fall events among adults of all ages, with individuals 85 years or older at greatest risk. These risks should be considered when prescribing opioids, particularly for individuals with preexisting risk factors or when opioids are prescribed at higher doses. Targeted falls prevention efforts may be most effective within the first month following opioid initiation.

Ten-year association between change in speech-in-noise recognition and falls due to balance problems: a longitudinal cohort study

BACKGROUND

This study examined the relationship between speech-in-noise recognition and incident/recurrent falls due to balance problems ten years later (RQ-1); 10-year change in speech-in-noise recognition and falls (RQ-2a), as well as the role of dizziness in this relationship (RQ-2b). The association between hearing aid use and falls was also examined (RQ-3).

METHODS

Data was collected from the Netherlands Longitudinal Study on Hearing between 2006 and December 2022. Participants completed an online survey and digits-in-noise test every five years. For this study, data was divided into two 10-year follow-up time intervals: T0 (baseline) to T2 (10-year follow-up), and T1 (5-years) to T3 (15-years). For all RQs, participants aged ≥ 40 years at baseline, without congenital hearing loss, and non-CI users were eligible (n = 592). Additionally, for RQ-3 participants with a speech reception threshold in noise (SRTn) ≥ -5.5 dB signal-to-noise ratio were included (n = 422). Analyses used survey variables on hearing, dizziness, falls due to balance problems, chronic health conditions, and psychosocial health. Logistic regressions using General Estimating Equations were conducted to assess all RQs.

RESULTS

Among individuals with obesity, those with poor baseline SRTn had a higher odds of incident falls ten years later (odds ratio (OR):14.7, 95% confidence interval (CI) [2.12, 103]). A 10-year worsening of SRTn was significantly associated with a higher odds of recurrent (OR: 2.20, 95% CI [1.03, 4.71]) but not incident falls. No interaction was found between dizziness and change in SRTn. Hearing aid use (no use/ < 2 years use vs. ≥ 2 years) was not significantly associated with incident nor recurrent falls. Although there was a significant interaction with sex for this association, the effect of hearing aid use on incident/recurrent falls was not statistically significant among males nor females.

CONCLUSIONS

A longitudinal association between the deterioration in SRTn and recurrent falls due to balance problems after 10 years was confirmed in this study. This result stresses the importance of identifying declines in hearing earlier and justifies including hearing ability assessments within fall risk prevention programs. Mixed results of hearing aid use on fall risk warrant further investigation into the temporality of this association and possible differences between men and women.

Fall risk and cardiovascular outcomes of first-line antihypertensive medications in nursing home residents

BACKGROUND

Little evidence exists about the comparative effects of first-line antihypertensive medications (i.e., renin-angiotensin-aldosterone converting enzyme inhibitors (RAASi), amlodipine, or thiazide diuretics) in older adults with limited life expectancy. We compared the rates of injurious falls and short-term cardiovascular events between different first-line antihypertensive medication classes in adults receiving care in nursing homes (NH).

METHODS

This was a retrospective cohort of Medicare fee-for-service beneficiaries receiving care in NHs. Patients newly dispensed first-line antihypertensive medications were identified using Part D claims (2015-2018) and linked with clinical assessments (i.e., Minimum Data Set). Fall-related injuries (FRI), hip fractures, and major adverse cardiac events (MACE) outcomes were identified using hospitalization claims. Patients were followed from the date of antihypertensive dispensing until the occurrence of outcomes, death, disenrollment, or 6-month follow-up. Inverse-probability-of-treatment-weighted (IPTW) cause-specific hazards regression models were used to compare outcomes between patients who were new users of RAASi, amlodipine, or thiazides.

RESULTS

Our cohort included 16,504 antihypertensive users (RAASi, n = 9574; amlodipine, n = 5049; thiazide, n = 1881). Mean age was 83.5 years (± 8.2), 70.6% were female, and 17.2% were non-white race. During a mean follow-up of 5.3 months, 326 patients (2.0%) experienced an injurious fall, 1590 (9.6%) experienced MACE, and 2123 patients (12.9%) died. The intention-to-treat IPTW hazard ratio (HR) for injurious falls for amlodipine (vs RAASi) use was 0.85 (95% confidence interval (CI) 0.66-1.08) and for thiazides (vs RAASi) was 1.22 (95% CI 0.88-1.66). The rates of MACE were similar between those taking anti-hypertensive medications. Thiazides were discontinued more often than other classes; however, inferences were largely unchanged in as-treated analyses. Subgroup analyses were generally consistent.

CONCLUSIONS

Older adults with limited life expectancy experience similar rates of injurious falls and short-term cardiovascular events after initiating any of the first-line antihypertensive medications.

Development and external validation of the eFalls tool: a multivariable prediction model for the risk of ED attendance or hospitalisation with a fall or fracture in older adults

BACKGROUND

Falls are common in older adults and can devastate personal independence through injury such as fracture and fear of future falls. Methods to identify people for falls prevention interventions are currently limited, with high risks of bias in published prediction models. We have developed and externally validated the eFalls prediction model using routinely collected primary care electronic health records (EHR) to predict risk of emergency department attendance/hospitalisation with fall or fracture within 1 year.

METHODS

Data comprised two independent, retrospective cohorts of adults aged ≥65 years: the population of Wales, from the Secure Anonymised Information Linkage Databank (model development); the population of Bradford and Airedale, England, from Connected Bradford (external validation). Predictors included electronic frailty index components, supplemented with variables informed by literature reviews and clinical expertise. Fall/fracture risk was modelled using multivariable logistic regression with a Least Absolute Shrinkage and Selection Operator penalty. Predictive performance was assessed through calibration, discrimination and clinical utility. Apparent, internal-external cross-validation and external validation performance were assessed across general practices and in clinically relevant subgroups.

RESULTS

The model's discrimination performance (c-statistic) was 0.72 (95% confidence interval, CI: 0.68 to 0.76) on internal-external cross-validation and 0.82 (95% CI: 0.80 to 0.83) on external validation. Calibration was variable across practices, with some over-prediction in the validation population (calibration-in-the-large, -0.87; 95% CI: -0.96 to -0.78). Clinical utility on external validation was improved after recalibration.

CONCLUSION

The eFalls prediction model shows good performance and could support proactive stratification for falls prevention services if appropriately embedded into primary care EHR systems.

Experiences of Older Adults, Physiotherapists, and Aged Care Staff in the TOP UP Telephysiotherapy Program: Interview Study of the TOP UP Interventions

BACKGROUND

Telehealth provides opportunities for older adults to access health care. However, limited research exists on the use of telehealth within aged care services, particularly regarding physiotherapy-led fall prevention and mobility programs. Understanding the experiences and interactions of older adults, physiotherapists, and aged care service providers is crucial for the scale-up and sustainability of such essential programs. The TOP UP study, a hybrid type 1 effectiveness-implementation randomized controlled trial in aged care, used a supported multidisciplinary telephysiotherapy model to motivate older adults to engage in exercises to improve mobility and reduce falls.

OBJECTIVE

This qualitative substudy aims to achieve 2 primary objectives: to describe the experiences and acceptability of the TOP UP intervention for older people, physiotherapists, and aged care support workers and managers and to gain an in-depth understanding of program implementation.

METHODS

A purposive recruitment strategy was used to select 18 older adults who participated in the TOP UP intervention, ensuring variation in age, gender, residential status (home or residential aged care), geographic location, and cognitive levels. In addition, 7 physiotherapists, 8 aged care support workers, and 6 managers from 7 different aged care provider partners participated in this study. Semistructured interviews were conducted to explore stakeholders' experiences with the TOP UP program, gather suggestions for improvement, and obtain insights for the future implementation of similar telephysiotherapy programs. The interview framework and coding processes were informed by behavior changes and implementation frameworks. Data were analyzed using an abductive approach, informed by 2 behavioral change theories (Capability, Opportunity, Motivation, and Behavior Model and Self-Determination Theory) and the Nonadoption, Abandonment and Challenges to the Scale-Up, Spread and Sustainability of Health and Care Technologies framework.

RESULTS

All participants (n=39) reported high levels of acceptability for the TOP UP program and cited multiple perceived benefits. The thematic analysis generated 6 main themes: telephysiotherapy expands opportunity; tailored physiotherapy care with local support enhances motivation; engaging, older adult-friendly educational resources build capability; flexible reablement approach fosters autonomy; telephysiotherapy is safe, effective, and acceptable for many; and organizational commitment is required to embed telehealth. The motivation to exercise was enhanced by Zoom's convenience, use of tailored web-based exercise resources, and companionable local support.

CONCLUSIONS

This study highlights the inherent value of telephysiotherapy in aged care, emphasizing the need for investment in staff training, local support, and older adult-friendly resources in future telephysiotherapy iterations. TOP UP represents a convenient and flexible web-based care model that empowers many older adults to receive sustainable, high-quality care precisely when and where they need it.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN 1261000734864; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12621000734864.

Topic evolution before fall incidents in new fallers through natural language processing of general practitioners' clinical notes

BACKGROUND

Falls involve dynamic risk factors that change over time, but most studies on fall-risk factors are cross-sectional and do not capture this temporal aspect. The longitudinal clinical notes within electronic health records (EHR) provide an opportunity to analyse fall risk factor trajectories through Natural Language Processing techniques, specifically dynamic topic modelling (DTM). This study aims to uncover fall-related topics for new fallers and track their evolving trends leading up to falls.

METHODS

This case-cohort study utilised primary care EHR data covering information on older adults between 2016 and 2019. Cases were individuals who fell in 2019 but had no falls in the preceding three years (2016-18). The control group was randomly sampled individuals, with similar size to the cases group, who did not endure falls during the whole study follow-up period. We applied DTM on the clinical notes collected between 2016 and 2018. We compared the trend lines of the case and control groups using the slopes, which indicate direction and steepness of the change over time.

RESULTS

A total of 2,384 fallers (cases) and an equal number of controls were included. We identified 25 topics that showed significant differences in trends between the case and control groups. Topics such as medications, renal care, family caregivers, hospital admission/discharge and referral/streamlining diagnostic pathways exhibited a consistent increase in steepness over time within the cases group before the occurrence of falls.

CONCLUSIONS

Early recognition of health conditions demanding care is crucial for applying proactive and comprehensive multifactorial assessments that address underlying causes, ultimately reducing falls and fall-related injuries.

[Management of polypharmacy in older people with multimorbidity]

If the individual diagnoses of older people with multimorbidity are treated according to guidelines and by different specialists, confusing medication plans are sometimes the consequence. Therefore, a regular and structured drug evaluation is essential. As the life goals of patients can be very different, especially in older age, certain preliminary considerations should be made when starting, prescribing or discontinuing medication, taking into account the individual situation, including geriatric aspects. Updated so-called positive and negative lists provide assistance as to which medications are suitable or unsuitable for older people. Discontinuing certain medications when the life expectancy is reduced certainly makes sense but undertreatment of symptoms that cause distress to people, such as pain, should definitely be avoided.

Association of polypharmacy with occurrence of loneliness and social isolation among older adults

BACKGROUND

Polypharmacy is increasing. The longitudinal association of polypharmacy and social isolation has not been previously reported. The aim of this study was to explore longitudinal associations of polypharmacy with loneliness and social isolation among older adults.

METHODS

Participants aged 60 years and above in southern Sweden were invited for participation. A total of 1526 and 2556 participants were included in the separate analyses for loneliness and social isolation. Polypharmacy was defined as taking five or more medications. Associations of polypharmacy with occurrence of loneliness and social isolation were estimated using logistic regression models.

RESULTS

During follow-up, 409 and 414 participants developed loneliness and social isolation, respectively. The odds for loneliness occurrence were higher for participants with polypharmacy compared to participants without polypharmacy (OR, 1.37; 95% CI, 1.05-1.78; P = 0.020). For participants without polypharmacy, the probability of developing loneliness was 0.28 (95% CI, 0.25-0.31), while for those with polypharmacy this probability was 25% higher (0.35; 95% CI, 0.30-0.39). The odds for social isolation occurrence were higher for participants with polypharmacy compared to participants without polypharmacy (OR, 1.29; 95% CI, 1.02-1.64; P = 0.036). For participants without polypharmacy, the probability of developing social isolation was 0.16 (95% CI, 0.14-0.18), while for those with polypharmacy this probability was 18% higher (0.19; 95% CI, 0.17-0.22).

CONCLUSIONS

Polypharmacy was associated with loneliness and social isolation occurrence among older adults. Consideration of loneliness and social isolation are warranted when caring for older adults taking multiple medications.

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

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

In-Hospital Fall Risk Prediction by Objective Measurement of Lower Extremity Function in a High-Risk Population

OBJECTIVES

Limited data exist regarding association between physical performance and in-hospital falls. This study was performed to investigate the association between physical performance and in-hospital falls in a high-risk population.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The study population consisted of 1200 consecutive patients with a median age of 74 years (50.8% men) admitted to a ward with high incidence rates of falls, primarily in the departments of geriatrics and neurology, in a university hospital between January 2019 and December 2021.

METHODS

Short Physical Performance Battery (SPPB) was measured after treatment in the acute phase. As the primary end point of the study, the incidence of in-hospital falls was examined prospectively based on data from mandatory standardized incident report forms and electronic patient records.

RESULTS

SPPB assessment was performed at a median of 3 days after admission, and the study population had a median SPPB score of 3 points. Falls occurred in 101 patients (8.4%) over a median hospital stay of 15 days. SPPB score showed a significant inverse association with the incidence of in-hospital falls after adjusting for possible confounders (adjusted odds ratio for each 1-point decrease in SPPB: 1.19, 95% CI 1.10-1.28; P < .001), and an SPPB score ≤6 was significantly associated with increased risk of in-hospital falls. Inclusion of SPPB with previously identified risk factors significantly increased the area under the curve for in-hospital falls (0.683 vs. 0.740, P = .003).

CONCLUSION AND IMPLICATIONS

This study demonstrated an inverse association of SPPB score with risk of in-hospital falls in a high-risk population and showed that SPPB assessment is useful for accurate risk stratification in a hospital setting.

Polypharmacy, physical activity, and sedentary time in older adults: A scoping review

OBJECTIVE

To map out the studies that have investigated the associations of polypharmacy and/or potentially inappropriate medication (PIM) use with physical activity and sedentary time in older adults.

METHODS

We conducted a literature search from inception to December 2022 in PubMed, Embase, Web of Science, and Scopus.

INCLUSION CRITERIA

observational studies including older adults (≥60 years); English, Portuguese, and Spanish languages; any definition of polypharmacy; implicit and explicit criteria of PIM use; physical activity and/or sedentary time data.

RESULTS

Fourteen cross-sectional studies were included; 11 defined polypharmacy as ≥5 medications (prevalence ranging from 9.5 % to 57 %). No study reported information on PIM use. Most studies included participants aged <80 years. Twelve studies included self-reported measures of physical activity, while two studies used accelerometer-measured physical activity. Ten studies included analyses adjusted for confounders, and nine considered polypharmacy as an outcome. All of them demonstrated an inverse association between physical activity and polypharmacy, irrespective of the definition of polypharmacy and the assessment method employed (self-reported or accelerometry). One study reported an inverse association between polypharmacy (as the exposure) and physical activity (as the outcome). None of the studies investigated the association between sedentary time and polypharmacy.

CONCLUSIONS

Limited evidence suggests an inverse association between physical activity and polypharmacy in older adults. However, the relationship between PIM use, physical activity, and sedentary time remains unknown. Longitudinal studies utilizing objectively-measured physical activity and sedentary time are needed to better clarify the relationship between these movement behaviors and polypharmacy and/or PIM use in older adults.

A Comprehensive Analysis of Risk Factors Associated With Inpatient Falls

OBJECTIVES

The primary objective of this study was to identify the relationship between rates of falls among hospitalized patients and the use of inpatient medications associated with falls.

METHODS

This is a retrospective study on patients older than 60 years, hospitalized between January 1, 2021, and December 31, 2021. Ventilated patients and patients with a length of stay or fall less than 48 hours after admission were excluded. Falls were determined by assessing documented post fall assessments in the medical record. Patients who fell were matched 3:1 with control patients based on demographic data (age, sex, length of stay up to the fall time, and Elixhauser Comorbidity score). For controls, a pseudo time to fall was assigned based on matching. Medication information was gathered from barcode administration data. Statistical analysis was conducted using R and RStudio.

RESULTS

A total of 6363 fall patients and 19,089 controls met the inclusion and exclusion criteria. Seven drug classes were identified as statistically significant ( P < 0.001) in increasing an inpatient's rate of falling: angiotensin-converting enzyme inhibitors (unadjusted odds ratio [OR], 1.22), antipsychotics (OR, 1.93), benzodiazepines (OR, 1.57), serotonin modulators (OR, 1.2), selective serotonin-reuptake inhibitors (OR, 1.26), tricyclics and norepinephrine reuptake inhibitors (OR, 1.45), and miscellaneous antidepressants (OR, 1.54).

CONCLUSIONS

Hospitalized patients older than 60 years are more likely to fall while taking angiotensin-converting enzyme inhibitors, antipsychotics, benzodiazepines, serotonin modulators, selective serotonin-reuptake inhibitors, tricyclics, norepinephrine reuptake inhibitors, or miscellaneous antidepressants. Patients on opiates and diuretics had a significant decrease in rate of falls.

Effects of a clinical decision support system and patient portal for preventing medication-related falls in older fallers: Protocol of a cluster randomized controlled trial with embedded process and economic evaluations (ADFICE_IT)

BACKGROUND

Falls are the leading cause of injury-related mortality and hospitalization among adults aged ≥ 65 years. An important modifiable fall-risk factor is use of fall-risk increasing drugs (FRIDs). However, deprescribing is not always attempted or performed successfully. The ADFICE_IT trial evaluates the combined use of a clinical decision support system (CDSS) and a patient portal for optimizing the deprescribing of FRIDs in older fallers. The intervention aims to optimize and enhance shared decision making (SDM) and consequently prevent injurious falls and reduce healthcare-related costs.

METHODS

A multicenter, cluster-randomized controlled trial with process evaluation will be conducted among hospitals in the Netherlands. We aim to include 856 individuals aged ≥ 65 years that visit the falls clinic due to a fall. The intervention comprises the combined use of a CDSS and a patient portal. The CDSS provides guideline-based advice with regard to deprescribing and an individual fall-risk estimation, as calculated by an embedded prediction model. The patient portal provides educational information and a summary of the patient's consultation. Hospitals in the control arm will provide care-as-usual. Fall-calendars will be used for measuring the time to first injurious fall (primary outcome) and secondary fall outcomes during one year. Other measurements will be conducted at baseline, 3, 6, and 12 months and include quality of life, cost-effectiveness, feasibility, and shared decision-making measures. Data will be analyzed according to the intention-to-treat principle. Difference in time to injurious fall between the intervention and control group will be analyzed using multilevel Cox regression.

DISCUSSION

The findings of this study will add valuable insights about how digital health informatics tools that target physicians and older adults can optimize deprescribing and support SDM. We expect the CDSS and patient portal to aid in deprescribing of FRIDs, resulting in a reduction in falls and related injuries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05449470 (7-7-2022).

Associations between doses of fall-risk-increasing drugs (FRIDs) and falls of hospitalized patients

Falls are a serious public health problem in the aging population because of the associated clinical and socioeconomic impact. Although previous studies have investigated fall-risk-increasing drugs (FRIDs), few studies have focused on dosage among adult inpatients. This study aimed to evaluate associations between fall risk and dosage of different FRIDs classes in hospital inpatients. Inpatients who experienced falls at medical or surgical wards of Changhua Christian Hospital from January 2017 to December 2021 were identified and matched by age, sex, and hospital ward to randomly selected controls (four per case). Anonymous patient data were extracted from the hospital medical data repository, including demographic characteristics, comorbidities, fall-risk scores, and drug prescriptions. Medication dosages were computed using the anatomical therapeutic chemical classification and the defined daily dose system of the World Health Organization. A total of 852 cases and 3408 controls were identified as eligible. Reducing the use of CNS-active medications, administering lower doses of sedative-hypnotics, prescribing sufficient dopaminergic anti-Parkinson agents, and using NSAIDs instead of opioids are imperative in preventing falls among hospitalized patients according to the findings in the study.

Anticoagulant use in older persons at risk for falls: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical narrative review was to summarise the existing knowledge on the use of anticoagulants and potential adverse events in older people at risk of falls with a history of atrial fibrillation or venous thromboembolism. The review also offers practical steps prescribers can take when (de-)prescribing anticoagulants to maximise safety.

METHODS

Literature searches were conducted using PubMed, Embase and Scopus. Additional articles were identified by searching reference lists.

RESULTS

Anticoagulants are often underused in older people due to concerns about the risk of falls and intracranial haemorrhage. However, evidence suggests that the absolute risk is low and outweighed by the reduction in stroke risk. DOACs are now recommended first line for most patients due to their favourable safety profile. Off-label dose reduction of DOACs is not recommended due to reduced efficacy with limited reduction in bleeding risk. Medication review and falls prevention strategies should be implemented before prescribing anticoagulation. Deprescribing should be considered in severe frailty, limited life expectancy and increased bleeding risk (e.g., cerebral microbleeds).

CONCLUSION

When considering whether to (de-)prescribe anticoagulants, it is important to consider the risks associated with stopping therapy in addition to potential adverse events. Shared decision-making with the patient and their carers is crucial as patient and prescriber views often differ.

European position paper on polypharmacy and fall-risk-increasing drugs recommendations in the World Guidelines for Falls Prevention and Management: implications and implementation

Falls prevention and management in older adults is a critical global challenge. One of the key risk factors for falls is the use of certain medications. Therefore, to prevent medication-related falls, the following is recommended in the recent World Guidelines for Falls Prevention and Management: (1) assess for fall history and the risk of falls before prescribing potential fall-risk-increasing drugs (FRIDs), (2) use a validated, structured screening and assessment tool to identify FRIDs when performing a medication review, (3) include medication review and appropriate deprescribing of FRIDs as a part of the multifactorial falls prevention intervention, and (4) in long-term care residents, if multifactorial intervention cannot be conducted due to limited resources, the falls prevention strategy should still always include deprescribing of FRIDs.In the present statement paper, the working group on medication-related falls of the World Guidelines for Falls Prevention and Management, in collaboration with the European Geriatric Medicine Society (EuGMS) Task and Finish group on FRIDs, outlines its position on how to implement and execute these recommendations in clinical practice.Preferably, the medication review should be conducted as part of a comprehensive geriatric assessment to produce a personalized and patient-centered assessment. Furthermore, the major pitfall of the published intervention studies so far is the suboptimal implementation of medication review and deprescribing. For the future, it is important to focus on gaining which elements determine successful implementation and apply the concepts of implementation science to decrease the gap between research and practice.

Centrally acting antihypertensives and alpha-blockers in people at risk of falls: therapeutic dilemmas-a clinical review

PURPOSE

The aim of this clinical review was to summarise the existing knowledge on the adverse effects of alpha-blockers and centrally acting antihypertensives, the effect these may have on falls risk, and guide deprescribing of these medications.

METHODS

Literature searches were conducted using PubMed and Embase. Additional articles were identified by searching reference lists and reference to personal libraries. We discuss the place of alpha-blockers and centrally acting antihypertensives in the treatment of hypertension and methods for deprescribing.

RESULTS

Alpha-blockers and centrally acting antihypertensives are no longer recommended for the treatment of hypertension unless all other agents are contraindicated or not tolerated. These medications carry a significant falls risk and non-falls risk-associated side effects. Tools to aid and guide de-prescribing and monitoring of the withdrawal of these medication classes are available to assist the clinician including information on reducing the risk of withdrawal syndromes.

CONCLUSIONS

Centrally acting antihypertensives and alpha-blockers increase the risk of falls through a variety of mechanisms-principally by increasing the risk of hypotension, orthostatic hypotension, arrhythmias and sedation. These agents should be prioritised for de-prescribing in older frailer individuals. We identify a number of tools and a withdrawal protocol to aid the clinician in identifying and de-prescribing these medications.

Prescribing patterns of fall risk-increasing drugs in older adults hospitalized for heart failure

BACKGROUND

Older adults hospitalized for heart failure (HF) are at risk for falls after discharge. One modifiable contributor to falls is fall risk-increasing drugs (FRIDs). However, the prevalence of FRIDs among older adults hospitalized for HF is unknown. We describe patterns of FRIDs use and examine predictors of a high FRID burden.

METHODS

We used the national biracial REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a prospective cohort recruited from 2003-2007. We included REGARDS participants aged ≥ 65 years discharged alive after a HF hospitalization from 2003-2017. We determined FRIDs -cardiovascular (CV) and non-cardiovascular (non-CV) medications - at admission and discharge from chart abstraction of HF hospitalizations. We examined the predictors of a high FRID burden at discharge via modified Poisson regression with robust standard errors.

RESULTS

Among 1147 participants (46.5% women, mean age 77.6 years) hospitalized at 676 hospitals, 94% were taking at least 1 FRID at admission and 99% were prescribed at least 1 FRID at discharge. The prevalence of CV FRIDs was 92% at admission and 98% at discharge, and the prevalence of non-CV FRIDs was 32% at admission and discharge. The most common CV FRID at admission (88%) and discharge (93%) were antihypertensives; the most common agents were beta blockers (61% at admission, 75% at discharge), angiotensin-converting enzyme inhibitors (36% vs. 42%), and calcium channel blockers (32% vs. 28%). Loop diuretics had the greatest change in prevalence (53% vs. 72%). More than half of the cohort (54%) had a high FRID burden (Agency for Healthcare Research and Quality (AHRQ) score ≥ 6), indicating high falls risk after discharge. In a multivariable Poisson regression analysis, the factors strongly associated with a high FRID burden at discharge included hypertension (PR: 1.41, 95% CI: 1.20, 1.65), mood disorder (PR: 1.24, 95% CI: 1.10, 1.38), and hyperpolypharmacy (PR: 1.88, 95% CI: 1.64, 2.14).

CONCLUSIONS

FRID use was nearly universal among older adults hospitalized for HF; more than half had a high FRID burden at discharge. Further work is needed to guide the management of a common clinical conundrum whereby guideline indications for treating HF may contribute to an increased risk for falls.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effects of pharmaceutical interventions on potentially inappropriate medications in older patients: a systematic review and meta-analysis

Introduction

Potentially inappropriate medications (PIMs) is a particular concern in older patients and is associated with negative health outcomes. As various interventions have been developed to manage it, we performed a systematic review and meta-analysis to evaluate the effect of pharmaceutical interventions on outcomes of PIMs in older patients.

Methods

Meta-analysis of eligible randomized controlled trials (RCTs) was conducted to report the outcomes of pharmaceutical interventions in older patients searching from the databases of Cochrane Library, PubMed, Embase, Web of Science, Clinicaltrials.gov, SinoMed and Chinese Clinical Trial Registry (ChiCTR). The PRISMA guidelines were followed and the protocol was registered in PROSPERO (CRD42019134754). Cochrane bias risk assessment tool and the modified Jadad scale were used to assess the risk bias. RevMan software was used for data processing, analysis and graphical plotting.

Results

Sixty-five thousand, nine hundred seventy-one patients in 14 RCTs were included. Of the primary outcomes, pharmaceutical interventions could significantly reduce the incidence of PIMs in older patients (OR = 0.51, 95% CI: 0.42, 0.62; p < 0.001), and the number of PIMs per person (MD = -0.41, 95%CI: -0.51, -0.31; p < 0.001), accompanying by a low heterogeneity. Subgroup analysis showed that the application of computer-based clinical decision support for pharmacological interventions could remarkably decrease the incidence of PIMs and two assessment tools were more effective. Of the secondary outcomes, the meta-analysis showed that pharmacological interventions could reduce the number of drugs used per person (MD = -0.94, 95%CI: -1.51, -0.36; p = 0.001) and 30-day readmission rate (OR = 0.58, 95%CI: 0.36, 0.92; p = 0.02), accompanying by a low heterogeneity. However, the pharmaceutical interventions demonstrated no significant improvement on all-cause mortality and the number of falls.

Conclusion

Our findings supported the efficacy of pharmaceutical interventions to optimize the use and management of drugs in older patients.

Systematic review registration

https://clinicaltrials.gov/, CRD42019134754.

The association between diuretics and falls in older adults: A systematic review and meta-analysis

OBJECTIVE

Diuretic intake increases the risk of falling. However, previous studies have shown inconsistent correlations between diuretics and falls. This meta-analysis aimed to provide a comprehensive overview of the relationship between diuretic use and risk of falls in older adult individuals.

METHODS

Six databases (Cochrane Library, PubMed, Medline, CINAHL, Web of Science, and EMBASE) were searched from their inception to November 9, 2022. The risk of bias was independently evaluated using the Newcastle-Ottawa Quality Assessment Scale. A comprehensive meta-analysis was used to analyze the eligible studies.

RESULTS

Fifteen articles were analyzed. Studies have shown that diuretics can increase the risk of falls in older adult individuals. The probability of falls in older adult individuals who used diuretics was 1.185 times higher than in those who did not take diuretics.

CONCLUSION

Diuretics were significantly associated with an increased risk of falls.

Costs and Survival of Patients having Experienced a Hospitalized Fall-Related Injury in France: A Population-Based Study

OBJECTIVES

To assess the annual costs 2 years before and 2 years after a hospitalized fall-related injury (HFRI) and the 2-year survival among the population 75+ years old.

DESIGN

We performed a population-based, retrospective cohort study using the French national health insurance claims database.

SETTING AND PARTICIPANTS

Patients 75+ years old who had experienced a fall followed by hospitalization, identified using an algorithm based on International Classification of Diseases codes. Data related to a non-HFRI population matched on the basis of age, sex, and geographical area were also extracted.

METHODS

Cost analyses were performed from a health insurance perspective and included direct costs. Survival analyses were conducted using Kaplan-Meier curves and Cox regression. Descriptive analyses of costs and regression modeling were carried out. Both regression models for costs and on survival were adjusted for age, sex, and comorbidities.

RESULTS

A total of 1495 patients with HFRI and 4484 non-HFRI patients were identified. Patients with HFRI were more comorbid than the non-HFRI patients over the entire periods, particularly in the year before and the year after the HFRI. Patients with HFRI have significantly worse survival probabilities, with an adjusted 2.14-times greater risk of death over 2-year follow-up and heterogeneous effects determined by sex. The annual incremental costs between patients with HFRI and non-HFRI individuals were €1294 and €2378, respectively, 2 and 1 year before the HFRI, and €11,796 and €1659, respectively, 1 and 2 years after the HFRI. The main cost components differ according to the periods and are mainly accounted for by paramedical acts, hospitalizations, and drug costs. When fully adjusted, the year before the HFRI and the year after the HFRI are associated with increase in costs.

CONCLUSIONS AND IMPLICATIONS

We have provided real-world estimates of the cost and the survival associated with patients with HFRI. Our results highlight the urgent need to manage patients with HFRI at an early stage to reduce the significant mortality as well as substantial additional cost management. Special attention must be paid to the fall-related increasing drugs and to optimizing management of comorbidities.

Association of medication use with falls and mortality among long-term care residents: a longitudinal cohort study

BACKGROUND

Falls in long-term care are common. The aim of our study was to explore how medication use is associated with incidence of falls, related consequences, and all-cause mortality among long-term care residents.

METHODS

Five hundred thirty two long-term care residents aged 65 years or older participated in this longitudinal cohort study in 2018-2021. Data on medication use were retrieved from medical records. Polypharmacy was defined as use of 5-10 medications and excessive polypharmacy as use of > 10 medications. The numbers of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment. Participants were followed for three years for mortality. All analysis were adjusted for age, sex, Charlson Comorbidity Index, Clinical dementia rating, and mobility.

RESULTS

A total of 606 falls occurred during the follow-up. Falls increased significantly with the number of medications used. Fall rate was 0.84/person-years (pyrs) (95% CI 0.56 to 1.13) for the non-polypharmacy group, 1.13/pyrs (95% CI 1.01 to 1.26) for the polypharmacy group, and 1.84/pyrs (95% CI 1.60 to 2.09) for the excessive polypharmacy group. Incidence rate ratio for falls was 1.73 (95% CI 1.44 to 2.10) for opioids, 1.48 (95% CI 1.23 to 1.78) for anticholinergic medication, 0.93 (95% CI 0.70 to 1.25) for psychotropics, and 0.91 (95% CI 0.77 to 1.08) for Alzheimer medication. The three-year follow-up showed significant differences in mortality between the groups, the lowest survival rate (25%) being in the excessive polypharmacy group.

CONCLUSION

Polypharmacy, opioid and anticholinergic medication use predicted incidence of falls in long-term care. The use of more than 10 medications predicted all-cause mortality. Special attention should be paid to both number and type of medications when prescribing in long-term care.

Attainment of NICE blood pressure targets among older people with newly diagnosed hypertension: nationwide linked electronic health records cohort study

BACKGROUND

it is not known if clinical practice reflects guideline recommendations for the management of hypertension in older people and whether guideline adherence varies according to overall health status.

AIMS

to describe the proportion of older people attaining National Institute for Health and Care Excellence (NICE) guideline blood pressure targets within 1 year of hypertension diagnosis and determine predictors of target attainment.

METHODS

a nationwide cohort study of Welsh primary care data from the Secure Anonymised Information Linkage databank including patients aged ≥65 years newly diagnosed with hypertension between 1st June 2011 and 1st June 2016. The primary outcome was attainment of NICE guideline blood pressure targets as measured by the latest blood pressure recording up to 1 year after diagnosis. Predictors of target attainment were investigated using logistic regression.

RESULTS

there were 26,392 patients (55% women, median age 71 [IQR 68-77] years) included, of which 13,939 (52.8%) attained a target blood pressure within a median follow-up of 9 months. Success in attaining target blood pressure was associated with a history of atrial fibrillation (OR 1.26, 95% CI 1.11, 1.43), heart failure (OR 1.25, 95% CI 1.06, 1.49) and myocardial infarction (OR 1.20, 95% CI 1.10, 1.32), all compared to no history of each, respectively. Care home residence, the severity of frailty, and increasing co-morbidity were not associated with target attainment following adjustment for confounder variables.

CONCLUSIONS

blood pressure remains insufficiently controlled 1 year after diagnosis in nearly half of older people with newly diagnosed hypertension, but target attainment appears unrelated to baseline frailty, multi-morbidity or care home residence.

[Polypharmacy in nursing homes: options to improve drug therapy safety]

Patients in need of care usually suffer from multiple chronic conditions and therefore receive a high number of drugs. Polypharmacy involves multiple risks, for example, drug-drug and drug-disease interactions, adverse effects and potentially inappropriate medication (PIM), more hospital admissions, and increased mortality.Residents in long-term care facilities are particularly sensitive to adverse drug reactions because of age-related changes, frailty, and the high prevalence of dementia. Numerous drugs have side effects that lead to sedation, particularly in old age, and increase the risk of falls. In addition, anticholinergic effects negatively modify cognition. These PIMs are frequently prescribed to nursing home residents.The medication process in long-term care facilities is complex and requires numerous coordinated processes. In addition to the correct administration, the nursing staff have other important tasks such as monitoring the effects and potential adverse drug reactions and communicating their observations to the prescribing physicians and home-supplying pharmacists. The nursing staff therefore play a crucial role in the prescription of psychotropic drugs and contribute to the medication quality for nursing home residents. National and international studies indicate that improvements of polypharmacy and drug therapy safety in nursing homes can only be achieved by interprofessional collaboration.

Patient Falls in Seclusion Rooms in Psychiatric Inpatient Care: A Sociotechnical Probabilistic Risk Modeling Study

BACKGROUND

Patient falls are a major adverse event in psychiatric inpatient care.

PURPOSE

To model the risk for patient falls in seclusion rooms in psychiatric inpatient care.

METHODS

Sociotechnical probabilistic risk assessment (ST-PRA) was used to model the risk for falls. Data sources were the research team, literature review, and exploration groups of psychiatric nurses. Data were analyzed with fault tree analysis.

RESULTS

The risk for a patient fall in a seclusion room was 1.8%. Critical paths included diagnosis of a psychiatric disorder, the mechanism of falls, failure to assess and prevent falls, and psychological or physical reason. The most significant individual risk factor for falls was diagnosis of schizophrenia.

CONCLUSIONS

Falls that occur in seclusion events are associated with physical and psychological risk factors. Therefore, risk assessment methods and fall prevention interventions considering patient behavioral disturbance and physiological risk factors in seclusion are warranted.

Cardiovascular disease, muscle function, and long-term falls risk: The Perth Longitudinal Study of Ageing Women

BACKGROUND

A few cross-sectional studies have highlighted inconsistent associations between cardiovascular disease (CVD) and musculoskeletal conditions. We sought to investigate the relationship between clinical CVD including subtypes, compromised muscle function, as well as incident self-reported and injurious falls in older women.

MATERIALS AND METHODS

1431 community-dwelling older women (mean age ± SD; 75.2 ± 2.7 years) were included in over 14.5 years of a prospective study, the Perth Longitudinal Study of Ageing in Women. CVD (up to 18-years prior to the baseline visit) and injurious fall hospitalizations over 14.5 years were obtained from linked health records. Self-reported falls for five years were obtained via a written adverse event diary posted every four months. Timed-Up-and-Go (TUG) test and hand grip strength were used to assess mobility and muscle strength, respectively. Mobility impairment was defined as TUG performance >10.2 sec and muscle weakness characterized as grip strength <22 kg.

RESULTS

Over 5-years, 411 (28.7%) women reported a falls, while 567 (39.6%) were hospitalized due to an injurious fall over 14.5 years. Prior CVD events were associated with 32% (HR 1.32 95%CI, 1.06-1.64) and 29% (HR 1.29 95%CI, 1.07-1.56) increased risk of self-reported and injurious falls, respectively, in multivariable-adjusted models. When considering subtypes of CVD, only cerebrovascular disease was related to self-reported (HR 1.77; 95%CI, 1.15-2.72) and injurious falls requiring hospitalization (HR 1.51; 95%CI, 1.00-2.27). CVD was also associated with cross-sectional and prospective mobility impairments. However, no evidence for such relationships was observed for muscle weakness.

CONCLUSIONS

Prevalent CVD events, particularly cerebrovascular disease, are related to an increased risk of long-term falls. These findings highlight the need to recognize increased falls risk in patients with CVD. Further, there is a need to understand whether incorporating prevalent CVD into falls screening tools improves risk stratification or affects model calibration.