Risk of falls associated with antihypertensive medication: population-based case-control study

Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents

Importance

Limited evidence exists on the association between initiation of antihypertensive medication and risk of fractures in older long-term nursing home residents.

Objective

To assess the association between antihypertensive medication initiation and risk of fracture.

Design, Setting, and Participants

This was a retrospective cohort study using target trial emulation for data derived from 29 648 older long-term care nursing home residents in the Veterans Health Administration (VA) from January 1, 2006, to October 31, 2019. Data were analyzed from December 1, 2021, to November 11, 2023.

Exposure

Episodes of antihypertensive medication initiation were identified, and eligible initiation episodes were matched with comparable controls who did not initiate therapy.

Main Outcome and Measures

The primary outcome was nontraumatic fracture of the humerus, hip, pelvis, radius, or ulna within 30 days of antihypertensive medication initiation. Results were computed among subgroups of residents with dementia, across systolic and diastolic blood pressure thresholds of 140 and 80 mm Hg, respectively, and with use of prior antihypertensive therapies. Analyses were adjusted for more than 50 baseline covariates using 1:4 propensity score matching.

Results

Data from 29 648 individuals were included in this study (mean [SD] age, 78.0 [8.4] years; 28 952 [97.7%] male). In the propensity score-matched cohort of 64 710 residents (mean [SD] age, 77.9 [8.5] years), the incidence rate of fractures per 100 person-years in residents initiating antihypertensive medication was 5.4 compared with 2.2 in the control arm. This finding corresponded to an adjusted hazard ratio (HR) of 2.42 (95% CI, 1.43-4.08) and an adjusted excess risk per 100 person-years of 3.12 (95% CI, 0.95-6.78). Antihypertensive medication initiation was also associated with higher risk of severe falls requiring hospitalizations or emergency department visits (HR, 1.80 [95% CI, 1.53-2.13]) and syncope (HR, 1.69 [95% CI, 1.30-2.19]). The magnitude of fracture risk was numerically higher among subgroups of residents with dementia (HR, 3.28 [95% CI, 1.76-6.10]), systolic blood pressure of 140 mm Hg or higher (HR, 3.12 [95% CI, 1.71-5.69]), diastolic blood pressure of 80 mm Hg or higher (HR, 4.41 [95% CI, 1.67-11.68]), and no recent antihypertensive medication use (HR, 4.77 [95% CI, 1.49-15.32]).

Conclusions and Relevance

Findings indicated that initiation of antihypertensive medication was associated with elevated risks of fractures and falls. These risks were numerically higher among residents with dementia, higher baseline blood pressures values, and no recent antihypertensive medication use. Caution and additional monitoring are advised when initiating antihypertensive medication in this vulnerable population.

Unintentional Injury Death Among Solid Organ Transplant Recipients: Trends and Risk Factors

Unintentional injury death (UID) is a leading cause of mortality worldwide, and individuals with chronic diseases are at higher risk. Though organ transplant can improve the lives of those with chronic disease, these individuals remain in suboptimal physical and mental health after surgery that predisposes them to UID. To quantify the scale of UID among solid organ transplant recipients, we performed a retrospective analysis using United Network of Organ Sharing data from adults who underwent kidney, liver or pancreas transplant between 2000-2021. Our study aimed to identify risk factors for UID in this cohort by comparing basic patient, donor, and transplant characteristics of the groups (UID or all other cause death). The largest proportion of UID was seen in the kidney group (.8%), followed by liver (.7%) and then pancreas (.3%). Male sex was the most significant risk factor among kidney and liver recipients. Whites had a higher risk for UID relative to their non-White counterparts in the kidney and liver groups. In both groups, advancing age conferred a protective effect, whereas higher functional status was a risk factor. Our findings shed new light on a significant source of mortality within the transplant population.

Circumstances of unintentional fall-related adult deaths: Utah, 2010-2020

OBJECTIVE

Fall-related deaths have been on the rise nationwide. Our objective was to characterise the trend in unintentional fall-related adult deaths in Utah and evaluate the underlying and contributing causes associated with these deaths.

METHODS

We used 2010-2020 Utah death certificate data and included all Utah deaths aged 18 and older with a fall listed on their death records as the underlying or contributing cause of death in the analysis.

RESULTS

From 2010 to 2020, the overall age-adjusted unintentional fall death rate increased 70% from 15.7 to 26.8 per 100 000 person-years, while the overall age-adjusted death rate increase was 12% at the time. On average, the group with falls as one of the contributing causes had 4.9 other contributing causes, while the group with falls as an underlying cause had 3.3; the two averages were statistically different. Incidence of death increased 60% (12.1-19.4 per 100 000) for falls classified as the underlying cause of death and 103% (3.6-7.3 per 100 000) for those with fall as a contributing cause. Coding for the type of fall became more specific with a 30% decrease in unspecified fall (International Classification of Diseases, 10th revision code W19) (5.9-4.1 per 100 000).

CONCLUSION

There was an increasing trend of unintentional fall-related adult deaths in Utah from 2010 to 2020. This increase is consistent with national trends. Our data supports there is more specific reporting of fall deaths, but better reporting alone cannot explain the uptrend. Furthermore, the deaths with falls as contributing causes increased the most, and these individuals have more comorbidities.

The combination of locomotive syndrome and poor sleep quality is a risk factor of falls among community-dwelling middle-aged and older women: A cross-sectional study

AIM

The combination of locomotive syndrome (LS) and poor sleep quality (PQ) has not yet been shown to result in falls or to affect bone conditions in old age and middle age. [Correction added on 1 December 2023, after first online publication: The preceding sentence has been updated for clarity.] METHODS: This cross-sectional study enrolled 2233 community-dwelling middle-aged to older Japanese women. LS and PSQ were assessed by the stand-up test, two-step test, the 25-question Geriatric Locomotive Function Scale, and the Pittsburgh Sleep Quality Index (PSQI). Participants with both LS 1-3 (any) and a PSQI score ≥6 were classified as belonging to the LS(+)/PSQ(+) group. The incidence of falls in the previous month was collected using a self-administered questionnaire. Bone conditions were evaluated using an ultrasonic bone densitometer.

RESULTS

The LS(+)/PSQ(+) group independently had a higher risk of falls after adjusting for confounding factors than the LS(-)/PSQ(-) group using multiple logistic regression analysis (odds ratio 1.92, 95% confidence interval 1.01-3.65, P < 0.05). No relationships between LS(-)/PSQ(+) and LS(+)/PSQ(-) groups and the incidences of fall were observed (P > 0.05). [Correction added on 1 December 2023, after first online publication: The two preceding sentences have been corrected to provide greater clarity.] The LS(+)/PSQ(+) group had lower trabecular bone density and cortical bone thickness than the LS(-)/PSQ(-) group (P < 0.05).

CONCLUSION

The combination of LS and PSQ is an independent risk factor of falls, indicating that assessing both LS and PSQ could be useful in detecting middle-aged and older women with low bone density and thickness who fall easily at an early stage. Geriatr Gerontol Int 2023; 23: 912-918.

Prevalence of falls, injury from falls and associations with chronic diseases among community-dwelling older adults in Guangzhou, China: a cross-sectional study

Introduction

As a developing country with the largest older adult population in the world, strengthening the research on falls among the older adults is undoubtedly an urgent item in China. This study aimed to explore the prevalence and risk factors associated with falls and injury from falls among community-dwelling older adults in Guangzhou, China, particularly focusing on their associations with chronic diseases.

Methods

A total of 1,629 participants aged 65 years and above were selected from 11 counties in Guangzhou by the multi-stage stratified random sampling method in 2021. Socio-demographic characteristics, health and lifestyle factors, the status of falls, and injury from falls were measured by structured questionnaires through face-to-face interviews. Chi-square tests and logistic regression analysis were used to identify factors associated with falls and injury from falls. Chord diagrams were used to explore their associations with chronic diseases.

Results

A total of 251 participants (15.41%, 95% CI: 13.98%-17.25%) reported falls, and 162 participants (9.46%, 95% CI:7.72%-11.55%) indicated an injury from falls. Logistic regression analysis showed the results as follows: female patients (adjusted OR = 1.721, 95% CI: 1.681-1.761) aged ≥80 years (1.910, 1.847-1.975), unemployed (1.226, 1.171-1.284), uninsured (1.555, 1.448-1.671), average monthly household income of 2,001-4,000 CNY (1.878, 1.827-1.930), number of services provided by the community health center ≥13 times per year (1.428, 1.383-1.475), illness within 2 weeks (1.633, 1.595-1.672), high-intensity physical activity (2.254, 2.191-2.32), sedentary (1.094, 1.070-1.117), and number of chronic disease illnesses ≥3 (1.930, 1.870-1.993). Meanwhile, those risk factors were also associated with injury from falls. The older adults with medium-intensity physical activity were at lower risk (0.721, 0.705-0.737) of falls and higher risk (1.086, 1.057-1.117) of being injured from falls. Chord diagrams showed the correlations between chronic diseases and falls and injury from falls among community-dwelling older adults in Guangzhou, China.

Conclusion

The high prevalence of falls is found among community-dwelling older adults in Guangzhou, China, which is related to multiple factors such as demographic variables, lifestyle, and health status, especially for chronic diseases. Therefore, targeted interventions should be developed and implemented urgently.

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.

Diuretic use and risk of falls in older women with urinary incontinence

OBJECTIVE

To determine the association between diuretic use and falls in community-dwelling older women with urinary incontinence (UI).

METHODS

We conducted an analytic cross-sectional study using patients' electronic medical records. Patients were women with UI, 65 years or older seen at a urogynecology clinic between January 1, 2018 and September 30, 2019. We used logistic regression analysis to explore the associations between falls and diuretic use.

RESULTS

The study included 108 women, mean age of 75.2 ±7.5 years. Twenty-two (20%) reported one or more falls within the past year and 32 (30%) were diuretic users. Fall prevalence in diuretic users and non-users were 25% (8/32) and 18.4% (14/76), respectively. Diuretic use was not associated with falls (OR = 0.74, 95%CI = 0.22-2.52). Post-hoc analysis revealed inadequate sample size.

CONCLUSIONS

Diuretics use may not be a risk factor for falls in ambulatory older women with UI. A larger sample will be needed to confirm.

The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study

BACKGROUND

Antihypertensives are effective at reducing the risk of cardiovascular disease, but limited data exist quantifying their association with serious adverse events, particularly in older people with frailty. This study aimed to examine this association using nationally representative electronic health record data.

METHODS AND FINDINGS

This was a retrospective cohort study utilising linked data from 1,256 general practices across England held within the Clinical Practice Research Datalink between 1998 and 2018. Included patients were aged 40+ years, with a systolic blood pressure reading between 130 and 179 mm Hg, and not previously prescribed antihypertensive treatment. The main exposure was defined as a first prescription of antihypertensive treatment. The primary outcome was hospitalisation or death within 10 years from falls. Secondary outcomes were hypotension, syncope, fractures, acute kidney injury, electrolyte abnormalities, and primary care attendance with gout. The association between treatment and these serious adverse events was examined by Cox regression adjusted for propensity score. This propensity score was generated from a multivariable logistic regression model with patient characteristics, medical history and medication prescriptions as covariates, and new antihypertensive treatment as the outcome. Subgroup analyses were undertaken by age and frailty. Of 3,834,056 patients followed for a median of 7.1 years, 484,187 (12.6%) were prescribed new antihypertensive treatment in the 12 months before the index date (baseline). Antihypertensives were associated with an increased risk of hospitalisation or death from falls (adjusted hazard ratio [aHR] 1.23, 95% confidence interval (CI) 1.21 to 1.26), hypotension (aHR 1.32, 95% CI 1.29 to 1.35), syncope (aHR 1.20, 95% CI 1.17 to 1.22), acute kidney injury (aHR 1.44, 95% CI 1.41 to 1.47), electrolyte abnormalities (aHR 1.45, 95% CI 1.43 to 1.48), and primary care attendance with gout (aHR 1.35, 95% CI 1.32 to 1.37). The absolute risk of serious adverse events with treatment was very low, with 6 fall events per 10,000 patients treated per year. In older patients (80 to 89 years) and those with severe frailty, this absolute risk was increased, with 61 and 84 fall events per 10,000 patients treated per year (respectively). Findings were consistent in sensitivity analyses using different approaches to address confounding and taking into account the competing risk of death. A strength of this analysis is that it provides evidence regarding the association between antihypertensive treatment and serious adverse events, in a population of patients more representative than those enrolled in previous randomised controlled trials. Although treatment effect estimates fell within the 95% CIs of those from such trials, these analyses were observational in nature and so bias from unmeasured confounding cannot be ruled out.

CONCLUSIONS

Antihypertensive treatment was associated with serious adverse events. Overall, the absolute risk of this harm was low, with the exception of older patients and those with moderate to severe frailty, where the risks were similar to the likelihood of benefit from treatment. In these populations, physicians may want to consider alternative approaches to management of blood pressure and refrain from prescribing new treatment.

Severe Ground Fall Injury Associated with Alcohol Consumption in Geriatric Patients

This study investigated characteristics of geriatric patients sustaining ground fall injury related to alcohol consumption and analyzed factors associated with the severity of such injuries in both alcohol- and non-alcohol-related cases. We retrospectively reviewed geriatric patients sustaining ground falls who were admitted to six university hospitals from 2011 to 2018. Patients were classified into alcohol and non-alcohol groups. Their general characteristics, clinical characteristics, and factors of injury severity were analyzed. A total of 31,177 patients were reviewed. Factors significantly associated with alcohol-related ground-fall injuries were: male, 65~84 years old, injury time other than 06:00~11:59, transportation to emergency department (ED) by ambulance and from other hospitals, injured in residential facilities, transportation areas, public or commercial facilities, activities other than paid or unpaid, non-slippery floor, obstacles, concrete floor, and absence of lights. Factors associated with severe injury after ground fall in alcohol-related cases were: male, injury time at between 06:00 and 17:59, transportation to the ED via ambulance from other hospitals, injured in residential facility, and slippery floor. Risk factors for severity in alcohol-related geriatric fall injury included: male sex, daytime injury, transportation by ambulance, injury in a residential facility, and slippery floor condition. Prophylactic measures and therapeutic interventions by ED teams are needed for the management of such cases.

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

PURPOSE

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

METHOD

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

RESULT

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

CONCLUSION

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

Effectiveness of nursing care provided for fall prevention: Survival analysis of nursing records in a tertiary hospital

AIM

This study was carried out to analyze nursing care provided to patients on high and low fall-risk days and to evaluate the effectiveness of nursing care in terms of preventing falls.

METHODS

A retrospective review of medical records was conducted for patients admitted to a tertiary hospital in Korea. General and clinical information, fall occurrences, Hendrich II Fall Risk Model (HFRM II) fall-risk assessment scores, nursing care related to fall prevention, and medications administered were extracted.

RESULTS

Data from 43,267 days of records for 11,718 patients were analyzed. Nursing assessment, intervention, and administration of medication were provided more frequently on high fall-risk days than on low fall-risk days. Analysis performed on the entire cohort days showed fall occurrence was significantly associated with infrequent mobility assessment and greater usage of anti-anxiety agents. On high fall-risk days, fall occurrence was related to less restraint assessment and greater usage of vessel dilatators.

CONCLUSIONS

The implementation of risk-targeted interventions for fall prevention based on fall-risk assessment is needed. For general fall prevention, assessment of patients' mobility should be strengthened. For high fall-risk patients, it may be more effective for nurses to focus on assessing restraints, evaluating medication records, and withdrawing medications related to falls.

Fall predictors beyond fall risk assessment tool items for acute hospitalized older adults: a matched case-control study

We investigated whether clinical factors including comorbidities, medications, and laboratory results predict inpatient fall risk in older adults. The participants in this case–control study included hospitalized older adults with acute conditions who had falls during their hospital stay (case group) and 410 hospitalized older adults who did not experience falls (control group). Data on medical history, fall risk assessment (Morse Fall Scale; MFS), medications, and laboratory results were obtained. Conditional logistic regression analysis was performed to estimate the association between clinical factors and falls. Receiver operating characteristic curves and area under the curve (AUC) were used to determine whether clinical factors could discriminate between fallers and controls. We evaluated three models: (M1) MFS, (M2) M1 plus age, sex, ward, and polypharmacy, and (M3) M2 plus clinical factors. Patients with diabetes mellitus or MFS scores ≥ 45 had the highest risk of falls. Calcium channel blockers, diuretics, anticonvulsants, and benzodiazepines were associated with high fall risk. The AUC of the three models was 0.615, 0.646, and 0.725, respectively (M1 vs. M2, P = 0.042 and M2 vs. M3, P < .001). Examining clinical factors led to significant improvements in fall prediction beyond that of the MFS in hospitalized older adults.

A systematic review and meta-analysis of fall incidence and risk factors in elderly patients after total joint arthroplasty

BACKGROUND

Falls in the elderly have become a serious social problem worldwide. Approximately a third of persons fall at least once in the year after total joint arthroplasty (TJA), but preventing and treating falls is still challenging in clinical practice. Until now, no formal systematic review or meta-analysis was performed to summarize the risk factors of falls after TJA. The present study aimed to quantitatively and comprehensively conclude the risk factors of falls after TJA in elderly patients.

METHODS

The electronic databases to be searched include CNKI, Embase, Medline, and Cochrane central database (all up to November 2018). All studies on the risk factors of falls after TJA in elderly patients without language restriction were reviewed. Process of evaluation of identified studies and extraction of data were independently conducted by 2 reviewers, qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis completed. All analyses were performed by the software Stata 11.0.

RESULTS

A total of 14 studies were included, which altogether included 1284456 patients with TJA, of them 12879 cases of falls occurred after surgery, suggesting the accumulated incidence of 13.1% and the prevalence of in-hospital falls was 1.0%. This study has provided evidence for the preventing of falls in the elderly patients who were underwent TJA. Outcome measures include advanced age, female, Overweight (BMI≥25 kg/m), falls history, use of walking aid, diabetes, cardiac disease, hypertension, COPD and depressive symptoms. The ABC Scale was significantly negatively correlated with falls after lower extremity joint replacement.

CONCLUSIONS

Related prophylaxis strategies should be implemented in elderly patients involved with above-mentioned risk factors to prevent falls after TJA.

Identification of elders at higher risk for fall with statewide electronic health records and a machine learning algorithm

OBJECTIVE

Predicting the risk of falls in advance can benefit the quality of care and potentially reduce mortality and morbidity in the older population. The aim of this study was to construct and validate an electronic health record-based fall risk predictive tool to identify elders at a higher risk of falls.

METHODS

The one-year fall prediction model was developed using the machine-learning-based algorithm, XGBoost, and tested on an independent validation cohort. The data were collected from electronic health records (EHR) of Maine from 2016 to 2018, comprising 265,225 older patients (≥65 years of age).

RESULTS

This model attained a validated C-statistic of 0.807, where 50 % of the identified high-risk true positives were confirmed to fall during the first 94 days of next year. The model also captured in advance 58.01 % and 54.93 % of falls that happened within the first 30 and 30-60 days of next year. The identified high-risk patients of fall showed conditions of severe disease comorbidities, an enrichment of fall-increasing cardiovascular and mental medication prescriptions and increased historical clinical utilization, revealing the complexity of the underlying fall etiology. The XGBoost algorithm captured 157 impactful predictors into the final predictive model, where cognitive disorders, abnormalities of gait and balance, Parkinson's disease, fall history and osteoporosis were identified as the top-5 strongest predictors of the future fall event.

CONCLUSIONS

By using the EHR data, this risk assessment tool attained an improved discriminative ability and can be immediately deployed in the health system to provide automatic early warnings to older adults with increased fall risk and identify their personalized risk factors to facilitate customized fall interventions.

Sodium-glucose co-transporter 2 inhibitors and the risk of fractures: A propensity score-matched cohort study

PURPOSE

To determine the risk of fractures associated with sodium-glucose co-transporter 2 inhibitors (SGLT2i) compared with dipeptidyl peptidase-4 inhibitors (DPP4i).

METHODS

We conducted a retrospective cohort study using data from the Truven Health MarketScan (2009-2015) databases. Our cohort included patients newly initiating treatment with SGLT2i or DPP-4i between 1 April 2013 and 31 March 2015 that were matched 1:1 using high dimensional propensity scores. Patients were followed up in an as-treated approach starting from initiation of treatment until the earliest of any fracture, treatment discontinuation, disenrollment, or end of data (31 December 2015). Risk of fractures was determined at any time during the follow-up, early in therapy (1-14 days of the follow-up), and later in therapy (15 days and beyond). Cox proportional hazards models were used to determine hazard ratios and robust 95% confidence intervals (95% CI).

RESULTS

After matching, our cohort included 30 549 patients in each treatment group. Over a median follow-up of 219 days, there were 745 fractures overall. The most common site for fractures was the foot (32.7%). The effect estimates for fracture risk occurring at any time during follow-up, early in therapy, and later in therapy were HR 1.11 [95% CI 0.96-1.28], HR 1.82 [95% CI 0.99-3.32], and HR 1.07 [95% CI 0.92-1.24], respectively.

CONCLUSION

There is a possible increase in risk for fractures early in therapy with SGLT2i. Beyond this initial period, SGLT2is had no apparent effect on the incidence of fractures.

Evidence synthesis based on non-randomised studies-a critical review of studies leading to conclusions on fall risk properties of loop diuretics/beta-blockers

PURPOSE

To describe methodological and reporting issues in non-randomised comparative drug safety studies pooled in meta-analyses, with focus on confounding by indication.

METHODS

All studies included in statistically significant meta-analyses in a recent publication investigating fall risk properties of cardiovascular drugs were reviewed. Study characteristics were extracted and assessed.

RESULTS

Nine studies, including between 498 and 321,995 individuals, contributed data to the significant meta-analyses in which loop diuretics and beta-blockers were associated with falls, five published in 2015. Five individual studies reported a statistically significant association. In the five cohort studies, characteristics of exposed vs unexposed individuals were either not reported (n = 3) or differed substantially regarding morbidity (n = 2). Drug treatment was determined at baseline, and data on falls were collected for up to 2 years thereafter. Out of the four case-control studies, the cases and controls in only one study were matched for morbidity. Morbidity characteristics of fallers compared with non-fallers were either not reported (n = 2) or they differed (n = 1) or were reported according to the matched-for diseases (n = 1). Confounding by indication was explicitly discussed in two studies. None of the abstract conclusions considered causality issues or the possibility of confounding by indication.

CONCLUSIONS

Confounding by indication is a major issue in non-randomised comparative drug safety studies, a problem which may be concealed in meta-analyses. To enhance such research, compared groups need to be balanced regarding relevant factors including morbidities and characteristics adequately reported. Confounding by indication needs to be explicitly discussed and highlighted in the abstract conclusion.

Effects of Antihypertensive Class on Falls, Syncope, and Orthostatic Hypotension in Older Adults: The ALLHAT Trial

Hypertension treatment has been implicated in falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether the choice of antihypertensive agent influences the risk of falls, syncope, and OH in older adults is unknown. ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) was a randomized clinical trial that compared the effects of hypertension first-step therapy on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). In a subpopulation of ALLHAT participants, age 65 years and older, we determined the relative risk of falls, syncope, OH, or a composite based on Centers for Medicare and Medicaid Services and Veterans Affairs claims, using Cox regression. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) on outcomes in Cox models adjusted for age, sex, and race. Among 23 964 participants (mean age 69.8±6.8 years, 45% women, 31% non-Hispanic black) followed for a mean of 4.9 years, we identified 267 falls, 755 syncopes, 249 OH, and 1157 composite claims. There were no significant differences in the cumulative incidences of events across randomized drug assignments. However, amlodipine increased risk of falls during the first year of follow-up compared with chlorthalidone (hazard ratio [95% CI]: 2.24 [1.06-4.74]; P=0.03) or lisinopril (hazard ratio [95% CI]: 2.61 [1.03-6.72]; P=0.04). Atenolol use (N=928) was not associated with any of the 3 individual or composite claims. In older adults, the choice of antihypertensive agent had no effect on risk of fall, syncope, or OH long-term. However, amlodipine increased risk of falls within 1 year of initiation. These short-term findings require confirmation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

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

OBJECTIVE

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

DESIGN

Prospective cohort study.

SETTING

Irish Community Pharmacy.

PARTICIPANTS

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

MEASURES

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

RESULTS

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

CONCLUSION

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

Characteristics of fall-related traumatic brain injury in older adults

BACKGROUND

Older adults admitted for falls and its complications, including traumatic brain injury (TBI), is increasing. Recent studies have shown that those with falls who presented to the emergency department (ED) had an increased frequency of ED revisits, especially those with head trauma.

AIM

To determine the characteristics and predictors of fall-related traumatic brain injury (FRTBI) in older adults.

METHODS

Retrospective medical chart review of 339 patients aged 65 years and older admitted for TBI in 2014 due to a fall. Characteristics analysed include demographics, fall circumstances, prior ED visits, polypharmacy, readmission, functional status and specialist outpatient clinic utilisation before and after FRTBI.

RESULTS

A total of 339 (37.4%) patients admitted due to FRTBI was 65 years old and older; 112 (33.0%) for subdural haemorrhage (SDH); 227 (67.0%) for head injury (HI), with a mean age of 80 years. A total of 46 (41.1%) patients with SDH and 107 (47.1%) with HI had a previous ED visit within the last year, while 22 (19.6%) of SDH and 49 (21.6%) of HI had hospitalisation 3 months prior to FRTBI. FRTBI was associated with significant decline in activities of daily living, polypharmacy and increased specialist outpatient clinic appointments (P < 0.001). Mortality was 11 (3.2%). Mild cognitive impairment or dementia was significantly associated with admissions for FRTBI, 3.31 (95% confidence interval 1.68-6.51, P = 0.001) using adjusted logistic regression.

CONCLUSION

FRTBI is associated with significant functional decline and increased resource utilisation with almost half of the patients having had prior ED visits or hospitalisation. Future studies should focus on falls risk assessment and interventions for high-risk older adults prior to discharge from ED and hospital, and its impact on readmissions due to FRTBI.

Thiazide diuretic usage and risk of fracture: a meta-analysis of cohort studies

Inconsistent findings in regard to association between thiazide diuretic use and the risk of fracture have been reported during the past decade. This updated meta-analysis, which pooled data from 11 qualified prospective designed studies, found that thiazides have a significant protective effect on fracture risk.

INTRODUCTION

An updated comprehensive meta-analysis examine the association between thiazide diuretic use and therisk of fracture is needed.

METHODS

Cohort studies regarding thiazide diuretic exposure and the risk of fracture, published from inception to May 1 2017, were identified through MEDLINE, EMBASE, SCOPUS, and the Cochrane Database of Systematic Reviews. The literature search, study selection, study appraisal, and data extraction were pre-defined in the protocol and were independently conducted by two investigators. Due to the heterogeneity of the original studies, a random effects model was used to pool the confounder-adjusted relative risk (RR).

RESULTS

Eleven eligible cohort studies involving 2,193,160 participants were included for analysis. Overall, thiazide diuretic users, as compared with non-users, had a significant 14% reduction in the risk of all fractures (relative risk [RR], 0.86; 95% confidence interval [CI], 0.80-0.93; p = 0.009) and an 18% reduction in the risk of hip fracture (RR, 0.82; 95%CI, 0.80-0.93; p = 0.009). However, the effect size associated with thiazide use became slightly weaker when the analysis was limited to only high-quality original studies (quality score > 8) (RR, 0.89; 95%CI, 0.80-0.99; p = 0.005), studies with a larger sample size (> 10,000) (RR, 0.90; 95%CI, 0.80-1.00; p = 0.002), and studies published after 2007 (RR, 0.92; 95%CI, 0.82-1.02; p = 0.001).

CONCLUSION

Our findings indicate that thiazide diuretic use may convey a decreased risk of fracture and as such, the protective effect of this class of medicine should be considered when prescribing thiazide diuretics in clinical practice.

Very poor agreement between routine outpatient clinic office and ambulatory blood pressure: time to improve an old hospital outpatient clinic routine?

OBJECTIVE

We investigated the agreement between elevated outpatient clinic office blood pressure (OC-OBP) as measured in the daily routine in our University Hospital Cardiology Outpatient Clinic and subsequent awake ambulatory blood pressure (AABP).

METHODS

In all patients referred for ambulatory blood pressure monitoring from our Cardiology Outpatient Clinic, we identified OC-OBP and changes in medication in the period from 1 January 2014 to 15 September 2015. The AABP was used as a reference measurement for the OC-OBP.

RESULTS

A total of 183 patients were included in the study. Their mean age was 62.1±14.0 years and 49% were women. The mean systolic OC-OBP was 166.8±17.9 mmHg and the difference between the mean systolic OC-OBP and AABP was 28.0±19.5 mmHg (P<0.001) with 95% limits of agreement from -10.2 to +66.3 mmHg. The difference in mean systolic OC-OBP and AABP was 18.6±14.7 mmHg in patients less than 45 years (n=21), 24.8±18.2 mmHg in patients 45-74 years (n=121) and 42.3±18.5 mmHg in patients more than or equal to 75 years (n=41). In 32 (17%) of the patients, the antihypertensive treatment was intensified before the AABP, but in nine (28%) of these patients, the antihypertensive treatment was reduced again after the AABP because of low blood pressure.

CONCLUSION

Routine OC-OBP in a busy cardiology clinic agrees poorly with AABP and may lead to unnecessary treatment and pharmacologically induced symptomatic hypotension, particularly in elderly patients. The results of this study urgently call for alternative solutions to routine OC-OBP in hospital outpatient clinics.

Repurposing of approved cardiovascular drugs

Research and development of new drugs requires both long time and high costs, whereas safety and tolerability profiles make the success rate of approval very low. Drug repurposing, applying known drugs and compounds to new indications, has been noted recently as a cost-effective and time-unconsuming way in developing new drugs, because they have already been proven safe in humans. In this review, we discuss drug repurposing of approved cardiovascular drugs, such as aspirin, beta-blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, cardiac glycosides and statins. Regarding anti-tumor activities of these agents, a number of experimental studies have demonstrated promising pleiotropic properties, whereas all clinical trials have not shown expected results. In pathological conditions other than cancer, repurposing of cardiovascular drugs is also expanding. Numerous experimental studies have reported possibilities of drug repurposing in this field and some of them have been tried for new indications ('bench to bedside'), while unexpected results of clinical studies have given hints for drug repurposing and some unknown mechanisms of action have been demonstrated by experimental studies ('bedside to bench'). The future perspective of experimental and clinical studies using cardiovascular drugs are also discussed.

Low vegetable intake increases the risk of fall-related fragility fracture in postmenopausal Taiwanese women, a prospective pilot study in the community

BACKGROUND

The aim of this prospective study was to investigate the relationship between lifestyle factors including nutrition intake and the incidence of fall-related fragility fractures in postmenopausal women.

METHODS

A total of 1169 female volunteers were recruited from participants at the morning health examinations held at each local public health center in the West Chiayi County of Taiwan at the beginning of the study. Laboratory examinations, anthropometric measurements, and questionnaire interviews inquiring about lifestyle factors, including weekly nutrition intake, were performed. Subsequently, four follow-up telephone interviews at intervals of about 6-12 months were performed to inquire about instances of falls and fractures.

RESULTS

Nine hundred and fifty-three subjects responded at least once to the four telephone interviews, and there were 183 postmenopausal women, with a mean age of 68.8 ± 8.3 (49-87) years, reporting falls. Of the 183 women, 25 had incurred new fractures from low-energy impacts. Statistical analysis revealed that older age and hypertension were associated with increased risks of falling. Intake of other deep-colored (nondark-green) vegetables and light-colored vegetables as well as total vegetable intake were associated with reduced risk of fall-related fragility fracture.

CONCLUSION

Among postmenopausal women, older age and the presence of hypertension were associated with increased risks of falls. Increased vegetable intake might be helpful to reduce the incidence of fall-related fragility fractures.

Hypertension and aging

Hypertension is a highly prevalent condition with numerous health risks, and the incidence of hypertension is greatest among older adults. Traditional discussions of hypertension have largely focused on the risks for cardiovascular disease and associated events. However, there are a number of collateral effects, including risks for dementia, physical disability, and falls/fractures which are increasingly garnering attention in the hypertension literature. Several key mechanisms--including inflammation, oxidative stress, and endothelial dysfunction--are common to biologic aging and hypertension development and appear to have key mechanistic roles in the development of the cardiovascular and collateral risks of late-life hypertension. The objective of the present review is to highlight the multi-dimensional risks of hypertension among older adults and discuss potential strategies for treatment and future areas of research for improving overall care for older adults with hypertension.

Challenges in the Management of Hypertension in Older Populations

The prevalence of hypertension increases with age making it a significant health concern for older persons. Aging involves a range of physiological changes such as increases in arterial stiffness, widening pulse pressure, changes in renin and aldosterone levels, decreases in renal salt excretion, declining in renal function, changes in the autonomic nervous system sensitivity and function and changes to endothelial function all of which may not only affect blood pressure but may also affect individual response to pharmacotherapy used to manage hypertension and prevent end organ damage and other complications associated with poor blood pressure control.Unlike many chronic conditions where there is limited evidence for management in older populations, there is good evidence regarding the management of hypertension in the elderly. The findings from multiple large, robust trials have provided a solid evidence-base regarding the management of hypertension in older adults, showing that reduction of blood pressure in older hypertensive populations is associated with reduced mortality and morbidity. Diuretics, agents action on the renin angiotensin system, beta blockers and calcium channel blockers have all been well studied in older populations both in view of the benefits associated with blood pressure lowering and the risks associated with associated adverse events. While all antihypertensive agents will lower blood pressure, when managing hypertension in older persons the choice of agent is dependent not only on the ability to lower blood pressure but also on the potential for harm with older persons. Understanding such potential harms in older populations is essential with older persons experiencing increased sensitivity to many of the adverse effects such as dizziness associated with the use of antihypertensive agents.Despite the wealth of evidence regarding the benefits of managing hypertension in the old and very old, a significant proportion of older individuals with hypertension have suboptimal BP control. While there is good evidence supporting blood pressure lowering in older antihypertensive agents, these have not yet been optimally translated fully into clinical guidelines and clinical practice. There appear to be considerable differences between guidelines in terms of the guidance given to clinicians. Differences in interpretation of the evidence, as well as differences in study design and populations all contribute to differences in the guideline recommendations with respect to older populations, despite the strength of the underlying scientific evidence. Differences around who is considered "old" and what BP targets and management are considered appropriate may lead to confusion among clinicians and further contribute to the evidence-practice lag.

Benefits and risks of antihypertensive medications in the elderly

Hypertension is highly prevalent in older age and accounts for a large proportion of cardiovascular (CV) morbidity and mortality worldwide. Isolated systolic hypertension is more common in the elderly than younger adults and associated with poor outcomes such as cerebrovascular disease and acute coronary events. International guidelines are inconsistent in providing recommendations on optimal blood pressure targets in hypertensive elderly patients as a result of the limited evidence in this population. Evidence from clinical trials supports the use of antihypertensive drugs in hypertensive elderly patients due to benefits in reducing CV disease and mortality. However, elderly participants in these trials may not be typical of elderly patients seen in routine clinical practice, and the potential risks associated with use of antihypertensive drugs in the elderly are not as well studied as younger participants. Therefore, the purpose of this review was to provide a comprehensive summary of the benefits and risks of the use of antihypertensive drugs in elderly patients (aged ≥65 years), highlighting landmark clinical trials and observational studies. We will focus on specific outcomes relating to the benefits and risks of these medications in hypertensive elderly patients, such as CV disease, cognitive decline, dementia, orthostatic hypotension, falls, fractures, cancer and diabetes, in order to provide an update of the most relevant and current evidence to help inform clinical decision-making.

The association of antihypertensives with postural blood pressure and falls among seniors residing in the community: a case-control study

BACKGROUND

A drop in postural blood pressure (BP) may contribute to falls, while antihypertensives have been considered to induce postural drop or orthostatic hypotension (OH) and falls among older people. However, this relationship between antihypertensives, postural BP and the risk of falls has never been evaluated in a single study.

OBJECTIVE

To examine the association of postural BP changes and BP therapy with the risk of falls among community-dwelling older people in a case-control manner.

METHOD

Cases (n = 202) included participants aged ≥ 65 years with two falls or one injurious fall while controls (n = 156) included participants ≥ 65 years with no falls in the preceding 12 months. Antihypertensives usage and medical history were recorded. Supine BP measurements were obtained at 10 min rest and at 1, 2 and 3 min after standing. Orthostatic hypotension was defined as a reduction in BP of 20/10 mmHg within 3 min of standing.

RESULTS

Individual antihypertensive classes were not associated with falls. Minimal standing systolic BP (SBP) was significantly lower among fallers [128 (± 27·3) vs. 135·7 (± 24·7) mmHg; P = 0·01], but fallers were not more likely to fulfil the diagnostic criteria for OH. Diuretics were associated with OH and α-blockers were associated with minimal standing SBP. Univariate analysis revealed that the use of ≥ 2 antihypertensives was associated with recurrent and injurious falls [OR,1.97;CI,1.2-3.1], which was no longer significant aftermultivariateadjustment for age and number of comorbidities [OR, 1.6; CI, 0.95-2.6].

DISCUSSION

Minimal standing SBP or a lower SBP at 2 or 3minutes standing was associated with falls rather than OH using consensus definition. Association between ≥ 2 antihypertensives and falls was attenuated by increasing age and comorbidities. Our findings challenge previous assumptions that OH or the use of antihypertensives is associated with falls. Future studies should now seek to link these findings prospectively with falls in order to guide decision-making for BP lowering therapy among older patients.

Medications associated with falls in older people: systematic review of publications from a recent 5-year period

PURPOSE

Falls are an important public health problem in older people. Medication use is considered a risk factor for falls. This study systematically reviewed recent studies to determine the medications that might be associated with the risk of falling in older people.

METHODS

We conducted a systematic review of prospective and retrospective studies identified through the MEDLINE and CINAHL databases that quantitatively assessed the contribution of medications to falls risk in participants ≥60 years old published in English between May 2008 and April 2013.

RESULTS

The search identified 1,895 articles; 36 articles met the inclusion criteria. Of the 19 studies that investigated the effect of polypharmacy on the risk of falling, six studies reported that the risk of falling increased with polypharmacy. Data on the use of antihypertensive medications including calcium channel blockers, beta-blockers, and angiotensin system blocking medications were collected in 14 studies, with mixed results. Twenty-nine studies reported an association between the risk of falls and psychotropic medications including sedatives and hypnotics, antidepressants, and benzodiazepines.

CONCLUSIONS

The use of sedatives and hypnotics and antidepressants including tricyclic antidepressants, selective serotonin reuptake inhibitors, and serotonin norepinephrine reuptake inhibitors appears to be related with an increased risk of falls. It is not clear if the use of antihypertensive medications is associated with the risk of falls in older people.

Risk of hip/femur fractures during the initiation period of α-adrenoceptor blocker therapy among elderly males: a self-controlled case series study

AIMS

This study aimed to evaluate the risk of hip/femur fractures during the initiation period of α-adrenoceptor blocker therapy using the National Health Insurance claims database, Taiwan, with a self-controlled case series design.

METHODS

All male beneficiaries aged over 50 years as of 2007, who were incident users of α-adrenoceptor blockers and also had a diagnosis of hip/femur fracture within the 2007-2009 study period were identified. The first day when the α-adrenoceptor blocker was prescribed was set as the index date. We partitioned the initial 21 day period following the index date as the post-exposure risk period 1, days 22-60 after the index date as the post-exposure risk period 2, the 21 day period prior to the index date as the pre-exposure risk period 1 and days 22-60 prior to the index date as the pre-exposure risk period 2. The remainder of the study period was defined as the unexposed period. The incidence rate ratio (IRR) of hip/femur fractures within each risk period compared with the unexposed period was estimated using a conditional Poisson regression model.

RESULTS

A total of 5875 men were included. Compared with the unexposed period, the IRR of hip/femur fractures was 1.36 (95% confidence interval 1.06, 1.74, P = 0.017) within the post-exposure risk period 1 for patients without concomitant prescriptions of anti-hypertensive agents.

CONCLUSIONS

Use of α-adrenoceptor blockers was associated with a small but significant increase in the risk of hip/femur fractures during the early initiation period in patients without concomitant prescriptions of anti-hypertensive agents.

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

BACKGROUND

Medication use is a potentially modifiable risk factor for falling; psychotropic and cardiovascular drugs have been indicated as main drug groups that increase fall risk. However, evidence is mainly based on studies that recorded falls retrospectively and/or did not determine medication use at the time of the fall. Therefore, we investigated the associations indicated in the literature between medication use and falls, using prospectively recorded falls and medication use determined at the time of the fall.

METHODS

Data from the B-PROOF (B-vitamins for the prevention of osteoporotic fractures) study were used, concerning community-dwelling elderly aged ≥65 years. We included 2,407 participants with pharmacy dispensing records. During the 2- to 3-year follow-up, participants recorded falls using a fall calendar. Cox proportional hazard models were applied, adjusting for potential confounders including age, sex, health status variables and concomitant medication use.

RESULTS

During follow-up, 1,147 participants experienced at least one fall. Users of anti-arrhythmic medication had an increased fall risk (hazard ratio [HR] 1.61; 95% confidence interval [CI] 1.12-2.32) compared with non-users. Similarly, non-selective beta-blocker use was associated with an increased fall risk (HR 1.41 [95% CI 1.12-1.78]), while statin use was associated with a lower risk (HR 0.81 [95% CI 0.71-0.94]). Benzodiazepine use (HR 1.32 [95% CI 1.02-1.71]), and antidepressant use (HR 1.40 [95% CI 1.07-1.82]) were associated with an increased fall risk. Use of other cardiovascular and psychotropic medication was not associated with fall risk.

CONCLUSION

Our results strengthen the evidence for an increased fall risk in community-dwelling elderly during the use of anti-arrhythmics, non-selective beta-blockers, benzodiazepines, and antidepressant medication. Clinicians should prescribe these drugs cautiously and if possible choose safer alternatives for older patients.

Reexamining the Effect of Antihypertensive Medications on Falls in Old Age

Conflicting data on the relationship between antihypertensive medications and falls in elderly people may lead to inappropriate undertreatment of hypertension in an effort to prevent falls. We aimed to clarify the relationships between the chronic use of different classes of antihypertensive medications and different types of falls, to determine the effect of medication dose, and to assess whether the risk of falls is associated with differences in cerebral blood flow. We assessed demographics, clinical characteristics, and chronic antihypertensive medication use in 598 community-dwelling people with hypertension, aged 70 to 97 years, then followed them prospectively for self-reported falls using monthly calendar postcards and telephone interviews. Antihypertensive medication use was not associated with an increased risk of falls. Participants reporting use of angiotensin-converting enzyme inhibitors had a significantly decreased 1-year risk of injurious falls (odds ratio, 0.62; 95% confidence interval, 0.39-0.96), whereas those using calcium channel blockers had a decreased risk of all falls (odds ratio, 0.62; 95% confidence interval, 0.42-0.91) and indoor falls (odds ratio, 0.57; 95% confidence interval, 0.36-0.91), compared with participants not taking these drugs. Larger doses of these classes were associated with a lower fall risk. Participants taking calcium channel blockers had higher cerebral blood flow than those not taking these medications. In relatively healthy community-dwelling elderly people, high doses of antihypertensive agents are not associated with an increased risk of falls.

Hyponatremia and hypokalemia as risk factors for falls

BACKGROUND/OBJECTIVES

Fall accidents may reduce an individual's quality of life and ability to perform the activities of daily life, and may delay recovery from illness. Consequently, medical institutions need to take measures to prevent falls. There are various risk factors for falls, including advanced age, illness and medication effects. Although hyponatremia and hypokalemia have been reported to increase the rate of falls, how they affect falls is not fully understood.

SUBJECTS/METHODS

We retrospectively examined 2948 patients, ⩾18 years old who had been hospitalized for ⩾3 days at Gifu (Japan) Municipal Hospital between May 2012 and April 2013 to determine the effects of hyponatremia and hypokalemia on the risk of falls. After the patients had been divided into fall and non-fall groups, their data were subjected to univariate and multiple regression analysis to identify significant differences.

RESULTS

The univariate analysis results revealed significant differences between the groups in terms of age (⩾65 years); the presence of hyponatremia, hypokalemia, central nervous system disease, cardiovascular disease and/or peripheral nerve/muscular disease; intake of medications that increase the risk of falls; and increased sedative dosage. The multivariate analysis results revealed significant differences between the groups in terms of the presence of hyponatremia (odds ratio (OR), 1.751; 95% confidence interval (CI), 1.020-3.005), hypokalemia (OR, 2.209; 95% CI, 1.280-3.813), central nervous system disease (OR, 2.492; 95% CI, 1.629-3.814) and/or age ⩾65 years (OR, 2.180; 95% CI, 1.242-3.826).

CONCLUSIONS

The results indicated that the presence of hyponatremia or hypokalemia increases the risk of falls.

Effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and relevant pharmacological interventions on fall risk in elderly patients

BACKGROUND

Falls among the elderly are an issue internationally and a public health problem that brings substantial economic and quality-of-life burdens to individuals and society. Falls prevention is an important measure of nursing quality and patient safety. Numerous studies have evaluated the association of medication use with fall risk in elderly patients. However, an up-to-date review has not been available to summarize the multifaceted pharmaceutical concerns in the prevention of medication-related falls.

MATERIALS AND METHODS

Relevant literature was identified by performing searches in PubMed, Web of Science, and the Cochrane Library, covering the period until February 2014. We included studies that described an association between medications and falls, and effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and pharmacological interventions on fall risk in elderly patients. The full text of each included article was critically reviewed, and data interpretation was performed.

RESULTS

Fall-risk-increasing drugs (FRIDs) include central nervous system-acting agents, cough preparations, nonsteroidal anti-inflammatory drugs, anti-Alzheimer's agents, antiplatelet agents, calcium antagonists, diuretics, α-blockers, digoxin, hypoglycemic drugs, neurotoxic chemotherapeutic agents, nasal preparations, and antiglaucoma ophthalmic preparations. The degree of medication-related fall risk was dependent on one or some of the following factors: drug pharmacokinetic/pharmacodynamic properties (eg, elimination half-life, metabolic pathway, genetic polymorphism, risk rating of medications despite belonging to the same therapeutic class) and/or characteristics of medication use (eg, number of medications and drug-drug interactions, dose strength, duration of medication use and time since stopping, medication change, prescribing appropriateness, and medication adherence). Pharmacological interventions, including withdrawal of FRIDs, pharmacist-conducted clinical medication review, and computerized drug alerts, were effective in reducing fall risk.

CONCLUSION

Based on the literature review, clear practical recommendations for clinicians to prevent falls in the elderly included making a list of FRIDs, establishing a computerized alert system for when to e-prescribe FRIDs, seeking an alternative drug with lower fall risk, withdrawing FRIDs if clinically indicated, taking pertinent cautions when the use of FRIDs cannot be avoidable, paying attention to prescribing appropriateness, simplifying the medication regimen, strengthening pharmacist-conducted clinical medication review, ensuring the label of each FRID dispensed contains a corresponding warning sign, being careful when medication change occurs, enhancing medication adherence, and mandating for periodic reassessment of potential risk associated with the patient's medication regimen. Further studies should be conducted in this area, such as investigating whether medication reconciliation and improving medication adherence could decrease the rate of falls.

Trends in hypertension prevalence, awareness, treatment, and control among US adults 80 years and older, 1988-2010

The authors examined trends in systolic blood pressure (SBP) and diastolic blood pressure (DBP) and the prevalence, awareness, treatment, and control of hypertension in 1988-1994 (n=1164), 1999-2004 (n=1,026), and 2005-2010 (n=1048) among US adults 80 years and older in serial National Health and Nutrition Examination Surveys. Hypertension was defined as SBP ≥140 mm Hg, DBP ≥90 mm Hg, or use of antihypertensive medication. Awareness and treatment were defined by self-report and control as SBP/DBP<140/90 mm Hg. Mean SBP decreased from 147.3 mm Hg to 140.1 mm Hg and mean DBP from 70.2 mm Hg to 59.4 mm Hg between 1988-1994 and 2005-2010. The prevalence, awareness, and treatment of hypertension each increased over time. Controlled hypertension increased from 30.4% in 1988-1994 to 53.1% in 2005-2010. The proportion of patients taking 3 classes of antihypertensive medication increased from 7.0% to 30.9% between 1988-1994 and 2005-2010. Increases in awareness, treatment, and control of hypertension and antihypertensive polypharmacy have been observed among very old US adults.

Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults

IMPORTANCE The effect of serious injuries, such as hip fracture and head injury, on mortality and function is comparable to that of cardiovascular events. Concerns have been raised about the risk of fall injuries in older adults taking antihypertensive medications. The low risk of fall injuries reported in clinical trials of healthy older adults may not reflect the risk in older adults with multiple chronic conditions. OBJECTIVE To determine whether antihypertensive medication use was associated with experiencing a serious fall injury in a nationally representative sample of older adults. DESIGN, PARTICIPANTS, AND SETTING Competing risk analysis as performed with propensity score adjustment and matching in the nationally representative Medicare Current Beneficiary Survey cohort during a 3-year follow-up through 2009. Participants included 4961 community-living adults older than 70 years with hypertension. EXPOSURES Antihypertensive medication intensity based on the standardized daily dose for each antihypertensive medication class that participants used. MAIN OUTCOMES AND MEASURES Serious fall injuries, including hip and other major fractures, traumatic brain injuries, and joint dislocations, ascertained through Centers for Medicare & Medicaid Services claims. RESULTS Of the 4961 participants, 14.1% received no antihypertensive medications; 54.6% were in the moderate-intensity and 31.3% in the high-intensity antihypertensive groups. During follow-up, 446 participants (9.0%) experienced serious fall injuries, and 837 (16.9%) died. The adjusted hazard ratios for serious fall injury were 1.40 (95% CI, 1.03-1.90) in the moderate-intensity and 1.28 (95% CI, 0.91-1.80) in the high-intensity antihypertensive groups compared with nonusers. Although the difference in adjusted hazard ratios across the groups did not reach statistical significance, results were similar in the propensity score-matched subcohort. Among 503 participants with a previous fall injury, the adjusted hazard ratios were 2.17 (95% CI, 0.98-4.80) for the moderate-intensity and 2.31 (95% CI, 1.01-5.29) for the high-intensity antihypertensive groups. CONCLUSIONS AND RELEVANCE Antihypertensive medications were associated with an increased risk of serious fall injuries, particularly among those with previous fall injuries. The potential harms vs benefits of antihypertensive medications should be weighed in deciding to continue treatment with antihypertensive medications in older adults with multiple chronic conditions.

High hip fracture risk in men with severe aortic calcification: MrOS study

A significant link between cardiovascular disease and osteoporosis is established in postmenopausal women, but data for men are scarce. We tested the hypothesis that greater severity of abdominal aortic calcification (AAC) was associated with an increased risk of nonspine fracture in 5994 men aged ≥ 65 years. AAC was assessed on 5400 baseline lateral thoracolumbar radiographs using a validated visual semiquantitative score. Total hip bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry. Incident nonspine fractures were centrally adjudicated. After adjustment for age, body mass index (BMI), total hip BMD, fall history, prior fracture, smoking status, comorbidities, race, and clinical center, the risk of nonspine fracture (n=805) was increased among men with higher AAC (hazard ratio [HR] quartile 4 [Q4] [AAC score ≥ 9] versus quartile 1 [Q1] [0-1], 1.36; 96% confidence interval [CI], 1.10-1.68). This association was due to an increased risk of hip fracture (n=178) among men with higher AAC (HR Q4 versus Q1, 2.33; 95% CI, 1.41-3.87). By contrast, the association between AAC and the risk of nonspine, nonhip fracture was weaker and not significant (HR Q4 versus Q1, 1.22; 95% CI, 0.96-1.55). The findings regarding higher AAC and increased risk of fracture were not altered in additional analyses accounting for degree of trauma, estimated glomerular filtration rate, presence of lumbar vertebral fractures (which may bias AAC assessment), preexisting cardiovascular disease, ankle brachial index, or competing risk of death. Thus, in this large cohort of elderly men, greater AAC was independently associated with an increased risk of hip fracture, but not with other nonspine fractures. These findings suggest that AAC assessment may be a useful method for identification of older men at high risk of hip fracture.

Circumstances and contributing causes of fall deaths among persons aged 65 and older: United States, 2010

OBJECTIVES

To determine whether the increasing fall death rate among people aged 65 and older is due in part to temporal changes in recording the underlying cause of death.

DESIGN

Analyses of multiple cause of death data using the online Centers for Disease Control and Prevention Wide-ranging ON-line Data for Epidemiologic Research system, which uses the National Center for Health Statistics' Multiple Cause of Death data set.

SETTING

United States, 1999 to 2010.

PARTICIPANTS

People aged 65 and older with a fall listed on their death record as the underlying or a contributing cause of death.

MEASUREMENTS

Circumstances and contributing causes off all deaths--records listing International Classification of Diseases, Tenth Revision, codes W00 to W19 as the underlying cause of death--and underlying causes for records with falls as a contributing cause were examined. Joinpoint regression analysis was used to assess trends in the proportion of fall and fall-associated deaths to total deaths for 1999 to 2010.

RESULTS

In 2010, there were 21,649 fall deaths and 5,402 fall-associated deaths among people aged 65 and older; 48.7% of fall deaths involved a head injury. Approximately half the fall death records included diseases of the circulatory system as contributing causes. From 1999 to 2010, there was a trend toward more-specific reporting of falls circumstances, although total deaths remained unchanged. The proportion of fall deaths to total deaths increased 114.3%, and that of fall-associated deaths to total deaths increased 43.1%.

CONCLUSION

The reasons behind the increasing older adult fall death rate deserve further investigation. Possible contributing factors include changing trends in underlying chronic diseases and better reporting of falls as the underlying cause of death.