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Hua CL, Nelson I, Cornell PY, White EM, Thomas KS. Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias. J Am Med Dir Assoc 2024; 25:105087. [PMID: 38885933 PMCID: PMC11283979 DOI: 10.1016/j.jamda.2024.105087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVES To examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD). DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS We leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 to 2015. METHODS We estimated Poisson models examining the relationships of personal care aide, registered nurse (RN), licensed practical nurse (LPN), and total nursing hours with injury-related ED visits. Models were adjusted for resident characteristics (ie, age, race, sex, dual eligibility, presence and number of chronic conditions), AL community characteristics (percentage of residents on Medicaid, average resident acuity), year fixed effects, and assisted living fixed effects. We examined all injury-related ED visits and injury-related ED visits resulting in hospital admission as separate outcomes. RESULTS The sample included 122,700 person-months, representing 12,144 fee-for-service Medicare beneficiaries with ADRD within 455 different AL communities in Ohio between 2007 and 2015. Median total nursing hours increased from 1.34 in 2007 to 1.69 in 2015. In the fully adjusted model, an increase in 1 RN-hour per resident-day was associated with a decrease in the risk of any injury-related ED visit (incidence rate ratio 0.59, 95% CI 0.36-0.96), representing a 53% decrease. Changes in RN-hours were not associated with injury-related inpatient hospitalizations. Changes in total nursing, LPN, and personal care aide hours were not associated with changes in the risk of injury-related ED visits or inpatient hospitalizations. CONCLUSIONS AND IMPLICATIONS Increases in RN staffing hours were associated with reduced injury-related ED use among AL residents with ADRD. RNs provide surveillance and care oversight that may help mitigate injury risk, and they are able to physically assess residents at the time of a fall and/or injury, which can preempt unnecessary ED transfers.
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Affiliation(s)
- Cassandra L Hua
- Center for Health Statistics and Department of Public Health, University of Massachusetts Lowell, Lowell, MA, USA.
| | - Ian Nelson
- Scripps Gerontology Center, Miami University, Oxford, OH, USA
| | - Portia Y Cornell
- Centre for the Digital Transformation of Health/Centre for Health Policy, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Elizabeth M White
- Center for Gerontology and Healthcare Research and the Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kali S Thomas
- Center for Equity in Aging, Johns Hopkins School of Nursing, Johns Hopkins University, Baltimore, MD, USA
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Yoshikawa A, Ramirez G, Smith ML, Foster M, Nabil AK, Jani SN, Ory MG. Opioid Use and the Risk of Falls, Fall Injuries and Fractures among Older Adults: A Systematic Review and Meta-Analysis. J Gerontol A Biol Sci Med Sci 2021; 75:1989-1995. [PMID: 32016284 DOI: 10.1093/gerona/glaa038] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is increasing concern about opioid use as a pain treatment option among older adults. Existing literature implies an association between opioid use and fracture, increasing the risk of death and disabilities; yet, this relationship with other fall-related outcomes has not been fully explored. We performed a meta-analysis to evaluate the associations between opioid use and adverse health outcomes of falls, fall injuries, and fractures among older adults. METHODS A systematic literature search was conducted using nine databases: Medline, Embase, CINAHL, PsycInfo, Global Health, Northern Light Sciences Conference Abstracts, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We log-transformed effect sizes (relative risk [RR], odds ratio [OR], and hazard ratio [HR]) to compute pooled risk estimates comparable across the studies. The random-effects model was applied to calculate the pooled risk estimates due to heterogeneity. Meta-regressions explored differences in risk estimates by analysis method, study design, setting, and study quality. RESULTS Thirty studies, providing 34 relevant effect sizes, met the inclusion criteria for this meta-analysis. Overall, opioid use was significantly associated with falls, fall injuries, and fractures, with effect sizes ranging from 0.15 to 0.71. In meta-regressions, no selected factors explained heterogeneity. CONCLUSION While heterogeneity is present, results suggest an increased risk of falls, fall injuries, and fractures among older adults who used opioids. Findings highlight the need for opioid education and nonopioid-related pain management interventions among older adults to decrease fall-related risk.
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Affiliation(s)
- Aya Yoshikawa
- Center for Population Health and Aging, Texas A&M University, College Station
| | - Gilbert Ramirez
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station
| | - Matthew Lee Smith
- Center for Population Health and Aging, Texas A&M University, College Station.,Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station.,Department of Health Promotion and Behavior, College of Public Health, The University of Georgia, Athens
| | - Margaret Foster
- Medical Sciences Library, Texas A&M University, College Station
| | - Anas K Nabil
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station
| | - Sagar N Jani
- Center for Population Health and Aging, Texas A&M University, College Station.,Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station
| | - Marcia G Ory
- Center for Population Health and Aging, Texas A&M University, College Station.,Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station
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Lee SK, Ahn J, Shin JH, Lee JY. Application of Machine Learning Methods in Nursing Home Research. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6234. [PMID: 32867250 PMCID: PMC7503291 DOI: 10.3390/ijerph17176234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/23/2020] [Accepted: 08/24/2020] [Indexed: 12/13/2022]
Abstract
Background: A machine learning (ML) system is able to construct algorithms to continue improving predictions and generate automated knowledge through data-driven predictors or decisions. Objective: The purpose of this study was to compare six ML methods (random forest (RF), logistics regression, linear support vector machine (SVM), polynomial SVM, radial SVM, and sigmoid SVM) of predicting falls in nursing homes (NHs). Methods: We applied three representative six-ML algorithms to the preprocessed dataset to develop a prediction model (N = 60). We used an accuracy measure to evaluate prediction models. Results: RF was the most accurate model (0.883), followed by the logistic regression model, SVM linear, and polynomial SVM (0.867). Conclusions: RF was a powerful algorithm to discern predictors of falls in NHs. For effective fall management, researchers should consider organizational characteristics as well as personal factors. Recommendations for Future Research: To confirm the superiority of ML in NH research, future studies are required to discern additional potential factors using newly introduced ML methods.
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Affiliation(s)
- Soo-Kyoung Lee
- College of Nursing, Keimyung University, 1095, Dalgubeol-daero, Dalseo-gu, Daegu 42601, Korea;
| | - Jinhyun Ahn
- Department of Management Information Systems, Jeju National University, Jeju-do 63243, Korea;
| | - Juh Hyun Shin
- College of Nursing, Ewha Womans University, Seoul 03760, Korea;
| | - Ji Yeon Lee
- College of Nursing, Ewha Womans University, Seoul 03760, Korea;
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Yue Q, Ma Y, Teng Y, Zhu Y, Liu H, Xu S, Liu J, Liu J, Zhang X, Teng Z. An updated analysis of opioids increasing the risk of fractures. PLoS One 2020; 15:e0220216. [PMID: 32271762 PMCID: PMC7145014 DOI: 10.1371/journal.pone.0220216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 03/01/2020] [Indexed: 01/18/2023] Open
Abstract
Objective To assess the relationship between opioid therapy for chronic noncancer pain and fracture risk by a meta-analysis of cohort studies and case-control studies. Methods The included cohort studies and case-control studies were identified by searching the PubMed and EMBASE databases from their inception until May 24, 2019. The outcome of interest was a fracture. This information was independently screened by two authors. When the heterogeneity among studies was significant, a random effects model was used to determine the overall combined risk estimate. Results In total, 12 cohort studies and 6 case-control studies were included. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of the included literature, and 14 of the studies were considered high-quality studies. The overall relative risk of opioid therapy and fractures was 1.78 (95% confidence interval (CI) 1.53–2.07). Subgroup analyses revealed sources of heterogeneity, sensitivity analysis was stable, and no publication bias was observed. Conclusions The meta-analysis showed that the use of opioids significantly increased the risk of fracture.
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Affiliation(s)
- Qiaoning Yue
- Department of Orthopedic Surgery, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Yue Ma
- Department of Pharmacy, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Yirong Teng
- Department of General Medicine, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Yun Zhu
- Department of Health Screening Center, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Hao Liu
- Department of Emergency Medicine, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Shuanglan Xu
- Department of Respiratory Medicine, The Fourth Affiliated Hospital of Kunming Medical University, The Second People's Hospital of Yunnan Province, Kunming, China
| | - Jie Liu
- Department of Respiratory Medicine, The Fourth Affiliated Hospital of Kunming Medical University, The Second People's Hospital of Yunnan Province, Kunming, China
| | - Jianping Liu
- Department of Science and Education, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Xiguang Zhang
- Department of Orthopedic Surgery, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
- * E-mail: (ZT); (XZ)
| | - Zhaowei Teng
- Department of Orthopedic Surgery, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
- * E-mail: (ZT); (XZ)
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Day BF, Rosenthal GL. Social isolation proxy variables and prescription opioid and benzodiazepine misuse among older adults in the U.S.: A cross-sectional analysis of data from the National Survey on Drug Use and Health, 2015-2017. Drug Alcohol Depend 2019; 204:107518. [PMID: 31494444 DOI: 10.1016/j.drugalcdep.2019.06.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Prescription drug misuse in older adults is a growing public health problem. It is important to understand factors which predispose older adults to misuse prescription drugs, and social isolation may play an important role. In this study, we examined the association between social isolation proxy variables (living alone, being unmarried, and not attending religious services) and prescription opioid/benzodiazepine misuse in older adults. METHODS With pooled cross-sectional data from the National Survey on Drug Use and Health (2015-2017), we used multinomial multiple logistic regression models to analyze the association between each social isolation proxy variable and past-year prescription opioid/benzodiazepine misuse. We controlled for potentially confounding variables including sociodemographic, physical/mental health, and substance use variables. RESULTS Being unmarried was associated with approximately three times increased odds of combined opioid and benzodiazepine misuse (OR 2.98, 95% CI 1.75, 5.08), a finding that persisted after adjusting for multiple potential confounders. Further analysis showed this finding persisted for divorced/separated and never married individuals, but not widowed. Not attending religious services was also associated with prescription opioid/benzodiazepine misuse, but only in unadjusted analyses. There was no association between living alone and opioid/benzodiazepine misuse. CONCLUSION Increased odds of combined opioid and benzodiazepine prescription drug misuse was observed among unmarried older adults. Given the susceptibility of older adults to the harms of these medications, further exploration of the role of marital relationships and other forms of social connectedness in prescription drug misuse in this vulnerable population is indicated.
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Affiliation(s)
- Brendan F Day
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201 United States.
| | - Geoffrey L Rosenthal
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201 United States; Department of Pediatrics, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD, 21201 United States
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Zimmermann J, Swora M, Pfaff H, Zank S. Organizational factors of fall injuries among residents within German nursing homes: secondary analyses of cross-sectional data. Eur J Ageing 2019; 16:503-512. [PMID: 31798374 DOI: 10.1007/s10433-019-00511-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The present study explored risk factors for fall injuries among nursing home residents, with a specific focus on the influence of organizational structure within facilities and their environment, which have been insufficiently investigated in the European context. For the analyses, secondary data collected in 2016 from 220 nursing homes across Germany were used. As a risk adjustment, two separate models were calculated for fall injuries among residents without (N = 7320) and with cognitive impairment (N = 8633). Results showed that residents without cognitive impairment had a decreased risk of fall injuries by 40.1% (P < 0.01), while those with cognitive impairment were at an increased risk of 23.8% (P < 0.05) when living in facilities that had dementia care units. However, disparities were found between federal states for both groups of residents (P < 0.05 vs. P < 0.01, respectively). Similarly, a higher proportion of registered nurses were associated with decreased risk of fall injuries among cognitively impaired residents (45.6%), which differed between federal states (P < 0.01). Facilities with homelike environments had a 16.7% (P < 0.05) lower risk of fall injuries among cognitively impaired residents than did traditionally organized facilities. Further research is needed to explain the disparities between German federal states using representative samples.
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Affiliation(s)
- Jaroslava Zimmermann
- 1Graduate School GROW - Gerontological Research on Well-Being, University of Cologne, Cologne, Germany
| | - Michael Swora
- 2Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences & Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- 2Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences & Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Susanne Zank
- 3Rehabilitative Gerontology, Faculty of Human Sciences, University of Cologne, Cologne, Germany
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Zullo AR, Zhang T, Banerjee G, Lee Y, McConeghy KW, Kiel DP, Daiello LA, Mor V, Berry SD. Facility and State Variation in Hip Fracture in U.S. Nursing Home Residents. J Am Geriatr Soc 2018; 66:539-545. [PMID: 29336024 PMCID: PMC5849498 DOI: 10.1111/jgs.15264] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To quantify the variation in hip fracture incidence across U.S. nursing home (NH) facilities and states and examine how hip fracture incidence varies according to facility- and state-level characteristics. DESIGN Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. SETTING U.S. NHs with 100 or more beds. PARTICIPANTS Long-stay NH residents between May 1, 2007, and April 30, 2008, from 1,481 facilities and 46 U.S. states (N = 201,892). MEASUREMENTS Incident hip fractures were ascertained using Medicare Part A diagnostic codes. Each resident was followed for up to 2 years. RESULTS The mean adjusted incidence rate of hip fractures for all facilities was 3.13 (95% confidence interval (CI) = 3.01-3.26) per 100 person-years (range 1.20, 95% CI = 1.15-1.26 to 6.40, 95% CI = 6.07-6.77). Facilities with the highest rates of hip fracture had greater percentages of residents taking psychoactive medications (top tertile 27.2%, bottom tertile 24.8%), and fewer nursing (top tertile 3.43, bottom tertile 3.53) and direct care (top tertile 3.22, bottom tertile 3.29) hours per day per resident. The combination of state and facility characteristics explained 6.7% of the variation in hip fracture, and resident characteristics explained 7.6%. CONCLUSION Much of the variation in hip fracture incidence remained unexplained, although these findings indicate that potentially modifiable state and facility characteristics such as psychoactive drug prescribing and minimum staffing requirements could be addressed to help reduce the rate of hip fracture in U.S. NHs.
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Affiliation(s)
- Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI
| | - Tingting Zhang
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Geetanjoli Banerjee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Kevin W. McConeghy
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI
| | - Douglas P. Kiel
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Lori A. Daiello
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Sarah D. Berry
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Institute for Aging Research, Hebrew SeniorLife, Boston, MA
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Al-Jumaili AA, Doucette WR. Comprehensive Literature Review of Factors Influencing Medication Safety in Nursing Homes: Using a Systems Model. J Am Med Dir Assoc 2017; 18:470-488. [DOI: 10.1016/j.jamda.2016.12.069] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 12/16/2016] [Accepted: 12/23/2016] [Indexed: 10/20/2022]
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Abstract
This research studied 12,507 residents in 1174 nursing homes from the 2004 National Nursing Home Survey. A multinomial logistic regression model was used to predict risk-adjusted probabilities of pressure ulcers with 4 stages. A medical director or a director of nursing on board reduced the odds of ulcers. Facilities offering clusters of beds for rehabilitation and special care programs for hospice care or behavior problems reduced the odds of stage IV ulcers.
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11
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Hyponatremia: incidence, risk factors, and consequences in the elderly in a home-based primary care program. Clin Nephrol 2016; 84:75-85. [PMID: 26042411 PMCID: PMC6350235 DOI: 10.5414/cn108453] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2015] [Indexed: 12/17/2022] Open
Abstract
Aims: To determine the incidence, risk factors, etiology, and associations of hyponatremia in community-dwelling elderly with geriatric morbidity and mortality. Materials: Elderly participants of a single center home-based primary care program were included. Method: Retrospective chart review was conducted on demographic and clinical variables, comorbid diseases, frailty by Fried criteria and biochemical tests over a 1-year period. Primary outcome measure was a composite of falls, fractures due to falls, and hospitalization witnessed within the first year of enrollment into the program. Secondary outcome was all-cause mortality. Results: The study population (n = 608) had a mean age of 84.3 ± 9.3 years and was largely female (77.1%) and African-American (89.5%). Mean follow-up was 41.5 months. Frailty was seen in 44.4%. Incidence of all-cause mortality was 26.9%. Initial hyponatremia occurred in 8.71% (n = 53), and persistent hyponatremia (> 6 months of low serum sodium) in 4.1% (n = 25) of the study population. The major causes of hyponatremia included multiple potential causes, idiopathic syndrome of inappropriate anti-diuretic hormone (SIADH) and medications (thiazides and selective serotonin reuptake inhibitor (SSRI)). Primary outcome was independently associated with frailty (Odds ratio (OR) of 2.33) and persistent but not initial hyponatremia (OR 3.52). Secondary outcome was independently associated with age > 75 years (OR 2.88) and Afro-American race (OR 2.09) only but not to frailty or hyponatremia. Conclusions: Hyponatremia is common in home-bound elderly patients and its persistence independently contributes to falls, fractures, and hospitalization but not mortality. Our study highlights a new association of hyponatremia with frailty and underscores the need to study time-dependent association of hyponatremia with epidemiological outcomes.
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Banerjee G, Zullo AR, Berry SD, Lee Y, McConeghy K, Kiel DP, Mor V. Geographic Variation in Hip Fracture Among United States Long-Stay Nursing Home Residents. J Am Med Dir Assoc 2016; 17:865.e1-3. [PMID: 27461867 DOI: 10.1016/j.jamda.2016.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 06/09/2016] [Accepted: 06/09/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Despite high rates of hip fracture among United States (US) nursing home (NH) residents, little is known about geographic variation in hip fracture incidence. We used nationally representative data to identify geographic variation in hip fracture among US NH residents. DESIGN AND SETTING Retrospective cohort study using Part A claims for a 100% of Medicare enrollees in 15,289 NHs linked to NH minimum data set and Online Survey, Certification, and Reporting databases. PARTICIPANTS A total of 891,085 long-stay (continuous residence of ≥100 days) NH residents ≥65 years old. MEASUREMENTS Medicare Part A claims documenting a hip fracture. Mean incidence rates of hip fracture for long-stay NH residents were calculated for each state and US Census Division from 2007 to 2010. RESULTS The age-, sex-, and race-adjusted incidence rate of hip fracture ranged from 1.49 hip fractures/100 person-years (Hawaii) to 3.60 hip fractures/100 person-years (New Mexico), with a mean of 2.38 (standard deviation 0.43) hip fractures/100 person-years. The mean incidence of hip fracture was 1.7-fold greater in the highest quintile than the lowest. CONCLUSIONS We observed modest US state and regional variation in hip fracture incidence among long-stay NH residents. Future studies should assess whether state policies or NH characteristics explain the variation.
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Affiliation(s)
- Geetanjoli Banerjee
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI.
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
| | - Sarah D Berry
- Hebrew Senior Life, Institute for Aging Research and Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Yoojin Lee
- Center for Gerontology Health Care Research, Brown University, Providence, RI
| | - Kevin McConeghy
- Providence VA Medical Center, Brown University, Providence, RI
| | - Doug P Kiel
- Hebrew Senior Life, Institute for Aging Research and Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Vincent Mor
- Center for Gerontology Health Care Research, Brown University, Providence, RI
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Treatment of Osteoporosis in Australian Residential Aged Care Facilities: Update on Consensus Recommendations for Fracture Prevention. J Am Med Dir Assoc 2016; 17:852-9. [PMID: 27349626 DOI: 10.1016/j.jamda.2016.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/09/2016] [Accepted: 05/10/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Older people living in residential aged care facilities (RACFs) are at a higher risk of suffering fractures than the community-dwelling older population. The first Consensus Conference on Treatment of Osteoporosis in RACFs in Australia, held in Sydney in July 2009, aimed to address some of the issues relating to the treatment of older residents with osteoporosis in RACFs. Considering that the field of osteoporosis diagnosis and management has significantly advanced in the last 5 years and that new evidence has been generated from studies performed within RACFs, a Second Consensus Conference was held in Sydney in November 2014. METHODS An expert panel met in November 2014 in Penrith, NSW, Australia in an attempt to reach a consensus on diverse issues related to the treatment of osteoporosis at RACFs. Participants were selected by the scientific committee on the basis of their practice in an RACF and/or major published articles. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short, evidence-based presentation, when possible. RESULTS This article provides an update on the most relevant evidence on osteoporosis in older people living in RACFs graded according to its level, quality, and relevance. CONCLUSION As with the first consensus, it is hoped that this statement will constitute an important guide to aid physicians in their decision making while practicing at RACFs.
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Abstract
IMPORTANCE Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose. OBJECTIVE To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. PROCESS The Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category. EVIDENCE SYNTHESIS Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (≥1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects. RECOMMENDATIONS There are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone. CONCLUSIONS AND RELEVANCE The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.
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Affiliation(s)
- Deborah Dowell
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tamara M Haegerich
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Roger Chou
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016; 65:1-49. [PMID: 26987082 DOI: 10.15585/mmwr.rr6501e1] [Citation(s) in RCA: 1991] [Impact Index Per Article: 248.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, and recommendations are made on the basis of a systematic review of the scientific evidence while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee. It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options. This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death. CDC has provided a checklist for prescribing opioids for chronic pain (http://stacks.cdc.gov/view/cdc/38025) as well as a website (http://www.cdc.gov/drugoverdose/prescribingresources.html) with additional tools to guide clinicians in implementing the recommendations.
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Affiliation(s)
- Deborah Dowell
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
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Powell-Cope G, Campbell R, Hahm B, Bulat T, Westphal J. Sociotechnical probabilistic risk modeling to predict injurious falls in community living centers. ACTA ACUST UNITED AC 2016; 53:881-892. [PMID: 28273322 DOI: 10.1682/jrrd.2015.08.0165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 01/29/2016] [Indexed: 11/05/2022]
Abstract
The goal of this study was to apply sociotechnical probabilistic risk assessment to prioritize risks and prevention strategies for serious injurious falls of residents in nursing homes. Risk modeling teams consisted of 26 clinical and nonclinical staff from three Department of Veterans Affairs community living centers and one state Veteran's nursing home. Participants met in groups several times to identify and assign probabilities to provider and resident at-risk behaviors and equipment failures. They identified prevention strategies for the failures that accounted for the highest levels of risk. Six scenarios were modeled: (1) transferring from bed to wheelchair, (2) propelling from bedside to bathroom, (3) transferring from wheelchair to toilet, (4) transferring from toilet to wheelchair, (5) propelling from bathroom to bedside, and (6) transferring from wheelchair to bed. The greatest paths of risk were for residents with impaired mobility and high fragility. A 26% reduction in injurious falls could be achieved by (1) reducing the number of unassisted transfers through a modest improvement in response time to alarms, (2) installing automatic brake locks on 90% of wheelchairs, (3) making the wheelchair maintenance process highly reliable, and (4) decreasing improper transfer techniques by 10%.
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Affiliation(s)
- Gail Powell-Cope
- Department of Veterans Affairs Health Services Research and Development Center of Innovation on Disability and Rehabilitation Research
| | | | - Bridget Hahm
- Department of Veterans Affairs Health Services Research and Development Center of Innovation on Disability and Rehabilitation Research
| | - Tatjana Bulat
- Veterans Integrated Service Network 8 Patient Safety Center of Inquiry, James A. Haley Veterans' Hospital, Tampa, FL
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Marier A, Olsho LEW, Rhodes W, Spector WD. Improving prediction of fall risk among nursing home residents using electronic medical records. J Am Med Inform Assoc 2015; 23:276-82. [PMID: 26104743 DOI: 10.1093/jamia/ocv061] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 05/04/2015] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Falls are physically and financially costly, but may be preventable with targeted intervention. The Minimum Data Set (MDS) is one potential source of information on fall risk factors among nursing home residents, but its limited breadth and relatively infrequent updates may limit its practical utility. Richer, more frequently updated data from electronic medical records (EMRs) may improve ability to identify individuals at highest risk for falls. METHODS The authors applied a repeated events survival model to analyze MDS 3.0 and EMR data for 5129 residents in 13 nursing homes within a single large California chain that uses a centralized EMR system from a leading vendor. Estimated regression parameters were used to project resident fall probability. The authors examined the proportion of observed falls within each projected fall risk decile to assess improvements in predictive power from including EMR data. RESULTS In a model incorporating fall risk factors from the MDS only, 28.6% of observed falls occurred among residents in the highest projected risk decile. In an alternative specification incorporating more frequently updated measures for the same risk factors from the EMR data, 32.3% of observed falls occurred among residents in the highest projected risk decile, a 13% increase over the base MDS-only specification. CONCLUSIONS Incorporating EMR data improves ability to identify those at highest risk for falls relative to prediction using MDS data alone. These improvements stem chiefly from the greater frequency with which EMR data are updated, with minimal additional gains from availability of additional risk factor variables.
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Affiliation(s)
| | | | - William Rhodes
- Abt Associates, U.S. Health Division, Cambridge, MA, USA
| | - William D Spector
- Agency for Healthcare Research & Quality, U.S. Department of Health & Human Services, Rockville, MD, USA
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Teng Z, Zhu Y, Wu F, Zhu Y, Zhang X, Zhang C, Wang S, Zhang L. Opioids contribute to fracture risk: a meta-analysis of 8 cohort studies. PLoS One 2015; 10:e0128232. [PMID: 26030421 PMCID: PMC4452583 DOI: 10.1371/journal.pone.0128232] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 04/24/2015] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate the association between chronic opioid use for non-cancer pain and fracture risk by conducting a meta-analysis of cohort studies. Methods Cohort studies were identified by searching PubMed and EMBASE from their inception to July 2014. A fracture was considered an endpoint. The information was extracted by two authors independently. When the heterogeneity was significant, a random-effects model was used to calculate the overall pooled risk estimates. Results Eight cohort studies were included in the final meta-analysis. On the basis of the Newcastle-Ottawa Scale (NOS), six studies were considered to be of high quality. The overall combined relative risk for the use of opioids and fractures was 1.88 (95% confidence interval [CI] 1.51-2.34). A subgroup analysis revealed the sources of heterogeneity. The sensitivity analysis indicated stable results, and no publication bias was observed. Conclusions This meta-analysis of cohort studies demonstrates that opioids significantly increase the risk of fractures.
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Affiliation(s)
- Zhaowei Teng
- Department of Orthopedic Surgery, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
- * E-mail: (ZWT); (XGZ)
| | - Yun Zhu
- Department of Nephrology, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Feihu Wu
- Department of Anesthesiology, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Yanhong Zhu
- Department of Anesthesiology, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Xiguang Zhang
- Department of Orthopedic Surgery, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
- * E-mail: (ZWT); (XGZ)
| | - Chuanlin Zhang
- Department of Orthopedic Surgery, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Shuangneng Wang
- Department of Orthopedic Surgery, The People’s Hospital of Yuxi City, The 6th Affiliated Hospital of Kunming Medical University, Yuxi, Yunan, China
| | - Lei Zhang
- Trauma Center of Yunnan Province, The Second People's Hospital of Yunnan Province, Kunming, Yunan, China
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Rhodes W, Olsho LEW, Sexton Ward A, Spector WD. Use of Monte Carlo simulation to inform design decisions for pairwise cluster randomization. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2015. [DOI: 10.1007/s10742-015-0138-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shen C, Chen F, Zhang Y, Guo Y, Ding M. Association between use of antiepileptic drugs and fracture risk: a systematic review and meta-analysis. Bone 2014; 64:246-53. [PMID: 24780876 DOI: 10.1016/j.bone.2014.04.018] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 04/11/2014] [Accepted: 04/17/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND It has been shown that antiepileptic drugs (AEDs) may have a detrimental effect on bone health and translate into an increased risk of bone fracture. We aimed to comprehensively evaluate the association between use of AEDs and fracture risk. METHODS We searched NCBI (PubMed), ISI Web of Science, the Cochrane Library and EMBASE databases for studies reporting fracture risk among users of AEDs. Random-effects meta-analysis was used to pool results across studies. RESULTS Twenty-two studies met the inclusion criteria. Overall, there was a significant increase in fracture risk among users of AEDs involving 1,292,910 participants, with a mean/median age of 36-82 years (relative risk (RR)=1.86; 95% confidence interval (CI) 1.62-2.12). When we limited the studies to those on osteoporosis-related fractures, the RR was still significant. Both liver enzyme-inducing antiepileptic drugs (LEI AEDs) and non-LEI AEDs were associated with an increase in fracture risk, although the estimate for LEI AEDs was higher than that of non-LEI AEDs (RR=1.18; 95% CI 1.11-1.25). For some specific AEDs, use of phenobarbiturate (PB), topiramate (TPM) and phenytoin (PHT) suggested an increase in fracture risk of 78%, 39% and 70%, respectively. CONCLUSIONS The study suggests a robust association between use of AEDs and fracture risk (particularly for LEI AEDs). It also suggests that several specific AEDs such as PB, TPM and PHT may be associated with an increased risk of fracture.
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Affiliation(s)
- Chunhong Shen
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Feng Chen
- Department of Neurology, Ningbo Medical Treatment Center Lihuili Hospital, Ningbo 315000, China
| | - Yinxi Zhang
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Yi Guo
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China
| | - Meiping Ding
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, China.
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Backhaus R, Verbeek H, van Rossum E, Capezuti E, Hamers JP. Nurse Staffing Impact on Quality of Care in Nursing Homes: A Systematic Review of Longitudinal Studies. J Am Med Dir Assoc 2014; 15:383-93. [DOI: 10.1016/j.jamda.2013.12.080] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 12/19/2013] [Accepted: 12/23/2013] [Indexed: 11/27/2022]
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Haring B, Pettinger M, Bea JW, Wactawski-Wende J, Carnahan RM, Ockene JK, Wyler von Ballmoos M, Wallace RB, Wassertheil-Smoller S. Laxative use and incident falls, fractures and change in bone mineral density in postmenopausal women: results from the Women's Health Initiative. BMC Geriatr 2013; 13:38. [PMID: 23635086 PMCID: PMC3645973 DOI: 10.1186/1471-2318-13-38] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 04/22/2013] [Indexed: 12/20/2022] Open
Abstract
Background Laxatives are among the most widely used over-the-counter medications in the United States but studies examining their potential hazardous side effects are sparse. Associations between laxative use and risk for fractures and change in bone mineral density [BMD] have not previously been investigated. Methods This prospective analysis included 161,808 postmenopausal women (8907 users and 151,497 nonusers of laxatives) enrolled in the WHI Observational Study and Clinical Trials. Women were recruited from October 1, 1993, to December 31, 1998, at 40 clinical centers in the United States and were eligible if they were 50 to 79 years old and were postmenopausal at the time of enrollment. Medication inventories were obtained during in-person interviews at baseline and at the 3-year follow-up visit on everyone. Data on self-reported falls (≥2), fractures (hip and total fractures) were used. BMD was determined at baseline and year 3 at 3 of the 40 clinical centers of the WHI. Results Age-adjusted rates of hip fractures and total fractures, but not for falls were similar between laxative users and non-users regardless of duration of laxative use. The multivariate-adjusted hazard ratios for any laxative use were 1.06 (95% confidence interval [CI], 1.03-1.10) for falls, 1.02 (95% CI, 0.85-1.22) for hip fractures and 1.01 (95% CI, 0.96-1.07) for total fractures. The BMD levels did not statistically differ between laxative users and nonusers at any skeletal site after 3-years intake. Conclusion These findings support a modest association between laxative use and increase in the risk of falls but not for fractures. Its use did not decrease bone mineral density levels in postmenopausal women. Maintaining physical functioning, and providing adequate treatment of comorbidities that predispose individuals for falls should be considered as first measures to avoid potential negative consequences associated with laxative use.
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Affiliation(s)
- Bernhard Haring
- Department of Internal Medicine I, Comprehensive Heart Failure Center, University of Würzburg, Oberdürrbacher Strasse 6, Würzburg 97080, Germany.
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Nurminen J, Puustinen J, Piirtola M, Vahlberg T, Lyles A, Kivelä SL. Opioids, antiepileptic and anticholinergic drugs and the risk of fractures in patients 65 years of age and older: a prospective population-based study. Age Ageing 2013. [PMID: 23204431 DOI: 10.1093/ageing/afs178] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND in men, the concomitant use of two or more benzodiazepines or two or more antipsychotics is associated with an increased risk of fracture(s). Potential associations between the concomitant use of drugs with central nervous system effects and fracture risk have not been studied. OBJECTIVE the purpose was to describe the gender-specific risk of fractures in a population aged 65 years or over associated with the use of an opioid, antiepileptic or anticholinergic drug individually; or, their concomitant use with each other; or the concomitant use of one of these with a psychotropic drug. METHODS this study was part of a prospective, population-based study performed in Lieto, Finland. Information about fractures in 1,177 subjects (482 men and 695 women) was confirmed with radiology reports. RESULTS at 3 years of follow-up, the concomitant use of an opioid with an antipsychotic was associated with an increased risk of fractures in men. During the 6-year follow-up, the concomitant use of an opioid with a benzodiazepine was also related to the risk of fractures for males. No significant associations were found for females. CONCLUSION the concomitant use of an opioid with an antipsychotic, or with a benzodiazepine may increase the risk of fractures in men aged 65 years and older.
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Affiliation(s)
- Janne Nurminen
- Department of Family Medicine, University of Turku, Lemminkäisenkatu 1 20014, Turku, Finland.
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Galik E, Resnick B. Psychotropic medication use and association with physical and psychosocial outcomes in nursing home residents. J Psychiatr Ment Health Nurs 2013; 20:244-52. [PMID: 22500725 DOI: 10.1111/j.1365-2850.2012.01911.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Psychotropic medications are commonly prescribed for older adults living in long-term care settings. Use of these medications has been associated with negative functional outcomes. The purpose of this study was to describe the prevalence of psychotropic medication use among nursing home residents, and to explore the relationship of psychotropic medication use on physical and psychosocial outcomes. A secondary data analysis was done using baseline measures from the Res-Care Intervention Study. The sample included 419 residents from 12 nursing homes. There were 288 participants (69%) who were prescribed at least one psychotropic medication, with 81 participants (19%) receiving antipsychotics, 248 (59%) receiving antidepressants, 50 (12%) receiving anxiolytics and 37 (9%) receiving sedative/hypnotics. Controlling for gender, age and cognition, physical outcomes were significantly lower in residents receiving psychotropic medications (F= 3.2, P= 0.01) compared to those not receiving psychotropic medications. Psychosocial outcomes were significantly lower in those residents receiving psychotropic mediations (F= 2.0, P= 0.04). The findings from this study provide additional support for the prevalence of psychotropic medication use among nursing home residents and suggest that residents receiving psychotropic medications may be less likely to engage in functional activities and experience decreased quality of life.
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Affiliation(s)
- E Galik
- University of Maryland School of Nursing, Baltimore, MD 21201, USA.
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Carbone LD, Chin AS, Lee TA, Burns SP, Svircev JN, Hoenig HM, Akhigbe T, Weaver FM. The association of opioid use with incident lower extremity fractures in spinal cord injury. J Spinal Cord Med 2013; 36:91-6. [PMID: 23809522 PMCID: PMC3595973 DOI: 10.1179/2045772312y.0000000060] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE To determine the association between opioid use and lower extremity fracture risk in men with spinal cord injury (SCI). DESIGN Retrospective cohort study. SETTING Veterans Affairs Healthcare System. PARTICIPANTS In total, 7447 male Veterans with a history of a traumatic SCI identified from the Veterans Affairs (VA) Spinal Cord Dysfunction Registry (SCD) from September 2002 through October 2007 and followed through October 2010. OUTCOME MEASURES Incident lower extremity fractures by use of opioids. RESULTS In individuals identified from the VA SCD Registry 2002-2007, opioid use was quite common, with approximately 70% of the cohort having received a prescription for an opioid. Overall, there were 892 incident lower extremity fractures over the time period of this study (597 fractures in the opioid users and 295 fractures in the non-opioid users). After adjusting for covariates, there was a statistically significant relationship between opioid use and increased risk for lower extremity fractures (hazard ratio 1.82 (95% confidence interval 1.59-2.09)). Shorter duration of use (<6 months) and higher doses were positively related to fracture risk (P < 0.0001). CONCLUSIONS Opioid use is quite common in SCI and is associated with an increased risk for lower extremity fractures. Careful attention to fracture prevention is warranted in patients with SCI, particularly upon initiation of an opioid prescription and when higher doses are used.
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Affiliation(s)
- Laura D. Carbone
- Department of Research, Veterans Affairs Medical Center, Memphis, TN, USA; and Department of Medicine, Division of Connective Tissues Disorders, University of Tennessee Health Science Center, Memphis, TN, USA,Correspondence to: Laura Carbone, University of Tennessee Health Science Center, 956 Court Avenue, Rm G326, Memphis, TN 38163-0001, USA.
| | - Amy S. Chin
- Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr VA Hospital, Hines, IL, USA
| | - Todd A. Lee
- University of Illinois at Chicago, Chicago, IL, USA
| | - Stephen P. Burns
- VA Puget Sound Health Care System & Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jelena N. Svircev
- VA Puget Sound Health Care System & Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | | | - Titilola Akhigbe
- Department of Research, Veterans Affairs Medical Center, Memphis, TN, USA; and Department of Medicine, Division of Connective Tissues Disorders, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Frances M. Weaver
- Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr VA Hospital, Hines, IL, USA
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Rabenda V, Nicolet D, Beaudart C, Bruyère O, Reginster JY. Relationship between use of antidepressants and risk of fractures: a meta-analysis. Osteoporos Int 2013; 24:121-37. [PMID: 22638709 DOI: 10.1007/s00198-012-2015-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 04/27/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED It has been shown that antidepressants would have a direct action on bone metabolism and would be associated with increased fracture risk. Results from this large meta-analysis show that both SSRIs and TCAs are associated with a moderate and clinically significant increase in the risk of fractures of all types. INTRODUCTION This study seeks to investigate the relationship between use of antidepressants and the risk of fracture. METHODS An exhaustive systematic research of case-control and cohort studies published or performed between 1966 and April 2011 that reported risk estimates of fracture associated with use of antidepressants was performed using MEDLINE, PsycINFO, and the Cochrane Systematic Review Database, manual review of the literature, and congressional abstracts. Inclusion, quality scoring, and data abstraction were performed systematically by three independent reviewers. RESULTS A total of 34 studies (n = 1,217,464 individuals) were identified. Compared with non-users, the random effects pooled RR of fractures of all types, among antidepressant users, were 1.39 (95%CI 1.32-1.47). Use of antidepressants were associated with a 42 %, 47 %, and 38 % risk increase in non-vertebral, hip, and spine fractures, respectively ([For non-vertebral fractures: RR = 1.42, 95%CI 1.34-1.51]; [For hip fractures: RR = 1.47, 95%CI 1.36-1.58]; [For spine fractures: RR = 1.38, 95%CI 1.19-1.61]). Studies examining SSRI use showed systematically a higher increase in the risk of fractures of all types, non-vertebral, and hip fractures than studies evaluating TCA use. CONCLUSIONS Results from this large meta-analysis show that both SSRIs and TCAs are associated with a moderate and clinically significant increase in the risk of fractures of all types.
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Affiliation(s)
- V Rabenda
- Department of Public Health, Epidemiology and Health Economics, University of Liège, CHU-Bât. B23, 4000, Liège, Belgium.
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Exposure to medicines among patients admitted for hip fracture and the case-fatality rate at 1 year: a longitudinal study. Eur J Clin Pharmacol 2012; 68:1525-31. [PMID: 22527343 DOI: 10.1007/s00228-012-1273-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 03/15/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To describe the demographic and clinical characteristics and the pre-fracture exposure to medicines of patients admitted for a hip fracture, and to explore their association with fatal outcome 1 year after the fracture. METHODS All patients ≥ 65 years old admitted for a hip fracture in a tertiary hospital in Barcelona between January 1 and December 31 2007 were included. Data on the patients' clinical characteristics before and during hospital admission and on pre-fracture exposures to medicines were collected from the clinical records. One-year mortality was checked by approaching the patients and their families and was cross-checked with the national mortality statistics database. A Cox proportional hazards analysis was carried out. RESULTS Four hundred and fifty-six patients [mean age (SD) 82.9 (7.2) years, 73.5 % female], were admitted with hip fracture during the study period. Almost 80 % of the patients (363, 79.6 %) had three or more associated conditions, and 41.7 % received pre-fracture treatment with five or more drugs. The case-fatality rate during hospital admission was 4.6 % (21 patients). One hundred and seven patients died within 1 year (23.5 %). Advanced age, male gender, two or more associated chronic conditions, cancer, severe cognitive impairment, and treatment with opiates before fracture were significantly associated with the risk of dying. An inverse association was recorded between mortality and pre-hospital exposure to medicines for osteoporosis. CONCLUSIONS One-quarter of patients admitted for hip fracture died within 1 year after the fracture. Exposure to opiates before hip fracture was associated with an increased 1-year death rate, whereas treatment with drugs for osteoporosis was associated with a decrease in death rate. These results should be confirmed in studies with detailed prospective collection of information on exposure to medicines.
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Teresi JA, Ramirez M, Remler D, Ellis J, Boratgis G, Silver S, Lindsey M, Kong J, Eimicke JP, Dichter E. Comparative effectiveness of implementing evidence-based education and best practices in nursing homes: effects on falls, quality-of-life and societal costs. Int J Nurs Stud 2011; 50:448-63. [PMID: 21807366 DOI: 10.1016/j.ijnurstu.2011.07.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 06/24/2011] [Accepted: 07/03/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The aim was to conduct a comparative effectiveness research study to estimate the effects on falls, negative affect and behavior, and the associated societal costs of implementing evidence-based education and best practice programs in nursing homes (NHs). DESIGN A quasi-experimental design, a variant of a cluster randomized trial of implementation research examining transfer of research findings into practice, was used to compare outcomes among three groups of residents in 15 nursing homes per group. METHODS Forty-five NHs participated in one of three conditions: (1) standard training, (2) training and implementation modules provided to facility staff, or (3) staff training and implementation modules augmented by surveyor training. After application of exclusion and matching criteria, nursing homes were selected at random within three regions of New York State. Outcomes were assessed using medical records and the Minimum Data Set (MDS). RESULTS The main finding was of a significant reduction of between 5 and 12 annual falls in a typical nursing home. While both intervention groups resulted in fall reduction, the larger and significant reduction occurred in the group without surveyor training. A significant reduction in negative affect associated with training staff and surveyors was observed. Net cost savings from fall prevention was estimated. CONCLUSIONS A low cost intervention targeting dissemination of evidence-based best practices in nursing homes can result in the potential for fall reduction, and cost savings.
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Affiliation(s)
- Jeanne A Teresi
- Research Division, Hebrew Home at Riverdale, 5901 Palisade Avenue, Riverdale, NY 10471, USA.
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Kang Y, Meng H, Miller NA. Rurality and nursing home quality: evidence from the 2004 National Nursing Home Survey. THE GERONTOLOGIST 2011; 51:761-73. [PMID: 21719631 DOI: 10.1093/geront/gnr065] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE OF THE STUDY To evaluate the impact of rural geographic location on nursing home quality of care in the United States. DESIGN AND METHODS The study used cross-sectional observational design. We obtained resident- and facility-level data from 12,507 residents in 1,174 nursing homes from the 2004 National Nursing Home Survey. We used multilevel regression models to predict risk-adjusted rates of hospitalization, influenza and pneumococcal vaccination, and moderate to severe pain while controlling for resident and facility characteristics. RESULTS Adjusting for covariates, residents in rural facilities were more likely to experience hospitalization (odds ratio [OR] = 1.50, 95% confidence interval [CI] = 1.16-1.94) and moderate to severe pain (OR = 1.68, 95% CI = 1.35-2.09). Significant facility-level predictors of higher quality included higher percentage of Medicaid beneficiaries, accreditation status, and special care programs. Medicare payment findings were mixed. Significant resident-level predictors included dementia diagnosis and being a "long-stay" resident. IMPLICATIONS Rural residents were more likely to reside in facilities without accreditations or special care programs, factors that increased their odds of receiving poorer quality of care. Policy efforts to enhance Medicare payment approaches as well as increase rural facilities' accreditation status and provision of special care programs will likely reduce quality of care disparities in facilities.
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Affiliation(s)
- Yu Kang
- Department of Public Health and Health Sciences, University of Michigan-Flint, 2102 W.S. White Building, 303 East Kearsley Street, Flint, MI 48502-1950, USA.
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Bloch F, Thibaud M, Dugué B, Brèque C, Rigaud AS, Kemoun G. Laxatives as a risk factor for iatrogenic falls in elderly subjects: myth or reality? Drugs Aging 2011; 27:895-901. [PMID: 20964463 DOI: 10.2165/11584280-000000000-00000] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND The multifactorial nature of falls is well known, and several studies on falls in the elderly have reported that laxatives can be a risk factor, but without attempting to discuss possible mechanisms to explain this role. OBJECTIVE We aimed to isolate studies in which the risk factors for falls in the elderly related to laxatives have been evaluated and to carry out a meta-analysis combining the results of all identified good-quality studies. METHODS Systematic literature review using the keywords 'accidental fall/numerical data' and 'risk factors'. This was followed by a manual search for articles cited in the previously identified publications. Articles were analysed if they had study populations aged ≥60 years, reported on falls occurring in everyday life, were observational or interventional studies that identified laxatives as a risk factor for falls, and were written in French or English. Articles of this type that were considered to be of good quality were included in the meta-analysis. RESULTS 3747 indexed articles published between 1981 and 2007 were identified. Of these, seven articles met all inclusion criteria and were analysed. The odds ratio (95% CI) for the association between use of laxatives and fall occurrence in subjects participating in the good-quality trials (n = 4) included in the meta-analysis was 2.03 (1.52, 2.72). This result was statistically homogeneous (percentage of the total variation across studies due to heterogeneity [I2] = 0). CONCLUSIONS Elderly subjects treated with laxatives were twice as likely to fall compared with non-laxative users. The causal relationship was probably not directly attached to a side effect of the substance used, but rather a reflection of other pathologies (e.g. older age, confinement to bed, concomitant Parkinson's disease) that may themselves cause falls.
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Affiliation(s)
- Frédéric Bloch
- Department of Gerontology, Assistance Publique-Hôpitaux de Paris (Hôpital Broca), Paris, France.
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Rigler SK, Ellerbeck E, Whittle J, Mahnken J, Cook-Wiens G, Shireman TI. Comparing methods to identify hip fracture in a nursing home population using Medicare claims. Osteoporos Int 2011; 22:57-61. [PMID: 20503037 PMCID: PMC2990808 DOI: 10.1007/s00198-010-1264-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 03/09/2010] [Indexed: 10/19/2022]
Abstract
UNLABELLED The inpatient principal diagnosis in Medicare claims identified 96% of hip fractures in hospitalized nursing home residents with high rates of confirmation by other claims files. INTRODUCTION Hip fracture is typically identified in Medicare claims by examining only the principal diagnosis in the inpatient file, but this simple approach might be inadequate for nursing home residents. Our objective was to examine the impact of varied operational definitions for identifying hip fracture hospitalizations in administrative claims data. METHODS We conducted a retrospective examination of Medicare inpatient and outpatient claims data for dually Medicaid- and Medicare-eligible nursing home residents in 1999 in California, Florida, Missouri, New Jersey, and Pennsylvania (n = 197,514). We determined the number of hip fractures identified in inpatient (Medicare A) diagnoses codes using differing definitions that varied according to whether or not hip fracture was required to be the principal diagnosis and whether or not confirmatory imaging and procedure codes were required to be found in other (Medicare B) claims files. RESULTS Hip fractures were found in any inpatient diagnosis position in 4,680 subjects, with 4,479 of these found in the principal diagnosis position. With either approach to diagnosis position, confirmatory imaging and procedure codes were identified for 95% of persons hospitalized with hip fracture. CONCLUSION The principal diagnosis alone will identify 96% of hip fracture diagnoses in hospitalized nursing home residents. Such diagnoses are confirmed at very high rates by other sources of claims data. Researchers may be confident using a simple approach to identifying hip fracture hospitalizations in this population, using inpatient claims alone and interrogating only the principal diagnosis position.
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Affiliation(s)
- S K Rigler
- Department of Internal Medicine, University of Kansas School of Medicine, Kansas City, KS, USA.
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Lee RH, Lyles KW, Colón-Emeric C. A review of the effect of anticonvulsant medications on bone mineral density and fracture risk. ACTA ACUST UNITED AC 2010; 8:34-46. [PMID: 20226391 DOI: 10.1016/j.amjopharm.2010.02.003] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Osteoporosis and seizure disorders are common diagnoses in older adults and often occur concomitantly. OBJECTIVE The goal of this review was to discuss the current hypothesis for the pathogenesis of anticonvulsant-induced bone density loss and the evidence regarding the risk for osteoporosis and fractures in older individuals. METHODS A review of the literature was performed, searching in MEDLINE and CINAHL for articles published between 1990 and October 2009 with the following search terms: anticonvulsant OR antiepileptic; AND osteoporosis OR bone density OR fracture OR absorptiometry, photon. Studies within the pediatric population, cross-sectional studies, and studies whose results were published in a language other than English were excluded. RESULTS A search of the published literature yielded >300 results, of which 24 met the inclusion and exclusion criteria and were included in this review. Hepatic enzyme induction by certain anticonvulsant medications appears to contribute to increased metabolism of 25-hydroxyvitamin D to inactive metabolites, which results in metabolic bone disease. There is increasing evidence that anticonvulsant use is associated with a higher risk of osteoporosis and clinical fractures, especially among older agents such as phenobarbital, carbamazepine, phenytoin, and valproate. Several observational studies suggest a class effect among anticonvulsant agents, associated with clinically significant reductions in bone mineral density and fracture risk. The use of anticonvulsant medications increases the odds of fracture by 1.2 to 2.4 times. However, only 2 large-scale observational studies have specifically examined the risk among those aged >65 years. This review also identified a randomized controlled trial whose results suggest that supplementation with high-dose vitamin D may be associated with increased bone mineral density in patients taking anticonvulsant medications. However, no randomized controlled trials investigating therapeutic agents to prevent fracture in this population were identified. Consequently, there are no formal practice guidelines for the monitoring, prevention, and management of bone disease among those taking anticonvulsants. CONCLUSIONS Observational studies suggest an association between use of anticonvulsant medications, reduced bone mineral density, and increased fracture risk. Randomized clinical trials are needed to guide the management of bone disease among those who use anticonvulsants.
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Affiliation(s)
- Richard H Lee
- Division of Geriatrics, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA.
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Duque G, Close JJ, Jager JP, Ebeling PR, Inderjeeth C, Lord S, McLachlan AJ, Reid IR, Troen BR, Sambrook PN. Treatment for osteoporosis in Australian residential aged care facilities: consensus recommendations for fracture prevention. Med J Aust 2010; 193:173-9. [DOI: 10.5694/j.1326-5377.2010.tb03839.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 03/30/2010] [Indexed: 11/17/2022]
Affiliation(s)
- Gustavo Duque
- Ageing Bone Research Program, Sydney Medical School – Nepean Campus, University of Sydney, Sydney, NSW
| | - Jacqueline J Close
- Prince of Wales Medical Research Institute, University of New South Wales, Sydney, NSW
| | | | - Peter R Ebeling
- Department of Medicine, Western Hospital, University of Melbourne, Melbourne, VIC
| | - Charles Inderjeeth
- Area Rehabilitation and Aged Care, National Institute of Clinical Studies and University of Western Australia, Perth, WA
| | - Stephen Lord
- Prince of Wales Medical Research Institute, University of New South Wales, Sydney, NSW
| | - Andrew J McLachlan
- Faculty of Pharmacy, University of Sydney and Centre for Education and Research in Ageing, Sydney, NSW
| | - Ian R Reid
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Bruce R Troen
- Department of Geriatric Medicine, Miller School of Medicine, University of Miami, Miami, Fla, USA
| | - Philip N Sambrook
- Kolling Institute for Medical Research, Sydney Medical School – Northern Campus, University of Sydney, Sydney, NSW
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Psychotropic drugs and the risk of fractures in old age: a prospective population-based study. BMC Public Health 2010; 10:396. [PMID: 20602803 PMCID: PMC2910682 DOI: 10.1186/1471-2458-10-396] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Accepted: 07/06/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is evidence that the use of any psychotropic and the concomitant use of two or more benzodiazepines are related to an increased risk of fractures in old age. However, also controversial results exist. The aim was to describe associations between the use of a psychotropic drug, or the concomitant use of two or more of these drugs and the risk of fractures in a population aged 65 years or over. METHODS This study was a part of a prospective longitudinal population-based study carried out in the municipality of Lieto, South-Western Finland. The objective was to describe gender-specific associations between the use of one psychotropic drug [benzodiazepine (BZD), antipsychotic (AP) or antidepressant (AD)] or the concomitant use of two or more psychotropic drugs and the risk of fractures in a population 65 years or over. Subjects were participants in the first wave of the Lieto study in 1990-1991, and they were followed up until the end of 1996. Information about fractures confirmed with radiology reports in 1,177 subjects (482 men and 695 women) during the follow-up was collected from medical records. Two follow-up periods (three and six years) were used, and previously found risk factors of fractures were adjusted as confounding factors separately for men and women. The Poisson regression model was used in the analyses. RESULTS The concomitant use of two or more BZDs and the concomitant use of two or more APs were related to an increased risk of fractures during both follow-up periods after adjusting for confounding factors in men. No similar associations were found in women. CONCLUSIONS The concomitant use of several BZDs and that of several APs are associated with an increase in the risk of fractures in older men. Our findings show only risk relations. We cannot draw the conclusion that these drug combinations are causes of fractures.
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Antiepileptic drug use, falls, fractures, and BMD in postmenopausal women: findings from the women's health initiative (WHI). J Bone Miner Res 2010; 25:873-81. [PMID: 19839772 PMCID: PMC3153335 DOI: 10.1359/jbmr.091027] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Antiepileptic drugs (AEDs) are used increasingly in clinical practice to treat a number of conditions. However, the relationship between the use of these medications, particularly the newer AEDs, and fracture risk has not been well characterized. We used data from the Women's Health Initiative (WHI) to determine the relationship bewteen the use of AEDs and falls, fractures, and bone mineral density (BMD) over an average of 7.7 years of follow-up. We included 138,667 women (1,385 users of AEDs and 137,282 nonusers) aged 50 to 79 years in this longitudinal cohort analyses. After adjustment for covariates, use of AEDs was positively associated with total fractures [hazard ratio (HR) = 1.44, 95% confidence interval (CI) 1.30-1.61], all site-specific fractures including the hip (HR = 1.51, 95% CI 1.05-2.17), clinical vertebral fractures (HR = 1.60, 95% CI 1.20-2.12), lower arm or wrist fractures (HR = 1.40, 95% CI 1.11-1.76), and other clinical fractures (HR = 1.46, 95% CI 1.29-1.65) and two or more falls (HR = 1.62, 95% CI 1.50-1.74) but not with baseline BMD or changes in BMD (p > or = .064 for all sites). Use of more than one and use of enzyme-inducing AEDs were significantly associated with total fractures (HR = 1.55, 95% CI 1.15-2.09 and HR = 1.36, 95% CI 1.09-1.69, respectively). We conclude that in clinical practice, postmenopausal women who use AEDs should be considered at increased risk for fracture, and attention to fall prevention may be particularly important in these women.
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Saunders KW, Dunn KM, Merrill JO, Sullivan M, Weisner C, Braden JB, Psaty BM, Von Korff M. Relationship of opioid use and dosage levels to fractures in older chronic pain patients. J Gen Intern Med 2010; 25:310-5. [PMID: 20049546 PMCID: PMC2842546 DOI: 10.1007/s11606-009-1218-z] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Revised: 07/14/2009] [Accepted: 11/20/2009] [Indexed: 01/13/2023]
Abstract
BACKGROUND Opioids have been linked to increased risk of fractures, but little is known about how opioid dose affects fracture risk. OBJECTIVE To assess whether risk of fracture increases with opioid dose among older patients initiating sustained use of opioids for chronic non-cancer pain. DESIGN A cohort study that uses Cox proportional hazards models to compare fracture risk among current opioid users vs. persons no longer using opioids. PARTICIPANTS Members of an integrated health care plan (N = 2,341) age 60 years and older who received 3+ opioid prescriptions within a 90-day period for chronic, non-cancer pain between 2000 and 2005. MEASUREMENTS Time-varying measures of opioid use and average daily dose in morphine equivalents were calculated from automated data. Fractures were identified from automated data and then validated through medical record review. RESULTS Compared with persons not currently using opioids, opioid use was associated with a trend towards increased fracture risk (1.28 (95% CI (0.99, 1.64 )). Higher dose opioid use (>or=50 mg/day) was associated with a 9.95% annual fracture rate and a twofold increase in fracture risk (2.00 (95% CI (1.24, 3.24)). Of the fractures in the study cohort, 34% were of the hip or pelvis, and 37% were associated with inpatient care. CONCLUSIONS Higher doses (>or=50 mg/day) of opioids for chronic non-cancer pain were associated with a 2.00 increase in risk of fracture confirmed by medical record review. Clinicians should consider fracture risk when prescribing higher-dose opioid therapy for older adults.
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Anticonvulsant use, bipolar disorder, and risk of fracture among older adults in the Veterans Health Administration. Am J Geriatr Psychiatry 2010; 18:245-55. [PMID: 20224520 DOI: 10.1097/jgp.0b013e3181bf9ebd] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate the association between anticonvulsant use and fracture risk among older patients, including those with bipolar disorder (BD), an indicated condition for treatment with this class of medications. DESIGN A prospective cohort study with 4.5 years of follow-up analyzed using both Cox proportional hazards modeling and propensity score techniques. SETTING National sample selected from Veterans Health Administration records. PARTICIPANTS A representative sample of 67,387 Veterans Administration patients aged 50 years and older selected in fiscal year 2002 and followed until 2006, including 29,029 with a diagnosis of BD identified from the Veterans Administration National Psychosis Registry. Pharmacy records identified 19,635 patients who had ever used anticonvulsant medications. MEASUREMENTS Incident fracture at any site and incident hip fracture indicated by administrative data. RESULTS There were 4,367 fractures over the 4.5-year study period. Approximately two-thirds of patients with BD were prescribed anticonvulsants, and diagnosis of BD was associated with 20% increased risk of fracture independent of anticonvulsant use. Cumulative incidence of fracture was higher among anticonvulsant users relative to never users (35.7 per 1,000 versus 14.2 per 1,000 person-years). In fully adjusted models, anticonvulsant use was associated with over twofold greater risk of fracture (hazard ratio: 2.42, 95% confidence interval: 2.23-2.633). Current use was associated with the greater risk of fracture relative to former use. Duration of anticonvulsant use was significantly associated with increased fracture risk in a graded, nonlinear manner. CONCLUSIONS Use of anticonvulsants is associated with increased risk of fracture among older patients with BD and among those without serious mental illness.
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Kinsella S, Moran S, Sullivan MO, Molloy MG, Eustace JA. Hyponatremia independent of osteoporosis is associated with fracture occurrence. Clin J Am Soc Nephrol 2010; 5:275-80. [PMID: 20056759 PMCID: PMC2827601 DOI: 10.2215/cjn.06120809] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 11/29/2009] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Mild hyponatremia has traditionally been considered benign, but it may be associated with gait and attention deficits and an increased risk of falls that may result in fracture. A retrospective study was conducted to quantify the association of hyponatremia with fracture occurrence and to examine whether this relationship is independent of osteoporosis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study analyzed 1408 consecutive female patients who underwent bone mineral density measurement (Lunar IDXA) between September 1, 2006 and April 11, 2007 and who had available laboratory data. Self reported fracture occurrence was confirmed by radiology report or attendance at a fracture clinic. The significance and independence of the association of hyponatremia with fracture was quantified using logistic regression. RESULTS The mean (SD) serum sodium ([Na(+)]) was 140.6 (3.0) mmol/L; 59 (4.2%) had [Na(+)] < 135 mmol/L. Forty-five percent of subjects were osteoporotic and 18% had a prior fracture. Hyponatremia was present in 8.7% of those with versus 3.2% of those without a confirmed fracture (P < 0.001). On multivariate logistic regression analysis controlling for age, T-score, chronic kidney disease stage, osteoporotic risk factors (amenorrhea, family history, regular steroid use, smoking history, alcohol use, history of liver disease, and low-calcium diet), and osteoporosis treatments (calcium and vitamin D supplements, antiresorptives, and hormonal replacement therapy), [Na(+)] < 135 versus [Na(+)] >or= 135 mmol/L remained significantly and independently associated with fracture occurrence (P < 0.01). CONCLUSIONS Mild hyponatremia may be a readily identifiable and potentially modifiable risk factor for fracture.
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Liu H, Grando V, Zabel R, Nolen J. Pilot study evaluating fear of falling and falls among older rolling walker users. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2009. [DOI: 10.12968/ijtr.2009.16.12.45423] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hao Liu
- Physical Therapy Department, University of Central Arkansas, Conway, Arkansas, USA
| | - Victoria Grando
- College of Nursing and Healthcare Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Reta Zabel
- Physical Therapy Department, St Angelo State University, St Angelo, Texas, USA
| | - Jeff Nolen
- Physical Therapy Department, University of Central Arkansas, Conway, Arkansas
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Abstract
Problem solving using a collaborative approach may reduce the risk of falls in the nursing home. Interventions need to be tailored to the individual's cognitive and physical impairments as well as be feasible in the particular long-term care setting. Polypharmacy, Vitamin D deficiency, delirium, and urinary incontinence are among several risks for falls that are discussed in this article.
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Abstract
The older senior is at high risk for osteoporosis. It is important for healthcare providers to be fully aware of the potential risks and benefits of diagnosing and treating osteoporosis in the older senior population. Data indicate that bone mineral density testing is under-utilized and drug therapy is often not initiated when indicated in this population. Bone mineral density testing with central dual energy x-ray absorptiometry is essential and cost-effective in this population. All older seniors should be educated on a bone-healthy lifestyle including age-appropriate weight-bearing exercise and smoking cessation if necessary. It is important to remember that falls play a very important role in the risk for osteoporotic fractures, especially in the older senior. All older seniors should be evaluated annually for falls and strategies should be implemented to reduce fall risk in this population. The risk for vitamin D insufficiency and deficiency is high in the older senior and can contribute to falls and fractures. Adequate intakes of calcium and vitamin D are important and deficiencies need to be treated. Data on osteoporosis drug therapy in the older senior are lacking. Based on data from subgroup analyses of large osteoporosis trials in postmenopausal women, current osteoporosis therapies appear safe and efficacious in the older senior and most will live long enough to derive a benefit from these therapies. Further studies are needed in older seniors, especially men, to better understand the risks and benefits of pharmacologic therapy for the management of osteoporosis.
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Affiliation(s)
- Sheryl F Vondracek
- Department of Clinical Pharmacy, School of Pharmacy C238-L15, University of Colorado Denver, Aurora, CO 80045, USA.
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Berry SD, Samelson EJ, Ngo L, Bordes M, Broe KE, Kiel DP. Subsequent fracture in nursing home residents with a hip fracture: a competing risks approach. J Am Geriatr Soc 2008; 56:1887-92. [PMID: 18721221 DOI: 10.1111/j.1532-5415.2008.01918.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the incidence and predictors of subsequent fracture in nursing home residents with a hip fracture, accounting for the competing risk of death. DESIGN Dynamic cohort study. SETTING Hebrew Rehabilitation Center, a 725-bed, long-term care facility in Boston, Massachusetts. PARTICIPANTS Long-term care residents with a surgically repaired hip fracture (1999-2006) followed through June 30, 2007, for the occurrence of subsequent fracture at any skeletal site. MEASUREMENTS Information on age, sex, anatomic location, type of repair, body mass index (BMI), comorbidities, functional status, cognitive status, and medication use were evaluated as potential risk factors for subsequent fracture. RESULTS The study included 184 residents with a baseline hip fracture. Thirty-nine residents (7 men, 32 women) experienced a subsequent fracture over a median follow-up of 1.1 years. After the baseline hip fracture, 6% of residents experienced a subsequent fracture within 6 months, 12% within 1 year, and 21% within 5 years. In addition, 23% of residents died within 6 months, 31% within 1 year, and 60% within 5 years. High functional status was associated with a five times greater risk of subsequent fracture (high vs low functional status, hazard ratio=5.10, P<.005). Age, sex, BMI, comorbidities, cognitive status, and medication use were not associated with subsequent fracture. CONCLUSION Hip fractures are a sentinel event in nursing home residents, with a high incidence of subsequent fracture and death occurring within 1 year. Identification of prefracture characteristics and postfracture complications associated with mortality should help guide secondary prevention efforts in nursing home residents.
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Affiliation(s)
- Sarah D Berry
- Hebrew SeniorLife, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts 02131, USA.
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Affiliation(s)
- Andrea Gruneir
- Department of Community Health, Brown University, Providence, Rhode Island 02912; ,
| | - Vincent Mor
- Department of Community Health, Brown University, Providence, Rhode Island 02912; ,
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French DD, Campbell RR, Powell-Cope GM. A National View of Injuries in VHA Nursing Homes. J Am Med Dir Assoc 2007; 8:547-8. [DOI: 10.1016/j.jamda.2007.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Indexed: 10/22/2022]
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