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Wang L, Pronk AC, van Poelgeest EP, Briggs R, Claassen JAHR, Jansen S, Klop M, de Lange FJ, Meskers CCGM, Odekerken VJJ, Payne SJ, Trappenburg MC, Thijs RD, Uleman JF, Hoekstra AG, van der Velde N. Applying systems thinking to unravel the mechanisms underlying orthostatic hypotension related fall risk. GeroScience 2023; 45:2743-2755. [PMID: 37115348 PMCID: PMC10651607 DOI: 10.1007/s11357-023-00802-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Orthostatic hypotension (OH) is an established and common cardiovascular risk factor for falls. An in-depth understanding of the various interacting pathophysiological pathways contributing to OH-related falls is essential to guide improvements in diagnostic and treatment opportunities. We applied systems thinking to multidisciplinary map out causal mechanisms and risk factors. For this, we used group model building (GMB) to develop a causal loop diagram (CLD). The GMB was based on the input of experts from multiple domains related to OH and falls and all proposed mechanisms were supported by scientific literature. Our CLD is a conceptual representation of factors involved in OH-related falls, and their interrelatedness. Network analysis and feedback loops were applied to analyze and interpret the CLD, and quantitatively summarize the function and relative importance of the variables. Our CLD contains 50 variables distributed over three intrinsic domains (cerebral, cardiovascular, and musculoskeletal), and an extrinsic domain (e.g., medications). Between the variables, 181 connections and 65 feedback loops were identified. Decreased cerebral blood flow, low blood pressure, impaired baroreflex activity, and physical inactivity were identified as key factors involved in OH-related falls, based on their high centralities. Our CLD reflects the multifactorial pathophysiology of OH-related falls. It enables us to identify key elements, suggesting their potential for new diagnostic and treatment approaches in fall prevention. The interactive online CLD renders it suitable for both research and educational purposes and this CLD is the first step in the development of a computational model for simulating the effects of risk factors on falls.
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Affiliation(s)
- Liping Wang
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
| | - Anouschka C Pronk
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
| | - Eveline P van Poelgeest
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands.
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands.
| | - Robert Briggs
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Jurgen A H R Claassen
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Sofie Jansen
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marjolein Klop
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Frederik J de Lange
- Amsterdam UMC location University of Amsterdam, Cardiology and Cardiothoracic Surgery, Meibergdreef 9, Amsterdam, The Netherlands
| | - Carel C G M Meskers
- Amsterdam UMC location Vrije Universiteit Amsterdam, Rehabilitation Medicine, De Boelelaan, 1117, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Vincent J J Odekerken
- Amsterdam UMC location University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Stephen J Payne
- Institute of Applied Mechanics, National Taiwan University, Taipei, Taiwan
| | | | - Roland D Thijs
- Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
- Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, The Netherlands
| | - Jeroen F Uleman
- Department of Geriatric Medicine, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
- Institute for Advanced Study, Amsterdam, The Netherlands
| | - Alfons G Hoekstra
- Computational Science Lab, Informatics Institute, Faculty of Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Nathalie van der Velde
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Geriatrics, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands
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Seppala LJ, Kamkar N, van Poelgeest EP, Thomsen K, Daams JG, Ryg J, Masud T, Montero-Odasso M, Hartikainen S, Petrovic M, van der Velde N. Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review and meta-analysis. Age Ageing 2022; 51:afac191. [PMID: 36153749 PMCID: PMC9509688 DOI: 10.1093/ageing/afac191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND our aim was to assess the effectiveness of medication review and deprescribing interventions as a single intervention in falls prevention. METHODS DESIGN systematic review and meta-analysis. DATA SOURCES Medline, Embase, Cochrane CENTRAL, PsycINFO until 28 March 2022. ELIGIBILITY CRITERIA randomised controlled trials of older participants comparing any medication review or deprescribing intervention with usual care and reporting falls as an outcome. STUDY RECORDS title/abstract and full-text screening by two reviewers. RISK OF BIAS Cochrane Collaboration revised tool. DATA SYNTHESIS results reported separately for different settings and sufficiently comparable studies meta-analysed. RESULTS forty-nine heterogeneous studies were included. COMMUNITY meta-analyses of medication reviews resulted in a risk ratio (RR) of 1.05 (95% confidence interval, 0.85-1.29, I2 = 0%, 3 studies(s)) for number of fallers, in an RR = 0.95 (0.70-1.27, I2 = 37%, 3 s) for number of injurious fallers and in a rate ratio (RaR) of 0.89 (0.69-1.14, I2 = 0%, 2 s) for injurious falls. HOSPITAL meta-analyses assessing medication reviews resulted in an RR = 0.97 (0.74-1.28, I2 = 15%, 2 s) and in an RR = 0.50 (0.07-3.50, I2 = 72% %, 2 s) for number of fallers after and during admission, respectively. LONG-TERM CARE meta-analyses investigating medication reviews or deprescribing plans resulted in an RR = 0.86 (0.72-1.02, I2 = 0%, 5 s) for number of fallers and in an RaR = 0.93 (0.64-1.35, I2 = 92%, 7 s) for number of falls. CONCLUSIONS the heterogeneity of the interventions precluded us to estimate the exact effect of medication review and deprescribing as a single intervention. For future studies, more comparability is warranted. These interventions should not be implemented as a stand-alone strategy in falls prevention but included in multimodal strategies due to the multifactorial nature of falls.PROSPERO registration number: CRD42020218231.
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Affiliation(s)
- Lotta J Seppala
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Nellie Kamkar
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | - Eveline P van Poelgeest
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Katja Thomsen
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Joost G Daams
- Research Support, Medical Library, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ Amsterdam, The Netherlands
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- ODIN (Odense Deprescribing INitiative), Denmark
| | - Tahir Masud
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Manuel Montero-Odasso
- Gait and Brain Laboratory, Lawson Research Health Institute, Parkwood Hospital, London Ontario, Canada
- Schulich School of Medicine and Dentistry, London Ontario, Canada
- Departments of Medicine (Geriatrics) and of Epidemiology and Biostatistics, University of Western Ontario, London Ontario, Canada
| | | | - Mirko Petrovic
- Department of Internal Medicine and Paediatrics (Section of Geriatrics), Ghent University, Ghent, Belgium
| | - Nathalie van der Velde
- Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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Hatoum T, Sheldon RS. Syncope and the aging patient: Navigating the challenges. Auton Neurosci 2021; 237:102919. [PMID: 34856496 DOI: 10.1016/j.autneu.2021.102919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
Syncope in the elderly patient is a common presentation and the most common causes are usually non-cardiac. Older adults however are more challenging dilemmas as their presentation is complicated by co-morbidities, mainly cardiovascular and neurodegenerative disorders. Frailty and cognitive impairment add to the ambiguity of the presentation, and polypharmacy is often a major modifiable contributing factor. Vasovagal syncope is a common presentation throughout life even as we age. It has a favorable prognosis and conservative management usually suffices. Vasovagal syncope in this population may be misdiagnosed as accidental falls and is frequently associated with injury, as is carotid sinus syndrome. The initial approach to these patients entails a detailed history and physical examination including a comprehensive medication history, orthostatic vital signs, and a 12-lead electrocardiogram. Further cardiac and neuroimaging rarely helps, unless directed by specific clinical findings. Head-up tilt testing and carotid sinus massage retain their diagnostic accuracy and safety in the elderly, and implantable loop recorders provide important information in many elderly patients with unexplained falls and syncope. The starting point in management of this population with non-cardiac syncope is attempting to withdraw unnecessary vasoactive and psychotropic medications. Non-pharmacologic and pharmacologic therapy for syncope in the elderly has limited efficacy and safety concerns. In selected patients, pacemaker therapy might offer symptomatic relief despite lack of efficacy when vasodepression is prominent. An approach focused on primary care with targeted specialist referral seems a safe and effective strategy.
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Affiliation(s)
- Tarek Hatoum
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.
| | - Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
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Abstract
Polypharmacy describes the concomitant use of multiple medicines and represents a growing global challenge attributable to aging populations with an increasing prevalence of multimorbidity. Polypharmacy can be appropriate but is problematic when the increased risk of harm from interactions between drugs or between drugs and diseases or the burden of administering and monitoring medicines outweighs plausible benefits. Polypharmacy has a substantial economic impact in service demand and hospitalization as well as a detrimental impact on patients' quality of life. Apart from causing avoidable harm, polypharmacy can also lead to therapeutic failure, with up to 50% of patients who take four or more medications not taking them as prescribed. Guidance is needed to support patients and clinicians in defining and achieving realistic goals of drug treatment, and system change is necessary to aid implementation. This article outlines lessons from two programs that aim to address these challenges: the Scottish polypharmacy guidance on realistic prescribing and the European Union SIMPATHY project.
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Affiliation(s)
- Alpana Mair
- Effective Prescribing and Therapeutics, Scottish Government, Edinburgh EH1 3DG, United Kingdom;
| | | | - Tobias Dreischulte
- Quality, Safety, and Informatics Research Group, University of Dundee, Dundee DD1 4HN, United Kingdom.,Department of General Practice and Family Medicine, Ludwig Maximilian University Munich, 80366 Munich, Germany
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Mol A, Bui Hoang PTS, Sharmin S, Reijnierse EM, van Wezel RJA, Meskers CGM, Maier AB. Orthostatic Hypotension and Falls in Older Adults: A Systematic Review and Meta-analysis. J Am Med Dir Assoc 2019; 20:589-597.e5. [PMID: 30583909 DOI: 10.1016/j.jamda.2018.11.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 11/02/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Orthostatic hypotension is a potential risk factor for falls in older adults, but existing evidence on this relationship is inconclusive. This study addresses the association between orthostatic hypotension and falls. DESIGN Systematic review and meta-analysis of the cross-sectional and longitudinal studies assessing the association between orthostatic hypotension and falls, as preregistered in the PROSPERO database (CRD42017060134). SETTING AND PARTICIPANTS A literature search was performed on February 20, 2017, in MEDLINE (from 1946), PubMed (from 1966), and EMBASE (from 1947) using the terms orthostatic hypotension, postural hypotension, and falls. References of included studies were screened for other eligible studies. Study selection was performed independently by 2 reviewers using the following inclusion criteria: published in English; mean/median age of the population ≥65 years; blood pressure measurement before and after postural change; and assessment of the association of orthostatic hypotension with falls. The following studies were excluded: conference abstracts, case reports, reviews, and editorials. Data extraction was performed independently by 2 reviewers. MEASURES Unadjusted odds ratios of the association between orthostatic hypotension and falls were used for pooling using a random effects model. Studies were rated as high, moderate, or low quality using the Newcastle-Ottawa Scale. RESULTS Out of 5646 studies, 63 studies (51,800 individuals) were included in the systematic review and 50 studies (49,164 individuals) in the meta-analysis. Out of 63 studies, 39 were cross-sectional and 24 were longitudinal. Orthostatic hypotension was positively associated with falls (odds ratio 1.73, 95% confidence interval 1.50-1.99). The result was independent of study population, study design, study quality, orthostatic hypotension definition, and blood pressure measurement method. CONCLUSIONS AND IMPLICATIONS Orthostatic hypotension is significantly positively associated with falls in older adults, underpinning the clinical relevance to test for an orthostatic blood pressure drop and highlighting the need to investigate orthostatic hypotension treatment to potentially reduce falls.
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Affiliation(s)
- Arjen Mol
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands; Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Faculty of Science, Nijmegen, the Netherlands
| | - Phuong Thanh Silvie Bui Hoang
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, City Campus, Parkville, Melbourne, Victoria, Australia
| | - Sifat Sharmin
- Melbourne Academic Centre for Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Melbourne, Victoria, Australia
| | - Esmee M Reijnierse
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, City Campus, Parkville, Melbourne, Victoria, Australia
| | - Richard J A van Wezel
- Department of Biophysics, Donders Institute for Brain, Cognition and Behaviour, Radboud University, Faculty of Science, Nijmegen, the Netherlands; Department of Biomedical Signals and Systems, Technical Medical Centre, University of Twente, Zuidhorst Building, Enschede, the Netherlands
| | - Carel G M Meskers
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands; Department of Rehabilitation Medicine, Amsterdam UMC, VU University Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Andrea B Maier
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands; Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, City Campus, Parkville, Melbourne, Victoria, Australia.
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Mol A, Reijnierse EM, Bui Hoang PTS, van Wezel RJ, Meskers CG, Maier AB. Orthostatic hypotension and physical functioning in older adults: A systematic review and meta-analysis. Ageing Res Rev 2018; 48:122-144. [PMID: 30394339 DOI: 10.1016/j.arr.2018.10.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/17/2018] [Accepted: 10/17/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Orthostatic hypotension (OH) may negatively affect physical functioning and aggravate morbidities, but existing evidence is contradictory. METHODS MEDLINE (from 1946), PubMed (from 1966) and EMBASE databases (from 1947) were systematically searched for studies on the association of OH and physical functioning in older adults, categorized as: balance, gait characteristics, walking speed, Timed Up and Go time, handgrip strength (HGS), physical frailty, exercise tolerance, physical activity, activities of daily living (ADL), and performance on the Hoehn and Yahr scale (HY) and Unified Parkinson's Disease Rating Scale (UPDRS). Study quality was assessed using the Newcastle Ottawa Scale. RESULTS Forty-two studies were included in the systematic review (29,421 individuals) and 29 studies in the meta-analyses (23,879 individuals). Sixteen out of 42 studies reported a significant association of OH with worse physical functioning. Meta-analysis showed a significant association of OH with impaired balance, ADL performance and HY/UPDRS III performance, but not with gait characteristics, mobility, walking speed, TUG, HGS, physical frailty, exercise tolerance, physical activity and UPDRS II performance. CONCLUSIONS OH was associated with impaired balance, ADL performance and HY/UPDRS III performance, but not with other physical functioning categories. The results suggest that OH interventions could potentially improve some aspects of physical functioning.
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Brignole M, Moya A, de Lange FJ, Deharo JC, Elliott PM, Fanciulli A, Fedorowski A, Furlan R, Kenny RA, Martín A, Probst V, Reed MJ, Rice CP, Sutton R, Ungar A, van Dijk JG. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J 2018; 39:1883-1948. [PMID: 29562304 DOI: 10.1093/eurheartj/ehy037] [Citation(s) in RCA: 954] [Impact Index Per Article: 159.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Solari D, Tesi F, Unterhuber M, Gaggioli G, Ungar A, Tomaino M, Brignole M. Stop vasodepressor drugs in reflex syncope: a randomised controlled trial. Heart 2016; 103:449-455. [DOI: 10.1136/heartjnl-2016-309865] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/19/2016] [Accepted: 08/30/2016] [Indexed: 01/12/2023] Open
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Kragh Ekstam A, Elmståhl S. Do fall-risk-increasing drugs have an impact on mortality in older hip fracture patients? A population-based cohort study. Clin Interv Aging 2016; 11:489-96. [PMID: 27199553 PMCID: PMC4857759 DOI: 10.2147/cia.s101832] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study was to assess the mortality in hip fracture patients with regard to use of fall-risk-increasing drugs (FRIDs), by comparing survival in exposed and nonexposed individuals. Design This was a general population-based cohort study. Settings Data on hip fracture patients were retrieved from three national databases. Participants All hip fracture patients aged 60 years or older in a Swedish county in 2006 participated in this study. Measurements We studied the mortality in hip fracture patients by comparing those exposed to FRIDs, combinations of FRIDs, and polypharmacy to nonexposed patients, adjusting for age and sex. For survival estimates in patients using four or more FRIDs, a Cox regression analysis was used, adjusting for age, sex, and use of any four or more drugs. Results First-year all-cause mortality was 24.6% (N=503) in 2,043 hip fracture patients aged 60 years or older, including 170 males (33.8%) and 333 females (66.2%). Patients prescribed four or more FRIDs, five or more drugs (polypharmacy), psychotropic drugs, and cardiovascular drugs showed significantly increased first-year mortality. Exposure to four or more FRIDs (518 patients, 25.4%) was associated with an increased mortality at 30 days with odds ratios (ORs) 2.01 (95% confidence interval [CI] 1.44–2.79), 90 days with OR 1.56 (95% CI 1.19–2.04), 180 days with OR 1.54 (95% CI 1.20–1.97), and 365 days with OR 1.43 (95% CI 1.13–1.80). Cox regression analyses adjusted for age, sex, and use of any four or more drugs showed a significantly higher mortality in patients treated with four or more FRIDs at 90 days (P=0.015) and 180 days (P=0.012) compared to patients treated with three or less FRIDs. Conclusion First-year all-cause mortality was significantly higher in older hip fracture patients exposed before the fracture to FRIDs, in particular to four or more FRIDs, polypharmacy, psychotropic, and cardiovascular drugs. Interventions aiming to optimize both safety and benefit of drug treatment for older people should include limiting the use of FRIDs.
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Affiliation(s)
- Annika Kragh Ekstam
- Division of Geriatric Medicine, Department of Health Sciences, Lund University, Skåne University Hospital, Malmö, Sweden; Department of Medicine, Hässleholm Hospital, Hässleholm, Sweden
| | - Sölve Elmståhl
- Division of Geriatric Medicine, Department of Health Sciences, Lund University, Skåne University Hospital, Malmö, Sweden
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Managing Syncope in the Elderly: The Not So Simple Faint in Aging Patients. Can J Cardiol 2016; 32:1124-31. [PMID: 27402366 DOI: 10.1016/j.cjca.2016.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/18/2016] [Accepted: 04/18/2016] [Indexed: 11/22/2022] Open
Abstract
Providing care to the elderly patient with syncope poses problems that are unusual in their complexity. The differential diagnosis is broad, and sorting through it is made more difficult by the relative lack of symptoms surrounding the faint. Indeed, distinguishing faints from falls is often problematic. Many elderly patients are frail and are at risk of trauma if they should have an unprotected faint or fall to the ground. However, not all elderly patients are frail, and definitions of frailty vary. Providing accurate, effective, and appropriate care for the frail elderly patient who faints may require a multidisciplinary approach.
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Brignole M, Arabia F, Ammirati F, Tomaino M, Quartieri F, Rafanelli M, Del Rosso A, Rita Vecchi M, Russo V, Gaggioli G. Standardized algorithm for cardiac pacing in older patients affected by severe unpredictable reflex syncope: 3-year insights from the Syncope Unit Project 2 (SUP 2) study. Europace 2015; 18:1427-33. [DOI: 10.1093/europace/euv343] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/07/2015] [Indexed: 11/12/2022] Open
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Jansen S, Bhangu J, de Rooij S, Daams J, Kenny RA, van der Velde N. The Association of Cardiovascular Disorders and Falls: A Systematic Review. J Am Med Dir Assoc 2015; 17:193-9. [PMID: 26455926 DOI: 10.1016/j.jamda.2015.08.022] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 08/21/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Cardiovascular disorders are recognized as risk factors for falls in older adults. The aim of this systematic review was to identify cardiovascular disorders that are associated with falls, thus providing angles for optimization of fall-preventive care. DESIGN Systematic review. DATA SOURCES Medline and Embase. ELIGIBILITY CRITERIA FOR SELECTING STUDIES studies addressing persons aged 50 years and older that described cardiovascular risk factors for falls. Key search terms for cardiovascular abnormalities included all synonyms for the following groups: structural cardiac abnormalities, cardiac arrhythmia, blood pressure abnormalities, carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), vasovagal syncope (VVS), postprandial hypotension (PPH), arterial stiffness, heart failure, and cardiovascular disease. Quality of studies was assed using the Newcastle-Ottawa Scale. RESULTS Eighty-six studies were included. Of studies that used a control group, most consistent associations with falls were observed for low blood pressure (BP) (4/5 studies showing a positive association), heart failure (4/5), and cardiac arrhythmia (4/6). Higher prevalences of CSH (4/6), VVS (2/2), and PPH (3/4) were reported in fallers compared with controls in most studies, but most of these studies failed to show clear association measures. Coronary artery disease (6/10), orthostatic hypotension (9/25), general cardiovascular disease (4/9), and hypertension (7/25) all showed inconsistent associations with falls. Arterial stiffness was identified as an independent predictor for falls in one study, as were several echocardiographic abnormalities. CONCLUSION Several cardiovascular associations with falls were identified, including low BP, heart failure, and arrhythmia. These results provide several angles for optimizing fall-preventive care, but further work on standard definitions, as well as the exact contribution of individual risk factors on fall incidence is now important to find potential areas for preventive interventions.
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Affiliation(s)
- Sofie Jansen
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jaspreet Bhangu
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland; Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland.
| | - Sophia de Rooij
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; University Centre for Geriatric Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Joost Daams
- Department of Clinical Library, Academic Medical Center, University of Amsterdam, the Netherlands
| | - Rose Anne Kenny
- Department of Medical Gerontology, Trinity College Dublin, Dublin, Ireland; Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Nathalie van der Velde
- Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Stam H, van der Wouden JC, van der Horst HE, Maarsingh OR. Impairment reduction in older dizzy people in primary care: study protocol for a cluster randomised controlled trial. Trials 2015. [PMID: 26209097 PMCID: PMC4514942 DOI: 10.1186/s13063-015-0848-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The management of dizziness in older patients is primarily diagnosis-oriented. However, in 40 % of older patients with dizziness, GPs are not able to identify an underlying cause, and a number of common underlying causes of dizziness cannot (or hardly) be treated. In this study we will investigate the effectiveness of a prognosis-oriented approach in the management of dizziness in older patients. This prognosis-oriented approach comprises identification of patients at risk for chronic dizziness with persistent impairment by identifying risk factors for an unfavourable course of dizziness. Patients at risk for chronic dizziness with persistent impairment will be offered treatment addressing the identified modifiable risk factors. Methods/Design This study will be performed in primary care. An intervention study and a validation study will be conducted in a three-arm cluster randomised design. In the intervention study we will investigate a risk factor guided multi-component intervention. The risk factor guided intervention includes: (1) medication adjustment in case of three or more prescribed fall-risk-increasing drugs, (2) stepped care in case of anxiety disorder and/or depression, and (3) exercise therapy in case of impaired functional mobility. The primary outcome measure is dizziness-related impairment, which will be assessed with the Dizziness Handicap Inventory. Secondary outcome measures are quality of life, anxiety disorder and depression, use of fall-risk-increasing drugs, dizziness frequency, fall frequency, and healthcare utilization. Discussion This study is, to date, the first study that will investigate the effectiveness of a prognosis-oriented approach for reducing dizziness-related impairment in older people in primary care. Offering treatment that addresses identified modifiable risk factors to patients at high risk for chronic dizziness is unique. The pragmatic design of this study will enable evaluation of the outcomes in real-life routine practice conditions. An effective intervention will not only reduce dizziness-related impairment, but may also decrease healthcare utilization and healthcare costs. The previously developed risk score that will be validated alongside the intervention study will enable GPs to identify patients at high risk for chronic dizziness with persistent impairment. Trial registration Netherlands Trial Register (identifier: NTR4346), registration date 15 December 2013.
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Affiliation(s)
- Hanneke Stam
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, room D550, 1081 BT, Amsterdam, The Netherlands.
| | - Johannes C van der Wouden
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, room D550, 1081 BT, Amsterdam, The Netherlands.
| | - Henriëtte E van der Horst
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, room D550, 1081 BT, Amsterdam, The Netherlands.
| | - Otto R Maarsingh
- Department of General Practice and Elderly Care Medicine and EMGO Institute for Health and Care Research, VU University Medical Center, Van der Boechorststraat 7, room D550, 1081 BT, Amsterdam, The Netherlands.
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14
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Zia A, Kamaruzzaman SB, Tan MP. Blood pressure lowering therapy in older people: Does it really cause postural hypotension or falls? Postgrad Med 2015; 127:186-93. [DOI: 10.1080/00325481.2015.996505] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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15
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Dovjak P. [Diagnostics and treatment of syncope]. Z Gerontol Geriatr 2014; 47:703-12; quiz 713-4. [PMID: 25398191 DOI: 10.1007/s00391-014-0824-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A transient loss of consciousness in the elderly is in most cases caused by syncope of cardiac origin. The underlying cause of syncope is of prognostic importance and should be clarified in every single case even if a definitive diagnosis can be established in only approximately two thirds of all cases. The definitive diagnosis is the key for appropriate therapeutic measures to prevent recurrences. Flowcharts can help to implement considerate and efficient stepwise diagnostic procedures. The most important diagnostic measures and treatment options according to medical evidence are presented.
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Affiliation(s)
- Peter Dovjak
- Salzkammergutklinikum Gmunden, Miller von Aichholzstraße 49, 4810, Gmunden, Österreich,
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16
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Sutton R, Brignole M. Twenty-eight years of research permit reinterpretation of tilt-testing: hypotensive susceptibility rather than diagnosis. Eur Heart J 2014; 35:2211-2212. [DOI: 10.1093/eurheartj/ehu255] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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17
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Milos V, Bondesson Å, Magnusson M, Jakobsson U, Westerlund T, Midlöv P. Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care. BMC Geriatr 2014; 14:40. [PMID: 24674152 PMCID: PMC3986685 DOI: 10.1186/1471-2318-14-40] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 03/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Falls are the most common cause of injuries and hospital admissions in the elderly. The Swedish National Board of Health and Welfare has created a list of drugs considered to increase the fall risk (FRIDs) and drugs that might cause/worsen orthostatism (ODs). This cross-sectional study was aimed to assess FRIDs and their correlation with falls in a sample of 369 community-dwelling and nursing home patients aged ≥75 years and who were using a multi-dose drug dispensing system. METHODS Data were collected from the patients' electronic medication lists. Retrospective data on reported falls during the previous three months and severe falls during the previous 12 months were collected. Primary outcome measures were incidence of falls as well as numbers of FRIDs and ODs in fallers and non-fallers. RESULTS The studied sample had a high incidence of both reported falls (29%) and severe falls (17%). Patients were dispensed a mean of 2.2 (SD 1.5) FRIDs and 2.0 (SD 1.6) ODs. Fallers used on average more FRIDs. Severe falls were more common in nursing homes patients. More women than men experienced severe falls. There were positive associations between number of FRIDs and the total number of drugs (p < 0.01), severe falls (p < 0.01) and female sex (p = 0.03). There were also associations between number of ODs and both total number of drugs (p < 0.01) and being community dwelling (p = 0.02). No association was found between number of ODs and severe falls. Antidepressants and anxiolytics were the most frequently dispensed FRIDs. CONCLUSIONS Fallers had a higher number of FRIDs. Numbers of FRIDs and ODs were correlated with the total number of drugs dispensed. Interventions to reduce falls in the elderly by focusing on reducing the total number of drugs and withdrawal of psychotropic medications might improve the quality and safety of drug treatment in primary care.
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Affiliation(s)
- Veronica Milos
- Center for Primary Health Care Research, Institution of Clinical Sciences, Lund University, Lund, Sweden.
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18
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Orthostatic hypotension, diabetes, and falling in older patients: a cross-sectional study. Br J Gen Pract 2013; 62:e696-702. [PMID: 23265229 DOI: 10.3399/bjgp12x656838] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although orthostatic hypotension (OH) is more prevalent in old age, and in patients with diabetes, the prevalence of OH in older patients with type 2 diabetes mellitus is unknown. AIM To establish the prevalence of OH, and its association with falling, in home-dwelling older participants with and without type 2 diabetes. DESIGN AND SETTING A cross-sectional study in primary care in the Netherlands. METHOD A total of 352 patients with type 2 diabetes, and 211 without participated in this study. OH was defined as a fall in blood pressure of at least 20 mmHg systolic or 10 mmHg diastolic after either 1 or 3 minutes in an upright position. Feelings of dizziness, light-headedness, or faintness during the standing period were documented as orthostatic complaints. Fall risk was assessed with a validated risk profile instrument. RESULTS The prevalence of OH was 28% (95% CI = 24% to 33%) and 18% (95% CI = 13% to 23%) in participants with and without type 2 diabetes, respectively. OH was not related to falling, while the presence of orthostatic complaints in itself was associated with both previous fall incidents as well as a high fall risk, even after adjustment for OH. The adjusted odds ratios were 1.65 (95% CI = 1.00 to 2.72) and 8.21 (95% CI = 4.17 to 16.19), respectively. CONCLUSION OH is highly prevalent in home-dwelling older people with and without type 2 diabetes. Those with orthostatic complaints had an increased risk for falling, whereas those with OH were not.
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Solari D, Maggi R, Oddone D, Solano A, Croci F, Donateo P, Brignole M. Clinical context and outcome of carotid sinus syndrome diagnosed by means of the 'method of symptoms'. Europace 2013; 16:928-34. [DOI: 10.1093/europace/eut283] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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20
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Uhart M, Odouard E, Carlier C, Maire P, Ducher M, Bourguignon L. [Relationship between benzodiazepines use and falls in the elderly: a multicenter study in three geriatric centers of a university hospital]. ANNALES PHARMACEUTIQUES FRANÇAISES 2012; 70:46-52. [PMID: 22341008 DOI: 10.1016/j.pharma.2011.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 09/12/2011] [Accepted: 10/10/2011] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Benzodiazepines are widely used in the elderly, but may induce potentially severe iatrogenic events like falls. The analysis of their use is difficult because of the numerous molecules and dosages available. The aim of the present study is to build a tool to monitor their consumption and to evaluate the relation between this consumption and patient's falls reported in three geriatric institutions. METHODS Conversion coefficients found in the literature allowed the expression of benzodiazepine action with a unique comparator: diazepam. Benzodiazepine consumption observed during 20 consecutive months was collected and weighted by hospital activity. A correlation between benzodiazepine consumption and the number of falls reported during the same period was researched. RESULTS Benzodiazepine consumption expressed in milligrams of diazepam-equivalent per hospitalization day is significantly linked to the number of falls expressed during the same period (R=0.63; p<0.01). However, no statistical bound was found between monthly falls variations and monthly benzodiazepine consumption variations. These results corroborate others published studies: benzodiazepine consumptions are statistically linked to falls, but the reduction of this consumption is of poor predictive value, maybe because of the multifactorial nature of falls. DISCUSSION AND CONCLUSION The expression of benzodiazepine consumption in diazepam-equivalent enables one to estimate the general exposition of patients and to compare the use of each molecule. The statistical link between this indicator and a major iatrogenic event like falls makes it a tool worth interest for both clinicians and pharmacists.
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Affiliation(s)
- M Uhart
- Service pharmaceutique, hôpital Antoine-Charial, hospices civils de Lyon, groupement hospitalier de gériatrie, Francheville, France
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21
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Abstract
SummaryOrthostatic hypotension (OH) occurs in up to 30% of community-dwelling older people. Its presence confers a greater risk of incident co-morbid disease and all-cause mortality. As per guidelines, first-line treatment should consist of non-pharmacological therapies. Effective lifestyle modification advice includes the avoidance of rapid postural changes and large meals. Physical counter-manoeuvres, when comprehensively described, effectively abate symptom progression. Patients should drink 1.5 to 2 litres of water daily, though reports suggest only half of older people comply with this regime. Moderate salt consumption is advised, though with caution as supine hypertension often co-exists. Compression hosiery benefits older people and, contrary to popular opinion, is well tolerated. Potential, future therapies include impedance threshold devices. Older patients with OH frequently have co-morbid disease such that a pharmacological approach is ill-advised. They respond well to non-pharmacological therapies and these should form the primary therapeutic approach.
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22
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Syncope and near-syncope as a multifactorial problem in geriatric inpatients: Systemic hypotension is an underrated predictor for syncope exclusively. Adv Med Sci 2011; 56:352-60. [PMID: 22112434 DOI: 10.2478/v10039-011-0052-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Syncope (SC) and near-syncope (NS) are still misunderstood syndromes. Aim of study was to determine the risk factors for SC, NS, as well as for both entities (SC/NS) in geriatric inpatients reporting these events within the last year, irrespectively of the reason of admission to hospital. MATERIAL AND METHODS The retrospective study covered 250 patients, consecutively admitted to the geriatric ward. Patients were assigned to the three models: SC and/or NS in total, n=106; isolated NS, n=72; SC with co-existing NS, if any, n=34, and compared with patients without any such events (n=144). The patients underwent a comprehensive geriatric assessment and complete clinical investigation. The binary logistic regression was applied to predict risk factors for each of the models. RESULTS Falls were most predictive for NS model (OR 35.4; 95% CI 10.3-121.1), and systemic hypotension for SC model (OR 92.9; 95% CI 6.1-1421.0). The highest specificity (85%) and sensitivity (81%) were found for the SC/NS model, with the highest contribution by falls (OR 18.1; 95% CI, 7.6-45.2), orthostatic hypotension (OR 8.1; 95% CI, 3.5-18.5), a history of stroke or transient ischemic attack, treatment with an angiotensin receptor blocker, plasma creatinine >1.4mg/dL, negatively self-rated health, vertigo, pathology of carotid arteries, and lack of hypertension. CONCLUSIONS Syncope and near-syncope in geriatric inpatients have multifactorial and cumulative aetiology, with blurred, frequently overlapping boundaries between them. The falls, postural hypotension, and/or brain hypoperfusion of different origin seem to be most predictive of the both events, however low systemic blood pressure was predictive for the syncope exclusively.
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23
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Abstract
The association between drugs and falls has been widely studied in the past 3 decades, with increasingly robust evidence of a causal link. Both specific classes of drugs and the total number of drugs taken are associated with falls. This review examines some of the reasons why older people are at greater risk of drug-related adverse events such as falls. We discuss the role of drugs in general and polypharmacy (the concurrent use of multiple drugs) on the risk of falling, with a focus on community-dwelling older people. We critically appraise the evidence that specific classes of drugs, such as benzodiazepines and antidepressants, increase the risk of falling and that falls can be prevented through interventions that target medications.
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Affiliation(s)
- Nichola Boyle
- Centre for Education and Research on Ageing, Building 18, Concord Repatriation General Hospital, Concord, New South Wales 2139, Australia.
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25
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Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, Deharo JC, Gajek J, Gjesdal K, Krahn A, Massin M, Pepi M, Pezawas T, Ruiz Granell R, Sarasin F, Ungar A, van Dijk JG, Walma EP, Wieling W. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009; 30:2631-71. [PMID: 19713422 DOI: 10.1093/eurheartj/ehp298] [Citation(s) in RCA: 1202] [Impact Index Per Article: 80.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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26
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Kearney F, Moore A. Treatment of combined hypertension and orthostatic hypotension in older adults: more questions than answers still remain. Expert Rev Cardiovasc Ther 2009; 7:557-60. [PMID: 19505268 DOI: 10.1586/erc.09.51] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sirkin AJ, Rosner NG. Hypertensive management in the elderly patient at risk for falls. ACTA ACUST UNITED AC 2009; 21:402-8. [DOI: 10.1111/j.1745-7599.2009.00418.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Krecinic T, Mattace-Raso F, Van Der Velde N, Pereira G, Van Der Cammen T. Orthostatic hypotension in older persons: a diagnostic algorithm. J Nutr Health Aging 2009; 13:572-5. [PMID: 19536427 DOI: 10.1007/s12603-009-0109-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Orthostatic hypotension (OH) is a frequent phenomenon in older persons and usually has a multifactorial origin. When the diagnosis is suspected, the work-up should initially be directed at the most prevalent causes. This clinical algorithm may be a useful tool in the diagnostic process.
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Affiliation(s)
- T Krecinic
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
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29
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Mussi C, Ungar A, Salvioli G, Menozzi C, Bartoletti A, Giada F, Lagi A, Ponassi I, Re G, Furlan R, Maggi R, Brignole M. Orthostatic Hypotension As Cause of Syncope in Patients Older Than 65 Years Admitted to Emergency Departments for Transient Loss of Consciousness. J Gerontol A Biol Sci Med Sci 2009; 64:801-6. [DOI: 10.1093/gerona/glp028] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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30
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Levy HB. Pharmacologic therapy and the impact on falls in the elderly. Expert Rev Clin Pharmacol 2008; 1:721-3. [PMID: 24410600 DOI: 10.1586/17512433.1.6.721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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31
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Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc 2008; 56:1946-52. [PMID: 18771457 DOI: 10.1111/j.1532-5415.2008.01916.x] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Thousands of Americans are injured or die each year from adverse drug reactions, many of which are preventable. The burden of harm conveyed by the use of medications is a significant public health problem, and therefore, improving the medication-use process is a priority. Recent and ongoing efforts to improve the medication-use process have focused primarily on improving medication prescribing, and not much emphasis has been put on improving medication discontinuation. A formalized approach for rationally discontinuing medications is a necessary antecedent to improving medication safety and improving the nation's quality of care. This article proposes a conceptual framework for revising the prescribing stage of the medication-use process to include discontinuing medications. This framework has substantial practice and research implications, especially for the clinical care of older persons, who are particularly susceptible to the adverse effects of medications.
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Affiliation(s)
- Kevin T Bain
- Department of Quality Outcomes, excelleRx Inc, an Omnicare Company, Philadelphia, Pennsylvania 19102, USA.
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