Clinical practice algorithms: Medication management to reduce fall risk in the elderly—Part 4, Anticoagulants, anticonvulsants, anticholinergics/bladder relaxants, and antipsychotics

Polypharmacy Management in Older Patients

Medications to treat disease and extend life in our patients often amass in quantities, resulting in what has been termed "polypharmacy." This imprecise label usually describes the accumulation of 5, and often more, medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. Polypharmacy is associated with resulting increased hospitalizations and higher costs of care for individuals and health care systems. To reduce polypharmacy, we delineate a systematic, consultative approach to identify highest-risk medications and drug-therapy problems. We address strategic reductions (deprescribing) of medications in palliative care, long-term care, and ambulatory older adults. Best practices for reducing opioids, benzodiazepines, and other high-risk medications include education about risk and agreement by patients and their families, advocates, and care teams. Addressing deprescribing should be within the framework of patients' health status as their care and goals transition from longevity to a plan of maintaining alertness, comfort, and satisfaction of quality of life. A team approach to address polypharmacy and avoidance of high-risk therapy is optimal within long-term care. Patients with terminal illnesses or those moving toward a comfort-care emphasis benefit from medication adjustments that are recognized beneficially within each patient's care goals. In caring for older adults, the acknowledgement that complicated regimens and high-risk medications requires a care plan to reduce or prevent medication-related problems and costs that are associated with polypharmacy.

Tricyclic Antidepressant and/or γ-Aminobutyric Acid-Analog Use Is Associated With Fall Risk in Diabetic Peripheral Neuropathy

BACKGROUND/OBJECTIVES

Peripheral neuropathy is a common diabetes complication that can increase fall risk. Regarding fall risk, the impact of pain management using tricyclic antidepressants (TCAs) or γ-aminobutyric acid (GABA) analogs is unclear because these medications can also cause falls. This study investigates the impact of these drugs on fall and fracture risk in older diabetic peripheral neuropathy (DPN) patients.

DESIGN

Historical cohort study with 1-to-1 propensity matching of TCA/GABA-analog users and nonusers.

SETTING

Nationally representative 5% Medicare sample between the years 2008 and 2010.

PARTICIPANTS

After applying all selection criteria, 5,550 patients with prescription and 22,200 patients without prescription of TCAs/GABA-analogs were identified. Both patient groups were then stratified for fall history and matched based on propensity of receiving TCAs/GABA-analogs within each group.

MEASUREMENTS

Patients were followed until the first incidence of fall or the first incidence of fracture during the follow-up period (for up to 5 years).

RESULTS

After matching, users and nonusers were largely similar. After covariate adjustment, TCA/GABA-analog use was associated with a statistically significant increase in fall risk (adjusted hazard ratio [HR] = 1.11; 95% confidence interval [CI] = 1.03-1.20), but was not associated with fracture risk (adjusted HR = 1.09; 95% CI = 0.99-1.19) in the conventional analysis. Treating TCA/GABA-analog use as a time-dependent covariate resulted in statistically significant associations of TCA/GABA-analog use with both fall and fracture risk (HR = 1.26 [95% CI = 1.17-1.36]; and HR = 1.12 [95% CI = 1.02-1.24], respectively).

CONCLUSION

Among older patients with DPN, GABA-analogs or TCAs increase fall risk and possibly fracture risk. Use of these medications is therefore a potentially modifiable risk factor for falls and fractures in this population.

[The development of clinical practice algorithms for the appropriate use of psychotropic drugs in older persons with high risk of falls]

Psychotropic drugs (hypno-sedatives, antidepressants and antipsychotics) are commonly used in the older population. On the long term, psychotropic drug use in older persons is associated with several negative functional outcomes such as an increased risk of falls. Gradual withdrawal of psychotropic drugs in older persons is feasible and leads to a significant reduction of falls. Both withdrawal of psychotropic drugs as well as the initiation of appropriate treatment with psychotropic drugs requires knowledge, consultation and cooperation between disciplines and a mentality change among healthcare professionals. In order to inform and support healthcare professionals, the Centre of Expertise for Fall and Fracture Prevention Flanders developed three clinical practice algorithms for the appropriate use of psychotropic drugs in older persons with high risk of falls and a fact sheet with background information.

Risk of falls associated with antiepileptic drug use in ambulatory elderly populations: A systematic review

BACKGROUND

Falls are a major cause of morbidity and mortality in older adults. About a third of those aged 65 years or older fall at least once each year, which can result in hospitalizations, hip fractures and nursing home admissions that incur high costs to individuals, families and society. The objective of this clinical review was to assess the risk of falls in ambulatory older adults who take antiepileptic drugs, medications that can increase fall risk and decrease bone density.

METHODS

PubMed, EMBASE, MEDLINE and the Cochrane Library electronic databases were searched from inception to July 2014. Case-control, quasi-experimental and observational design studies published in English that assessed quantifiable fall risk associated with antiepileptic drug use in ambulatory patient populations with a mean or median age of 65 years or older were eligible for inclusion. One author screened all titles and abstracts from the initial search. Two authors independently reviewed and abstracted data from full-text articles that met eligibility criteria.

RESULTS

Searches yielded 399 unique articles, of which 7 met inclusion criteria-4 prospective or longitudinal cohort studies, 1 cohort study with a nested case-control, 1 cross-sectional survey and 1 retrospective cross-sectional database analysis. Studies that calculated the relative risk of falls associated with antiepileptic drug use reported a range of 1.29 to 1.62. Studies that reported odds ratios of falls associated with antiepileptic drug use ranged from 1.75 to 6.2 for 1 fall or at least 1 fall and from 2.56 to 7.1 for more frequent falls.

DISCUSSION

Health care professionals should monitor older adults while they take antiepileptic drugs to balance the need for such pharmacotherapy against an increased risk of falling and injuries from falls.

A qualitative understanding of patient falls in inpatient mental health units

BACKGROUND

Falls are the leading cause of injury-related deaths among people age 65 and older, and fractures are the major category of serious injuries produced by falls.

OBJECTIVE

Determine market segment-specific recommendations for "selling" falls prevention in acute inpatient psychiatry.

DESIGN

Descriptive using focus groups.

SETTING

One inpatient unit at a Veterans' hospital in the Southeastern United States and one national conference of psychiatric and mental health nurses.

PATIENTS

A convenience sample of 22 registered nurses and advanced practice nurses, one physical therapist and two physicians participated in one of six focus groups.

INTERVENTION

None.

MEASUREMENTS

Focus groups were conducted by expert facilitators using a semistructured interview guide. Focus groups were recorded and transcribed. Content analysis was used to organize findings.

RESULTS

Findings were grouped into fall risk assessment, clinical fall risk precautions, programmatic fall prevention, and "selling" fall prevention in psychiatry. Participants focused on falls prevention instead of fall injury prevention, were committed to reducing risk, and were receptive to learning how to improve safety. Participants recognized unique features of their patients and care settings that defined risk, and were highly motivated to work with other disciplines to keep patients safe.

CONCLUSIONS

Selling fall injury prevention to staff in psychiatric settings is similar to selling fall injury prevention to staff in other health care settings. Appealing to the larger construct of patient safety will motivate staff in psychiatric settings to implement best practices and customize these to account for unique population needs characteristics.

Risk factors for falls in hospitalized adult patients: an integrative review

Objective: Identifying risk factors for the occurrence of falls in hospitalized adult patients. Method: Integrative review carried out in the databases of LILACS, SciELO, MEDLINE and Web of Science, including articles published between 1989 and 2012. Results: Seventy-one articles were included in the final sample. Risk factors for falls presented in this review were related to patients (intrinsic), the hospital setting and the working process of health professionals, especially in nursing (extrinsic). Conclusion: The systematic screening of risk factors for falls was identified as a contributing factor to the reduction of this injury, helping the non-occurrence of this event that, despite being preventable, can have serious consequences including death.


Helping pharmacists to reduce fall risk in long-term care: A clinical tool to facilitate the medication review process

BACKGROUND

One-third to one-half of adults older than 65 fall at least once per year. Fall prevention through medication management requires little effort and has consistently been shown to reduce risk of falls. The objective of this study was to further develop and perform preliminary pilot testing of an algorithm designed to assist consultant pharmacists in systematically identifying medications that might be modifiable, in order to reduce the risk of falls in older adults. We hypothesized that algorithm use would increase the number of fall-related medication change recommendations made to physicians.

METHODS

Four consultant pharmacists were trained to use the algorithm during their routine medication reviews over a 3-week period. An informal survey was administered at the end of the study period to assess the algorithm.

RESULTS

Overall, 51% of residents of long-term facilities had 1 or more recommendations for medication changes related to reducing fall risk (range 0-3 recommendations per resident), with an average 0.675 recommendations made per resident. There were more recommendations for men compared with women and for residents receiving more medications, but the number of recommendations did not correspond with age. All 4 pharmacists agreed that the algorithm was useful and worthwhile.

DISCUSSION

The absolute 20% increase in recommendations related to falls supports the study hypothesis. Time was cited as a barrier to using the algorithm, but this should decrease with continued use of this tool.

CONCLUSION

This preliminary study furthered the development of and confirmed the possible utility and acceptability of a fall risk-reducing algorithm that may be used in practice.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Falls risk reduction and treatment of overactive bladder symptoms with antimuscarinic agents: a scoping review

AIMS

Overactive bladder (OAB) symptoms are associated with falls and fractures in older adults and treatment with antimuscarinic agents may decrease this falls risk. Bladder-specific antimuscarinic agents may also adversely affect falls risk because of drug-related cognitive impairment. Thus, a tension between effective treatment, falls risk reduction, and increased falls risk is created. We conducted a scoping review to determine whether sufficient studies exist to warrant a full systematic review of falls risk reduction through treatment of OAB and to identify gaps in current research.

METHODS

Using an iterative scoping approach, a search of electronic databases was undertaken using key terms. Studies in any setting of older adults who had fallen or were at risk for falls and were provided pharmacological treatment of OAB to reduce of falls or falls risk were sought. Relevant articles were identified, reviewed, and used to map research activity regarding the pharmacological treatment of OAB in older adults and its relationship to falls and falls risk reduction.

RESULTS

Only one study met our initial inclusion criteria. Six additional studies were useful in identification research gaps, particularly in terms of outcome measures.

CONCLUSIONS

Insufficient evidence exists to recommend antimuscarinic treatment as a strategy for falls reduction, and the contribution of such agents to increased falls risk is unclear. Future studies of antimuscarinic agents for OAB must include measures of falls and falls risk and cognitive effects.

Application of data mining to the identification of critical factors in patient falls using a web-based reporting system

PURPOSE

The implementation of an information system has become a trend in healthcare institutions. How to identify variables related to patient safety among accumulated data has been viewed as a main issue. The purpose of this study was to identify critical factors related to patient falls through the application of data mining to available data through a hospital information system.

METHOD

Data on a total of 725 patient falls were obtained from a web-based nursing incident reporting system at a medical center in Taiwan. In the process of data mining, feature selection was applied as the first step, after which 10 critical factors were selected to predict the dependent variables (injury versus non-injury). An artificial neural network (ANN) analysis was applied to develop a predictive model and a multivariate stepwise logistic regression was performed for comparison purposes.

RESULTS

The ANN model produced the following results: a Receiver-Operating-Character (ROC) curve indicated 77% accuracy, the positive predictive value (PPV) was 68%, and the negative predictive value (NPV) was 72%; while the multivariate stepwise logistic regression only identified 3 variables (fall assessment, anti-psychosis medication and diuretics) as significant predictors with ROC curve of 42%, PPV of 26.24%, and NPV of 87.12%.

CONCLUSION

In addition to medication use such as anti-psychotic and diuretics, nursing intervention where a fall assessment is conducted could represent a critical factor related to outcomes of fall incidence.

Risk for fractures with centrally acting muscle relaxants: an analysis of a national Medicare Advantage claims database

BACKGROUND

In older adults, both muscle relaxants and benzodiazepines are associated with sedation and cognitive impairment. Although benzodiazepines have been linked to falls and fracture injuries, no studies have examined the risk of fracture associated with muscle relaxants.

OBJECTIVE

To determine whether muscle relaxants identified in the Beers criteria are associated with an increased risk of fracture injuries and to compare this risk to that with benzodiazepine use.

METHODS

We conducted a case-control study using both medical and pharmacy claims data from 1.5 million enrollees in the Medicare Advantage plans of a large health maintenance organization. We matched 8164 cases of fractures with 8164 controls based on age, sex, health plan, and comorbidities. We measured the use of muscle relaxants, short-acting benzodiazepines, and long-acting benzodiazepines. Adjusted odds ratios were estimated using conditional logistic regression.

RESULTS

After adjusting demographic and clinical covariates, muscle relaxants, long-acting benzodiazepines, and short-acting benzodiazepines were associated with a high risk of fracture injuries, with odds ratios of 1.40 (95% CI 1.15 to 1.72; p < 0.001), 1.9 (95% CI 1.49 to 2.43; p < 0.001), and 1.33 (95% CI 1.15 to 1.55; p < 0.001), respectively.

CONCLUSIONS

An elevated risk of fracture injuries was noted among older adults using muscle relaxants. Our findings provide evidence of an association between the risk of fractures and the use of centrally acting muscle relaxants in older adults. This association supports current recommendations advising extreme caution in prescribing muscle relaxants to older adults.