Willingness to Change Medications Linked to Increased Fall Risk: A Comparison between Age Groups

Retrospective Investigation and Research on Fall Events Among Hospitalized Patients in the Rehabilitation Department

Objective

We investigated the clinical characteristics, fall outcomes, and related factors of falls in patients who were hospitalized in the rehabilitation department, and explored strategies to reduce the incidence of falls and prevent falls in patients.

Methods

Data from 60 patients who fell in the rehabilitation department between 2016 and 2021 were analyzed for clinical characteristics, associated factors, incidence of falls, injuries, and patient demographics. Under the random stratified sampling method, 60 patients who did not fall during the same period were selected as the control group, and relevant data was collected. Measurement data were compared using an independent sample t-test. Enumeration data were compared using chi-squared (χ2) test was employed to compare these data between the two groups. Non-parametric data were analyzed using the Mann-Whitney U-test. Factors potentially influencing falls were scrutinized through both univariate and binary logistic regression analyses.

Results

The median annual incidence of falls among patients who were hospitalized in the rehabilitation department was 0.04%, while the overall fall injury rate was 60%. Falls were most prevalent within 30 days of hospitalization (71.67%). The most common fall-related condition was craniocerebral disease (83.33%). The incidents of falls location of fall were mainly reported in nearby areas of rehabilitation ward (70%). Most accidents occurred between 7:00 a.m.-12:00 p.m. and 3:01 p.m.-6:00 p.m. (63.33%), and dyskinesia was the most common cause of falls (71.67%). There were 39 patients (65.00%) with Barthel Index (BI) scores ranging between 40-60.

Conclusion

Patients in the rehabilitation department had a greater incidence of falls and fall injuries. Within 30 days of admission, patients with moderately dependent craniocerebral disorders and dyskinesia frequently experienced falls during typical daytime shifts in areas characterized by endemic conditions.

Deprescribing electronic case reviews for older veterans at risk for falls: Effects on drug burden and falls

BACKGROUND

Falls are the most common medication-related safety event in older adults. Deprescribing fall risk-increasing drugs (FRIDs) may mitigate fall risk. This study assesses the effects of an innovative deprescribing program in reducing FRID burden and falls-related acute visits over 1 year.

METHODS

The Falls Assessment of Medications in the Elderly (FAME) Program is a pilot deprescribing program designed to improve medication safety in Veterans aged ≥65, screening positive for high fall risk at the Durham Veterans Affairs Health Care System. Central case finding and electronic case reviews with deprescribing recommendations were completed by an interdisciplinary team, forwarded to prescribers for approval, then implemented during follow-up telephone visits by FAME team. Primary outcome was change in FRID burden calculated by modified Drug Burden Index (DBI) at 1 year and an exploratory outcome was 1-year fall-related acute visits.

RESULTS

Overall, 472 patients (236 intervention cases, 236 matched controls) were included in the study. Of the 236 patients receiving a FAME deprescribing plan, 147 had recommendations approved by prescriber and patient. In the intention-to-treat analysis, the 1-year change in modified DBI was -0.15 (95% CI -0.23, -0.08) in the intervention cohort and -0.11 (-0.21, -0.00) in the matched control cohort (p = 0.47). The odds of increasing DBI by a clinically important threshold of 0.5 was significantly lower in the FAME cohort (OR 0.37, 0.21, 0.66). Fall-related acute events occurred in 6.3% of patients in the intervention group versus 11.0% in control patients over a one-year period (p = 0.10).

CONCLUSIONS

The program was associated with a significantly lower odds of further increasing FRID burden at 1 year compared to matched controls. An electronic case review and telephone counseling program has the potential to reduce drug-related falls in high-risk older adults.

Older Adult and Healthcare Provider Beliefs About Fall Prevention Strategies

Introduction: Older adults reported about 36 million falls in 2018. Although effective strategies are available to address risk factors and minimize fall risk, little is known about older adults' and healthcare providers' awareness of these strategies. This study describes and compares healthcare providers' and older adults' beliefs about fall prevention and strategies. Methods: Demographic and fall-related data for older adults were obtained from the 2019 fall cohort of Porter Novelli ConsumerStyles. Similar data from primary care practitioners, nurse practitioners, and physician assistants were gathered from the 2019 cohort of DocStyles. Results: Most providers (91.3%) and older adults (85.1%) believed falls can be prevented. Both providers and older adults were most likely to consider strength and balance exercises (90.7% and 82.8%, respectively) and making homes safer (90.5% and 79.9%, respectively) as strategies that help prevent falls. More providers reported that managing medications (84.2%) and tai chi (45.7%) can prevent falls compared to older adults (24.0% and 21.7%, respectively; P < .0001). Conclusion: More healthcare providers than older adults indicated evidence-based strategies exist to reduce falls. Increased patient and provider communication can increase awareness about the benefits of evidence-based strategies such as tai chi, strength and balance exercises, and medication management.

Innovative approaches to analysing aged care falls incident data: international classification for patient safety and correspondence analysis

Falls in residential aged care facilities (RACFs) are common and can have significant health consequences. Understanding how and why falls occur in RACFs is an essential step to design targeted fall prevention and intervention programmes; however, little is known about falls' mechanisms in RACFs. This study aims to use international incident classification systems and novel analysis techniques to describe factors that contribute to falls requiring hospitalization in RACFs. Retrospective data of falls assessed by nurses as requiring hospitalization from 429 residents in 22 Australian RACFs in 2019 were used. Data were reviewed using a modified version of the International Classification for Patient Safety (ICPS), which categorizes patient safety into incident types and contributing factors using a three-tiered structure. The ICPS codes were summarized using the descriptive statistics. The association between assigned ICPS codes were analysed using correspondence analysis. Six hundred and three falls assessed as requiring hospitalization were classified into 659 incident types, with the most common incident type being 'patient incidents' (injury sustained/adverse effect in the health care system) (603, 91.5%) at Level 1, 'falls' (601, 91.2%) at Level 2, and 'falls involving bedrooms' (214, 32.5%) at Level 3. The 603 falls had 1082 contributing factors, with the most common contributing factor being 'patient factors' (events affected by factors associated with the patient) (982, 90.8%) at Level 1, 'patient not elsewhere classified' (characteristics of the patient contributed to the incident not classified elsewhere) (571, 52.8%) at Level 2, and 'loss of balance' (361, 33.4%) at Level 3. In a correspondence analysis, three dimensions were responsible for 81.2% of the variation in falls incidents and environmental and organizational factors were important factors contributing to falls. The application of the ICPS demonstrated that personal factors (e.g. pre-existing physical and psychological health or impairment) were the most common contributing factors to falls assessed as requiring hospitalization, while the correspondence analysis highlighted the role of environmental and organizational factors. The results signal the need for more research into multifactorial falls prevention interventions in RACFs.

Special Report from the CDC: Provider knowledge and practices around driving safety and fall prevention screening and recommendations for their older adult patients, DocStyles 2019

INTRODUCTION

Falls and motor-vehicle crashes (MVCs) are leading causes of unintentional injury deaths among older adults (65+) in the United States. Injury prevention resources exist to help healthcare providers reduce fall and MVC risk among older adult patients. However, awareness of these resources among healthcare providers is unclear.

METHODS

Questions were included in the 2019 DocStyles survey that assessed healthcare provider awareness of three injury prevention resources: (1) the American Geriatrics Society's (AGS's) Clinician's Guide to Assessing and Counseling Older Drivers, (2) the Clinical Assessment of Driving Related Skills (CADReS), and (3) the Centers for Disease Control and Prevention's (CDC) Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative. We also explored the circumstances and current practices for counseling older adult patients on fall prevention and driving safety.

RESULTS

Only 20% of providers reported awareness of any of the injury prevention resources. Providers were more likely to report either screening for fall risk or unsafe driving when an older adult presented with a fall concern (74.5%) or driving concern or recent crash (85.1%), compared to annual screening for fall risk (67.7%) or driving safety (47.7%). More providers reported discussing the increased fall or MVC risk associated with patient medications, referring patient for driving fitness evaluations, or discussing alternative transportation options with the patient after adverse events or patient-initiated concerns compared to routine annual discussions.

CONCLUSION

Healthcare gaps persist in the screening and assessment of older adult risk factors for falls and unsafe driving. Limited provider awareness of clinical resources related to preventing older adult falls and unsafe driving may be contributing to these healthcare gaps.

PRACTICAL APPLICATIONS

Improving healthcare provider awareness of these resources could help them identify older adults at risk of a fall or MVC and promote injury prevention efforts in their clinical practices.

Provider knowledge, beliefs, and self‐efficacy to deprescribe opioids and sedative‐hypnotics

BACKGROUND

While many studies have assessed and measured patient attitudes toward deprescribing, less quantitative research has addressed the provider perspective. We thus sought to describe provider knowledge, beliefs, and self-efficacy to deprescribe, with a focus on opioids and sedative-hypnotics.

METHODS

An electronic anonymous survey was distributed to primary care providers at Kaiser Permanente Washington. Two reminder emails were sent. The survey included 10 questions on general deprescribing, and six questions each specific to opioid and sedative-hypnotic deprescribing. Knowledge questions used a multiple-choice response option format. Questions addressing beliefs and self-efficacy (i.e., confidence) used a 0-10 Likert scale. Scales were dichotomized at ≥7 to define agreement (belief questions) or confidence (self-efficacy questions). We calculated descriptive statistics to summarize the responses.

RESULTS

Of 370 eligible primary care providers, 95 (26%) completed the survey. For general deprescribing questions, a majority believed that lack of patient willingness, withdrawal symptoms and fear of symptom return, and time constraints impeded deprescribing. Approximately half chose the correct answers about opioid deprescribing, 21% were confident that they could alleviate patient concerns about opioid tapering, and 32% were confident managing chronic non-cancer pain without opioids. For sedative-hypnotics, 64%-87% of respondents correctly answered questions about risks and the relative effectiveness of alternatives, but only one-third correctly answered a question about sedative-hypnotic tapering. Roughly half were confident in their ability to successfully engage patients in sedative deprescribing conversations and select alternatives. Only 54% and 34% were confident in writing a tapering protocol for opioids and sedative-hypnotics, respectively.

CONCLUSION

Results suggest that raising provider awareness of patient willingness to deprescribe, addressing knowledge gaps, and increasing self-efficacy for deprescribing are important targets for improving deprescribing. Support for writing tapering protocols and prescribing evidence-based drug and non-drug alternatives may be important to improve care.