Evaluation of a Student Pharmacist-Driven Fall-Prevention Program for Older People

There is limited research on the impact of fall prevention education for older community-living people led by student pharmacists, which includes a medication review to identify Fall Risk-Increasing Drugs (FRIDs). Study objectives were to first assess the knowledge and behavioral intentions of older people after attending a student pharmacist-led fall-prevention program (FPP) and secondly to quantify the number of FRIDs identified during a medication review. Between October 2022 and April 2023, four independent-living facilities and two senior centers served as programming locations. Events began with a fall prevention-focused presentation provided by student pharmacists. Attendees voluntarily filled out surveys to assess their knowledge and behavioral intentions regarding fall prevention. Optional medication reviews were offered. Additional survey questions were asked of medication review participants. If FRIDs were identified, the individual was provided documentation to share with their prescriber. Fall prevention bingo was offered at select events to review educational content and engage those waiting for a medication review. Eighty-six older people attended the presentations; 45 people completed medication reviews across six sites. Survey information was available for 65 presentation attendees and 29 medication review participants. After programming, 64 out of 65 participants stated they felt comfortable speaking to their pharmacist or provider about falls and their medications. Most survey respondents correctly selected which medications increase fall risk. Twenty-two of 29 medication review participants were taking at least one FRID. The FPP described showed positive results through a post-survey evaluation. Participants demonstrated knowledge of fall hazards including medications and a willingness to discuss falls and FRIDs with health professionals. These factors may lead to concrete interventions to avoid falls and their associated health consequences for older people.

Does the type of lower extremity fracture affect long-term opioid usage? A meta-analysis

INTRODUCTION

 Patients recovering from musculoskeletal trauma have a heightened risk of opioid dependence and misuse, as these medications are typically required for pain management. The purpose of this meta-analysis was to examine the association between fracture type and chronic opioid use following fracture fixation in patients who sustain lower extremity trauma.

MATERIALS AND METHODS

A meta-analysis was performed using PubMed and Web of Science to identify articles reporting chronic opioid use in patients recovering from surgery for lower extremity fractures. 732 articles were identified using keyword and MeSH search functions, and 9 met selection criteria. Studies were included in the final analysis if they reported the number of patients who remained on opioids 6 months after surgery for a specific lower extremity fracture (chronic usage). Logistic regressions and descriptive analyses were performed to determine the rate of chronic opioid use within each fracture type and if age, year, country of origin of study, or pre-admission opioid use influenced chronic opioid use following surgery.

RESULTS

Bicondylar and unicondylar tibial-plateau fractures had the largest percentage of patients that become chronic opioid users (29.7-35.2%), followed by hip (27.8%), ankle (19.7%), femoral-shaft (18.5%), pilon (17.2%), tibial-shaft (13.8%), and simple ankle fractures (2.8-4.7%).Most opioid-naive samples had significantly lower rates of chronic opioid use after surgery (2-9%, 95% CI) when compared to samples that allowed pre-admission opioid use (13-50%, 95% CI). There were no significant associations between post-operative chronic opioid use and age, year, or country of origin of study.

CONCLUSIONS

 Patients with lower extremity fractures have substantial risk of becoming chronic opioid users. Even the lowest rates of chronic opioid use identified in this meta-analysis are higher than those in the general population. It is important that orthopedic surgeons tailor pain-management protocols to decrease opioid usage after lower extremity trauma.

Development and Pilot Testing of a Booklet Concerning Medications That Can Increase the Risk of Falls in Older People

Background: A common contributory factor to falls is the use of medicines, especially those commonly known as “fall-risk increasing drugs” (FRIDs). The use of FRIDs is common among older people (OP). However, OP and their family caregivers (FCGs) are largely unaware of FRIDs and their risks in increasing the risk of falls (ROF). Methods: A booklet which aims to provide information on topics related to FRIDs was developed. The booklet was reviewed by a panel of 14 reviewers, and the content validity index (CVI) for each subsection of the booklet was computed. Pilot testing of the booklet utilized a pre-post intervention study design and included 50 OP and 50 FCGs as study participants. Perceived knowledge of the participants was assessed prior to and after completing the booklet. Participants’ opinions on the usefulness and usability of the booklet were also obtained. Results: The booklet contained eight sections and each subsection of the booklet had a CVI ranging from 0.93 to 1.00. Completing the booklet resulted in improved perceived knowledge scores for each perceived knowledge item among both the OP and FCG groups (all items: p-value < 0.001). The participants perceived the booklet as useful and usable, as evidenced by almost all the perceived usefulness and usability items having a score of over 4.0. Conclusions: The FRIDs booklet developed in this study had good content validity and was widely accepted by the OP and FCGs. The positive effect on the participants’ knowledge of topics related to FRIDs means that the booklet could be useful as a patient education tool to enhance FRIDs knowledge and awareness among OP and FCGs.

Medication management for patients with hip fracture at a regional hospital and associated primary care units in Norway: a descriptive study based on a survey of clinicians' experience and a review of patient records

OBJECTIVE

Patients with hip fracture are at high risk of medication errors due to a combination of high age, comorbidities, polypharmacy and several care transitions after fracture. The aim was to study medication management tasks concerning patient safety: medication reconciliation, medication review and communication of key medication information in care transitions.

DESIGN

Descriptive study comprising a self-administered clinician survey (MedHipPro-Q) and a retrospective review of hospital medical records of patients with hip fracture.

SETTING

Regional hospital and the associated primary care units (South-Eastern Norway).

PARTICIPANTS

The survey received responses from 253 clinicians, 61 medical doctors and 192 nurses, involved in the medication management of patients with hip fracture, from acute admittance to the regional hospital, through an in-hospital fast track, primary care rehabilitation and back to permanent residence. Respondents' representativeness was unknown, introducing a risk of selection and non-response bias, and extrapolating findings should be done with caution. The patient records review included a random sample of records of patients with hip fracture (n=50).

OUTCOME MEASURES

Medication reconciliation, medication review and communication of medication information from two perspectives: the clinicians' (ie, experiences with medication management) and the practice (ie, documentation of completed medication management).

RESULTS

In the survey, most clinicians stated they performed medication reconciliation (79%) and experienced that patients often arrived without a medication list after care transition (37%). Doctors agreed that more patients would benefit from medication reviews (86%). In the hospital patient records, completed medication reconciliation was documented in most patients (76%). Medication review was documented in 2 of 50 patients (4%). Discharge summary guidelines were followed fully for 3 of 50 patients (6%).

CONCLUSION

Our study revealed a need for improved medication management for patients with hip fracture. Patients were at risk of medication information not being transferred correctly between care settings, and medication reviews seemed to be underused in clinical practice.

Pharmacological management, and potentially inappropriate prescriptions in patients with osteoporosis

BACKGROUND

The treatment of osteoporosis involves medications that reduce the risk of fractures, but some medications can decrease bone density. The aim was to identify the treatments, comorbidities, and prescriptions related to reducing bone mineral density in patients with osteoporosis.

RESEARCH DESIGN AND METHODS

A cross-sectional study that identified patterns of anti-osteoporotic drug prescriptions for outpatient use and potentially inappropriate prescriptions for patients with osteoporosis based on the drug-dispensing database of 8.5 million people in Colombia. All patients ≥65 years with a diagnosis of osteoporosis were included.

RESULTS

A total of 16,362 patients with osteoporosis were identified. They had a median age of 74.4 years, and 47.9% received anti-osteoporotic therapy, especially bisphosphonates (41.6%), and 86.5% received calcium and/or vitamin D supplement. 41.6% of those who had a history of bone fractures were prescribed anti-osteoporotic drugs. Potentially inappropriate prescriptions, especially corticosteroids at doses greater than 5mg prednisolone equivalent (4.4%), were found in 41.4% of cases and were more common in older patients and those with a history of fractures or with cardiovascular, digestive, neurological, psychiatric or neoplastic comorbidities.

CONCLUSIONS

A significant proportion of patients had potentially inappropriate prescriptions, especially older patients, those with certain comorbidities, and those receiving comedication with antirheumatic drugs.

Prevalence of Chronic Opioid Use in the Elderly After Hip Fracture Surgery

BACKGROUND

While interest has focused on opioid use after total hip arthroplasty, little research has investigated opioid use in elderly patients after hip fracture. We hypothesize that a substantial number of opioid-naïve elderly patients go on to chronic opioid use after hip fracture surgery.

METHODS

We reviewed a consecutive series of 219 patients 65 years and older who underwent surgical fixation between January 1, 2016 and February 28, 2019 for a native hip fracture. Patients were excluded for polytrauma, periprosthetic or pathologic fractures, recent major surgery, or death within 90 days of their hip surgery. The state prescription monitoring database was used to determine opioid use.

RESULTS

Overall, 58 patients (26%) were postoperative chronic opioid users. Of the initial 188 opioid-naïve patients, 43 (23%) became chronic users. Of the 31 preoperative opioid users, 15 (48%) continued as chronic users. Chronic postoperative users were more likely to be White (76% vs 91%, P = .04), younger (78 vs 82 years, P = .003), and preoperative opioid users (odds ratio 3.3, P = .007). Arthroplasty vs fixation did not affect the rate of chronic opioid use (P = .22).

CONCLUSION

Chronic opioid use is surprisingly common after hip fracture repair in the elderly. Twenty-three percent of opioid-naïve hip fracture patients became chronic users after surgery. Continued vigilance is needed by orthopedic surgeons to limit the amount and duration of postoperative narcotic prescriptions and to monitor for continued use.

Hospital-wide surveillance of fracture risk assessment by both FRAX and medication patterns in acute care hospital

To identify patients at a high risk for primary and secondary osteoporotic fractures using fracture risk assessments performed using the current method and the proposed method, in an acute care hospital and to identify departments where high-risk patients are admitted. This retrospective study included patients aged 40-90 years who were hospitalized at Fujita Health University Hospital. We collated the clinical data and prescriptions of all study participants. We also gathered data pertaining to risk factors according to Fracture Risk Assessment Tool (FRAX). Of the 1,595 patients, the mean number of major osteoporotic fracture risk predicted using FRAX was 11.73%. The department of rheumatology showed the highest fracture risk (18.55 ± 16.81) and had the highest number of patients on medications that resulted in reduced bone mineral density (1.07 ± 0.98 medication). Based on the FRAX, the proportion of patients in the high-risk group in this department was significantly higher compared with those in the remaining departments with respect to glucocorticoid administration, rheumatoid arthritis, and secondary osteoporosis. However, the departments included in the high-risk group were not necessarily the same as the departments included in the top group, based on the administered medications. FRAX score is calculated based on various risk factors; however, only glucocorticoid corresponds to medications. We should focus on medication prescription patterns in addition to FRAX to improve fracture risk assessment in hospital-wide surveillance. Therefore, we recommend the use of FRAX along with the prescribed medications to identify departments that admit high-risk patients.

Change in central nervous system-active medication use following fall-related injury in older adults

BACKGROUND

Central nervous system (CNS)-active medication use is an important modifiable risk factor for falls in older adults. A fall-related injury should prompt providers to evaluate and reduce CNS-active medications to prevent recurrent falls. We evaluated change in CNS-active medications up to 12 months following a fall-related injury in community-dwelling older adults compared with a matched cohort without fall-related injury.

METHODS

Participants were from the Adult Changes in Thought study conducted at Kaiser Permanente Washington. Fall-related injury codes between 1994 and 2014 defined index encounters in participants with no evidence of such injuries in the preceding year. We matched each fall-related injury index encounter with up to five randomly selected clinical encounters from participants without injury. Using automated pharmacy data, we estimated the average change in CNS-active medication use at 3, 6, and 12 months post-index according to the presence or absence of CNS-active medication use before index.

RESULTS

One thousand five hundred sixteen participants with fall-related injury index encounters (449 CNS-active users, 1067 nonusers) were matched to 7014 index encounters from people without fall-related injuries (1751 users, 5236 nonusers). Among CNS-active users at the index encounter, those with fall-related injury had an average decrease in standard daily doses (SDDs) at 12 months (-0.43; 95% CI: -0.63 to -0.23), and those without injury had a greater (p = 0.047) average decrease (-0.66; 95% CI: -0.78 to -0.55). Among nonusers at index, those with fall-related injury had a smaller increase than those without injury (+0.17, 95% CI: +0.13 to +0.21, vs. +0.24, 95% CI: +0.20 to +0.28, p = 0.005).

CONCLUSIONS

The differences in CNS-active medication use change over 12 months between those with and without fall-related injury were small and unlikely to be clinically significant. These results suggest that fall risk-increasing drug use is not reduced following a fall-related injury, thus opportunities exist to reduce CNS-active medications, a potentially modifiable risk factor for falls.

Use of Fall Risk-Increasing Drugs Around a Fall-Related Injury in Older Adults: A Systematic Review

OBJECTIVES

To examine: (1) prevalence of fall risk-increasing drug (FRID) use among older adults with a fall-related injury, (2) which FRIDs were most frequently prescribed, (3) whether FRID use was reduced following the fall-related healthcare episode, and (4) which interventions have reduced falls or FRID use in older adults with a history of falls.

DESIGN

Systematic review.

PARTICIPANTS

Observational and intervention studies that assessed (or intervened on) FRID use in participants aged 60 years or older who had experienced a fall.

MEASUREMENTS

PubMed and EMBASE were searched through June 30, 2019. Two reviewers independently extracted data and evaluated studies for bias. Discrepancies were resolved by consensus.

RESULTS

Fourteen of 638 articles met selection criteria: 10 observational studies and 4 intervention studies. FRID use prevalence at time of fall-related injury ranged from 65% to 93%. Antidepressants and sedatives-hypnotics were the most commonly prescribed FRIDs. Of the 10 observational studies, only 2 used a design adequate to capture changes in FRID use after a fall-related injury, neither finding a reduction in FRID use. Three randomized controlled studies conducted in various settings (hospital, emergency department, and community pharmacy) with 12-month follow-up did not find a reduction in falls with interventions to reduce FRID use, although the study conducted in the community pharmacy setting was effective in reducing FRID use. In a nonrandomized (pre-post) intervention study conducted in an outpatient geriatrics clinic, falls were reduced in the intervention group.

CONCLUSIONS

Limited evidence indicates high prevalence of FRID use among older adults who have experienced a fall-related injury and no reduction in overall FRID use following the fall-related healthcare encounter. There is a need for well-designed interventions to reduce FRID use and falls in older adults with a history of falls. Reducing FRID use as a stand-alone intervention may not be effective in reducing recurrent falls. J Am Geriatr Soc 68:1334-1343, 2020.

Prevalence of medication-related falls in 200 consecutive elderly patients with hip fractures: a cross-sectional study

Background

Hip fractures constitute a major health problem in elderly people and are often fall-related. Several factors can contribute to a fall episode leading to hip fracture, including fall-risk-increasing drugs (FRIDs), which are often used by elderly people.

We aimed to investigate the prevalence of medication-related falls and to assess the role of FRIDs and potentially inappropriate medications (PIMs) in a population of elderly patients hospitalized for a hip fracture.

Methods

We reviewed the patient records of 200 consecutive patients, aged ≥65 years, who were admitted for a hip fracture and evaluated whether medications were likely to have contributed to the fall episode. PIMs were identified using the Screening Tool of Older Persons’ Prescriptions version 2 (STOPP) and by evaluating indications, contra-indications and interactions of the prescribed medications for each patient.

Results

FRIDs were used by 175 patients (87.5%). Medications were considered a likely contributor to the fall in 82 patients (41%). These were most often psychotropic medications alone or in combination with antihypertensives and/or diuretics. The 82 patients with suspected medication-related falls used more medications, FRIDs and PIMs than the rest of the patients, and in 74 (90%) of the 82 patients, at least one medication considered to be a contributor to the fall was also a PIM.

Conclusions

The prevalence of suspected medication-related falls was 41%. It seems likely that a medication review could have reduced, though not eliminated, the risk of falling in this group of patients.

Fall-risk increasing drugs and recurrent injurious falls association in older patients after hip fracture: a cohort study protocol

Polypharmacy and fall-risk increasing drugs (FRIDS) have been associated with injurious falls. However, no information is available about the association between FRIDS and injurious falls after hospital discharge due to hip fracture in a very old population. We aim to assess the association between the use of FRIDS at discharge and injurious falls in patients older than 80 years hospitalized due to a hip fracture. A retrospective cohort study using routinely collected health data will be conducted at the Orthogeriatric Unit of a teaching hospital. Patients will be included at hospital discharge (2014), with a 2-year follow-up. Fall-risk increasing drugs will be recorded at hospital discharge, and exposure to drugs will be estimated from usage records during the 2-year follow-up. Injurious falls are defined as falls that lead to any kind of health care (primary or specialized care, including emergency department visits and hospital admissions). A sample size of 193 participants was calculated, assuming that 40% of patients who receive any FRID at discharge, and 20% who do not, will experience an injurious fall during follow up. This protocol explains the study methods and the planned analysis. We expect to find a relevant association between FRIDS at hospital discharge and the incidence of injurious falls in this very old, high risk population. If confirmed, this would support the need for a careful pharmacotherapeutic review in patients discharged after a hip fracture. However, results should be carefully interpreted due to the risk of bias inherent to the study design.

Fall-risk increasing drugs and prevalence of polypharmacy in older patients discharged from an Orthogeriatric Unit after a hip fracture

BACKGROUND

Polypharmacy and fall-risk increasing drugs (FRIDS) have been associated with injurious falls. We aimed to estimate the prevalence of polypharmacy and FRIDS in older patients discharged from an Orthogeriatric Unit after a hip fracture surgery.

METHODS

This study describes the baseline findings of a 2-year retrospective cohort study. We included patients older than 80 years discharged from an Orthogeriatric Unit who were able to walk before surgery. Patient's baseline variables, total number of drugs, and FRIDS at hospital discharge were collected.

RESULTS

We included 228 patients. The mean number of drugs and FRIDS prescribed at discharge was 11.6 ± 3.0 and 2.9 ± 1.6, respectively. Polypharmacy was prevalent in all patients except in three: 23.3% (5-9 drugs) and 75.9% (≥ 10 drugs). Only 11 patients had no FRIDS and 35.5% were on > 3 FRIDS. The most prevalent FRIDS were: agents acting on the renin-angiotensin system (43.9%) and anxiolytics (39.9%). The number of FRIDS was higher in patients with extreme polypharmacy (3.4 ± 1.5) than in those on 5-9 drugs (1.5 ± 1.0, p < 0.05). Independent people in performing instrumental activities had lower risk of extreme polypharmacy (≥ 10 drugs) or > 3 FRIDS: OR 0.39 (95% CI 0.18-0.83) and OR 0.41 (95% CI 0.20-0.84), respectively. People living in a nursing home had higher risk of > 3 FRIDS: OR 4.03 (95% CI 1.12-14.53).

CONCLUSIONS

Polypharmacy and fall-risk increasing drugs are prevalent in patients discharged from orthogeriatric care after surgery for a hip fracture. Interventions on drug use at hospital discharge could have a potential impact on falls in this high-risk population.

Opioid use after hip fracture surgery: A Danish nationwide cohort study from 2005 to 2015

BACKGROUND

There is currently a knowledge gap regarding persistent opioid use after hip fracture surgery. Thus, opioid use within a year after hip fracture surgery in patients with/without opioid use before surgery was examined.

METHODS

This population-based cohort study included all patients (aged ≥ 65) undergoing primary hip fracture surgery in Denmark (2005-2015) identified from the Danish Multidisciplinary Hip Fracture Database. Opioid use was assessed from The Danish National Health Service Prescription Database as redeemed prescriptions. The proportion of patients with ≥1 opioid prescription was computed within 6 months before surgery and each of four 3-month periods (quarters) after surgery, among patients alive first day in each period. Proportion differences (95% CI) were calculated for each quarter compared to before surgery. Proportions were calculated for users and nonusers before surgery, including initiators after first quarter.

RESULTS

This study included 69,456 patients. Proportion differences of opioid users were 35.0 (95% CI 34.5-35.5), 7.0 (95% CI 6.5-7.5), 2.9 (95% CI 2.4-3.4) and 1.4 percentage-points (95% CI 0.9-1.9) the four quarters after surgery compared to before. Among opioid nonusers before surgery, 54.7% (95% CI 54.3-55.1), 21.8% (95% CI 21.4-22.2), 17.8% (95% CI 17.4-18.2) and 16.8% (95% CI 16.4-17.2) were opioid users in 1st-4th quarter after surgery. However, 8.5% (95% CI 8.2-8.7) of the nonusers before surgery in 4th quarter initiated opioid use more than a quarter after surgery.

CONCLUSIONS

The proportion of opioid users increased after hip fracture surgery and was 1.4 percentage-points increased in fourth quarter compared to before. Of opioid nonusers before surgery, 16.8% were opioid users fourth quarter after surgery.

SIGNIFICANCE

Opioid use 1 year after hip fracture surgery is common, both in patients who were opioid users and nonusers before the surgery. These significant findings point out the need for indication of benefits and risks of opioid use in the acute and long-term management of patients undergoing hip fracture surgery.

Orthogeriatric treatment reduces potential inappropriate medication in older trauma patients: a retrospective, dual-center study comparing conventional trauma care and co-managed treatment

Background

Multimorbidity and polypharmacy are common challenges in the treatment of older trauma patients. Therefore, various integrated care models were developed over the last few years, merging the expertise of geriatricians and trauma surgeons. The aim of this study was to evaluate, if the number of prescriptions of potentially inappropriate medication (PIM) could be reduced in these patients by an interdisciplinary co-managed concept compared to conventional trauma care.

Methods

We conducted a retrospective, dual-center cohort study, including all patients aged 70 years and older admitted with a fracture of the hip or the proximal humerus within the study period. Patients were treated in the universities department of trauma surgery with two different hospital sites, one with conventional trauma care (CTC) and the other one with a certified orthogeriatric trauma unit (OGC). Based on the STOPP/START criteria by O´Mahony et al., PIMs were defined, which should be avoided in (ortho)geriatric patients. Medical records of each patient were analyzed at discharge. Besides patients basic information, all prescribed drugs, changes in the medication plan and who carried out these changes were collected. For statistical analysis based on the data quality and distribution, the t test, Mann–Whitney U test and the Chi-square test were used.

Results

A total of 95 patients were included, 73 of them females, with an average age of 82.59 years (SD ± 6.96). Mean length of hospital stay was 12.98 at CTC and 13.36 days at OGC (p = 0.536). Among conventional care (41 patients), prescription of one or more PIMs was found in 85.4% of the patients, whereas at the orthogeriatric ward (54 patients) only in 22.2% (p < 0.001). Besides that, changes in medication were made for 48.1% of the patients during their stay on the orthogeriatric ward.

Conclusions

Our findings show that an integrated care concept can reduce the number of prescriptions of PIMs significantly and potentially avoids adverse drug reactions and additional burdens in older trauma patients.

Comorbidities and medication use in patients with a recent clinical fracture at the Fracture Liaison Service

In this cross-sectional study, two-thirds of Fracture Liaison Service (FLS) patients had comorbidities and medications associated with increased bone- or fall-related fracture risk. Bone-related and fall-related fracture risk (BRR and FRR) were associated with age and fracture type, but not with gender or BMD. Systematic evaluation of these factors leads to a more profound assessment in FLS care.

INTRODUCTION

This study is a systematic evaluation of comorbidities and medications associated with increased fracture risk in patients aged 50-90 years with a recent fracture visiting the FLS.

METHODS

In this cross-sectional cohort study, comorbidities were classified according to ICD-10 and medications according to the Anatomic Therapeutic Chemical (ATC) classification and further categorized into those associated BRR and FRR.

RESULTS

Of 1282 patients (72% women; 65 ± 9 years), 53% had at least one BRR, 46% had at least one FRR, and 66% at least one BRR and/or FRR. At least one BRR, as well as at least one FRR were associated with age, BMI, and fracture type, but not with gender or BMD. The proportion of patients with only BRR (± 20%) or only FRR (± 10%) was similar among ages, gender, BMI, fracture type, and BMD. The combination of at least one BRR and at least one FRR was significantly associated with age, BMI, and major fractures, but not with gender or BMD.

CONCLUSION

Comorbidities and medications associated with increased fracture risk are present in two-thirds of patients visiting the FLS. In addition, the proportion of patients having a combination of BRR and FRR increased significantly with age, BMI, and fracture severity. This indicates that systematic evaluation of these factors is important for a more profound assessment of subsequent fracture risk in FLS care.

Falls-Related Drug Use and Risk of Falls Among Older Adults: A Study in a US Medicare Population

Background

Approximately one-third of community-dwelling older adults fall each year, and approximately 10% have falls requiring medical services. Among other factors, research studies have linked certain medications with an increased risk of falls.

Objective

The aim of this study was to examine the risk of falls relative to use patterns among new and continuing falls-related drug (FRD) users.

Methods

A 10% random sample, insured in AARP^® Medicare Supplement and AARP Medicare Part D Rx plans, was utilized to define new and continuing FRD users. New users had a 12-month pre-period without FRD use, whereas continuing users had at least one FRD in the pre-period. Both groups had 12-month follow-up after initiating or continuing FRD use. Characteristics associated with the risk of falls for new and continuing users were determined using multivariate logistic regression models.

Results

Among insureds, 44% used at least one of the FRD classes. Of these, 29% were new users (N = 35,340) and 71% were continuing users (N = 121,488). Fall rates for the two subgroups were similar at 7 and 8%, respectively. Characteristics associated with the risk of falls were previous injurious fall, use of two or more classes of FRDs, older age, poorer health, and being female. New users were at higher risk than continuing users.

Conclusion

New users of FRDs were at highest risk of falls, and continuing users were at increased risk, especially with higher numbers of FRD classes. Both groups could benefit from falls awareness and prevention programs.

Study of fall risk-increasing drugs in elderly patients before and after a bone fracture

BACKGROUND

Accidental falls have a significant economic and human impact. The use of certain drugs is one of the modifiable risk factors associated with these events.

OBJECTIVE

The aim of this study was to determine the prevalence of use and to explore changes in treatment with fall-related drugs in patients over 65 years of age admitted as a result of a fall-related fracture.

METHODS

Observational and prospective study performed in a tertiary level hospital. A list of fall risk-increasing drugs (FRIDs) was drawn up. The main study variables were number and type of FRIDs prescribed at admission and 1 month after the fracture and number, type, treating physician and place where changes in FRIDs were implemented.

RESULTS

In total, 252 patients were included. At admission, 91.3% were receiving at least one FRID, mean daily use was 3.1 FRIDs and the most frequently prescribed FRIDs were diuretics (18%), renin-angiotensin system-acting agents (15.8%) and antidepressants (15%). One month later, mean daily use was 3.4 FRIDs (p=0.099) and a significant increase was detected in the use of hypnotics (p=0.003) and antidepressants (p=0.042). A total of 327 changes in treatment were recorded (1.3 changes/patient). Of the changes, 52.6% were new prescriptions, 72.2% occurred at discharge and 56.6% were ordered by a geriatrician.

CONCLUSIONS

The use of FRIDs among patients with a fall-related fracture is very high. This use rises 1 month after the fracture, significantly in the case of hypnotics and antidepressants.

Patterns of drug prescriptions in an orthogeriatric ward as compared to orthopaedic ward: results from the Trondheim Hip Fracture Trial-a randomised clinical trial

Purpose

In the Trondheim Hip Fracture Trial, 397 home-dwelling patients with hip fractures were randomised to comprehensive geriatric care (CGC) in a geriatric ward or traditional orthopaedic care (OC). Patients in the CGC group had significantly better mobility and function 4 months after discharge. This study explores group differences in drug prescribing and possible associations with the outcomes in the main study.

Methods

Drugs prescribed at admission and discharge were registered from hospital records. Mobility, function, fear of falling and quality of life were assessed using specific rating scales. Linear regression was used to analyse association between drug changes and outcomes at 4 months.

Results

The mean age was 83 years, and 74% were females. The mean number (± SD) of drugs in the CGC and OC groups was 3.8 (2.8) and 3.9 (2.8) at inclusion and 7.1 (2.8) and 6.2 (3.0) at discharge, respectively (p = 0.003). The total number of withdrawals was 209 and 82 in the CGC and OC groups, respectively (p < 0.0001), and the number of starts was 844 and 526, respectively (p < 0.0001). A significant negative association was found between the number of drug changes during the hospital stay and mobility and function 4 months later in both groups. However, this association disappeared when adjusting for baseline function and comorbidities.

Conclusion

These secondary analyses suggest that there are significant differences in the pharmacological treatment between geriatric and orthopaedic wards, but these differences could not explain the beneficial effect of CGC in the Trondheim Hip Fracture Trial.

Electronic supplementary material

The online version of this article (doi:10.1007/s00228-017-2263-x) contains supplementary material, which is available to authorized users.

Clinical relevance of the STOPP/START criteria in hip fracture patients

Purpose

The aim of this study was to investigate the clinical relevance of potentially inappropriate medications (PIMs), identified by the STOPP criteria, and potential prescribing omissions (PPOs), identified by the START criteria, and to identify predictors for clinically relevant PIMs and PPOs.

Methods

The STOPP and START criteria were applied on the medication lists of 200 older hip fracture patients, consecutively recruited to a randomized controlled study in 2009. For each identified PIM and/or PPO, the clinical relevance was assessed at the individual level, using medical records from both hospital and primary care as well as data collected in the original study.

Results

A total of 555 PIMs/PPOs were identified in 170 (85%) patients (median age: 85 years, 67% female), 298 (54%) of which, in 141 (71%) patients, were assessed as clinically relevant. A greater proportion of PIMs than PPOs were clinically relevant: 71% (95% CI: 66%; 76%) vs. 32% (27%; 38%). A greater proportion of PPOs than PIMs could not be assessed with available information: 38% (32%; 44%) vs. 22% (17%; 27%). Number of drugs and multidose drug dispensing, but not age, sex, cognition, or nursing home residence, were associated with ≥1 clinically relevant PIMs/PPOs.

Conclusions

The present study illustrates that one in two PIMs/PPOs identified by the STOPP/START criteria is clearly clinically relevant, PIMs being clinically relevant to a greater extent than PPOs. Based on available information, the clinical relevance could not be determined in a non-negligible proportion of PIMs/PPOs. Number of drugs and multidose drug dispensing were associated with ≥1 clinically relevant PIMs/PPOs.

Patterns of Prescription Drug Use Before and After Fragility Fracture

IMPORTANCE

Patients who have a fragility fracture are at high risk for subsequent fractures. Prescription drugs represent 1 factor that could be modified to reduce the risk of subsequent fracture.

OBJECTIVE

To describe the use of prescription drugs associated with fracture risk before and after fragility fracture.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study conducted between February 2015 and March 2016 using a 40% random sample of Medicare beneficiaries from 2007 through 2011 in general communities throughout the United States. A total of 168 133 community-dwelling Medicare beneficiaries who survived a fracture of the hip, shoulder, or wrist were included. Cohort members were required to be enrolled in fee-for-service Medicare with drug coverage (Parts A, B, and D) and to be community dwelling for at least 30 days in the immediate 4-month postfracture period.

EXPOSURES

Prescription drug use during the 4-month period before and after a fragility fracture.

MAIN OUTCOMES AND MEASURES

Prescription fills for drug classes associated with increased fracture risk were measured using Part D retail pharmacy claims. These were divided into 3 categories: drugs that increase fall risk; drugs that decrease bone density; and drugs with unclear fracture risk mechanism. Drugs that increase bone density were also tracked.

RESULTS

A total of 168 133 patients with a fragility fracture (141 569 women; 84.2%) met the inclusion criteria for this study; 91.8% were white. Across all fracture types, the mean (SD) age was 80.0 (7.7) years, and 53.2% of the fracture cohort was hospitalized at the time of the index fracture, although this varied significantly depending on fracture type (100% of hip fractures, 8.2% of wrist fractures, and 15.0% of shoulder fractures). The frequency of discharge to an institution for rehabilitation following hospitalization also varied by fracture type, but the mean (SD) duration of acute rehabilitation did not: 28.1 (19.8) days. Most patients were exposed to at least 1 nonopiate drug associated with increased fracture risk in the 4 months before fracture (77.1% of hip, 74.1% of wrist, and 75.9% of shoulder fractures). Approximately 7% of these patients discontinued this drug exposure after the fracture, but this was offset by new users after fracture. Consequently, the proportion of the cohort exposed following fracture was unchanged (80.5%, 74.3%, and 76.9% for hip, wrist, and shoulder, respectively). There was no change in the average number of fracture-associated drugs used. This same pattern of use before and after fracture was observed across all 3 drug mechanism categories. Use of drugs to strengthen bone density was uncommon (≤25%) both before and after fracture.

CONCLUSIONS AND RELEVANCE

Exposure to prescription drugs associated with fracture risk is infrequently reduced following fragility fracture occurrence. While some patients eliminate their exposure to drugs associated with fracture, an equal number initiate new high-risk drugs. This pattern suggests there is a missed opportunity to modify at least one factor contributing to secondary fractures.

Association between drug-specific indicators of prescribing quality and quality of drug treatment: a validation study

Purpose

To evaluate the concurrent validity of three European sets of drug‐specific indicators of prescribing quality

Methods

In 200 hip fracture patients (≥65 years), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to three drug‐specific indicator sets (Swedish National Board of Health and Welfare, French consensus panel list, and German PRISCUS list). As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) and START (Screening Tool to Alert to Right Treatment).

Results

According to the Swedish, French, and German indicator sets, 82 (41%), 54 (27%), and 43 (22%) patients had potentially inappropriate drug treatment. A total of 141 (71%) patients had suboptimal drug treatment according to the gold standard. The sensitivity for the indicator sets was 0.51 (95% confidence interval: 0.43; 0.59), 0.33 (0.26; 0.41), and 0.29 (0.22; 0.37), respectively. The specificity was 0.83 (0.72; 0.91), 0.88 (0.77; 0.94), and 0.97 (0.88; 0.99). Suboptimal drug treatment was 2.0 (0.8; 5.3), 1.9 (0.7; 5.1), and 6.1 (1.3; 28.6) times as common in patients with potentially inappropriate drug treatment according to the indicator sets, after adjustments for age, sex, cognition, residence, multi‐dose drug dispensing, and number of drugs.

Conclusions

In this setting, the indicator sets had high specificity and low sensitivity. This needs to be considered upon use and interpretation. Copyright © 2015 The Authors Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons, Ltd.

Opioids in hip fracture patients: an analysis of mortality and post hospital opioid use

OBJECTIVE

The aim of this study was to investigate the use of opioids among hip fracture patients, and the potential relation between perioperative prescription of opioids, mortality and chronic opioid use. The purpose of this study was to investigate the use of opioids among hip fracture patients postoperatively and 90- and 180 days after discharge. The study also analysed predictors of early death at 30-, 90 and 365 days after discharge.

METHODS

We present data from the Orthopaedic Department at Bispebjerg University Hospital from 30 May 2010 and 31 March 2011 on 416 consecutively admitted hip fracture patients. Three patients died before surgery and were excluded from the analyses. Data were collected through medical records, hospital and national databases. Medication use was analysed before admission, at 3 and 6 months. Mortality data were analysed at 30 days, 6 months and 1 year.

RESULTS

24% were opioid users at admission, of whom 13% had an active malignant disease and 20% had been diagnosed with osteoporosis. 95% received opioids during admission, and 81% received a prescription for opioids at discharge. This fraction decreased to 36% at 3 months and 30% at 6 months. 2.9% of previous opioid naïve patients remained users at 6 months. Opioid use prior to admission and a pre-existing diagnosis of osteoporosis were the most significant factors associated with continued use at 3 and 6 months. The 30-day mortality was 10% and 1-year mortality was 27%. Mortality was associated with high age, ASA score>2, active cancer, high creatinine and leucocytosis. We found no association between opioids and mortality.

CONCLUSION

The results of our study indicate no general reason to refrain from prescribing opioids to hip fracture patients based on a fear of potential abuse or increased mortality.

Number of drugs in the medication list as an indicator of prescribing quality: a validation study of polypharmacy indicators in older hip fracture patients

Purpose

Indicators based on the number of drugs in the medication list are sometimes used to reflect quality of drug treatment. This study aimed to evaluate the concurrent validity of such polypharmacy indicators, i.e., their ability to differentiate between appropriate and suboptimal drug treatment.

Methods

In 200 hip fracture patients (≥65 years of age), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to indicators based on the number of drugs in the medication list. As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START). Suboptimal drug treatment was defined as ≥1 STOPP/START outcomes assessed as clinically relevant at the individual level.

Results

A total of 141 (71 %) patients had suboptimal drug treatment according to the gold standard. The corresponding figures according to the indicators ≥5 and ≥10 drugs were 149 (75) and 49 (25 %), respectively. The sensitivity for the indicators ≥5 and ≥10 drugs to detect suboptimal drug treatment was 0.86 (95 % confidence interval: 0.80; 0.92) and 0.32 (0.25; 0.40), respectively. The specificity was 0.53 (0.41; 0.65) and 0.93 (0.82; 0.97).

Conclusions

The findings suggest that no polypharmacy indicator could serve as a general indicator of prescribing quality; cut-offs for such indicators need to be chosen according to purpose.

Prevalence of suboptimal drug treatment in patients with and without multidose drug dispensing--a cross-sectional study

PURPOSE

The aim of this study was to compare the prevalence of suboptimal drug treatment in older patients with and without multidose drug dispensing (MDD).

METHODS

In 200 hip fracture patients (≥65 years of age), originally recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was compared between patients with and without MDD. Two specialist physicians independently assessed and then agreed on the quality of the drug treatment of each patient. Suboptimal drug treatment was defined as ≥1 STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) or ≥1 START (Screening Tool to Alert to Right Treatment) outcome assessed as clinically relevant after individual considerations had been made, i.e. over- or undertreatment (≥1 inappropriate and ≥1 missing drug, respectively).

RESULTS

Patients with MDD (n=100) differed from patients without MDD (n=100) in several ways, for example by being older (87.6 vs. 81.5 years) and using more drugs (8.4 vs. 5.9 drugs). The total number (±standard deviation) of inappropriate and/or missing drugs per person was greater in MDD patients compared with patients without MDD (1.92±1.52 vs. 1.06±1.29, P<0.0001); MDD patients had an additional 0.77 inappropriate drugs and an additional 0.09 missing drugs per person. The prevalence of suboptimal drug treatment was greater in patients with MDD than in those without MDD (86 vs. 55%, P<0.0001). Logistic regression revealed that suboptimal drug treatment was 8.0 times as common in MDD patients, after adjustments for age, sex, number of drugs, cognition, and residence (95% confidence interval 2.4; 26.9). Corresponding figures for over- and undertreatment were 2.9 (1.1; 7.4) and 1.8 (0.8; 4.3), respectively.

CONCLUSIONS

Suboptimal drug treatment, including over- and undertreatment, is more common in MDD patients than in patients who receive their drugs via ordinary prescriptions. The findings confirm safety concerns regarding quality of drug treatment in MDD patients.

Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care

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.

Effects of medication reviews performed by a physician on treatment with fracture-preventing and fall-risk-increasing drugs in older adults with hip fracture-a randomized controlled study

OBJECTIVES

To investigate whether medication reviews increase treatment with fracture-preventing drugs and decrease treatment with fall-risk-increasing drugs.

DESIGN

Randomized controlled trial (1:1).

SETTING

Departments of orthopedics, geriatrics, and medicine at Sahlgrenska University Hospital, Gothenburg, Sweden.

PARTICIPANTS

One hundred ninety-nine consecutive individuals with hip fracture aged 65 and older.

INTERVENTION

Medication reviews, based on assessments of risks of falls and fractures, regarding fracture-preventing and fall-risk-increasing drugs, performed by a physician, conveyed orally and in written form to hospital physicians during the hospital stay, and to general practitioners after discharge.

MEASUREMENTS

Primary outcomes were changes in treatment with fracture-preventing and fall-risk-increasing drugs 12 months after discharge. Secondary outcomes were falls, fractures, deaths, and physicians' attitudes toward the intervention.

RESULTS

At admission, 26% of intervention and 29% of control participants were taking fracture-preventing drugs, and 12% and 11%, respectively, were taking bone-active drugs, predominantly bisphosphonates. After 12 months, 77% of intervention and 58% of control participants were taking fracture-preventing drugs (P = .01), and 29% and 15%, respectively, were taking bone-active drugs (P = .04). Mean number of fall-risk-increasing drugs per participants was 3.1 (intervention) and 3.1 (control) at admission and 2.9 (intervention) and 3.1 (control) at 12 months (P = .62). No significant differences in hard endpoints were found. The responding physicians (n = 65) appreciated the intervention; on a scale from 1 (very bad) to 6 (very good), the median rating was 5 (interquartile range (IQR) 4-6) for the oral part and 5 (IQR 4-5.5) for the text part.

CONCLUSION

Medication reviews performed and conveyed by a physician increased treatment with fracture-preventing drugs but did not significantly decrease treatment with fall-risk-increasing drugs in older adults with hip fracture. Prescribing physicians appreciated this intervention.