Fall-Risk-Increasing Drugs: A Systematic Review and Meta-Analysis: I. Cardiovascular Drugs

Bone fragility in diabetes: novel concepts and clinical implications

Increased fracture risk represents an emerging and severe complication of diabetes. The resulting prolonged immobility and hospitalisations can lead to substantial morbidity and mortality. In type 1 diabetes, bone mass and bone strength are reduced, resulting in up to a five-times greater risk of fractures throughout life. In type 2 diabetes, fracture risk is increased despite a normal bone mass. Conventional dual-energy x-ray absorptiometry might underestimate fracture risk, but can be improved by applying specific adjustments. Bone fragility in diabetes can result from cellular abnormalities, matrix interactions, immune and vascular changes, and musculoskeletal maladaptation to chronic hyperglycaemia. This Review summarises how the bone microenvironment responds to type 1 and type 2 diabetes, and the mechanisms underlying fragility fractures. We describe the value of novel imaging technologies and the clinical utility of biomarkers, and discuss current and future therapeutic approaches that protect bone health in people with diabetes.

Anticholinergic Drug Use on Admission and the Risk of In-Hospital Falls in Older Hospitalized Patients

Purpose

In-hospital falls, especially among older patients, are a major and underestimated problem. Several studies have suggested a possible association between anticholinergic drug use and falls, but the results are inconclusive and studies focusing on in-hospital falls are scarce. The aim of the present study was to investigate whether anticholinergic drug exposure on admission is associated with in-hospital falls.

Patients and Methods

This retrospective chart review study was conducted in the Erasmus MC University Medical Center, Rotterdam, the Netherlands. Patients aged 65 years and older, who were acutely admitted to the geriatric ward between 2012 and 2015, were included. Anticholinergic drug exposure was determined with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew. Logistic regression was used to investigate the possible association between anticholinergic drug exposure and in-hospital falls. Analyses were adjusted for age, sex, fall history, fall as reason for admission, number of drugs on admission, use of a mobility aid and delirium.

Results

A total of 905 patients were included, of which 94 patients experienced one or more in-hospital falls. Each additional anticholinergic drug in use, according to the ARS, was associated with an increased odd of experiencing a fall (OR = 1.49, 95% CI: 1.06–2.10). Other measures, ie anticholinergic drug use (yes/no) and different categories of anticholinergic drug burden, measured with the ARS, ACB and list of Chew, were all not associated with in-hospital falls.

Conclusion

Anticholinergic drug exposure on admission is possibly not a main risk factor for in-hospital falls among older patients.

Risk of Fall-Related Injuries Associated with Antidepressant Use in Elderly Patients: A Nationwide Matched Cohort Study

Previous studies have reported a higher risk of falls among tricyclic antidepressant (TCA) users compared to selective serotonin reuptake inhibitor (SSRI) users, yet SSRIs are known as a safer antidepressant class for use in older adults. This study examined the effects of antidepressant use on the risk of fall-related injuries after classifying antidepressant drugs, polypharmacy, and central nervous system (CNS) drugs by therapeutic classes and identifying factors influencing risk of fall-related injuries. A retrospective matched cohort study based on propensity scores was conducted among older adults, aged 70–89 years, who initiated antidepressant use between 1 January 2012 and 31 December 2014 using the national health insurance system senior cohort in Korea. The proportional hazard Cox regression model was used to examine the association between fall-related injuries and antidepressants. The subgroup analyses were performed to assess the risk of fall-related injuries by the number of concurrently administered medications, therapeutic classes of antidepressants, and CNS class medications. This study found that duloxetine, escitalopram, paroxetine, amitriptyline, imipramine, and trazodone significantly increased the risk of fall-related injuries in older adults. When antidepressants were prescribed to older adults, prescribers carefully considered factors including the dose, number of concurrently administered medications, and therapeutic classes of CNS.

Survival of Frail Elderly with Delirium

This study aims to determine when frailty increases the risks of delirium mortality. Hospital patients falling into the elderly frail or pre-frail category were recruited, some without delirium, some with delirium at admission, and some who developed delirium during admission. We screened for frailty, cognitive status, and co-morbidities whenever possible and extracted drug information and mortality data from electronic health records. Kaplan–Meier estimates of survival probability functions were computed at four times, comparing delirium versus non delirium patients. Differences in survival were assessed by a log-rank test. Independent Cox’s regression was carried out to identify significant hazard risks (HR) at 1 month, 6 months, 1 year, and 2 years. Delirium predicted mortality (log-rank test, p < 0.0001) at all four censoring points. Variables with significant HRs were frailty indicators, comorbidities, polypharmacy, and the use of specific drugs. For the delirium cohort, variables with the most significant 2-year hazard risks (HR(95%CI)) were: male gender (0.43 20 (0.26,0.69)), weight loss (0.45 (0.26,0.74)), sit and stand up test (0.67 (0.49,0.92)), readmission within 30 days of discharge (0.50 (0.30,0.80)), cerebrovascular disease (0.45 (0.27,0.76)), head trauma (0.54 22 (0.29,0.98)), number of prescribed drugs (1.10 (1.03,1.18)), and the use of diuretics (0.57 (0.34,0.96)). These results suggest that polypharmacy and the use of diuretics increase mortality in frail elderly patients with delirium.

Motoric Cognitive Risk Syndrome: Symptoms, Pathology, Diagnosis, and Recovery

The motoric cognitive risk (MCR) syndrome is a pre-dementia condition, marked by the enhanced risk for Alzheimer's disease (AD) and vascular dementia, together with falls, disability, and abnormal movements. The research studies revealed the distinct neurological and non-neurological clinical gait irregularities during dementia and accelerated functional decline, such as postural and balance impairments, memory loss, cognitive failure, and metabolic dysfunctions. The disabling characteristics of MCR comprise altered afferent sensory and efferent motor responses, together with disrupted visual, vestibular, and proprioceptive components. The pathological basis of MCR relates with the frontal lacunar infarcts, white matter hyperintensity (WMH), gray matter atrophy in the pre-motor and pre-frontal cortex, abnormal cholinergic functioning, inflammatory responses, and genetic factors. Further, cerebrovascular lesions and cardiovascular disorders exacerbate the disease pathology. The diagnosis of MCR is carried out through neuropsychological tests, biomarker assays, imaging studies, questionnaire-based evaluation, and motor function tests, including walking speed, dual-task gait tests, and ambulation ability. Recovery from MCR may include cognitive, physical, and social activities, exercise, diet, nutritional supplements, symptomatic drug treatment, and lifestyle habits that restrict the disease progression. Psychotherapeutic counseling, anti-depressants, and vitamins may support motor and cognitive improvement, primarily through the restorative pathways. However, an in-depth understanding of the association of immobility, dementia, and cognitive stress with MCR requires additional clinical and pre-clinical studies. They may have a significant contribution in reducing MCR syndrome and the risk for dementia. Overall, the current review informs the vital connection between gait performance and cognition in MCR and highlights the usefulness of future research in the discernment and treatment of dementiating illness.

Role of medicines management in preventing falls in older people

Falls are common in older people and are a cause of preventable morbidity and mortality. As well as causing injury, falls can result in pain, distress, loss of confidence, loss of independence and increased mortality. Older people are more likely to visit an emergency department following a fall, therefore these incidents place a high burden on these patients and their carers, as well as on healthcare systems. Appropriate risk assessment accompanied by multifactorial falls prevention interventions can reduce the risk of falls. Assessments should include a medication review because various medicines, sometimes referred to as 'falls risk increasing drugs', can precipitate or contribute to falls. This article examines some of the medicines in this group that can contribute to falls, serious injuries and fractures in older people. It also discusses the importance of medicines management as part of falls risk assessment and prevention interventions.

Barriers and facilitators in using a Clinical Decision Support System for fall risk management for older people: a European survey

PURPOSE

Fall-Risk Increasing Drugs (FRIDs) are an important and modifiable fall-risk factor. A Clinical Decision Support System (CDSS) could support doctors in optimal FRIDs deprescribing. Understanding barriers and facilitators is important for a successful implementation of any CDSS. We conducted a European survey to assess barriers and facilitators to CDSS use and explored differences in their perceptions.

METHODS

We examined and compared the relative importance and the occurrence of regional differences of a literature-based list of barriers and facilitators for CDSS usage among physicians treating older fallers from 11 European countries.

RESULTS

We surveyed 581 physicians (mean age 44.9 years, 64.5% female, 71.3% geriatricians). The main barriers were technical issues (66%) and indicating a reason before overriding an alert (58%). The main facilitators were a CDSS that is beneficial for patient care (68%) and easy-to-use (64%). We identified regional differences, e.g., expense and legal issues were barriers for significantly more Eastern-European physicians compared to other regions, while training was selected less often as a facilitator by West-European physicians. Some physicians believed that due to the medical complexity of their patients, their own clinical judgement is better than advice from the CDSS.

CONCLUSION

When designing a CDSS for Geriatric Medicine, the patient's medical complexity must be addressed whilst maintaining the doctor's decision-making autonomy. For a successful CDSS implementation in Europe, regional differences in barrier perception should be overcome. Equipping a CDSS with prediction models has the potential to provide individualized recommendations for deprescribing FRIDs in older falls patients.

Degree of Safety Against Falls Provided by 4 Different Prosthetic Knee Types in People With Transfemoral Amputation: A Retrospective Observational Study

OBJECTIVE

People with transfemoral amputation have balance and mobility problems and are at high risk of falling. An adequate prosthetic prescription is essential to maximize their functional levels and enhance their quality of life. This study aimed to evaluate the degree of safety against falls offered by different prosthetic knees.

METHODS

A retrospective study was conducted using data from a center for prosthetic fitting and rehabilitation. Eligible individuals were adults with unilateral transfemoral amputation or knee disarticulation. The prosthetic knee models were grouped into 4 categories: locked knees, articulating mechanical knees (AMKs), fluid-controlled knees (FK), and microprocessor-controlled knees (MPK). The outcome was the number of falls experienced during inpatient rehabilitation while wearing the prosthesis. Association analyses were performed with mixed-effect Poisson models. Propensity score weighting was used to adjust causal estimates for participant confounding factors.

RESULTS

Data on 1486 hospitalizations of 815 individuals were analyzed. Most hospitalizations (77.4%) were related to individuals with amputation due to trauma. After propensity score weighting, the knee category was significantly associated with falls. People with FK had the highest rate of falling (incidence rate = 2.81 falls per 1000 patient days, 95% CI = 1.96 to 4.02). FK significantly increased the risk of falling compared with MPK (incidence rate ratio [IRRFK-MPK] = 2.44, 95% CI = 1.20 to 4.96). No other comparison among knee categories was significant.

CONCLUSIONS

Fluid-controlled prosthetic knees expose inpatients with transfemoral amputation to higher incidence of falling than MPK during rehabilitation training.

IMPACT

These findings can guide clinicians in the selection of safe prostheses and reduction of falls in people with transfemoral amputation during inpatient rehabilitation.

Deprescribing Medications that Increase the Risk of Falls in Older People: Exploring Doctors' Perspectives Using the Theoretical Domains Framework (TDF)

BACKGROUND

Falls can lead to hospitalisation and death in older people. Polypharmacy is a major risk factor, and deprescribing fall-risk increasing drugs (FRIDs) is one of several possible important preventive measures. The objective of this study was to explore the factors that influence doctors when deprescribing FRIDs in a hospital setting.

METHOD

Semi-structured interviews were conducted with consultant geriatricians and hospital doctors experienced in dealing with patients aged 65 years or older, at a large academic teaching hospital (~ 1000 beds), Dublin, Ireland. The interviews were directed by an interview guide and audio recorded and transcribed verbatim, with subsequent thematic analysis in NVivo 12 software.

RESULTS

A total of 18 participants were interviewed. Barriers to deprescribing included: insufficient time, incomplete patient records, changing medications initiated by other specialists and difficulties following up patients after discharge. Facilitators included: enhanced documentation through electronic patient records, the support of other healthcare professionals such as clinical pharmacists, and patients' engagement, which is considered essential for the success of the deprescribing process's outcome.

CONCLUSION

Deprescribing FRIDs in older adults in the hospital setting is challenging. Implementation of the process in practice requires combined effort from stakeholders to tackle everyday work environment challenges. Future studies are required examining the clinical effect of the suggested interventions and exploring patients' involvement in deprescribing decisions.

Usability of Electronic Health records in Predicting Short-term falls: Machine learning Applications in Senior Care Facilities (Preprint)

Background

Short-term fall prediction models that use electronic health records (EHRs) may enable the implementation of dynamic care practices that specifically address changes in individualized fall risk within senior care facilities.

Objective

The aim of this study is to implement machine learning (ML) algorithms that use EHR data to predict a 3-month fall risk in residents from a variety of senior care facilities providing different levels of care.

Methods

This retrospective study obtained EHR data (2007-2021) from Juniper Communities’ proprietary database of 2785 individuals primarily residing in skilled nursing facilities, independent living facilities, and assisted living facilities across the United States. We assessed the performance of 3 ML-based fall prediction models and the Juniper Communities’ fall risk assessment. Additional analyses were conducted to examine how changes in the input features, training data sets, and prediction windows affected the performance of these models.

Results

The Extreme Gradient Boosting model exhibited the highest performance, with an area under the receiver operating characteristic curve of 0.846 (95% CI 0.794-0.894), specificity of 0.848, diagnostic odds ratio of 13.40, and sensitivity of 0.706, while achieving the best trade-off in balancing true positive and negative rates. The number of active medications was the most significant feature associated with fall risk, followed by a resident’s number of active diseases and several variables associated with vital signs, including diastolic blood pressure and changes in weight and respiratory rates. The combination of vital signs with traditional risk factors as input features achieved higher prediction accuracy than using either group of features alone.

Conclusions

This study shows that the Extreme Gradient Boosting technique can use a large number of features from EHR data to make short-term fall predictions with a better performance than that of conventional fall risk assessments and other ML models. The integration of routinely collected EHR data, particularly vital signs, into fall prediction models may generate more accurate fall risk surveillance than models without vital signs. Our data support the use of ML models for dynamic, cost-effective, and automated fall predictions in different types of senior care facilities.

Isosteviol improves cardiac function and promotes angiogenesis after myocardial infarction in rats

Isosteviol has been indicated as a cardiomyocyte protector. However, the underlying mechanism remains unclear. Thus, we sought to confirm the protective effect of isosteviol after myocardial infarction in a model of permanent coronary artery occlusion and investigate the potential proangiogenic activity in vitro and in vivo. A 4-week permanent coronary artery occlusion rat model was generated, and the protective effect of isosteviol was evaluated by echocardiographic imaging and hemodynamics assays. The coronary capillary density was tested by immunochemistry and micro-computed tomography (μCT) imaging. The effect of isosteviol on endothelial cells was determined in human umbilical vein endothelial cells (HUVECs) in vitro and Tg (kdrl: EGFP) zebrafish in vivo. We also examined the expression of related transcription factors by real-time polymerase chain reaction (RT-qPCR). Isosteviol increased ejection fraction (EF), fractional shortening (FS), cardiac systolic index (CI), maximum rate of increase of left ventricular pressure (Max dp/dt), and left ventricular systolic pressure (LVSP) by 32%, 40%, 25%, 26%, and 10%, respectively, in permanent coronary artery occlusion rats. Interestingly, it also promoted coronary capillary density by 2.5-fold. In addition, isosteviol promoted the proliferation and branching of HUVECs in vitro. It also rescued intersegmental vessel (ISV) development and improved endothelial cell proliferation by approximately fivefold (4-6) in zebrafish embryos in vivo. Isosteviol also upregulated the expression of hypoxia inducible factor-1α (HIF-1α) and vascular endothelial growth factor A (VEGFA) in zebrafish by fourfold and 3.5-fold, respectively. Our findings suggest that isosteviol is a proangiogenic agent and that this activity is related to its protective effects against myocardial ischemia. After using the permanent coronary artery occlusion model, we demonstrated that isosteviol promotes angiogenesis directly and increases capillary density in myocardial ischemia rats. Isosteviol promotes angiogenesis in zebrafish in vivo and increases vascular endothelial cell proliferation in HUVECs and zebrafish. The angiogenesis activity of isosteviol may be correlated with VEGFA and HIF-1α signaling.

Protocol for a systematic review and meta-analysis assessing the effectiveness of deprescribing in falls prevention in older people

INTRODUCTION

One of the known risk factors for fall incidents is the use of specific medications, fall-risk-increasing drugs (FRIDs). However, to date, there is uncertainty related to the effectiveness of deprescribing as a single intervention in falls prevention. Thus, a comprehensive update of the literature focusing on all settings in which older people receive healthcare and all deprescribing interventions is warranted to enhance the current knowledge.

METHODS AND ANALYSIS

This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search was performed in Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PsycINFO (2 November 2020). We will also search in trial registers. We will include randomised controlled trials, in which any deprescribing intervention is compared with usual care and reports falls as an outcome. Both title and abstract screening and full-text screening will be done by two reviewers. The Cochrane Collaboration revised tool of Risk of Bias will be applied to perform risk of bias assessment. We will categorise the results separately for every setting. If a group of sufficiently comparable studies will be identified, we will perform a meta-analysis applying random effects model. We will investigate heterogeneity using a combination of visual inspection of the forest plot along with consideration of the χ2 test and the I2 statistic results. We have prespecified several subgroup and sensitivity analyses.

ETHICS AND DISSEMINATION

Ethics approval is not applicable for this study since no original data will be collected. The results will be disseminated through peer-reviewed publication and conference presentations. Furthermore, this systematic review will inform the recommendations of working group of polypharmacy and FRIDs of the anticipated World's Falls Guidelines.

PROSPERO REGISTRATION NUMBER

CRD42020218231.

Effects of anticholinergic and sedative medication use on fractures: A self-controlled design study

BACKGROUND/OBJECTIVES

Unintentional falls are a leading cause of injury for older adults, and evidence is needed to understand modifiable risk factors. We evaluated 1-year fall-related fracture risk and whether dispensing of medications with anticholinergic/sedating properties is temporally associated with an increased odds of these fractures.

DESIGN

A retrospective cohort study with nested self-controlled analyses conducted between January 1, 2014, and December 31, 2016.

SETTING

Twenty percent nationwide, random sample of US Medicare beneficiaries.

PARTICIPANTS

New users of medications with anticholinergic/sedating properties who were 66+ years old and had Medicare Parts A, B, and D coverage but no claims for medications with anticholinergic/sedating properties in the year before initiation were eligible.

MEASUREMENTS

We followed new users of medications with anticholinergic/sedating properties until first non-vertebral, fall-related fracture (primary outcome), Medicare disenrollment, death, or end of study data. We estimated the 1-year risk with corresponding 95% confidence intervals (CIs) of first fracture after new use. We applied the self-controlled case-crossover and case-time-control designs to estimate odds ratios (ORs) and 95% CIs by comparing anticholinergic and/or sedating medication exposure (any vs. none) during a 14-day hazard period preceding the fracture to exposure to these medications during an earlier 14-day control period.

RESULTS

A total of 1,097,989 Medicare beneficiaries initiated medications with anticholinergic/sedating properties in the study period. The 1-year cumulative incidence of fall-related fracture, accounting for death as a competing risk, was 5.0% (95% CI: 5.0%-5.0%). Using the case-crossover design (n = 41,889), the adjusted OR for the association between anticholinergic/sedating medications and fractures was 1.03 (95% CI: 0.99, 1.08). Accounting for the noted temporal trend using the case-time-control design (n = 209,395), the adjusted OR was 1.60 (95% CI: 1.52, 1.69).

CONCLUSION

Use of anticholinergic/sedating medication was temporally associated with an increased odds of fall-related fractures. Patients and their healthcare providers should consider pharmacologic and non-pharmacologic treatments for the target condition that are safer.

Exploring the Environment behind In-Patient Falls and Their Relation to Hospital Overcrowdedness-A Register-Based Observational Study

(1) Background: Inpatient falls are a serious threat to patients' safety and their extrinsic factors are, at present, insufficiently described. Additionally, hospital overcrowdedness is known for its malicious effects but its relation to the inpatient falls is currently underexplored. The aim of this study was to explore the distribution of falls and their extrinsic characteristics amongst a range of different clinics, and to explore the correlation and predictive ability of hospital overcrowding in relation to inpatient falls. (2) Methods: An observational, cross-sectional, registry-based study was conducted using retrospective data from an incidence registry of a hospital organization in Sweden during 2018. The registry provided data regarding the extrinsic factors of inpatient falls, including the clinics' overcrowdedness. Simple descriptive statistics, correlation analysis and simple linear regression analysis were used. (3) Results: Twelve clinics were included. A total of 870 inpatient falls were registered during 2018. Overcrowdedness and total amount of falls were positively and very strongly correlated (r = 0.875, p < 0.001). Overcrowdedness was a significant predictor of the total amount of inpatient falls (p < 0.001, α = 0.05). (4) Conclusions: The characteristics regarding inpatient falls vary among the clinics. Inpatient overcrowding might have a significant role in the prevalence of inpatient falls, but further high-evidence-level studies are required.

Development and internal validation of a risk prediction model for falls among older people using primary care electronic health records

Background

Currently used prediction tools have limited ability to identify community-dwelling older people at high risk for falls. Prediction models utilizing electronic health records (EHRs) provide opportunities but up to now showed limited clinical value as risk stratification tool, because of among others the underestimation of falls prevalence. The aim of this study was to develop a fall prediction model for community-dwelling older people using a combination of structured data and free text of primary care EHRs and to internally validate its predictive performance.

Methods

We used EHR data of individuals aged 65 or older. Age, sex, history of falls, medications, and medical conditions were included as potential predictors. Falls were ascertained from the free text. We employed the Bootstrap-enhanced penalized logistic regression with the least absolute shrinkage and selection operator to develop the prediction model. We used 10-fold cross-validation to internally validate the prediction strategy. Model performance was assessed in terms of discrimination and calibration.

Results

Data of 36 470 eligible participants were extracted from the data set. The number of participants who fell at least once was 4 778 (13.1%). The final prediction model included age, sex, history of falls, 2 medications, and 5 medical conditions. The model had a median area under the receiver operating curve of 0.705 (interquartile range 0.700–0.714).

Conclusions

Our prediction model to identify older people at high risk for falls achieved fair discrimination and had reasonable calibration. It can be applied in clinical practice as it relies on routinely collected variables and does not require mobility assessment tests.

Potentially inappropriate prescribing in a falls clinic using the STOPP and START criteria

Background Potentially inappropriate prescribing is increasingly common in older patients with falls. However, published indicators to assess inappropriate prescribing remains unestablished in many countries. Objective This study determined the burden and profile of potentially inappropriate prescribing among patients attending a falls clinic using the STOPP/START criteria and evaluated the factors for falls potentially associated to inappropriate prescribing. Setting University of Malaya Medical Centre Falls Clinic. Method Data of individuals aged ≥ 65 years referred to the falls and syncope clinic were extracted from the falls registry. Potentially inappropriate prescribing was determined with the STOPP/START version 2 criteria. The relationship between potentially inappropriate prescribing with polypharmacy (≥ 5 medications), comorbidities and clinical variables were determined using Pearson's chi-square and potential confounders adjusted for with multivariate regression. Main outcome measure Potentially inappropriate medicines and/or omitted medicines using STOPP/START criteria. Results Data from 421 individuals, aged 77.8 ± 6.7 years and 53.4% women, were included. Potentially inappropriate prescribing was present in 311 (73.9%). Potentially inappropriate medicines use accounted for 84.6% of the 325 prescriptions. 361/659 instances (54.8%) were falls-risk-increasing drugs, with vasodilators (49.3%) being the main potentially inappropriate medicine identified. Of the 177/421 with polypharmacy, 169/177 (95.5%) were exposed to ≥ one potentially inappropriate medicine. 129 instances of potentially omitted medicines were observed in 109 prescriptions (25.9%). Conclusion STOPP/START criteria are useful to identify potentially inappropriate prescribing at the falls and syncope clinic. This finding has important implications for medication review strategies at falls clinic. Future research should determine whether identifying potentially inappropriate prescribing may reduce adverse falls outcomes among patients in this setting.

The age-related decline in spatiotemporal gait characteristics is moderated by concerns of falling, history of falls & diseases, and sociodemographic-anthropometric characteristics in 60-94 years old adults

BACKGROUND

Associations between age, concerns or history of falling, and various gait parameters are evident. Limited research, however, exists on how such variables moderate the age-related decline in gait characteristics. The purpose of the present study was to investigate the moderating effects of concerns of falling (formerly referred to as fear of falling), history of falls & diseases, and sociodemographic characteristics on changes in gait characteristics with increasing age in the elderly.

METHODS

In this individual participant level data re-analysis, data from 198 participants (n = 125 females) from 60 to 94 years of age were analysed (mean 73.9, standard deviation 7.7 years). Dependent variables were major spatiotemporal gait characteristics, assessed using a capacitive force measurement platform (zebris FDM-T). Age (independent variable) and the moderating variables concerns of falling (FES-I), gender/sex, history of falls and fall-related medical records, number of drugs daily taken, and body mass index were used in the statistical analysis. Hierarchical linear mixed moderation models (multilevel analysis) with stepwise (forward) modelling were performed.

RESULTS

Decreases of gait speed (estimate = -.03, equals a decrease of 0.03 m/s per year of ageing), absolute (- 1.4) and gait speed-normalized (-.52) stride length, step width (-.08), as well as increases in speed normalized cadence (.65) and gait speed variability (.15) are all age-related (each p < .05). Overall and specific situation-related concerns of falling (estimates: -.0012 to -.07) were significant moderators. History of potentially gait- and/or falls-affecting diseases accelerated the age-related decline in gait speed (-.002) and its variability (.03). History of falls was, although non-significant, a relevant moderator (in view of increasing the model fit) for cadence (.058) and gait speed (-.0027). Sociodemographics and anthropometrics showed further moderating effects (sex moderated the ageing effect on stride length, .08; height moderated the effect on the normalised stride length, .26; BMI moderated the effects on step width, .003). .

CONCLUSION

Age-related decline in spatiotemporal gait characteristics is moderated by concerns of falling, (non-significantly) by history of falls, significantly by history of diseases, and sociodemographic characteristics in 60-94 years old adults. Knowing the interactive contributions to gait impairments could be helpful for tailoring interventions for the prevention of falls.

TRIAL REGISTRATION

Re-analysis of [21-24].

Process evaluation for the Care Homes Independent Pharmacist Prescriber Study (CHIPPS)

Background

Medicines management in care homes requires significant improvement. CHIPPS was a cluster randomised controlled trial to determine the effectiveness of integrating pharmacist independent prescribers into care homes to assume central responsibility for medicines management. This paper reports the parallel mixed-methods process evaluation.

Method

Intervention arm consisted of 25 triads: Care homes (staff and up to 24 residents), General Practitioner (GP) and Pharmacist Independent Prescriber (PIP). Data sources were pharmaceutical care plans (PCPs), pharmacist activity logs, online questionnaires and semi-structured interviews. Quantitative data were analysed descriptively. Qualitative data were analysed thematically. Results were mapped to the process evaluation objectives following the Medical Research Council framework.

Results

PCPs and activity logs were available from 22 PIPs. Questionnaires were returned by 16 PIPs, eight GPs, and two care home managers. Interviews were completed with 14 PIPs, eight GPs, nine care home managers, six care home staff, and one resident. All stakeholders reported some benefits from PIPs having responsibility for medicine management and identified no safety concerns. PIPs reported an increase in their knowledge and identified the value of having time to engage with care home staff and residents during reviews. The research paperwork was identified as least useful by many PIPs. PIPs conducted medication reviews on residents, recording 566 clinical interventions, many involving deprescribing; 93.8% of changes were sustained at 6 months. For 284 (50.2%) residents a medicine was stopped, and for a quarter of residents, changes involved a medicine linked to increased falls risk. Qualitative data indicated participants noted increased medication safety and improved resident quality of life. Contextual barriers to implementation were apparent in the few triads where PIP was not known previously to the GP and care home before the trial. In three triads, PIPs did not deliver the intervention.

Conclusions

The intervention was generally implemented as intended, and well-received by most stakeholders. Whilst there was widespread deprescribing, contextual factors effected opportunity for PIP engagement in care homes. Implementation was most effective when communication pathways between PIP and GP had been previously well-established.

Trial registration

The definitive RCT was registered with the ISRCTN registry (registration number ISRCTN 17847169).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07062-3.

Higher Readmission Rates After Hip Fracture Among Patients With Vestibular Disorders

OBJECTIVE

Falls in older adults are associated with high morbidity and mortality. Patients with vestibular disorders may have an increased risk. The purpose of this study was to examine the outcomes among patients with underlying vestibular disorders who have hip fractures and identify predictors of increased morbidity and mortality.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care academic medical center.

PATIENTS

Two hundred one adults diagnosed with a vestibular disorder and hip fracture due to a ground-level fall were compared to 327 age- and sex-matched controls with fractures due to ground-level falls without vestibular diagnoses. Patients were treated between 2013 and 2019.

MAIN OUTCOME MEASURES

Length of hospital stay, 30-day readmission rate, and 30-day mortality rate.

RESULTS

Thirty-day readmission rate after hip fracture was significantly increased in patients with vestibular disorders compared to matched controls (p < 0.001), odds ratio 3.12 (95% confidence interval 1.84-5.39). Reasons for readmission in the vestibular patient group included higher rates of repeat falls, infections, and recurrent vestibular symptoms. Use of medication classes associated with falls or hip fractures was not significantly different between groups, except for lower rates of antihypertensive use in the vestibular group (54.0% vs. 67.7%, p = 0.002). No significant difference was found for length of hospital stay (7.34 ± 4.95 vs. 8.14 ± 20.50 days, p = 0.51) or 30-day mortality rate (5.0% vs. 4.6%, p = 0.99). No significant differences were found between groups for age, sex, race, rate of surgical treatment for hip fracture, or disposition at discharge.

CONCLUSIONS

Patients with vestibular disorders are at a significantly higher risk of hospital readmission within 30 days after discharge for treatment for hip fracture.

Effects of Prescription Opioid Use on Traumatic Brain Injury Risk in Older Adults

OBJECTIVE

The objective of this study was to estimate the risk of traumatic brain injury (TBI) associated with opioid use among older adult Medicare beneficiaries.

SETTING

Five percent sample of Medicare administrative claims obtained for years 2011-2015.

PARTICIPANTS

A total of 50 873 community-dwelling beneficiaries 65 years and older who sustained TBI.

DESIGN

Case-crossover study comparing opioid use in the 7 days prior to TBI with the control periods of 3, 6, and 9 months prior to TBI.

MAIN MEASURES

TBI cases were identified using ICD-9 (International Classification of Diseases, Ninth Revision) and ICD-10 (International Classification of Diseases, Tenth Revision) codes. Prescription opioid exposure and concomitant nonopioid fall risk-increasing drug (FRID) use were determined by examining the prescription drug event file.

RESULTS

The 8257 opioid users (16.2%) were significantly younger (mean age 79.0 vs 80.8 years, P < .001). Relative to nonusers, opioid users were more likely to be women (77.0% vs 70.0%, P < .001) with a Charlson Comorbidity Index of 2 or more (43.7% vs 30.9%, P < .001) and higher concomitant FRID use (94.0% vs 82.7%, P < .001). Prescription opioid use independently increased the risk of TBI compared with nonusers (OR = 1.34; 95% CI, 1.28-1.40). In direct comparisons, we did not observe evidence of a significant difference in adjusted TBI risk between high- (≥90 morphine milligram equivalents) and standard-dose opioid prescriptions (OR = 1.01; 95% CI, 0.90-1.14) or between acute and chronic (≥90 days) opioid prescriptions (OR = 0.93; 95% CI, 0.84-1.02).

CONCLUSIONS

Among older adult Medicare beneficiaries, prescription opioid use independently increased risk for TBI compared with nonusers after adjusting for concomitant FRID use. We found no significant difference in adjusted TBI risk between high-dose and standard-dose opioid use, nor did we find a significant difference in adjusted TBI risk between acute and chronic opioid use. This analysis can inform prescribing of opioids to community-dwelling older adults for pain management.

Older Adults with Hypertension: Prevalence of Falls and Their Associated Factors

Falls are prominent health issues among older adults. Among hypertensive older adults, falls may have a detrimental effect on their health and wellbeing. The purpose of this study is to determine the prevalence of falls among hypertensive older adults and to identify the associated factors that contribute to their falls. This was a cross-sectional study conducted among two hundred and sixty-nine hypertensive older adults who were selected via systematic random sampling in two primary health clinics in Kuala Terengganu, Malaysia. Data on their socio-demographic details, their history of falls, medication history and clinical characteristics were collected. Balance and gait were assessed using the Performance Oriented Mobility Assessment (POMA). It was found that 32.2% of participants reported falls within a year. Polypharmacy (adjusted OR 2.513, 95% CI 1.339, 4.718) and diuretics (adjusted OR 2.803, 95% CI 1.418, 5.544) were associated with an increased risk of falls. Meanwhile, a higher POMA score (adjusted OR 0.940, 95% CI 0.886, 0.996) and the number of antihypertensives (adjusted OR 0.473, 95% CI 0.319, 0.700) were associated with a low incidence of falling among hypertensive older adults. Falls are common among hypertensive older adults. Older adults who are taking diuretics and have a polypharmacy treatment plan have a higher incidence of falls. However, older adults taking a higher number of anti-hypertensive medications specifically were not associated with an increased prevalence of falls.

Effect of medication on risk of traumatic brain injury in patients with bipolar disorder: A nationwide population-based cohort study

BACKGROUND

Increased traumatic brain injury (TBI) risk was found in patients with bipolar disorder (BPD). Whether the medications for BPD and dosage moderate the risk of TBI is not clear.

AIM

This study aimed to determine whether an association exists between BPD and TBI and whether the prescription of psychotropics moderates TBI risk.

METHODS

A total of 5606 individuals who had received diagnoses of BPD between January 1, 1997 and December 31, 2013 and 56,060 matched controls without BPD were identified from Taiwan's National Health Insurance Research Database. Cases and controls were followed until the date of TBI diagnosis.

RESULTS

BPD was associated with a high risk of TBI (adjusted hazard ratio (aHR): 1.85; 95% CI: 1.62-2.11). Patients with BPD, with or without a history of psychiatric hospitalization, had increased risks of TBI (aHR: 1.94, 95% CI: 1.57-2.4 and aHR: 1.82, 95% CI: 1.55-2.1, respectively). The prescription of typical antipsychotics (0 < defined daily dose (DDD) < 28: hazard ratio (HR) = 1.52, 95% CI: 1.19-1.94; ⩾28 DDD: HR = 1.54, 95% CI: 1.15-2.06) and tricyclic antidepressants (TCAs) (0 < DDD < 28: HR = 1.73, 95% CI: 1.26-2.39; ⩾28 DDD: HR = 1.52, 95% CI: 1.02-2.25) was associated with higher TBI risk. Patients receiving higher doses of benzodiazepines (BZDs) (cumulative dose ⩾28 DDD) had a higher TBI risk (HR = 1.53, 95% CI: 1.13-2.06).

CONCLUSION

Patients with BPD have a higher risk of TBI. The use of typical antipsychotics, TCAs, or high-dose BZDs increases the risk of TBI in BPD.

Trends in fall-related mortality and fall risk increasing drugs among older individuals in the United States,1999-2017

BACKGROUND

Previous studies have demonstrated increasing mortality due to falls among older adults. The objective of this study was to determine whether there was an increase in fall risk increasing drug prescribing and if this is concurrent with an increase in fall-related mortality in persons 65 years and older in the United States.

METHODS

The study is a serial cross-sectional analysis utilizing data from both the National Vital Statistics System (NVSS) and the medical expenditure panel survey (MEPS) for years 1999-2017. Adults aged 65 years and older were evaluated for death due to falls from the NVSS and for prescription fills of fall risk increasing drugs per the Stopping Elderly Accidents, Deaths, and Injuries-Rx (STEADI-Rx) fall checklist from the MEPS.

RESULTS

The analysis included 374 972 fall-related mortalities and 7 858 177 122 fills of fall risk increasing drugs. 563 037 964 persons age 65 and older received at least one fall risk increasing drug. Age-adjusted mortality due to falls increased from 29.40 per 100 000 in 1999 to 63.27 per 100 000 in 2017. The percent of persons who received at least one prescription for a fall risk increasing drug increased from 57% in 1999 to 94% in 2017 (p for trend <.0001).

CONCLUSIONS AND RELEVANCE

Both use of fall risk increasing drugs and mortality due to falls are on the rise. Fall risk increasing drugs may partially explain the increase in mortality due to falls; this cannot be firmly concluded from the current study. Future research examining the potential relationship between fall risk increasing drugs and fall-related mortality utilizing nationally representative person-level data are needed.

A Propensity Score Matched Approach to Assess the Associations of Commonly Prescribed Medications with Fall Risk in a Large Harmonized Cohort of Older Ambulatory Persons

Introduction

Several medication classes are considered to present risk factors for falls. However, the evidence is mainly based on observational studies that often lack adequate adjustment for confounders. Therefore, we aimed to assess the associations of medication classes with fall risk by carefully selecting confounders and by applying propensity score matching (PSM).

Methods

Data from several European cohorts, harmonized into the ADFICE_IT cohort, was used. Our primary outcome was time until the first fall within 1-year follow-up. The secondary outcome was a fall in the past year. Our exposure variables were commonly prescribed medications. We used 1:1 PSM to match the participants with reported intake of specific medication classes with participants without. We constructed Cox regression models stratified by the pairs matched on the propensity score for our primary outcome and conditional logistic regression models for our secondary outcome.

Results

In total, 32.6% of participants fell in the 1-year follow-up and 24.4% reported falling in the past year. ACE inhibitor users (prevalence of use 15.3%) had a lower fall risk during follow-up when matched to non-users, with a hazard ratio (HR) of 0.82 (95% CI 0.68–0.98). Also, statin users (prevalence of use 20.1%) had a lower risk, with an HR of 0.76 (95% CI 0.65–0.90). Other medication classes showed no association with risk of first fall. Also, in our secondary outcome analyses, statin users had a significantly lower risk. Furthermore, β-blocker users had a lower fall risk and proton pump inhibitor use was associated with a higher risk in our secondary outcome analysis.

Conclusion

Many commonly prescribed medication classes showed no associations with fall risk in a relatively healthy population of community-dwelling older persons. However, the treatment effects and risks can be heterogeneous between individuals. Therefore, focusing on identification of individuals at risk is warranted to optimize personalized falls prevention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-021-00876-0.

STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs

Background

Healthcare professionals are often reluctant to deprescribe fall-risk-increasing drugs (FRIDs). Lack of knowledge and skills form a significant barrier and furthermore, there is no consensus on which medications are considered as FRIDs despite several systematic reviews. To support clinicians in the management of FRIDs and to facilitate the deprescribing process, STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) and a deprescribing tool were developed by a European expert group.

Methods

STOPPFall was created by two facilitators based on evidence from recent meta-analyses and national fall prevention guidelines in Europe. Twenty-four panellists chose their level of agreement on a Likert scale with the items in the STOPPFall in three Delphi panel rounds. A threshold of 70% was selected for consensus a priori. The panellists were asked whether some agents are more fall-risk-increasing than others within the same pharmacological class. In an additional questionnaire, panellists were asked in which cases deprescribing of FRIDs should be considered and how it should be performed.

Results

The panellists agreed on 14 medication classes to be included in the STOPPFall. They were mostly psychotropic medications. The panellists indicated 18 differences between pharmacological subclasses with regard to fall-risk-increasing properties. Practical deprescribing guidance was developed for STOPPFall medication classes.

Conclusion

STOPPFall was created using an expert Delphi consensus process and combined with a practical deprescribing tool designed to optimise medication review. The effectiveness of these tools in falls prevention should be further evaluated in intervention studies.

Research on Beers Criteria and STOPP/START Criteria based on the FDA FAERS database

PURPOSE

Inappropriate medication criteria for the elderly have played an important role in ensuring the safety of medications for the elderly. Too few drugs included in the criteria cannot guarantee the safety of medication for the elderly. Too many drugs included in the criteria will result in less selective medication for the elderly. This paper uses real-world data to evaluate the relationship between antihypertensive drugs and falls, so as to provide references for experts and scholars to revise the criteria of potentially inappropriate medications for the elderly and clinical safe medication.

METHOD

We use the US Food and Drug Administration Adverse Event Reporting System (FDA FAERS) to evaluate the association between specific antihypertensive drugs in six categories (alpha-1 receptor blockers (α-1 blockers), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), beta-receptor blockers (β-blockers), and diuretics) and falls by data mining algorithms, including the reporting odds ratio (ROR), the proportional reporting ratio (PRR), Medicines and Healthcare Products Regulatory Agency (MHRA), and the empirical Bayes geometric mean (EBGM) and compared with the relevant drugs included in the Beers Criteria and STOPP/START Criteria.

RESULT

There are a total of 5,157,172 co-occurrences found in 973,447 reports aged 65 years or older from 2016 to 2019 in the FDA FAERS database, and the number of co-occurrences of falls is 5917 for the six categories of 51 antihypertensive drugs. Four kinds of mining methods overlap detection of 12 kinds of positive signal drugs, none of which are not included in the Beers Criteria and 7 drugs are included in the STOPP/START Criteria; 1-3 kinds of mining methods overlap detection of positive signal drugs, a total of 12 kinds, and one drug is included in the Beers Criteria and 5 drugs are included in the STOPP/START Criteria; 22 drugs have fall adverse events, but no positive signal is detected, and 13 drugs are included in STOPP/START Criteria; and 5 drugs have no fall adverse events and 3 drugs are included in the STOPP/START Criteria.

CONCLUSION

The FAERS database was used to confirm the potential connection between some antihypertensive drugs and fall adverse events through data mining algorithms. The Beers Criteria did not clearly indicate the antihypertensive drugs that caused falls, and the antihypertensive drugs included in the STOPP/START Criteria were too extensive and did not include β-blockers and diuretics. It is recommended that experts and scholars use real-world data (such as FAERS, EudraVigilance, WHO VigiBase, and so on) to further explore the relationship between specific antihypertensive drugs and falls in the elderly, so as to revise and improve the criteria for inappropriate medications for the elderly.

Community pharmacists' perceptions on providing fall prevention services: a mixed-methods study

Background Pharmacists may contribute to fall prevention particularly by identifying and deprescribing fall risk-increasing drugs (FRIDs) in patients with high fall risk. Objective To assess community pharmacists’ perceptions on providing fall prevention services, and to identify their barriers and facilitators in offering these fall prevention services including deprescribing of FRIDs. Setting A mixed-methods study was conducted with Dutch pharmacists. Method Quantitative (ranking statements on a Likert scale, survey) and qualitative data (semi-structured interviews) were collected. Out of 466 pharmacists who were invited to participate, 313 Dutch pharmacists ranked statements, about providing fall prevention, that were presented during a lecture, and 205 completed a survey. To explore pharmacists’ perceptions in-depth, 16 were interviewed. Quantitative data were analysed using descriptive statistics. All interviews were audiotaped and transcribed verbatim. The capability opportunity motivation-behaviour model was applied to interpret and analyse the findings of qualitative data. Main outcome measure Community pharmacists’ views on providing fall prevention. Results Pharmacists stated that they were motivated to provide fall prevention. They believed they were capable of providing fall prevention by FRID deprescribing. They perceived limited opportunities to contribute. Major barriers included insufficient multidisciplinary collaboration, patient unwillingness to deprescribe FRIDs, and lack of time. Facilitators included goal-setting behaviour, financial compensation, and skilled communication. Conclusion Despite the complex decision-making process in medication-related fall prevention, community pharmacists are motivated and feel capable of providing fall prevention. Opportunities for pharmacists to provide fall prevention services should be enhanced, for example by implementing multidisciplinary agreements.

Anticholinergic burden measures and older people's falls risk: a systematic prognostic review

Introduction

Several adverse outcomes have been associated with anticholinergic burden (ACB), and these risks increase with age. Several approaches to measuring this burden are available but, to date, no comparison of their prognostic abilities has been conducted. This PROSPERO-registered systematic review (CRD42019115918) compared the evidence behind ACB measures in relation to their ability to predict risk of falling in older people.

Methods

Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO) and PsycINFO (OVID) were searched using comprehensive search terms and a validated search filter for prognostic studies. Inclusion criteria included: participants aged 65 years and older, use of one or more ACB measure(s) as a prognostic factor, cohort or case-control in design, and reporting falls as an outcome. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.

Results

Eight studies reporting temporal associations between ACB and falls were included. All studies were rated high risk of bias in ⩾1 QUIPS tool categories, with five rated high risk ⩾3 categories. All studies (274,647 participants) showed some degree of association between anticholinergic score and increased risk of falls. Findings were most significant with moderate to high levels of ACB. Most studies (6/8) utilised the anticholinergic cognitive burden scale. No studies directly compared two or more ACB measures and there was variation in how falls were measured for analysis.

Conclusion

The evidence supports an association between moderate to high ACB and risk of falling in older people, but no conclusion can be made regarding which ACB scale offers best prognostic value in older people.

Plain language summary

A review of published studies to explore which anticholinergic burden scale is best at predicting the risk of falls in older people Introduction: One third of older people will experience a fall. Falls have many consequences including fractures, a loss of independence and being unable to enjoy life. Many things can increase the chances of having a fall. This includes some medications. One type of medication, known as anticholinergic medication, may increase the risk of falls. These medications are used to treat common health issues including depression and bladder problems. Anticholinergic burden is the term used to describe the total effects from taking these medications. Some people may use more than one of these medications. This would increase their anticholinergic burden. It is possible that reducing the use of these medications could reduce the risk of falls. We need to carry out studies to see if this is possible. To do this, we need to be able to measure anticholinergic burden. There are several scales available, but we do not know which is best.Methods: We wanted to answer: 'Which anticholinergic scale is best at predicting the risk of falling in older people?'. We reviewed studies that could answer this. We did this in a systematic way to capture all published studies. We restricted the search in several ways. We only included studies relevant to our question.Results: We found eight studies. We learned that people who are moderate to high users of these medications (often people who will use more than one of these medications) had a higher risk of falling. It was less clear if people who have a lower burden (often people who only use one of these medications) had an increased risk of falling. The low number of studies prevented us from determining if one scale was better than another.Conclusion: These findings suggest that we should reduce use of these medications. This could reduce the number falls and improve the well-being of older people.

Eight Orthostatic Haemodynamic Patterns in The Irish Longitudinal Study on Ageing (TILDA): Stability and Clinical Associations after 4 Years

Previous research cross-sectionally characterised eight morphological systolic blood pressure (SBP) active stand (AS) patterns using a clinical clustering approach at Wave 1 (W1) of the Irish Longitudinal Study on Ageing. We explored the longitudinal stability and clinical associations of these groupings at Wave 3 (W3), four years later. Eight AS groups had their clinical characteristics and AS patterns at W3 compared to W1. We explored longitudinal associations (new cognitive decline, falls, syncope, disability, and mortality) using multivariate logistic regression models. In total, 2938 participants (60% of Wave 1 sample) had adequate AS data from both W1 and 3 for analysis. We found no longitudinal stability of the eight AS groups or their morphological patterns between the waves. A pattern of impaired stabilisation and late deficit seemed more preserved and was seen in association with new cognitive decline (OR 1.63, 95% CI: 1.12–2.36, p = 0.011). An increase in antihypertensive usage seemed associated with reduced immediate SBP drops, improved AS patterns, and reduced orthostatic intolerance (OI). In pure longitudinal groups, AS patterns were not preserved after 4 years. AS patterns are longitudinally dynamic, and improvements after 4 years are possible even in the presence of higher antihypertensive burden.

Fall incidents in nursing home residents: development of a predictive clinical rule (FINDER)

OBJECTIVES

To develop (part I) and validate (part II) an electronic fall risk clinical rule (CR) to identify nursing home residents (NH-residents) at risk for a fall incident.

DESIGN

Observational, retrospective case-control study.

SETTING

Nursing homes.

PARTICIPANTS

A total of 1668 (824 in part I, 844 in part II) NH-residents from the Netherlands were included. Data of participants from part I were excluded in part II.

PRIMARY AND SECONDARY OUTCOME MEASURES

Development and validation of a fall risk CR in NH-residents. Logistic regression analysis was conducted to identify the fall risk-variables in part I. With these, three CRs were developed (ie, at the day of the fall incident and 3 days and 5 days prior to the fall incident). The overall prediction quality of the CRs were assessed using the area under the receiver operating characteristics (AUROC), and a cut-off value was determined for the predicted risk ensuring a sensitivity ≥0.85. Finally, one CR was chosen and validated in part II using a new retrospective data set.

RESULTS

Eleven fall risk-variables were identified in part I. The AUROCs of the three CRs form part I were similar: the AUROC for models I, II and III were 0.714 (95% CI: 0.679 to 0.748), 0.715 (95% CI: 0.680 to 0.750) and 0.709 (95% CI: 0.674 to 0.744), respectively. Model III (ie, 5 days prior to the fall incident) was chosen for validation in part II. The validated AUROC of the CR, obtained in part II, was 0.603 (95% CI: 0.565 to 0.641) with a sensitivity of 83.41% (95% CI: 79.44% to 86.76%) and a specificity of 27.25% (95% CI 23.11% to 31.81%).

CONCLUSION

Medication data and resident characteristics alone are not sufficient enough to develop a successful CR with a high sensitivity and specificity to predict fall risk in NH-residents.

TRIAL REGISTRATION NUMBER

Not available.

Gender differences in the effect of depression and cognitive impairment on risk of falls among community-dwelling older adults

BACKGROUND

The impact of the interrelationship between depression and cognitive impairment on risk of falls remains unclear. In addition, gender differences should be considered to further understand the relationships between depression, cognitive impairment, and risk of falls.

METHODS

Older adults who completed the Living Profiles of Older People Survey in Korea were included. In total, 14,055 participants completed the baseline survey, and 7,150 participants completed a follow-up survey after 3 years. We classified participants into 4 groups based on depression and cognitive impairment.

RESULTS

Using generalized estimating equation models, older adults with depression but without cognitive impairment had a higher risk of falls (OR=1.49, 95% CI=1.35-1.63), compared to a reference group with neither depression nor cognitive impairment. However, older adults who had cognitive impairment but not depression had a similar risk of falls (OR=1.03, 95% CI=0.91-1.16) to the reference group. Finally, older adults who had both depression and cognitive impairment had the highest risk of falls (OR=1.95, 95% CI=1.73-2.20) compared to the reference group. In addition, depression seemed to have a bigger effect on the risk of falls in men compared to women (p for interaction < 0.001).

LIMITATIONS

These results should be interpreted with caution, considering the use of screening tool for defining depression or cognitive impairment, and lack of information on psychotropic medication use.

CONCLUSIONS

Depression alone or depression combined with cognitive impairment was associated with higher risk of falls in older adults. In addition, gender differences in the risk of falls was noted.

Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis

OBJECTIVES

Prevention of falls and fall-related injuries is a priority due to the substantial health and financial burden of falls on patients and healthcare systems. Deprescribing medications known as 'fall-risk increasing drugs' (FRIDs) is a common strategy to prevent falls. We conducted a systematic review to determine its efficacy for the prevention of falls and fall-related complications.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL and grey literature from inception to 1 August 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials of FRID withdrawal compared with usual care evaluating the rate of falls, incidence of falls, fall-related injuries, fall-related fractures, fall-related hospitalisations or adverse effects related to the intervention in adults aged ≥65 years.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently performed citation screening, data abstraction, risk of bias assessment and certainty of evidence grading. Random-effects models were used for meta-analyses.

RESULTS

Five trials involving 1305 participants met eligibility criteria. Deprescribing FRIDs did not change the rate of falls (rate ratio (RaR) 0.98, 95% CI 0.63 to 1.51), the incidence of falls (risk difference 0.01, 95% CI -0.06 to 0.09; relative risk 1.04, 95% CI 0.86 to 1.26) or rate of fall-related injuries (RaR 0.89, 95% CI 0.57 to 1.39) over a follow-up period of 6-12 months. No trials evaluated the impact of deprescribing FRIDs on fall-related fractures or hospitalisations.

CONCLUSION

There is a paucity of robust high-quality evidence to support or refute that a FRID deprescribing strategy alone is effective at preventing falls or fall-related injury in older adults. Although there may be other reasons to deprescribe FRIDs, our systematic review found that it may result in little to no difference in the rate or risk of falls as a sole falls reduction strategy.

PROSPERO REGISTRATION NUMBER

CRD42016040203.

Interventions to Reduce Fall-Risk-Increasing Drug Use to Prevent Falls: A Narrative Review of Randomized Trials

BACKGROUND

Falls and fall-related injuries are of growing concern among older adults. Use of fall-risk-increasing drugs (FRIDs) is a potentially modifiable risk factor. This narrative review describes randomized controlled trials that focused on interventions to reduce FRID use and examined fall-related outcomes (e.g., falls, fractures, risk of injury) as the primary outcome.

METHODS

A comprehensive literature search was conducted to identify eligible studies. Two reviewers screened titles and abstracts and then performed a full-text review of relevant articles. Each study is summarized, and a discussion of strengths and limitations is provided.

RESULTS

7 of 22 trials were included in this narrative review. Two studies used a computerized decision support intervention, three used a health professional-led (pharmacist or geriatrician) intervention, and two were direct medication withdrawal interventions. Three studies showed a reduction in fall-related outcomes (two identified fall injuries using claims data; one used an injury risk prediction score). Of these, only one reported FRID reduction. Of four studies that did not find a reduction in falls, one study reported a significant reduction in FRIDs, two found no reduction, and one did not report on this outcome. Most interventions consisted of a one-time FRID assessment, and most targeted either providers or patients (not both).

CONCLUSION

Most interventions did not reduce FRID use or change fall-related outcomes. Future studies should test "multi-pronged" intervention strategies that simultaneously target both patients and their providers and include more than a single intervention interaction to reduce this modifiable fall risk factor.

Fall-Associated Drugs in Community-Dwelling Older Adults: Results from the ActiFE Ulm Study

OBJECTIVES

Many studies describing an association of drugs with falls focus mostly on drugs acting in the central nervous system. We aim to analyze the association of all drugs taken with falls in older adults.

DESIGN

Prospective population-based study (ActiFE study).

SETTING AND PARTICIPANTS

A total of 1377 community-dwelling older adults with complete recording of falls and baseline information on drug intake.

METHODS

Negative binomial regression was used to analyze the association of 34 drug classes with a 12-month incidence rate ratio (IRR) of falls adjusting for age, sex, comorbidities, gait speed, balance, chair rise, kidney function, liver disease, and smoking.

RESULTS

Participants took a median 3 drugs (interquartile range 1, 5), with 34.5% (n = 469) having ≥5 drugs. The median IRR for a fall per person-year was overall 0.72 [95% confidence interval (CI) 0.60-0.83] and 2.22 (95% CI 1.90-2.53) among those who experienced ≥1 fall. The following drug classes showed significant associations: antiparkinsonian medication [IRR 2.68 (95% CI 1.59-4.51)], thyroid therapy [IRR 1.40 (95% CI 1.08-1.81)], and systemic corticosteroids [IRR 0.33 (95% CI 0.13-0.81)]. Among fall-risk-increasing drugs only antiepileptics [IRR 2.16 (95% CI 1.10-4.24)] and urologicals [IRR 2.47 (95% CI 1.33-4.59)] were associated with falls in those participants without a prior fall history at baseline.

CONCLUSION AND IMPLICATIONS

Additional drug classes, such as antiparkinsonian medication, thyroid therapy, and systemic corticosteroids, might be associated with falls in older adults, possibly representing pharmacological effects on the musculoskeletal and central nervous systems. Further evaluations in larger study populations are recommended.

Fall predictors beyond fall risk assessment tool items for acute hospitalized older adults: a matched case-control study

We investigated whether clinical factors including comorbidities, medications, and laboratory results predict inpatient fall risk in older adults. The participants in this case–control study included hospitalized older adults with acute conditions who had falls during their hospital stay (case group) and 410 hospitalized older adults who did not experience falls (control group). Data on medical history, fall risk assessment (Morse Fall Scale; MFS), medications, and laboratory results were obtained. Conditional logistic regression analysis was performed to estimate the association between clinical factors and falls. Receiver operating characteristic curves and area under the curve (AUC) were used to determine whether clinical factors could discriminate between fallers and controls. We evaluated three models: (M1) MFS, (M2) M1 plus age, sex, ward, and polypharmacy, and (M3) M2 plus clinical factors. Patients with diabetes mellitus or MFS scores ≥ 45 had the highest risk of falls. Calcium channel blockers, diuretics, anticonvulsants, and benzodiazepines were associated with high fall risk. The AUC of the three models was 0.615, 0.646, and 0.725, respectively (M1 vs. M2, P = 0.042 and M2 vs. M3, P < .001). Examining clinical factors led to significant improvements in fall prediction beyond that of the MFS in hospitalized older adults.

Nutritional Status and Adverse Outcomes in Older Depressed Inpatients: A Prospective Study

OBJECTIVES

Significant weight loss and/or loss of appetite is a criterion of a depressive episode. While malnutrition is associated with many adverse health outcomes, the impact of malnutrition in late-life depression has hardly been examined. The present study aims to (1) evaluate the prevalence of malnutrition in depressed older inpatients, and (2) whether and which indices of malnutrition predict adverse health outcomes in late-life depression.

DESIGN

A prospective study at 6 months follow-up.

SETTING

A University-based psychiatric hospital.

PARTICIPANTS

105 older adults (psychiatric inpatients suffering from unipolar MDD).

MEASUREMENTS

Participants were evaluated according the Mini Nutritional Assessment (MNA) and anthropometric measures to assess their nutritional status. Multiple regression analyses were used to evaluate the association between the MNA score as well as anthropometric measures with either falls or rehospitalization for any reason.

RESULTS

Based on the MNA score, 78 (74.3%) patients were at risk of malnutrition and 13 (12.4%) actually presented malnutrition. Malnutrition was associated with a higher age, frailty, lower body mass index, and smaller calf circumference. During follow-up, 21 (20%) patients fell, 27 (25.7%) were rehospitalized, and 3 died (2.9%). The MNA score was associated with adverse health outcomes, but a low calf circumference predicted falling (OR 4.93 [95% CI: 1.42-17.2], p=.012) and a higher calf circumference rehospitalization (OR 1.17 [95% CI: 1.01-1.35], p=.032).

CONCLUSION

Malnutrition is prevalent in older depressed inpatients. In contrast to subjective proxies for malnutrition, which are common in depression, only objective measures of malnutrition predict adverse health outcomes such as falls and rehospitalization.

Effect of pharmacological treatment prior to admission on the outcome of older hip fracture patients

PURPOSE

We aim to relate the pharmacological treatment at admission of hip fracture patients with their prognosis.

METHODS

We designed a prospective study including 436 hip fracture patients. We classified all the pharmacological treatment prior to admission of each patient into 25 groups according to their active agent and indications. We followed-up patients for one year for survival, emergency department visits (EDV), and in-hospital re-admissions (RAD). Differential analysis was performed by chi-square test, U-Mann Whitney test, and logistic regression. In all cases, p ≤ 0.05 was considered statistically significant.

RESULTS

At 30-day follow-up, 14.9% patients noted EDV, 9.2% RAD, and 3.2% dead. Patients taking beta-blockers (p = 0.046), loop diuretics (p = 0.018) or antiparkinsonian (p = 0.009) showed an increased 30-day EDV; patients taking benzodiazepines (p = 0.014), loop diuretics (p = 0.009) or antiparkinsonian (p = 0.009), an increased 30-day RAD. At one-year follow-up, 50.7% patients noted EDV, 30.7% RAD, and 22.7% dead. Patients taking oral antidiabetics (p = 0.006) noted a greater one-year EDV; patients taking major opioids (p = 0.001), benzodiazepines (p = 0.016), cardiac agents (p = 0.046), loop diuretics (p = 0.042), beta-blockers (p = 0.018), oral anticoagulants (p = 0.013) or gastric prophylaxis (p = 0.020), greater RAD; patients taking cardiac agents (p = 0.024), loop diuretics (p = 0.006) or oral anticoagulants (p = 0.015), increased 1-year mortality rate.

CONCLUSIONS

The pharmacological treatment noted at admission for hip fracture patients is related to the outcome, in a dose-independent way. The pharmacological treatment could be an additional parameter that could help us to improve the decision-making process and the resource assignation of hip fracture patients. A proper medication review upon admission because of a hip fracture is warranted.

Relationships of the stand-up time to falls and fractures in patients with rheumatoid arthritis: Results from the CHIKARA study

AIM

Patients with rheumatoid arthritis (RA) have a higher risk of falls and fractures due to muscle weakness and painful joints of the lower extremities. Evaluation of muscle functions is important to predict falls and fractures. The aim was to investigate the relationships of muscle functions with falls and fractures in RA patients.

METHODS

Stand-up muscle power, speed, and stabilizing time were evaluated by a muscle function analyzer in 90 RA patients in the CHIKARA study (UMIN000023744). The relationships of the muscle functions with falls, fractures, body composition, Disease Activity Score of 28 joints - erythrocyte sedimentation rate (DAS28-ESR), modified Health Assessment Questionnaire (mHAQ) scores, Steinbrocker class, stage, sarcopenia, and frailty were investigated in a cross-sectional study.

RESULTS

Each parameter of muscle function was related to age, falls, frailty, and the leg muscle score. However, only stabilizing time was related with fractures (r = .217, P = .04). When stabilizing time was ≥ 1.13 and ≥1.36 seconds, the odds ratios for falls and fractures were increased 6.2-fold compared to < 1.13 seconds (95% CI: 1.2-20.1, P = .002) and 11.4-fold compared to <1.36 seconds (95% CI: 1.7-92.5, P = .071), respectively. Sarcopenia and skeletal muscle mass were not significantly related to each muscle function. There was a negative correlation between DAS28-ESR and power. Steinbrocker class and mHAQ had negative correlations with power and speed.

CONCLUSIONS

Sarcopenia and skeletal muscle mass were not adequate indicators of muscle functions in RA patients. Analyzing muscle functions is helpful to predict falls and fractures. Patients with extended stabilizing times should recognize the increased risk of falls and fractures.

Inclusion of medication-related fall risk in fall risk assessment tool in geriatric care units

BACKGROUND

Falls are common undesirable events for older adults in institutions. Even though the patient's fall risk may be scored on admission, the medication-induced fall risk may be ignored. This study developed a preliminary categorization of fall-risk-increasing drugs (FRIDs) to be added as a risk factor to the existing fall risk assessment tool routinely used in geriatric care units.

METHODS

Medication use data of older adults who had experienced at least one fall during a hospital ward or a nursing home stay within a 2-year study period were retrospectively collected from patient records. Medicines used were classified into three risk categories (high, moderate and none) according to the fall risk information in statutory summaries of product characteristics (SmPCs). The fall risk categorization incorporated the relative frequency of such adverse drug effects (ADEs) in SmPCs that were known to be connected to fall risk (sedation, orthostatic hypotension, syncope, dizziness, drowsiness, changes in blood pressure or impaired balance). Also, distribution of fall risk scores assessed on admission without considering medications was counted.

RESULTS

The fall-experienced patients (n = 188, 128 from the hospital and 60 from nursing home records) used altogether 1748 medicaments, including 216 different active substances. Of the active substances, 102 (47%) were categorized as high risk (category A) for increasing fall risk. Fall-experienced patients (n = 188) received a mean of 3.8 category A medicines (n = 710), 53% (n = 375) of which affected the nervous and 40% (n = 281) the cardiovascular system. Without considering medication-related fall risk, 53% (n = 100) of the patients were scored having a high fall risk (3 or 4 risk scores).

CONCLUSION

It was possible to develop a preliminary categorization of FRIDs basing on their adverse drug effect profile in SmPCs and frequency of use in older patients who had experienced at least one documented fall in a geriatric care unit. Even though more than half of the fall-experienced study participants had high fall risk scores on admission, their fall risk might have been underestimated as use of high fall risk medicines was common, even concomitant use. Further studies are needed to develop the FRID categorization and assess its impact on fall risk.

Helicobacter pylori Related Diseases and Osteoporotic Fractures (Narrative Review)

Osteoporosis (OP) and osteoporotic fractures (OFs) are common multifactorial and heterogenic disorders of increasing incidence. Helicobacter pylori (H.p.) colonizes the stomach approximately in half of the world's population, causes gastroduodenal diseases and is prevalent in numerous extra-digestive diseases known to be associated with OP/OF. The studies regarding relationship between H.p. infection (HPI) and OP/OFs are inconsistent. The current review summarizes the relevant literature on the potential role of HPI in OP, falls and OFs and highlights the reasons for controversies in the publications. In the first section, after a brief overview of HPI biological features, we analyze the studies evaluating the association of HPI and bone status. The second part includes data on the prevalence of OP/OFs in HPI-induced gastroduodenal diseases (peptic ulcer, chronic/atrophic gastritis and cancer) and the effects of acid-suppressive drugs. In the next section, we discuss the possible contribution of HPI-associated extra-digestive diseases and medications to OP/OF, focusing on conditions affecting both bone homeostasis and predisposing to falls. In the last section, we describe clinical implications of accumulated data on HPI as a co-factor of OP/OF and present a feasible five-step algorithm for OP/OF risk assessment and management in regard to HPI, emphasizing the importance of an integrative (but differentiated) holistic approach. Increased awareness about the consequences of HPI linked to OP/OF can aid early detection and management. Further research on the HPI-OP/OF relationship is needed to close current knowledge gaps and improve clinical management of both OP/OF and HPI-related disorders.

Prediction of fall events during admission using eXtreme gradient boosting: a comparative validation study

As the performance of current fall risk assessment tools is limited, clinicians face significant challenges in identifying patients at risk of falling. This study proposes an automatic fall risk prediction model based on eXtreme gradient boosting (XGB), using a data-driven approach to the standardized medical records. This study analyzed a cohort of 639 participants (297 fall patients and 342 controls) from Chang Gung Memorial Hospital, Chiayi Branch, Taiwan. A derivation cohort of 507 participants (257 fall patients and 250 controls) was collected for constructing the prediction model using the XGB algorithm. A comparative validation of XGB and the Morse Fall Scale (MFS) was conducted with a prospective cohort of 132 participants (40 fall patients and 92 controls). The areas under the curves (AUCs) of the receiver operating characteristic (ROC) curves were used to compare the prediction models. This machine learning method provided a higher sensitivity than the standard method for fall risk stratification. In addition, the most important predictors found (Department of Neuro-Rehabilitation, Department of Surgery, cardiovascular medication use, admission from the Emergency Department, and bed rest) provided new information on in-hospital fall event prediction and the identification of patients with a high fall risk.

Root cause analysis of fall-related hospitalisations among residents of aged care services

BACKGROUND

Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur.

AIMS

To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance.

METHODS

An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance.

RESULTS

Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services.

CONCLUSIONS

This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.

Genetic basis of falling risk susceptibility in the UK Biobank Study

Both extrinsic and intrinsic factors predispose older people to fall. We performed a genome-wide association analysis to investigate how much of an individual's fall susceptibility can be attributed to genetics in 89,076 cases and 362,103 controls from the UK Biobank Study. The analysis revealed a small, but significant SNP-based heritability (2.7%) and identified three novel fall-associated loci (Pcombined ≤ 5 × 10-8). Polygenic risk scores in two independent settings showed patterns of polygenic inheritance. Risk of falling had positive genetic correlations with fractures, identifying for the first time a pathway independent of bone mineral density. There were also positive genetic correlations with insomnia, neuroticism, depressive symptoms, and different medications. Negative genetic correlations were identified with muscle strength, intelligence and subjective well-being. Brain, and in particular cerebellum tissue, showed the highest gene expression enrichment for fall-associated variants. Overall, despite the highly heterogenic nature underlying fall risk, a proportion of the susceptibility can be attributed to genetics.

Using pharmacy dispensing data to predict falls in older individuals

Aims

Associations between individual medication use and falling in older individuals are well‐documented. However, a comprehensive risk score that takes into account overall medication use and that can be used in daily pharmacy practice is lacking. We, therefore, aimed to determine whether pharmacy dispensing records can be used to predict falls.

Methods

A retrospective cohort study was conducted using pharmacy dispensing data and self‐reported falls among 3454 Dutch individuals aged ≥65 years. Two different methods were used to classify medication exposure for each person: the drug burden index (DBI) for cumulative anticholinergic and sedative medication exposure as well as exposure to fall risk‐increasing drugs (FRIDs). Multinomial regression analyses, adjusted for age and sex, were conducted to investigate the association between medication exposure and falling classified as nonfalling, single falling and recurrent falling. The predictive performances of the DBI and FRIDs exposure were estimated by the polytomous discrimination index (PDI).

Results

There were 521 single fallers (15%) and 485 recurrent fallers (14%). We found significant associations between a DBI ≥1 and single falling (adjusted odds ratio: 1.30 [95% confidence interval {CI}: 1.02–1.66]) and recurrent falling (adjusted odds ratio: 1.60 [95%CI: 1.25–2.04]). The PDI of the DBI model was 0.41 (95%CI: 0.39–0.42) and the PDI of the FRIDs model was 0.45 (95%CI: 0.43–0.47), indicating poor discrimination between fallers and nonfallers.

Conclusion

The study shows significant associations between medication use and falling. However, the medication‐based models were insufficient and other factors should be included to develop a risk score for pharmacy practice.

Using the Drug Burden Index to identify older adults at highest risk for medication-related falls

BACKGROUND

The Drug Burden Index (DBI) was developed to assess patient exposure to medications associated with an increased risk of falling. The objective of this study was to examine the association between the DBI and medication-related fall risk.

METHODS

The study used a retrospective cohort design, with a 1-year observation period. Participants (n = 1562) were identified from 31 community pharmacies. We examined the association between DBI scores and four outcomes. Our primary outcome, which was limited to participants who received a medication review, indexed whether the review resulted in at least one medication-related recommendation (e.g., discontinue medication) being communicated to the participant's health care provider. Secondary outcomes indexed whether participants in the full sample: (1) screened positive for fall risk, (2) reported 1+ falls in the past year, and (3) reported 1+ injurious falls in the past year. All outcome variables were dichotomous (yes/no).

RESULTS

Among those who received a medication review (n = 387), the percentage of patients receiving at least one medication-related recommendation ranged from 10.2% among those with DBI scores of 0 compared to 60.2% among those with DBI scores ≥1.0 (Chi-square (4)=42.4, p < 0.0001). Among those screened for fall risk (n = 1058), DBI scores were higher among those who screened positive compared to those who did not (Means = 0.98 (SD = 1.00) versus 0.59 (SD = 0.74), respectively, p < 0.0001).

CONCLUSION

Our findings suggest that the DBI is a useful tool that could be used to improve future research and practice by focusing limited resources on those individuals at greatest risk of medication-related falls.

Analysis of the fall-related risk of pharmacotherapy in Czech hospitals: A case control study

RATIONALE, AIMS, AND OBJECTIVES

Falls are among the major problems occurring in hospital setting, when drugs are viewed as important modifiable risk factor of falling. The aim was to analyse the effect of pharmacotherapy on the risk of falls in hospitalized patients.

METHODS

A multicentre prospective case-control study was conducted in 2017 retrieving data from four hospitals in South Bohemia, Czech Republic. An online database was constructed to collect patient and fall-related data. Each fall that occurred during hospitalization was assigned to appropriate controls (no fall during hospitalization) based on gender, age, length of hospitalization, and the number of drugs. Univariate and multivariate correlations were performed with a significance level of P < .05.

RESULTS

A total of 222 fall cases (107 males; median age, 81 y) and 1076 controls (516 males; median age, 80 y) were included. According to the first ATC level classification, drugs from groups S, N, and P were significantly associated with fall-related risk compared with controls (P < .05); further analysis of ATC levels showed that only psycholeptics (N05), antipsychotics (N05A), and tiapride were significantly associated with falls. Regression analysis revealed use of psycholeptics N05 (OR = 2.06; 95% CI, 1.56-2.76), or ophthalmologicals S01 (OR = 2.72; 95% CI, 1.37-5.41), as factors with the highest fall-related risk.

CONCLUSIONS

Apart from the commonly considered fall-risk increasing drugs, other groups, such as ophthalmologicals, should also be considered; however, regarding clinical practice, it is difficult to evaluate the effects of individual drugs in the context of other risk factors of falls, due to the multifactorial nature of falls.

Polypharmacy, Hazardous Alcohol and Illicit Substance Use, and Serious Falls Among PLWH and Uninfected Comparators

BACKGROUND

Medication classes, polypharmacy, and hazardous alcohol and illicit substance abuse may exhibit stronger associations with serious falls among persons living with HIV (PLWH) than with uninfected comparators. We investigated whether these associations differed by HIV status.

SETTING

Veterans Aging Cohort Study.

METHODS

We used a nested case-control design. Cases (N = 13,530) were those who fell. Falls were identified by external cause of injury codes and a machine-learning algorithm applied to radiology reports. Cases were matched to controls (N = 67,060) by age, race, sex, HIV status, duration of observation, and baseline date. Risk factors included medication classes, count of unique non-antiretroviral therapy (non-ART) medications, and hazardous alcohol and illicit substance use. We used unconditional logistic regression to evaluate associations.

RESULTS

Among PLWH, benzodiazepines [odds ratio (OR) 1.24; 95% confidence interval (CI) 1.08 to 1.40] and muscle relaxants (OR 1.29; 95% CI: 1.08 to 1.46) were associated with serious falls but not among uninfected (P > 0.05). In both groups, key risk factors included non-ART medications (per 5 medications) (OR 1.20, 95% CI: 1.17 to 1.23), illicit substance use/abuse (OR 1.44; 95% CI: 1.34 to 1.55), hazardous alcohol use (OR 1.30; 95% CI: 1.23 to 1.37), and an opioid prescription (OR 1.35; 95% CI: 1.29 to 1.41).

CONCLUSION

Benzodiazepines and muscle relaxants were associated with serious falls among PLWH. Non-ART medication count, hazardous alcohol and illicit substance use, and opioid prescriptions were associated with serious falls in both groups. Prevention of serious falls should focus on reducing specific classes and absolute number of medications and both alcohol and illicit substance use.