Association between gaps in antihypertensive medication adherence and injurious falls in older community-dwelling adults: a prospective cohort study

The State of Use and Utility of Negative Controls in Pharmacoepidemiologic Studies

Uses of real-world data in drug safety and effectiveness studies are often challenged by various sources of bias. We undertook a systematic search of the published literature through September 2020 to evaluate the state of use and utility of negative controls to address bias in pharmacoepidemiologic studies. Two reviewers independently evaluated study eligibility and abstracted data. Our search identified 184 eligible studies for inclusion. Cohort studies (115, 63%) and administrative data (114, 62%) were, respectively, the most common study design and data type used. Most studies used negative control outcomes (91, 50%), and for most studies the target source of bias was unmeasured confounding (93, 51%). We identified 4 utility domains of negative controls: 1) bias detection (149, 81%), 2) bias correction (16, 9%), 3) P-value calibration (8, 4%), and 4) performance assessment of different methods used in drug safety studies (31, 17%). The most popular methodologies used were the 95% confidence interval and P-value calibration. In addition, we identified 2 reference sets with structured steps to check the causality assumption of the negative control. While negative controls are powerful tools in bias detection, we found many studies lacked checking the underlying assumptions. This article is part of a Special Collection on Pharmacoepidemiology.

Risk of adverse events following the initiation of antihypertensives in older people with complex health needs: a self-controlled case series in the United Kingdom

BACKGROUND

We assessed the risk of adverse events-severe acute kidney injury (AKI), falls and fractures-associated with use of antihypertensives in older patients with complex health needs (CHN).

SETTING

UK primary care linked to inpatient and mortality records.

METHODS

The source population comprised patients aged >65, with ≥1 year of registration and unexposed to antihypertensives in the year before study start. We identified three cohorts of patients with CHN, namely, unplanned hospitalisations, frailty (electronic frailty index deficit count ≥3) and polypharmacy (prescription of ≥10 medicines). Patients in any of these cohorts were included in the CHN cohort. We conducted self-controlled case series for each cohort and outcome (AKI, falls, fractures). Incidence rate ratios (IRRs) were estimated by dividing event rates (i) during overall antihypertensive exposed patient-time over unexposed patient-time; and (ii) in the first 30 days after treatment initiation over unexposed patient-time.

RESULTS

Among 42,483 patients in the CHN cohort, 7,240, 5,164 and 450 individuals had falls, fractures or AKI, respectively. We observed an increased risk for AKI associated with exposure to antihypertensives across all cohorts (CHN: IRR 2.36 [95% CI: 1.68-3.31]). In the 30 days post-antihypertensive treatment initiation, a 35-50% increased risk for falls was found across all cohorts and increased fracture risk in the frailty cohort (IRR 1.38 [1.03-1.84]). No increased risk for falls/fractures was associated with continuation of antihypertensive treatment or overall use.

CONCLUSION

Treatment with antihypertensives in older patients was associated with increased risk of AKI and transiently elevated risk of falls in the 30 days after starting antihypertensive therapy.

Older People Living Alone: A Predictive Model of Fall Risk

Falls in older people are a result of a combination of multiple risk factors. There are few studies involving predictive models in a community context. The aim of this study was to determine the validation of a new model for predicting fall risk in older adults (65+) living alone in community dwellings (n = 186; n = 117) with a test-retest reliability study. We consider in the predictive model the significant factors emerged from the bivariate analysis: age, zone, social community resources, physical exercise, self-perception of health, difficulty to keep standing, difficulty to sit and get up from a chair, strain to see, use of technical devices, hypertension and number of medications. The final model explained 28.5% of the risk of falling in older adults living alone in community dwellings. The AUC = 0.660 (se = 0.065, IC 95% 0.533-0.787, p = 0.017). The predictive model developed revealed a satisfactory discriminatory performance of the model and can contribute to clinical practice, with respect to the evaluation of risk of falling in this frailty group and preventing falls.

The association between diuretics and falls in older adults: A systematic review and meta-analysis

OBJECTIVE

Diuretic intake increases the risk of falling. However, previous studies have shown inconsistent correlations between diuretics and falls. This meta-analysis aimed to provide a comprehensive overview of the relationship between diuretic use and risk of falls in older adult individuals.

METHODS

Six databases (Cochrane Library, PubMed, Medline, CINAHL, Web of Science, and EMBASE) were searched from their inception to November 9, 2022. The risk of bias was independently evaluated using the Newcastle-Ottawa Quality Assessment Scale. A comprehensive meta-analysis was used to analyze the eligible studies.

RESULTS

Fifteen articles were analyzed. Studies have shown that diuretics can increase the risk of falls in older adult individuals. The probability of falls in older adult individuals who used diuretics was 1.185 times higher than in those who did not take diuretics.

CONCLUSION

Diuretics were significantly associated with an increased risk of falls.

Antihypertensive Medication Adherence and the Risk of Vascular Events and Falls After Stroke: A Real-World Effectiveness Study Using Linked Registry Data

BACKGROUND

Real-world evidence is limited on whether antihypertensive medications help avert major adverse cardiovascular events (MACE) after stroke without increasing the risk of falls. We investigated the association of adherence to antihypertensive medications on the incidence of MACE and falls requiring hospitalization after stroke.

METHODS

A retrospective cohort study of adults who were newly dispensed antihypertensive medications after an acute stroke (Australian Stroke Clinical Registry 2012-2016; Queensland and Victoria). Pharmaceutical dispensing records were used to determine medication adherence according to the proportion of days covered in the first 6 months poststroke. Outcomes between 6 and 18 months postdischarge included: (i) MACE, a composite outcome of all-cause death, recurrent stroke or acute coronary syndrome; and (ii) falls requiring hospitalization. Estimates were derived using Cox models, adjusted for >30 confounders using inverse probability treatment weights.

RESULTS

Among 4076 eligible participants (median age 68 years; 37% women), 55% had a proportion of days covered ≥80% within 6 months postdischarge. In the subsequent 12 months, 360 (9%) participants experienced a MACE and 337 (8%) experienced a fall requiring hospitalization. After achieving balance between groups, participants with a proportion of days covered ≥80% had a reduced risk of MACE (hazard ratio: 0.68; 95% CI: 0.54-0.84) and falls requiring hospitalization (subdistribution hazard ratio: 0.78; 95% CI: 0.62-0.98) than those with a proportion of days covered <80%.

CONCLUSIONS

High adherence to antihypertensive medications within 6 months poststroke was associated with reduced risks of both MACE and falls requiring hospitalization. Patients should be encouraged to adhere to their antihypertensive medications to maximize poststroke outcomes.

Falls in older persons living alone: the role of individual, social and environmental factors

OBJECTIVE

To identify the prevalence and the risk factors of falling in older people (65+) living alone.

METHOD

This is a descriptive and transversal study which included 186 participants, aged 65+ living alone in community-dwelling.

RESULTS

The prevalence of falls was 80.1% (95% CI 74.1-85.8). Considering the last 3 months, the prevalence of falls reduced to 22.2% (95% CI 17.5-29.9) and the number of falls reported was 2.4 (sd = 2.1). Most falls were accidental (n = 74, 59.7%), followed by dizziness (n = 15, 12.1%) and almost 50% occurred in the morning (n = 53, 45.3%). Considering the local where the falls occurred, 70 (57.4%) were at home (36.1% inside and 21.3% outside), 41 on the street (33.6%) and only 11 (9.0%) in a public place (4.1% inside and 4.9% outside). After the fall, 30.9% of the participants changed daily life after an event.

CONCLUSIONS

Falls among older adults is a multifactorial problem that requires integrated and multiprofessional interventions. Older age, living alone in an urban area, with insufficient resources, reduced physical activity and a poor self-perception are factors associated with a higher risk of falling. Similarly, older people who have difficulty standing, sitting and rising from a chair, as well as being hypertensive and taking a high number of medications are associated with a high risk of falling. Future research should develop and emphasize more national studies to confirm these results.

Variation in Mean Arterial Pressure Increases Falls Risk in Elderly Physically Frail and Prefrail Individuals Treated With Antihypertensive Medication

BACKGROUND

Impaired cerebral blood flow has been associated with an increased risk of falls. Mean arterial pressure (MAP) and variability in MAP have been reported to affect cerebral blood flow but their relationships to the risk of falls have not previously been reported.

METHODS

Utilising data from the Aspirin in Reducing Events in the Elderly trial participants, we estimated MAP and variability in MAP, defined as within-individual SD of MAP from baseline and first 2 annual visits. The relationship with MAP was studied in 16 703 participants amongst whom 1539 falls were recorded over 7.3 years. Variability in MAP was studied in 14 818 of these participants who experienced 974 falls over 4.1 years. Falls were confined to those involving hospital presentation. Cox regression was used to calculate hazard ratio and 95% CI for associations with falls.

RESULTS

Long-term variability in MAP was not associated with falls except amongst frail or prefrail participants using antihypertensive medications. Within this group each 5 mm Hg increase in long-term variability in MAP increased the risk of falls by 16% (hazard ratio, 1.16 [95% CI, 1.02-1.33]). Amongst the antihypertensive drugs studied, beta-blocker monotherapy (hazard ratio, 1.93 [95% CI, 1.17-3.18]) was associated with an increased risk of falls compared with calcium channel blockers.

CONCLUSIONS

Higher levels of long-term variability in MAP increase the risk of serious falls in older frail and prefrail individuals taking antihypertensive medications. The observation that the relationship was limited to frail and prefrail individuals might explain some of the variability of previous studies linking blood pressure indices and falls.

Clinical characteristics of older adults with hypertension and unrecognized cognitive impairment

To treat older patients with hypertension, it is important to detect cognitive impairment at an early stage because of its potential influence on treatment efficacy and functional prognosis. In this study, we aimed to identify the incidence and determinants of cognitive impairment in hypertensive patients aged 65 years and above who visited our outpatient clinic and were not previously diagnosed with cognitive impairment. Among 312 patients with hypertension, we found that 35% (n = 109) and 7.7% (n = 24) had cognitive impairment and dementia, respectively, as defined by the Mini-Mental State Examination (≤27 or ≤23, respectively). Patients with cognitive impairment were older, had lower levels of education, and had lower instrumental activities of daily living (IADL) scores than those without cognitive impairment. Multiple regression analysis revealed that age and IADL were associated with cognitive impairment in patients with hypertension. Regarding the treatment of hypertension, the office and home blood pressure levels, number of antihypertensive medications prescribed, and proportion of the use of each antihypertensive drug was equivalent between patients with and without cognitive impairment. Finally, patients with unrecognized cognitive impairment showed distinct clinical characteristics, including high antihypertensive medication burden and preserved IADL, when compared to hypertensive patients in the different cohorts of definitive mild cognitive impairment of a similar age. These findings suggest that older hypertensive patients are at a high risk of masked cognitive decline, even if they are functionally independent.

ADHERENCE AND BARRIERS TO DRUG THERAPY: RELATIONSHIP WITH THE RISK OF FALLS IN OLDER ADULTS

ABSTRACT Objective: to verify the association of adherence and barriers to drug therapy with the risk of falls and the sociodemographic, clinical and economic variables. Method: a cross-sectional study, carried out with 117 aged individuals in a Medical Clinic of Specialties for Older Adults in the Southeast region of the city of São Paulo (SP), from March to November 2019. The following scales were applied: Downton Fall Risk, Morisky-Green Test and Brief Medication Questionnaire. Logistic regression was use to verify the association between adherence to the treatment and types of barriers to adherence and the risk of falls. A 5% significance level was used. Results: the older adults with low adherence to the drug treatment presented 5.57 times more chances of having a high risk of falling when compared to those with greater adherence, and those with a barrier in the recall domain had 22.75 times more chances of having a high risk of falling, in relation to the aged individuals without barriers in the recall domain. Conclusion: low and average adherence to drug therapy and the barrier related to the recall domain were associated with high risk of falls in the older adults.

Prevalence of potentially serious alcohol-medication interactions in older adults in a community pharmacy setting: a cross-sectional study

OBJECTIVE

Previous prevalence estimates of POtentially Serious Alcohol-Medication INteractions in Older adults (POSAMINO) are based on in-home inventories of medications; however, this method is associated with under-reporting of medications when compared with dispensing records. This study aims to estimate the prevalence of POSAMINO among community-dwelling older adults using drug dispensing data from the community pharmacy setting.

DESIGN

Cross-sectional study.

SETTING

Irish Community Pharmacy.

PARTICIPANTS

1599 consecutive older adults presenting with a prescription to 1 of 120 community pharmacies nationwide; community-dwelling, aged ≥65 years, able to speak and understand English, with no evidence of cognitive impairment. The mean age of sample was 75.5 years (SD 6.5); 55% (n=884) female.

MEASURES

38 POSAMINO criteria were identified using participants' pharmacy dispensing records linked to self-reported alcohol consumption (beverage-specific quantity and frequency measures) over the last 12 months.

RESULTS

The overall prevalence of POSAMINO in the study population was 28%, with 10% at risk of at least one POSAMINO criteria and 18% at risk of two or more. Exposure to POSAMINO most commonly involved cardiovascular agents (19%) and central nervous system agents (15%). Exposure to a higher number of POSAMINO criteria was associated with younger age (adjusted incident rate ratio (AIRR): 0.97; 95% CI: 0.95 to 0.98), male sex (AIRR: 0.55; 95% CI: 0.45 to 0.67) and a higher number of comorbidities (AIRR: 1.05; 95% CI: 1.01 to 1.13).

CONCLUSION

This study adds to the growing body of evidence, which suggests that older adults are vulnerable to potentially serious alcohol-medication interactions, particularly those involving cardiovascular and central nervous system agents, increasing their risk of orthostatic hypotension, gastrointestinal bleeds and increased sedation. Application of the POSAMINO criteria at the point of prescribing may facilitate the risk stratification of older adults and prioritise alcohol screening and brief alcohol interventions in those at greatest risk of harm.