Development and Delphi consensus validation of the Medication-Related Fall screening and scoring tool

BACKGROUND

Falls are a significant public health problem and constitute a major cause of injuries and mortality. Risk factors for falls are multifactorial and include medication use.

AIM

To develop and investigate the content validity of the Medication-Related fall (MRF) screening and scoring tool.

METHOD

The MRF tool was developed from clinical practice guidelines addressing medication-related problems, and additional medications identified by specialist pharmacists across a region of the United Kingdom (Northern Ireland). Medication classes were categorised according to their 'potential to cause falls' as: high-risk (three points), moderate-risk (two points) or low-risk (one point). The overall medication-related falls risk for the patient was determined by summing the scores for all medications. The MRF was validated using Delphi consensus methodology, whereby three iterative rounds of surveys were conducted using SurveyMonkey®. Twenty-two experts from 10 countries determined their agreement with the falls risk associated with each medication on a 5-point Likert scale. Only medications with at least 75% of respondents agreeing or strongly agreeing were retained in the next round.

RESULTS

Consensus was reached for 19 medications/medication classes to be included in the final version of the MRF tool; ten were classified as high-risk, eight as moderate-risk and one as low-risk.

CONCLUSION

The MRF tool is simple and has the potential to be integrated into medicines optimisation to reduce falls risk and negative fall-related outcomes. The score from the MRF tool can be used as a clinical parameter to assess the need for medication review and clinical interventions.

Adaptation and validation of the revised Patients' Attitudes towards Deprescribing (rPATD) questionnaire for benzodiazepine receptor agonists

BACKGROUND

The revised Patients' Attitudes Towards Deprescribing (rPATD) questionnaire explores older adults' views on deprescribing in general. Those views may differ, however, when the target is a specific drug such as benzodiazepine receptor agonists (BZRA).

OBJECTIVE

This study aimed to adapt the 22-item French rPATD questionnaire to create a BZRA-specific instrument and to assess the psychometric properties of this new tool.

METHODS

The adaptation of the questionnaire comprised 3 steps: 1) item transformation during group discussions with 8 healthcare providers and 8 BZRA users (aged ≥65 years), 2) pre-test of the questionnaire with 12 other older adults to ensure items understanding, 3) evaluation of the psychometric properties of the new questionnaire with 221 older BZRA users recruited in Belgium, France, and Switzerland. Construct validity was assessed using exploratory factor analysis (EFA), internal consistency with Cronbach's alpha, and test-retest reliability with intraclass correlation coefficient (ICC).

RESULTS

After the pre-test, the questionnaire had 24 items (19 adapted from the French rPATD, 3 removed, and 5 added). The EFA, however, found that several items performed poorly. Eleven items were consequently removed, based on statistical performance and clinical relevance. Three factors were extracted from the EFA performed on the 11 retained items and were named "Concerns about stopping BZRA", "BZRA inappropriateness", and "Dependence on BZRA". The questionnaire also includes two global questions about willingness to reduce BZRA dosage and willingness to discontinue BZRA. All factors showed acceptable internal consistency (0.68 ≤ Cronbach's alpha ≤0.74). Two factors showed acceptable test-retest reliability. The "Concerns about stopping BZRA" factor was found to vary over time (ICC [95%CI]: 0.35[-0.02; 0.64]).

CONCLUSIONS

We developed and validated a 13-item questionnaire to evaluate the attitudes of older people towards BZRA deprescribing. Despite some limitations, this questionnaire appears to be a useful tool for facilitating shared decision-making on BZRA deprescribing.

Benzodiazepine Receptor Agonists Use and Cessation Among Multimorbid Older Adults with Polypharmacy: Secondary Analysis from the OPERAM Trial

BACKGROUND

Benzodiazepine receptor agonists (BZRAs) are commonly prescribed in older adults despite an unfavorable risk-benefit ratio. Hospitalizations may provide a unique opportunity to initiate BZRA cessation, yet little is known about cessation during and after hospitalization. We aimed to measure the prevalence of BZRA use before hospitalization and the rate of cessation 6 months later, and to identify factors associated with these outcomes.

METHODS

We conducted a secondary analysis of a cluster randomized controlled trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly [OPERAM]), comparing usual care and in-hospital pharmacotherapy optimization in adults aged 70 years or over with multimorbidity and polypharmacy in four European countries. BZRA cessation was defined as taking one or more BZRA before hospitalization and not taking any BZRA at the 6-month follow-up. Multivariable logistic regression was performed to identify factors associated with BZRA use before hospitalization and with cessation at 6 months.

RESULTS

Among 1601 participants with complete 6-month follow-up data, 378 (23.6%) were BZRA users before hospitalization. Female sex (odds ratio [OR] 1.52 [95% confidence interval 1.18-1.96]), a higher reported level of depression/anxiety (OR up to 2.45 [1.54-3.89]), a higher number of daily drugs (OR 1.08 [1.05-1.12]), use of an antidepressant (OR 1.74 [1.31-2.31]) or an antiepileptic (OR 1.46 [1.02-2.07]), and trial site were associated with BZRA use. Diabetes mellitus (OR 0.60 [0.44-0.80]) was associated with a lower probability of BZRA use. BZRA cessation occurred in 86 BZRA users (22.8%). Antidepressant use (OR 1.74 [1.06-2.86]) and a history of falling in the previous 12 months (OR 1.75 [1.10-2.78]) were associated with higher BZRA cessation, and chronic obstructive pulmonary disease (COPD) (OR 0.45 [0.20-0.91]) with lower BZRA cessation.

CONCLUSION

BZRA prevalence was high among included multimorbid older adults, and BZRA cessation occurred in almost a quarter of them within 6 months after hospitalization. Targeted BZRA deprescribing programs could further enhance cessation. Specific attention is needed for females, central nervous system-acting co-medication, and COPD co-morbidity.

REGISTRATION

ClinicalTrials.gov identifier: NCT02986425. December 8, 2016.

Barriers and enablers for deprescribing benzodiazepine receptor agonists in older adults: a systematic review of qualitative and quantitative studies using the theoretical domains framework

Background

Many strategies aimed at deprescribing benzodiazepine receptor agonists (BZRA) in older adults have already been evaluated with various success rates. There is so far no consensus on which strategy components increase deprescribing the most. Yet, despite an unfavourable benefit-to-risk ratio, BZRA use among older adults remains high. We systematically reviewed barriers and enablers for BZRA deprescribing in older adults.

Methods

Two reviewers independently screened records identified from five electronic databases—Medline, Embase, PsycINFO, CINAHL and the Cochrane library—and published before October 2020. They searched for grey literature using Google Scholar. Qualitative and quantitative records reporting data on the attitudes of older adults, caregivers and healthcare providers towards BZRA deprescribing were included. Populations at the end of life or with specific psychiatric illness, except for dementia, were excluded. The two reviewers independently assessed the quality of the included studies using the mixed-methods appraisal tool. Barriers and enablers were identified and then coded into domains of the theoretical domains framework (TDF) using a combination of deductive and inductive qualitative analysis. The most relevant TDF domains for BZRA deprescribing were then identified.

Results

Twenty-three studies were included 13 quantitative, 8 qualitative and 2 mixed-method studies. The points of view of older adults, general practitioners and nurses were reported in 19, 9 and 3 records, respectively. We identified barriers and enablers in the majority of TDF domains and in two additional themes: “patient characteristics” and “BZRA prescribing patterns”. Overall, the most relevant TDF domains were “beliefs about capabilities”, “beliefs about consequences”, “environmental context and resources”, “intention”, “goals”, “social influences”, “memory, attention and decision processes”. Perceived barriers and enablers within domains differed across settings and across stakeholders.

Conclusion

The relevant TDF domains we identified can now be linked to behavioural change techniques to help in the design of future strategies and health policies. Future studies should also assess barriers and enablers perceived by under-evaluated stakeholders (such as pharmacists, psychiatrists and health care professionals in the hospital setting).

Trial registration

This work was registered on PROSPERO under the title “Barriers and enablers to benzodiazepine receptor agonists deprescribing”. Registration number: CRD42020213035

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01206-7.

Current practice in benzodiazepine receptor agonists deprescribing on acute geriatric wards: a cohort study

Background

Benzodiazepine receptor agonist (BZRA) use is highly prevalent in hospitalised older people although these drugs are associated with numerous and serious adverse events. Deprescribing can reduce risks associated with chronic BZRA use. The aim of this study was to measure the prevalence of, and factors associated with, BZRA deprescribing in acute geriatric units.

Methods

During a one-year period, this multicentre retrospective study included patients aged ≥70 years, hospitalised in acute geriatric units, and using ≥1 BZRA on admission. BZRA deprescribing at discharge was defined as: ≥25% decrease in lorazepam-equivalent admission dose; discontinuation of all BZRAs; or cessation of a rescue prescription at discharge. BZRA cessation was defined as discontinuation of all BZRAs at discharge. We identified social, medical, geriatric and medication factors associated with BZRA deprescribing using logistic regression.

Results

In total, 561 patients were included (mean age: 85.3±5.9 years, 70% of women). BZRA deprescribing occurred in 240 (42.8%), including 85 with BZRA cessation (15.2%). Deprescribing occurred more frequently in patients with a BZRA-related adverse event on admission or during hospital stay (odds ratio (OR) 4.5; 95% confidence interval [2.6; 7.9]), with an antidepressant (1.6 [1.1; 2.4]) and a higher lorazepam-equivalent dosage on admission (OR 1.2 [1; 1.4]), and less frequently in patients with antipsychotic drug (OR 0.5 [0.3; 0.8]). BZRA cessation was more likely in patients with a BZRA-related adverse event (OR 2.2 [1.2; 4.3]) and a lower lorazepam-equivalent dosage on admission (OR 0.5 [0.3; 0.6]).

Conclusions

During hospitalisation in the acute geriatric units of our hospital, BZRA deprescribing occurred in 42.8% of the patients. Identification of an BZRA-related adverse event by the treating physician appears to be a major factor: this reactive deprescribing accounted for 74% of cases in our study. Further prospective studies are needed to measure long-term persistence of in-hospital deprescribing and encourage proactive management.

Mitigating Medication-Related Fall Risk Through Pharmacist-Prescriber Collaboration

Medications are known to increase the risk for fall in older adults, and pharmacists can contribute to fall risk prevention through medication therapy management services. STEADI-Rx is an initiative developed to facilitate fall risk reduction through pharmacist-prescriber collaboration. Key components of the STEADI-Rx algorithm are described as well as evidence supporting its integration in practice.

Importance, Errors, and Patterns of Quotations to Psychiatric Original Articles

Introduction A substantial rate of quotation errors has been reported in medical journal publications: about 25% of all quotations are wrong. It is, however, entirely unclear how important quotation errors are for the message of quoting articles.

Methods This is a case study in form of a retrospective quotation analysis of a cohort of 72 psychiatric original articles (index articles) from 5 German-language general psychiatric journals. Main outcomes were importance and accuracy of quotations from the 2 calendar years following the publication of index articles.

Results Fifty-one index articles were quoted 235 times in 109 quoting articles. Almost all quotations were of medium (76% [95% CI: 70%; 81%]) or high (20% [15%, 25%]) importance for the message of the quoting paper. Regarding quotation accuracy, 44 quotations (19% [14%; 24%]) were rated as minor, and 51 (22% [17%; 27%]) as major errors. In multivariable analyses, no statistically significant and practically relevant factors associated with quotation inaccuracy emerged, such as self-quotation, impact factor of the quoting journal, or importance. Among quoting articles, 7 (6% [3%; 13%]) showed a pattern of predominantly quoting index articles from the time span relevant to the calculation of the impact factor.

Discussion Quotations are important for the message of the quoting paper. Therefore, quotation errors may be detrimental to scientific reasoning and may undermine public trust in medical science. The present investigation is a case study, and its results are exploratory. While it is plausible that the findings translate into other environments, independent replication is needed.

Falling Again? Falls in Geriatric Adults-Risk Factors and Outcomes Associated With Recidivism

BACKGROUND

The elderly population is at increased risk of fall-related readmissions (FRRs). This study is aimed to identify the factors predictive of repeat falls and to analyze the associated outcomes.

METHODS

We studied the Nationwide Readmission Database for the year 2010 and identified the patients (≥65 years) who were admitted after falls, and from that subset, further analyzed patients with ≥1 FRRs. Descriptive statistics were used to analyze continuous and categorical variables. Multivariable logistic regression was used to identify predictors of readmission in geriatric patients after controlling for covariates.

RESULTS

A total of 358,581 initial fall-related admissions in geriatric adults were identified, and of these, 21,713 experienced ≥1 FRRs (6.06% risk of repeat fall-related admission). Females outnumbered males, and female gender was identified as an independent predictor of FRR (OR 1.10 95% CI 1.07-1.14 P = 0.000). The other independent predictors significantly associated with FRR were age (OR 1.007, 95% CI 1.005-1.009), depression (OR 1.25, 95% CI 1.21-1.30), drug abuse (OR 1.37, 95% CI 1.15-1.63), liver disease (OR 1.25, 95% CI 1.15-1.43, P < 0.001), psychosis (OR 1.16, 95% CI 1.09-1.23), valvular heart disease (OR 1.07, 95% CI 1.02-1.12), chronic pulmonary disease (OR 1.10, 95% CI 1.06-1.13), and number of chronic conditions (OR 1.022, 95% CI 1.016-1.29). Patients admitted emergently or urgently had higher odds of FRR (OR 1.44, 95% CI 1.36-1.52). Hospital demographic was a significant predictor of FRR, as hospitals with bed number >500 was associated with lower odds (OR 0.95, 95% CI 0.92-0.98, P < 0.001). Geriatric patients admitted at nonteaching hospitals and hospitals in large metro areas (population > 1 million) had higher odds of FRR (OR 1.10, 95% CI 1.03 - 1.16) and (OR 1.10, 95% C1 1.07-1.14), respectively. With respect to discharge disposition, patients in the FRR group were less likely to go home (5.9% versus 21.0%) or with home health care (12.6% versus 18.5%), but more likely to be discharged to skilled nursing or intermediate-care facilities (64.1% versus 54.9%) and short-term hospitals (2.8% versus 1.4%). The mortality rate was higher in the FRR group but was not statistically significant (OR 1.06, 95% CI 0.99-1.14).

CONCLUSIONS

Given the high burden of fall-related injuries and FRRs to patients and the health care system, it is essential to identify those who are at risk. This study provides a comprehensive list of high-risk predictors as well as the impact on patient outcomes, and hence a chance to intervene for patients with FRRs.

Deprescribing Benzodiazepines in Older Patients: Impact of Interventions Targeting Physicians, Pharmacists, and Patients

Benzodiazepines (BZDs; including the related Z-drugs) are frequently targets for deprescribing; long-term use in older people is harmful and often not beneficial. BZDs can result in significant harms, including falls, fractures, cognitive impairment, car crashes and a significant financial and legal burden to society. Deprescribing BZDs is problematic due to a complex interaction of drug, patient, physician and systematic barriers, including concern about a potentially distressing but rarely fatal withdrawal syndrome. Multiple studies have trialled interventions to deprescribe BZDs in older people and are discussed in this narrative review. Reported success rates of deprescribing BZD interventions range between 27 and 80%, and this variability can be attributed to heterogeneity of methodological approaches and limited generalisability to cognitively impaired patients. Interventions targeting the patient and/or carer include raising awareness (direct-to-consumer education, minimal interventions, and 'one-off' geriatrician counselling) and resourcing the patient (gradual dose reduction [GDR] with or without cognitive behavioural therapy, teaching relaxation techniques, and sleep hygiene). These are effective if the patient is motivated to cease and is not significantly cognitively impaired. Interventions targeted to physicians include prescribing interventions by audit, algorithm or medication review, and providing supervised GDR in combination with medication substitution. Pharmacists have less frequently been the targets for studies, but have key roles in several multifaceted interventions. Interventions are evaluated according to the Behaviour Change Wheel. Research supports trialling a stepwise approach in the cognitively intact older person, but having a low threshold to use less-consultative methods in patients with dementia. Several resources are available to support deprescribing of BZDs in clinical practice, including online protocols.

[Discontinuation of benzodiazepines in old age : When and if so, how?]

Although viewed critically in geriatrics, benzodiazepine use is still common among old people. Before reducing the dosage the following questions must be considered: 1. Are there indications for benzodiazepine treatment and will discontinuation cause relevant rebound symptoms of the initial disorder treated? 2. To what extent do the patient and other key persons consider discontinuation to be reasonable and will they support discontinuation? 3. Is the target complete withdrawal, a dose reduction or shift to another benzodiazepine drug which is more suitable in old age for pharmacokinetic reasons? This article provides assistance in answering these questions and some guidelines for the practical management of discontinuation. It is mandatory 1) to periodically address the problem of long-term benzodiazepine use when counseling the patient and key persons and 2) to be aware that several intermediate steps exist between continuation and complete discontinuation, which may be considered successful treatment.

Drug Burden Index in older adults: theoretical and practical issues

Anticholinergic and sedative medications are commonly used in older adults and are associated with adverse clinical outcomes. The Drug Burden Index was developed to measure the cumulative exposure to these medications in older adults and its impact on physical and cognitive function. This narrative review discusses the research and clinical applications of the Drug Burden Index, and its advantages and limitations, compared with other pharmacologically developed measures of high-risk prescribing.

Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies

Falls are the leading cause of injuries among older adults, aged 65 years and older. Furthermore, falls are an increasing public health problem because of ageing populations worldwide due to an increase in the number of older adults, and an increase in life expectancy. Numerous studies have identified risk factors and investigated possible strategies to prevent (recurrent) falls in community-dwelling older people and those living in long-term care facilities. Several types of drugs have been associated with an increased fall risk. Since drugs are a modifiable risk factor, periodic drug review among older adults should be incorporated in a fall prevention programme.

Effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and relevant pharmacological interventions on fall risk in elderly patients

BACKGROUND

Falls among the elderly are an issue internationally and a public health problem that brings substantial economic and quality-of-life burdens to individuals and society. Falls prevention is an important measure of nursing quality and patient safety. Numerous studies have evaluated the association of medication use with fall risk in elderly patients. However, an up-to-date review has not been available to summarize the multifaceted pharmaceutical concerns in the prevention of medication-related falls.

MATERIALS AND METHODS

Relevant literature was identified by performing searches in PubMed, Web of Science, and the Cochrane Library, covering the period until February 2014. We included studies that described an association between medications and falls, and effects of drug pharmacokinetic/pharmacodynamic properties, characteristics of medication use, and pharmacological interventions on fall risk in elderly patients. The full text of each included article was critically reviewed, and data interpretation was performed.

RESULTS

Fall-risk-increasing drugs (FRIDs) include central nervous system-acting agents, cough preparations, nonsteroidal anti-inflammatory drugs, anti-Alzheimer's agents, antiplatelet agents, calcium antagonists, diuretics, α-blockers, digoxin, hypoglycemic drugs, neurotoxic chemotherapeutic agents, nasal preparations, and antiglaucoma ophthalmic preparations. The degree of medication-related fall risk was dependent on one or some of the following factors: drug pharmacokinetic/pharmacodynamic properties (eg, elimination half-life, metabolic pathway, genetic polymorphism, risk rating of medications despite belonging to the same therapeutic class) and/or characteristics of medication use (eg, number of medications and drug-drug interactions, dose strength, duration of medication use and time since stopping, medication change, prescribing appropriateness, and medication adherence). Pharmacological interventions, including withdrawal of FRIDs, pharmacist-conducted clinical medication review, and computerized drug alerts, were effective in reducing fall risk.

CONCLUSION

Based on the literature review, clear practical recommendations for clinicians to prevent falls in the elderly included making a list of FRIDs, establishing a computerized alert system for when to e-prescribe FRIDs, seeking an alternative drug with lower fall risk, withdrawing FRIDs if clinically indicated, taking pertinent cautions when the use of FRIDs cannot be avoidable, paying attention to prescribing appropriateness, simplifying the medication regimen, strengthening pharmacist-conducted clinical medication review, ensuring the label of each FRID dispensed contains a corresponding warning sign, being careful when medication change occurs, enhancing medication adherence, and mandating for periodic reassessment of potential risk associated with the patient's medication regimen. Further studies should be conducted in this area, such as investigating whether medication reconciliation and improving medication adherence could decrease the rate of falls.

People's attitudes, beliefs, and experiences regarding polypharmacy and willingness to Deprescribe

OBJECTIVES

To capture people's attitudes, beliefs, and experiences regarding the number of medications they are taking and their feelings about stopping medications.

DESIGN

Administration of a validated questionnaire.

SETTING

Multidisciplinary ambulatory consulting service at the Royal Adelaide Hospital.

PARTICIPANTS

Participants were individuals aged 18 and older (median 71.5) taking at least one regular prescription medication; 100 participants completed all items of the questionnaire, 65 of whom were aged 65 and older.

MEASUREMENTS

Participants were administered the 15-item Patients' Attitudes Towards Deprescribing (PATD) questionnaire.

RESULTS

Participants were taking an average of 10 different prescription and nonprescription (including complementary), regular and as-needed medications. More than 60% felt that they were taking a "large number" of medications, and 92% stated that they would be willing to stop one or more of their current medications if possible. Number of regular medications, age, and number of medical conditions were not found to be correlated with willingness to stop a medication. The findings were similar in older and younger participants.

CONCLUSION

This study has shown that a cohort of mostly older adults were largely accepting of a trial of cessation of medication(s) that their prescriber deemed to be no longer required. Because few factors were associated with willingness to cease medications, all patients should be individually evaluated for deprescribing.

Psychotropic medications, including short acting benzodiazepines, strongly increase the frequency of falls in elderly

OBJECTIVES

Falls in the elderly are common and often serious. The aim of this study was to examine the association between the use of different classes of psychotropic medications, especially short acting benzodiazepines, and the frequency of falling in elderly. Study design This retrospective cohort study was performed with patients who visited the day clinic of the department of geriatric medicine of the University Medical Center Utrecht in the Netherlands between 1 January 2011 and 1 April 2012. Measurements Frequencies of falling in the past year and medication use were recorded. Logistic regression analysis was performed to assess the relationship between the frequency of falling in the past year and the use of psychotropic medications.

RESULTS

During this period 404 patients were included and 238 (58.9%) of them had experienced one or more falls in the past year. After multivariate adjustment, frequent falls remained significantly associated with exposure to psychotropic medications (odds ratio [OR] 1.96; 95% confidence interval [CI] 1.17-3.28), antipsychotics (OR 3.62; 95% CI 1.27-10.33), hypnotics and anxiolytics (OR 1.81; 95% CI 1.05-3.11), short-acting benzodiazepines or Z-drugs (OR 1.94; 95% CI 1.10-3.42) and antidepressants (OR 2.35; 95% CI 1.33-4.16).

CONCLUSIONS

This study confirms that taking psychotropic medication, including short-acting benzodiazepines, strongly increases the frequency of falls in elderly. This relation should be explicitly recognized by doctors prescribing for older people, and by older people themselves. If possible such medication should be avoided for elderly patients especially with other risk factors for falling.

Patterns of hypnotic medication use for sleep disturbance amongst hospital inpatients

OBJECTIVE

The objective of this article is to examine patterns of temazepam prescribing amongst inpatients at a Sydney teaching hospital.

METHOD

The study involved a retrospective file audit of 98.8% (n=410) of patients discharged from psychiatry, medical, surgical and obstetric and gynaecology wards of Nepean Hospital during a one-week period. Data was collected on patient demographics, temazepam and other sedative-hypnotic use, falls risk and analgesia use.

RESULTS

Sixteen per cent (n=64) of patients were prescribed temazepam during their stay. All patients from the psychiatry wards had been prescribed temazepam. Fifteen per cent (n=6) of falls risk patients had been prescribed temazepam. Temazepam prescription was associated with an increased length of stay, psychiatry and surgical wards, and higher use of analgesia.

CONCLUSIONS

Temazepam continues to be a frequently prescribed medication in the acute psychiatry setting. Its frequent prescription to patients in surgical wards and to those prescribed analgesic agents indicates that it still has a role in settling patients to sleep in the hospital setting.