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Modification of Potentially Inappropriate Prescribing Following Fall-Related Hospitalizations in Older Adults

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Abstract

Background

There is strong evidence that potentially inappropriate prescribing is associated with falls in older adults. Fall-related hospitalizations should trigger medication review.

Objectives

The aim of this before-and-after cohort study was to explore patterns of relevant potentially inappropriate prescribing in older people with fall-related hospitalizations.

Methods

Data on older adults with hospitalizations for falls, fractures and syncope between 2012 and 2016 were collected from 44 general practices in Ireland. Fall-related prescribing was defined from the Screening Tool for Older Persons’ Prescriptions (sedatives and vasodilators) and the Screening Tool to Alert doctors to Right Treatment (vitamin D). Prevalence of prescriptions were estimated from general practice and hospital discharge records. Mixed-effects logistic regression was conducted to compare the 12-month pre- and post-hospitalization periods.

Results

Overall, 927 individuals (68% female, average age 81.2 years; standard deviation 8.6) were included, 45% of whom had a diagnosis of fracture, 28% had syncope, and 27% had a fall without fracture/syncope. After adjustment for covariates and practice clustering effects, both vitamin D and sedatives had higher odds of prescription post-hospitalization (adjusted odds ratio [aOR] 4.47, 95% confidence interval [CI] 2.09–9.54, and aOR 1.75, 95% CI 1.29–2.39, respectively). With adjustments for age and sex, having a fracture was associated with new initiation of vitamin D (aOR 2.81, 95% CI 1.76–4.46) and having syncope was associated with continuing on vasodilators (aOR 1.99, 95% CI 1.06–3.74). No factors were associated with new sedative initiation.

Conclusion

Fall-related potentially inappropriate prescribing is prevalent in older adults who have a history of falls, and continues after discharge from hospital. Future studies should investigate why such prescribing is initiated after a fall-related hospitalization, and explore interventions that could reduce such hazardous prescribing.

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References

  1. National Office of Clinical Audit. Major trauma audit national report 2016. Dublin: 2018. https://www.noca.ie/publications. Accessed 10 Oct 2018.

  2. Kehoe A, Smith JE, Edwards A, Yates D, Lecky F. The changing face of major trauma in the UK. Emerg Med J. 2015;32:911–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Morrison A, Fan T, Sen SS, Weisenfluh L. Epidemiology of falls and osteoporotic fractures: a systematic review. Clinicoecon Outcomes Res. 2013;5:9–18.

    PubMed  Google Scholar 

  4. Close JC, Lord SR, Antonova EJ, Martin M, Lensberg B, Taylor M, et al. Older people presenting to the emergency department after a fall: a population with substantial recurrent healthcare use. Emerg Med J. 2012;29:742–7.

    Article  PubMed  Google Scholar 

  5. National Institute for Health and Care Excellence. Falls In older people: assessing risk and prevention. CG161. London: National Institute for Health and Care Excellence; 2013.

    Google Scholar 

  6. Grossman DC, Curry SJ, Owens DK, Barry MJ, Caughey AB, Davidson KW, et al. Interventions to prevent falls in community-dwelling older adults: US preventive services task force recommendation statement. JAMA. 2018;319:1696–704.

    Article  PubMed  Google Scholar 

  7. Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169:1952–60.

    Article  PubMed  Google Scholar 

  8. Seppala LJ, Wermelink A, de Vries M, Ploegmakers KJ, van de Glind EMM, Daams JG, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: II. Psychotropics. J Am Med Dir Assoc. 2018;19:371.e11–7.

    Article  Google Scholar 

  9. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society. updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;2015(63):2227–46.

    Article  Google Scholar 

  10. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44:213–8.

    Article  PubMed  Google Scholar 

  11. de Vries M, Seppala LJ, Daams JG, van de Glind EMM, Masud T, van der Velde N. Fall-risk-increasing drugs: a systematic review and meta-analysis: I. Cardiovascular drugs. J Am Med Dir Assoc. 2018;19:371–9.

    Article  PubMed  Google Scholar 

  12. Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. 2017;12:43.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46:72–83.

    Article  CAS  PubMed  Google Scholar 

  14. Gallagher P, Baeyens JP, Topinkova E, Madlova P, Cherubini A, Gasperini B, et al. Inter-rater reliability of STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria amongst physicians in six European countries. Age Ageing. 2009;38:603–6.

    Article  PubMed  Google Scholar 

  15. Hill-Taylor B, Sketris IS, Gardner DM, Thompson K. Concordance with a STOPP (Screening Tool Of Older Persons’ Potentially Inappropriate Prescriptions) criterion in Nova Scotia, Canada: benzodiazepine and zoplicone prescription claims by older adults with fall-related hospitalizations. J Popul Ther Clin Pharmacol. 2016;23:e1–12.

    CAS  PubMed  Google Scholar 

  16. McMahon CG, Cahir CA, Kenny RA, Bennett K. Inappropriate prescribing in older fallers presenting to an Irish emergency department. Age Ageing. 2014;43:44–50.

    Article  PubMed  Google Scholar 

  17. Pérez T, Moriarty F, Wallace E, McDowell R, Redmond P, Fahey T. Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study. BMJ. 2018;363:k4524.

    Article  PubMed  PubMed Central  Google Scholar 

  18. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg. 2014;12:1495–9.

    Article  Google Scholar 

  19. Sweeney J, Kearney P, Redmond P, Fahey T. Point of care morbidity coding; a feasibility study in primary care. Forum J Irish Coll Gen Pract. 2017;34:52–4.

    Google Scholar 

  20. National Centre for Classification in Health. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM). Sydney: The University of Sydney; 1998.

    Google Scholar 

  21. Nauta KJ, Groenhof F, Schuling J, Hugtenburg JG, van Hout HPJ, Haaijer-Ruskamp FM, et al. Application of the STOPP/START criteria to a medical record database. Pharmacoepidemiol Drug Saf. 2017;26:1242–7.

    Article  PubMed  Google Scholar 

  22. de Groot DA, de Vries M, Joling KJ, van Campen JP, Hugtenburg JG, van Marum RJ, et al. Specifying ICD9, ICPC and ATC codes for the STOPP/START criteria: a multidisciplinary consensus panel. Age Ageing. 2014;43:773–8.

    Article  PubMed  Google Scholar 

  23. WHO Collaborating Centre for Drug Statistics Methodology. ATC/DDD Index. 2015. http://www.whocc.no/atc_ddd_index/. Accessed 13 Jul 2015.

  24. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;2:CD007146.

    Google Scholar 

  25. Reeve E, Moriarty F, Nahas R, Turner JP, Kouladjian O’Donnell L, Hilmer SN. A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms. Expert Opin Drug Saf. 2018;17:39–49.

    Article  CAS  PubMed  Google Scholar 

  26. Boye ND, van der Velde N, de Vries OJ, van Lieshout EM, Hartholt KA, Mattace-Raso FU, et al. Effectiveness of medication withdrawal in older fallers: results from the Improving Medication Prescribing to reduce Risk Of FALLs (IMPROveFALL) trial. Age Ageing. 2017;46:142–6.

    PubMed  Google Scholar 

  27. Eckstrom E, Parker EM, Lambert GH, Winkler G, Dowler D, Casey CM. Implementing STEADI in academic primary care to address older adult fall risk. Innov Aging. 2017;1:igx028.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Mott DA, Martin B, Breslow R, Michaels B, Kirchner J, Mahoney J, et al. Impact of a medication therapy management intervention targeting medications associated with falling: results of a pilot study. J Am Pharm Assoc. 2016;56:22–8.

    Article  Google Scholar 

  29. Lasserre A, Younes N, Blanchon T, Cantegreil-Kallen I, Passerieux C, Thomas G, et al. Psychotropic drug use among older people in general practice: discrepancies between opinion and practice. Br J Gen Pract. 2010;60:e156–62.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Gould RL, Coulson MC, Patel N, Highton-Williamson E, Howard RJ. Interventions for reducing benzodiazepine use in older people: meta-analysis of randomised controlled trials. Br J Psychiatry. 2014;204:98–107.

    Article  PubMed  Google Scholar 

  31. Bell HT, Steinsbekk A, Granas AG. Factors influencing prescribing of fall-risk-increasing drugs to the elderly: a qualitative study. Scand J Prim Health Care. 2015;33:107–14.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Visschedijk J, Achterberg W, van Balen R, Hertogh C. Fear of falling after hip fracture: a systematic review of measurement instruments, prevalence, interventions, and related factors. J Am Geriatr Soc. 2010;58:1739–48.

    Article  PubMed  Google Scholar 

  33. Zijlstra GAR, Van Haastregt JCM, Van Rossum E, Van Eijk JTM, Yardley L, Kempen GIJM. Interventions to reduce fear of falling in community-living older people: a systematic review. J Am Geriatr Soc. 2007;55:603–15.

    Article  PubMed  Google Scholar 

  34. Zhao JG, Zeng XT, Wang J, Liu L. Association between calcium or vitamin D supplementation and fracture incidence in community-dwelling older adults: a systematic review and meta-analysis. JAMA. 2017;318:2466–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol. 2018;6(11):847–58.

    Article  CAS  PubMed  Google Scholar 

  36. Laird E, O’Halloran AM, Carey D, Healy M, O’Connor D, Moore P, et al. The prevalence of vitamin D deficiency and the determinants of 25(OH)D concentration in older irish adults: data from The Irish Longitudinal Study on Ageing (TILDA). J Gerontol A Biol Sci Med Sci. 2018;73:519–25.

    Article  PubMed  Google Scholar 

  37. Gallacher SJ, McQuillian C, Harkness M, Finlay F, Gallagher AP, Dixon T. Prevalence of vitamin D inadequacy in Scottish adults with non-vertebral fragility fractures. Curr Med Res Opin. 2005;21:1355–61.

    Article  CAS  PubMed  Google Scholar 

  38. Petrella RJ, Jones TJ. Do patients receive recommended treatment of osteoporosis following hip fracture in primary care? BMC Fam Pract. 2006;7:31.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Bromfield SG, Ngameni CA, Colantonio LD, Bowling CB, Shimbo D, Reynolds K, et al. Blood pressure, antihypertensive polypharmacy, frailty, and risk for serious fall injuries among older treated adults with hypertension. Hypertension. 2017;70:259–66.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. National Office of Clinical Audit. Irish Hip Fracture Database National Report 2017. Dublin: 2018. https://www.noca.ie/publications. Accessed 10 Jan 2019.

  41. Grimes T, Duggan C, Delaney T. Pharmacy services at admission and discharge in adult, acute, public hospitals in Ireland. Int J Pharm Pract. 2010;18:346–52.

    Article  PubMed  Google Scholar 

  42. Lee DC, McDermott F, Hoffmann T, Haines TP. ‘They will tell me if there is a problem’: limited discussion between health professionals, older adults and their caregivers on falls prevention during and after hospitalization. Health Educ Res. 2013;28:1051–66.

    Article  PubMed  Google Scholar 

  43. Health Services Executive. Making a start in integrated care for older persons. Dublin: Health Services Executive; 2017.

    Google Scholar 

  44. Renom-Guiteras A, Thurmann PA, Miralles R, Klaassen-Mielke R, Thiem U, Stephan A, et al. Potentially inappropriate medication among people with dementia in eight European countries. Age Ageing. 2018;47:68–74.

    Article  Google Scholar 

  45. Bischoff-Ferrari HA, Dawson-Hughes B, Orav EJ, Staehelin HB, Meyer OW, Theiler R, et al. Monthly high-dose vitamin D treatment for the prevention of functional decline: a randomized clinical trial. JAMA Intern Med. 2016;176:175–83.

    Article  PubMed  Google Scholar 

  46. Ryan C, O’Mahony D, Kennedy J, Weedle P, Byrne S. Potentially inappropriate prescribing in an Irish elderly population in primary care. Br J Clin Pharmacol. 2009;68:936–47.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Seppala LJ, van de Glind EMM, Daams JG, Ploegmakers KJ, de Vries M, Wermelink A, et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: II. Others. J Am Med Dir Assoc. 2018;19:3721–8.

    Article  Google Scholar 

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Acknowledgements

The authors gratefully acknowledge the contributions of all participating general practitioners and patients.

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Authors and Affiliations

  1. HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Mercer Building, Lower Mercer Street, Dublin 2, Ireland

    Mary E. Walsh, Fiona Boland, Frank Moriarty & Tom Fahey

Authors
  1. Mary E. Walsh
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  4. Tom Fahey
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Corresponding author

Correspondence to Mary E. Walsh.

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Funding

This study was funded by the Health Research Board (HRB) in Ireland through Grant no. HRC/2014/1 (TF).

Conflicts of interest

Mary E. Walsh, Fiona Boland, Frank Moriarty and Tom Fahey declare that they have no conflicts of interest.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

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Walsh, M.E., Boland, F., Moriarty, F. et al. Modification of Potentially Inappropriate Prescribing Following Fall-Related Hospitalizations in Older Adults. Drugs Aging 36, 461–470 (2019). https://doi.org/10.1007/s40266-019-00646-z

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