Psychotropic Drug Initiation or Increased Dosage and the Acute Risk of Falls: A Prospective Cohort Study of Nursing Home Residents

Background: Previous studies suggest that psychotropic drug changes may signal an acute period of time whereby a person is highly vulnerable to fall. It is unknown whether certain classes of psychotropic agents are less safe with respect to the acute risk of falls. Our purpose was to compare fall rates in the 7 days following a change of an antidepressant, antipsychotic, or benzodiazepine. We also identified specific times when residents are at high risk for falls with respect to a psychotropic drug change. Methods: Residents in our one-year study included 851 long term care residents from two nursing home facilities in Boston, MA, U.S.A. (May 2010 - May 2011). Drug changes (i.e., new prescriptions or increased dose of a previously used drug) were ascertained using the computerized provider order entry system, whereas falls were ascertained by incident reports. Negative binomial regression was used to compare the rate of falls following a drug change between medication classes. Further, we calculated the rate of falls for each of the 7 days before and 7 days after a psychotropic drug change. Results: Forty-eight percent of residents were prescribed a new prescription or increased dose of a psychotropic drug during the study. The rate of falls was similar in the 7 days following a change to a SSRI versus non-SSRI antidepressant (11.9 versus 14.4 falls/1,000 person years; p = 0.58), a typical versus an atypical antipsychotic (25.4 versus 17.1 falls/1,000 person years; p = 0.10), or a short versus long acting benzodiazepine (15.2 versus 13.9 falls/1,000 person years; p = 0.23). Fall risk was highest on day 4 before the drug change (19.0 falls/1,000 person days), on the day of the drug change through 2 days after the drug change (17.6-20.3 falls/1,000 person days), and 5-6 days after the drug change (17.6-19.0 falls/1,000 person days). Conclusions: In the nursing home, risk of falls was similar following a psychotropic drug change of any class. We observed higher fall risk in the days before, but mostly after the drug change. We recommend that nursing home residents be closely monitored following a psychotropic drug change in an effort to reduce falls

Heritability of Thoracic Spine Curvature and Genetic Correlations With Other Spine Traits: The Framingham Study

Hyperkyphosis is a common spinal disorder in older adults, characterized by excessive forward curvature of the thoracic spine and adverse health outcomes. The etiology of hyperkyphosis has not been firmly established, but may be related to changes that occur with aging in the vertebrae, discs, joints, and muscles, which function as a unit to support the spine. Determining the contribution of genetics to thoracic spine curvature and the degree of genetic sharing among co-occurring measures of spine health may provide insight into the etiology of hyperkyphosis. The purpose of our study was to estimate heritability of thoracic spine curvature using T4–T12 kyphosis (Cobb) angle and genetic correlations between thoracic spine curvature and vertebral fracture, intervertebral disc height narrowing, facet joint osteoarthritis (OA), lumbar spine volumetric bone mineral density (vBMD), and paraspinal muscle area and density, which were all assessed from computed tomography (CT) images. Participants included 2063 women and men in the second and third generation offspring of the original cohort of the Framingham Study. Heritability of kyphosis angle, adjusted for age, sex, and weight, was 54% (95% confidence interval [CI], 43% to 64%). We found moderate genetic correlations between kyphosis angle and paraspinal muscle area (math formulaG, –0.46; 95% CI, –0.67 to –0.26), vertebral fracture (math formulaG, 0.39; 95% CI, 0.18 to 0.61), vBMD (math formulaG, –0.23; 95% CI, –0.41 to –0.04), and paraspinal muscle density (math formulaG, –0.22; 95% CI, –0.48 to 0.03). Genetic correlations between kyphosis angle and disc height narrowing (math formulaG, 0.17; 95% CI, –0.05 to 0.38) and facet joint OA (math formulaG, 0.05; 95% CI, –0.15 to 0.24) were low. Thoracic spine curvature may be heritable and share genetic factors with other age-related spine traits including trunk muscle size, vertebral fracture, and bone mineral density

The MOBILIZE Boston Study: Design and methods of a prospective cohort study of novel risk factors for falls in an older population

<p>Abstract</p> <p>Background</p> <p>Falls are the sixth leading cause of death in elderly people in the U.S. Despite progress in understanding risk factors for falls, many suspected risk factors have not been adequately studied. Putative risk factors for falls such as pain, reductions in cerebral blood flow, somatosensory deficits, and foot disorders are poorly understood, in part because they pose measurement challenges, particularly for large observational studies.</p> <p>Methods</p> <p>The MOBILIZE Boston Study (MBS), an NIA-funded Program Project, is a prospective cohort study of a unique set of risk factors for falls in seniors in the Boston area. Using a door-to-door population-based recruitment, we have enrolled 765 persons aged 70 and older. The baseline assessment was conducted in 2 segments: a 3-hour home interview followed within 4 weeks by a 3-hour clinic examination. Measures included pain, cerebral hemodynamics, and foot disorders as well as established fall risk factors. For the falls follow-up, participants return fall calendar postcards to the research center at the end of each month. Reports of falls are followed-up with a telephone interview to assess circumstances and consequences of each fall. A second assessment is performed 18 months following baseline.</p> <p>Results</p> <p>Of the 2382 who met all eligibility criteria at the door, 1616 (67.8%) agreed to participate and were referred to the research center for further screening. The primary reason for ineligibility was inability to communicate in English. Results from the first 600 participants showed that participants are largely representative of seniors in the Boston area in terms of age, sex, race and Hispanic ethnicity. The average age of study participants was 77.9 years (s.d. 5.5) and nearly two-thirds were women. The study cohort was 78% white and 17% black. Many participants (39%) reported having fallen at least once in the year before baseline.</p> <p>Conclusion</p> <p>Our results demonstrate the feasibility of conducting comprehensive assessments, including rigorous physiologic measurements, in a diverse population of older adults to study non-traditional risk factors for falls and disability. The MBS will provide an important new data resource for examining novel risk factors for falls and mobility problems in the older population.</p

Increased Bone Resorption Is Associated With Increased Risk of Cardiovascular Events in Men: The MINOS Study

Better assessment of the association between cardiovascular disease and osteoporosis in older men may help identify shared etiologies for bone and heart health in this population. We assessed the association of BMD and bone turnover markers (BTMs) with risk of cardiovascular events (myocardial infarction or stroke) in 744 men ≥50 yr of age. During the 7.5-yr prospective follow-up, 43 strokes and 40 myocardial infarctions occurred in 79 men. After adjustment for confounders (age, weight, height, smoking, education, physical activity, self-reported history of diabetes, hypertension, and prevalent ischemic heart disease), men in the lowest quartile of BMD at the spine, whole body, and forearm had a 2-fold increased risk of cardiovascular events. Men in the highest quartile of bone resorption markers (deoxypyridinoline [DPD], C-telopeptide of type I collagen) had a 2-fold increased risk of cardiovascular events (e.g., multivariable-adjusted hazard ratio [including additional adjustment for BMD] was 2.11 [95% CI: 1.26–3.56], for the highest quartile of free DPD relative to the lowest three quartiles). The results were similar for men without prevalent ischemic heart disease and for myocardial infarction and stroke analyzed separately. Our data suggest that men with low BMD or high bone resorption may be at increased risk of myocardial infarction and stroke in addition to fracture. Thus, men with osteoporosis may benefit from screening for cardiovascular disease. Further study to elucidate the biological mechanism shared by bone and vascular disease may help efforts to identify men at risk or develop treatment

Management of persistent pain in older adults: The MOBILIZE Boston Study

Objectives: To describe the prevalence of pharmacological (PS) and nonpharmacological (NPS) pain management approaches used by older adults with persistent pain and to identify characteristics associated with use of these approaches. Design: Population-based cohort. Setting: Urban and suburban communities in the Boston, Massachusetts, area. Participants: Seven hundred sixty-five adults aged 64 and older underwent a home interview and clinic examination. Those reporting any persistent pain were included in this analysis (N = 599). Measurements: All prescription and nonprescription medications were recorded during the home interview. NPS modalities for pain management were assessed using a modification of the Pain Management Inventory. The baseline assessment included extensive measures of pain, health, and functioning. Results: More than one-third (37.5%) of participants reported using both PS and NPS modalities. Thirty-one percent reported use of NPS modalities alone, and 11.5% used PS modalities alone. NPS modalities (68.4%) were reported more frequently than PS modalities (49%). Women (odds ratio (OR) = 2.2, 95% confidence interval (CI) = 1.26–3.82), individuals with knee osteoarthritis (OR = 3.07, 95% CI = 1.6–5.9), and individuals with moderate to severe pain (OR = 5.02, 95% CI = 2.23–11.28) were more likely to report combined use of PS and NPS modalities. Characteristics associated with individual NPS modalities varied greatly. Conclusion: Only one-third of older adults with persistent pain reported pain management strategies consistent with current guidelines. Further research is required to understand reasons behind choices, barriers to adherence, and the benefits of multiple modalities that older adults with persistent pain use

Poor Adherence to Medications May Be Associated with Falls

BACKGROUND: Poor medication adherence is associated with negative health outcomes. We investigated whether poor medication adherence increases the rate of falls as part of Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston (MOBILIZE Boston), a prospective, community-based cohort recruited for the purpose of studying novel risk factors for falls. METHODS: A total of 246 men and 408 women (mean age, 78 years) were followed for the occurrence of falls (median follow-up, 1.8 years). Adherence was assessed by the Morisky scale based on the following four questions: whether an individual ever forgets, is careless at times, stops taking medications when feels better, or stops taking medications when feels worse. Low adherence was defined as a yes answer to one or more questions. High adherence was defined as a no answer to every question. RESULTS: Forty-eight percent of subjects were classified as having low medication adherence. The rate of falls in the low adherence group was 1.1 falls/person-year (95% confidence interval [CI]: 1.0-1.3) compared with 0.7 falls/person-year (95% CI: 0.6-0.8) in the high adherence group. After adjusting for age, sex, race/ethnicity, education, alcohol use, cognitive measures, functional status, depression, and number of medications, low medication adherence was associated with a 50% increased rate of falls compared with high medication adherence (rate ratio = 1.5, 95% CI: 1.2-1.9; p \u3c .001). CONCLUSIONS: Low medication adherence may be associated with an increased rate of falls among older adults. Future studies should confirm this association and explore whether interventions to improve medication adherence might decrease the frequency of falls and other serious health-related outcomes