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The article discusses research which examined the prevalence and risk factors for falls and fall-related injuries in the 2018 National Post-acute and Long-term Care Study conducted by the U.S. National Center for Health Statistics. The study analyze the demographic or clinical characteristics of residential care community residents associated with falls and fall-related injuries. It attributes falls and injuries to functional and cognitive impairment, multimorbidity and antipsychotic drug use.

Background: Gait speed decline, an early marker of functional impairment, is a sensitive predictor of adverse health outcomes in older adults. The effect of potentially inappropriate medications, including drug-disease and drug-drug interactions, on gait speed decline is not well known. Objective: The aim of this study was to determine if drug interactions impair functional status as measured by gait speed. Methods: The sample included 2402 older adults with medication and gait speed data from the Health, Aging and Body Composition study. The independent variable was the frequency of drug-disease and/or drug-drug interactions at baseline and 3 additional years. The main outcome was a clinically meaningful gait speed decline of ≥0.1 m/s the year following drug interaction assessment. Adjusted odds ratios and 95 % confidence intervals (CIs) were calculated using multivariate generalized estimating equations for both the overall sample and a sample stratified by gait speed at time of drug interaction assessment. Results: The prevalence of drug-disease and drug-drug interactions ranged from 7.6 to 9.3 and 10.5 to 12.3 %, respectively, with few participants (3.8-5.7 %) having multiple drug interactions. At least 22 % of participants had a gait speed decline of ≥0.1 m/s annually. Drug interactions were not significantly associated with gait speed decline overall or in the stratified sample of fast walkers. There was some evidence, however, that drug interactions increased the risk of gait speed decline among those participants with slower gait speeds, though p values did not reach statistical significance (adjusted odds ratio 1.22; 95 % CIs 0.96-1.56; p = 0.11). Moreover, a marginally significant dose-response relationship was seen with multiple drug interactions and gait speed decline (adjusted odds ratio 1.40; 95 % CIs 0.95-2.04; p = 0.08). Conclusions: Drug interactions may increase the likelihood of gait speed decline among older adults with evidence of preexisting debility. Future studies should focus on frail elders with less physiological reserve who may be more susceptible to the harms associated with potentially inappropriate medications. [ABSTRACT FROM AUTHOR]

Objectives To examine whether older adults taking nonsteroidal anti-inflammatory drugs ( NSAIDs) decreased the underuse of gastroprotective agents over time. Design Before-and-after study. Setting Health, Aging and Body Composition Study. Participants Daily users of a NSAID (prescription and over the counter ( OTC)) at visits in 2002-03 (preperiod; n = 404) and 2006-07 (postperiod; n = 172). The sample had a mean ± standard deviation age of 78.2 ± 2.7 at the preperiod visit and 81.9 ± 2.7 at the postperiod visit. The majority were white and female and had 12 or more years of education. Measurements Underusers were defined as persons taking nonselective NSAIDs who were at risk of peptic ulcer disease ( PUD; because of current warfarin or glucocorticoid use or history of PUD) and not using a proton pump inhibitor ( PPI) or persons taking cyclooxygenase 2 ( COX-2) selective NSAIDs and aspirin who were at risk of PUD (having at least one risk factor) and not using a PPI. Results Daily NSAID use decreased from 17.6% to 11.3% ( P < .001), and gastroprotective agent underuse decreased from 23.5% to 15.1% ( P = .008). Controlling for important covariates, having prescription insurance was somewhat protective against underuse in the preperiod (adjusted odds ratio ( AOR) = 0.78, 95% confidence interval ( CI) = 0.46-1.34; P = .37), but more so and significantly in the postperiod ( AOR = 0.41, 95% CI = 0.18-0.93; P = .03). Having prescription insurance was more protective in the post- than in the preperiod (less gastroprotective agent underuse; adjusted ratio of OR = 0.53, 95% CI = 0.22-1.29; P = .16), but this increased protection was not statistically significant. Conclusion In older daily NSAID users at high risk of PUD, having prescription insurance and adequate gastroprotective use was more common in the post- than in the preperiod. [ABSTRACT FROM AUTHOR]

Objectives To assess the association between multiple pharmacy use and medication adherence and potential drug-drug interactions ( DDIs) in older adults. Design Cross-sectional propensity score-weighted analysis. Setting 2009 claims data. Participants A nationally representative sample of 926,956 Medicare Part D beneficiaries aged 65 and older continuously enrolled in fee-for-service Medicare and Part D that year who filled one or more prescriptions at a community retail or mail order pharmacy. Measurements Multiple pharmacy use was defined as concurrent (overlapping time periods) or sequential use (non-overlapping time periods) of ≥2 pharmacies in the year. Medication adherence was calculated using a proportion of days covered of 0.80 or greater for eight therapeutic categories (beta-blockers, renin angiotensin system antagonists, calcium channel blockers, statins, sulfonylureas, biguanides (metformin), thiazolidinediones, and dipeptidyl peptidase- IV inhibitors). Potential DDIs arising from use of certain drugs across a broad set of classes were defined as the concurrent filling of two interacting drugs. Results Overall, 38.1% of the sample used multiple pharmacies. Those using multiple pharmacies (concurrently or sequentially) consistently had higher adjusted odds of nonadherence (ranging from 1.10 to 1.31, P < .001) across all chronic medication classes assessed after controlling for sociodemographic, health status, and access to care factors than single pharmacy users. The adjusted predicted probability of exposure to a DDI was also slightly higher for those using multiple pharmacies concurrently (3.6%) than for single pharmacy users (3.2%, adjusted odds ratio ( AOR) = 1.11, 95% confidence interval ( CI) = 1.08-1.15) but lower in individuals using multiple pharmacies sequentially (2.8%, AOR = 0.85, 95% CI = 0.81-0.91). Conclusions Filling prescriptions at multiple pharmacies was associated with lower medication adherence across multiple chronic medications and a small but statistically significant greater likelihood of DDIs in concurrent pharmacy users. [ABSTRACT FROM AUTHOR]

Objectives To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions ( ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics. Design Retrospective cohort. Setting Veterans Affairs Medical Centers. Participants Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006. Measurements Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications). Results Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio ( AOR) = 3.90, 95% confidence interval ( CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively). Conclusion ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy. [ABSTRACT FROM AUTHOR]

Objective. To examine the prevalence and correlates of non-opioid and opioid analgesic use and descriptively evaluate potential undertreatment in a sample of community-dwelling elders with symptomatic knee and/or hip osteoarthritis (OA). Design. Cross-sectional. Setting. Health, Aging, and Body Composition Study. Patients. Six hundred and fifty-two participants attending the year 6 visit (2002-03) with symptomatic knee and/or hip OA. Outcome Measures. Analgesic use was defined as taking ≥1 non-opioid and/or ≥1 opioid receptor agonist. Non-opioid and opioid doses were standardized across all agents by dividing the daily dose used by the minimum effective analgesic daily dose. Inadequate pain control was defined as severe/extreme OA pain in the past 30 days from a modified Western Ontario and McMaster Universities Osteoarthritis Index. Results. Just over half (51.4%) reported taking at least one non-opioid analgesic and approximately 10% was taking an opioid, most (88.5%) of whom also took a non-opioid. One in five participants (19.3%) had inadequate pain control, 39% of whom were using <1 standardized daily dose of either a non-opioid or opioid analgesic. In adjusted analyses, severe/extreme OA pain was significantly associated with both non-opioid (adjusted odds ratio [AOR] = 2.44; 95% confidence interval [95% CI] = 1.49-3.99) and opioid (AOR = 2.64; 95% CI = 1.26-5.53) use. Conclusions. Although older adults with severe/extreme knee and/or hip OA pain are more likely to take analgesics than those with less severe pain, a sizable proportion takes less than therapeutic doses and thus may be undertreated. Further research is needed to examine barriers to optimal analgesic use. [ABSTRACT FROM AUTHOR]

Background and aims: One‐third of opioid (OPI) overdose deaths involve concurrent benzodiazepine (BZD) use. Little is known about concurrent opioid and benzodiazepine use (OPI–BZD) most associated with overdose risk. We aimed to examine associations between OPI–BZD dose and duration trajectories, and subsequent OPI or BZD overdose in US Medicare. Design Retrospective cohort study. Setting: US Medicare. Participants: Using a 5% national Medicare data sample (2013–16) of fee‐for‐service beneficiaries without cancer initiating OPI prescriptions, we identified 37 879 beneficiaries (age ≥ 65 = 59.3%, female = 71.9%, white = 87.6%, having OPI overdose = 0.3%). Measurements During the 6 months following OPI initiation (i.e. trajectory period), we identified OPI–BZD dose and duration patterns using group‐based multi‐trajectory models, based on average daily morphine milligram equivalents (MME) for OPIs and diazepam milligram equivalents (DME) for BZDs. To label dose levels in each trajectory, we defined OPI use as very low (< 25 MME), low (25–50 MME), moderate (51–90 MME), high (91–150 MME) and very high (>150 MME) dose. Similarly, we defined BZD use as very low (< 10 DME), low (10–20 DME), moderate (21–40 DME), high (41–60 DME) and very high (> 60 DME) dose. Our primary analysis was to estimate the risk of time to first hospital or emergency department visit for OPI overdose within 6 months following the trajectory period using inverse probability of treatment‐weighted Cox proportional hazards models. Findings We identified nine distinct OPI–BZD trajectories: group A: very low OPI (early discontinuation)–very low declining BZD (n = 10 598; 28.0% of the cohort); B: very low OPI (early discontinuation)–very low stable BZD (n = 4923; 13.0%); C: very low OPI (early discontinuation)–medium BZD (n = 4997; 13.2%); D: low OPI–low BZD (n = 5083; 13.4%); E: low OPI–high BZD (n = 3906; 10.3%); F: medium OPI–low BZD (n = 3948; 10.4%); G: very high OPI–high BZD (n = 1371; 3.6%); H: very high OPI–very high BZD (n = 957; 2.5%); and I: very high OPI–low BZD (n = 2096; 5.5%). Compared with group A, five trajectories (32.3% of the study cohort) were associated with increased 6‐month OPI overdose risks: E: low OPI–high BZD [hazard ratio (HR) = 3.27, 95% confidence interval (CI) = 1.61–6.63]; F: medium OPI–low BZD (HR = 4.04, 95% CI = 2.06–7.95); G: very high OPI–high BZD (HR = 6.98, 95% CI = 3.11–15.64); H: very high OPI–very high BZD (HR = 4.41, 95% CI = 1.51–12.85); and I: very high OPI–low BZD (HR = 6.50, 95% CI = 3.15–13.42). Conclusions: Patterns of concurrent opioid and benzodiazepine use most associated with overdose risk among fee‐for‐service US Medicare beneficiaries initiating opioid prescriptions include very high‐dose opioid use (MME > 150), high‐dose benzodiazepine use (DME > 40) or medium‐dose opioid with low‐dose benzodiazepine use. [ABSTRACT FROM AUTHOR]

One's experience with dementia may affect their perceptions about dementia preventability, which in turn could influence preventive health behaviors. We aimed to examine how having a family history of dementia and caregiving experience are associated with perceptions about and self-efficacy for dementia preventability. Cross-sectional, self-administered survey. Participants reported whether they have had a family member with dementia and, among those who reported having a family member with dementia, whether they served as a caregiver. Outcomes were perceptions about the likelihood of dementia preventability, self-efficacy for dementia prevention, and benefits of specific dementia prevention strategies. Associations were assessed via partial proportional odds model for ordinal outcome variables and logistic regression for binary outcome variables. Of 1,575 respondents, 71% had a family member with dementia, of which 42% served as a caregiver. People with a family member with dementia were less likely to believe that dementia is preventable (aOR = 0.75, 95% CI: 0.58, 0.96) and had lower self-efficacy for dementia prevention (aOR = 0.71, 95% CI: 0.56, 0.90). The subgroup analysis among those with caregiving experience was consistent with the primary findings, showing less belief in the likelihood of dementia preventability (aOR = 0.69, 95% CI: 0.46, 1.03) and self-efficacy (aOR = 0.75, 95% CI: 0.56, 1.00). Having a family member with dementia is associated with unfavorable perceptions about dementia preventability. Incorporating family history of dementia into communication efforts about dementia risk reduction may help address potential barriers to preventive health behaviors. [ABSTRACT FROM AUTHOR]

Background: Central nervous system (CNS)‐active medication use is an important modifiable risk factor for falls in older adults. A fall‐related injury should prompt providers to evaluate and reduce CNS‐active medications to prevent recurrent falls. We evaluated change in CNS‐active medications up to 12 months following a fall‐related injury in community‐dwelling older adults compared with a matched cohort without fall‐related injury. Methods: Participants were from the Adult Changes in Thought study conducted at Kaiser Permanente Washington. Fall‐related injury codes between 1994 and 2014 defined index encounters in participants with no evidence of such injuries in the preceding year. We matched each fall‐related injury index encounter with up to five randomly selected clinical encounters from participants without injury. Using automated pharmacy data, we estimated the average change in CNS‐active medication use at 3, 6, and 12 months post‐index according to the presence or absence of CNS‐active medication use before index. Results: One thousand five hundred sixteen participants with fall‐related injury index encounters (449 CNS‐active users, 1067 nonusers) were matched to 7014 index encounters from people without fall‐related injuries (1751 users, 5236 nonusers). Among CNS‐active users at the index encounter, those with fall‐related injury had an average decrease in standard daily doses (SDDs) at 12 months (−0.43; 95% CI: −0.63 to −0.23), and those without injury had a greater (p = 0.047) average decrease (−0.66; 95% CI: −0.78 to −0.55). Among nonusers at index, those with fall‐related injury had a smaller increase than those without injury (+0.17, 95% CI: +0.13 to +0.21, vs. +0.24, 95% CI: +0.20 to +0.28, p = 0.005). Conclusions: The differences in CNS‐active medication use change over 12 months between those with and without fall‐related injury were small and unlikely to be clinically significant. These results suggest that fall risk‐increasing drug use is not reduced following a fall‐related injury, thus opportunities exist to reduce CNS‐active medications, a potentially modifiable risk factor for falls. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of inserting epidemiological information into lumbar spine imaging reports on subsequent nonsurgical and surgical procedures involving the thoracolumbosacral spine and sacroiliac joints. Design Analysis of secondary outcomes from the Lumbar Imaging with Reporting of Epidemiology (LIRE) pragmatic stepped-wedge randomized trial. Setting Primary care clinics within four integrated health care systems in the United States. Subjects 238,886 patients ≥18 years of age who received lumbar diagnostic imaging between 2013 and 2016. Methods Clinics were randomized to receive text containing age- and modality-specific epidemiological benchmarks indicating the prevalence of common spine imaging findings in people without low back pain, inserted into lumbar spine imaging reports (the "LIRE intervention"). The study outcomes were receiving 1) any nonsurgical lumbosacral or sacroiliac spine procedure (lumbosacral epidural steroid injection, facet joint injection, or facet joint radiofrequency ablation; or sacroiliac joint injection) or 2) any surgical procedure involving the lumbar, sacral, or thoracic spine (decompression surgery or spinal fusion or other spine surgery). Results The LIRE intervention was not significantly associated with subsequent utilization of nonsurgical lumbosacral or sacroiliac spine procedures (odds ratio [OR] = 1.01, 95% confidence interval [CI] 0.93–1.09; P  = 0.79) or any surgical procedure (OR = 0.99, 95 CI 0.91–1.07; P  = 0.74) involving the lumbar, sacral, or thoracic spine. The intervention was also not significantly associated with any individual spine procedure. Conclusions Inserting epidemiological text into spine imaging reports had no effect on nonsurgical or surgical procedure utilization among patients receiving lumbar diagnostic imaging. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Early recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)‐based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule [eRADAR]). DESIGN: Retrospective cohort study. SETTING: Kaiser Permanente Washington (KPWA), an integrated healthcare delivery system. PARTICIPANTS: A total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples. MEASUREMENTS: EHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills). RESULTS: Overall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31‐predictor model included markers of dementia‐related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic =.78; 95% confidence interval [CI] =.76‐.81) and validation (C statistic =.81; 95% CI =.78‐.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia. CONCLUSION: The eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103–111, 2019 [ABSTRACT FROM AUTHOR]

Objectives To describe facility-level variation in two measures of potentially inappropriate prescribing prevalent in Veterans Affairs ( VA) facilities-exposure to high-risk medications in elderly adults ( HRME) and drug-disease interactions ( Rx- DIS)-and to identify facility characteristics associated with high-quality prescribing. Design Cross-sectional. Setting VA Healthcare System. Participants Veterans aged 65 and older with at least one inpatient or outpatient visit in 2005-2006 ( N = 2,023,477; HRME exposure) and a subsample with a history of falls or hip fractures, dementia, or chronic renal failure (n = 305,059; Rx- DIS exposure). Measurements Incident use of any HRME ( iHRME) and incident Rx- DIS ( iRx- DIS) and facility-level rates and facility-level predictors of iHRME and iRx- DIS exposure, adjusting for differences in patient characteristics. Results Overall, 94,692 (4.7%) veterans had iHRME exposure. At the facility level, iHRME exposure ranged from 1.6% at the lowest facility to 12.8% at the highest (median 4.7%). In the subsample, 9,803 (3.2%) veterans had iRx-DIS exposure, with a facility-level range from 1.3% to 5.8% (median 3.2%). In adjusted analyses, veterans seen in facilities with formal geriatric education had lower odds of iHRME (odds ratio ( OR) = 0.86, 95% confidence interval ( CI) = 0.77-0.96) and iRx- DIS ( OR = 0.95, 95% CI = 0.88-1.01). Patients seen in facilities caring for fewer older veterans had greater odds of iHRME ( OR = 1.54, 95% CI = 1.35-1.75) and iRx- DIS exposure ( OR = 1.22, 95% CI = 1.11-1.33). Conclusion Substantial variation in the quality of prescribing for older adults exists across VA facilities, even after adjusting for patient characteristics. Higher-quality prescribing is found in facilities caring for a larger number of older veterans and facilities with formal geriatric education. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure. DESIGN: Cross-sectional retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006. MEASUREMENTS: Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status. RESULTS: Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS. CONCLUSION: The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults. [ABSTRACT FROM AUTHOR]