Medication Use and Falls Among Community Dwelling Seniors

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Medication Use and Falls Among Community Dwelling
Seniors
Don Voaklander, PhD Associate Professor Community
Health Sciences University of Northern British
Columbia
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• Epidemiology
• The study of the distribution and determinants of
  disease and injury in human populations

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• Injury Epidemiology
• Descriptive epidemiology
• Frequency
• Etiology (causes)
• Analytic epidemiology
• Risk factors
• Outcomes

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Haddon Matrix
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Haddon Matrix
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Epidemiology

• Approximately 1/3 of persons gt65 yr. living at
  home have one or more falls per year.
• Rate increases to 40 to 50 for persons over the
  age of 80 years
• Fall rate ranges from 1.25 to 2 times as great
  for females as for males
• Inconsistent findings on seasonal variation
• Some report a greater frequency during winter
  months

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Consequences of Falls

• Major consequences
• Fractures
• Hip
• Wrist
• Decreased mobility
• Psychosocial dysfunction
• Fear of falling
• Head injury
• Death
• Minor consequences
• Bruising, lacerations

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Etiology of Falls

• Falls are a typically a complex interaction of a
  number of factors
• Relating to the individual Intrinsic Factors
• Relating to the environment Extrinsic Factors

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Etiology of Falls (cont.)

• Extrinsic Factors
• Poor lighting
• Loose stones, uneven pavement
• Stairs
• Loose rugs, clutter, slippery floors
• Icy or wet surfaces
• Women tend to fall from trips while men fall from
  slips

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Etiology of Falls (cont.)

• Three categories of falls (Campbell et al, 1995)
• Fall with impairment or loss of consciousness
• Hypotension, cardiac arrhythmias, epilepsy, etc.
• Fall associated with acute illness
• Postural hypotension, dehydration, medication
  use, etc.
• Fall with impairment of gait or balance
• Incorrect sensory input, impaired motor function,
  etc.

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Etiology of Falls (cont.)

• Factors related to falls
• Physical decline in older persons
• Decreased skeletal muscle strength
• Decreased coordination
• Abnormal blood pressure
• Cardiac arrhythmia
• Impaired mobility and balance
• Visual deficits
• Multiple co-morbidity
• Medication use

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Etiology of Falls (cont.)

• Decreased Muscle Strength
• Deterioration in
• Isometric strength
• Dynamic strength
• Speed of muscle contraction
• Caused by
• Decrease in neural activity
• Reduced muscle fiber size
• Reduced muscle mass and cross sectional size
• Also associated with the bodys ability of
  withstand trauma

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Etiology of Falls (cont.)

• Decreased Coordination
• Gait speed declines 1.6 per year after age 65
• Variable cadence between legs
• Increased path deviation

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Etiology of Falls (cont.)

• Abnormal blood pressure
• Orthostatic hypotension
• Drop of 20mm of systolic BP after standing
• 2-25 of seniors suffer from this
• Postprandial hypotension
• Reduction in systolic BP after meals
• Carotid sinus hypersensitivity
• Can cause a drop of up to 50mm of systolic BP

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Etiology of Falls (cont.)

• Cardiac arrhythmia
• Inconsistent heart-rate
• Cerebrovascular insufficiency
• Cardiac output diminished
• Lower blood pressure

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Etiology of Falls (cont.)

• Impaired mobility and balance
• Deficits in sensory and motor functions
• Increased trunk sway
• Failures in the postural control mechanisms
• Inability to stand on one leg
• Impaired proprioception
• Vestibular disturbances
• Sense of imbalance even when lying down

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Etiology of Falls (cont.)

• Visual deficit
• Visual field loss
• Impaired contrast sensitivity
• Loss of night vision
• Weakened stereo vision
• Lack of depth perception

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Etiology of Falls (cont.)

• Multiple co-morbidity
• Depression, anxiety, insomnia, neuroses
• Osteoroporosis, osteoarthritis
• Cerebrovascular and cardiovascular disease
• Cognitive impairment
• Parkinsons disease
• Hypertension
• Incontinence, malnutrition, gait disorders

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Etiology of Falls (cont.)

• Medication Use
• Pharmokinetics
• Related to drug dosage, concentration and
  elimination
• Absorption is similar to younger persons
• Distribution, metabolism and elimination is
  affected by aging
• Due to reduced metabolic activity and renal
  function
• Pharmodynamics
• How drugs react in the body
• Increased sensitivity to drugs in older persons

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Etiology of Falls (cont.)

• Medication types
• CNS Active
• Sedatives, benzodiazapines
• Anti-depressants
• Anti-psychotics
• Opiates
• Others
• Cardiovascular drugs
• Anti-hypertensive medications
• Anti-convulsants

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The Present Study

• Part of a series of studies of injuries and
  medication use with seniors
• Falls in the Capital Health Region (Edmonton)
• Narcotic pain killers, anti-depressants and
  anti-convulsants associated with falls
• Farm related injury
• Narcotic pain killers, NSAIDS, sedatives
  associated with injury

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Rationale

• The role of medications as a contributing factor
  is important
• It is a potentially important modifiable factor.
• However, inconsistency in the literature
• risk of falling associated with specific classes
  of medications.

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Objectives

• To examine the association between medication use
  in community living persons aged gt 65 years and
  injurious falls requiring presentation to an
  Emergency Department.
• To estimate the above magnitude while controlling
  for potential confounding of underlying medical
  conditions.

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Methods

• Setting Province of Alberta
• Utilizing administrative data
• obtained 5 computerized administrative datasets
  deterministic linkage (PHNs)
• ACCS Emergency Encounters
• CIHI Hospital Abstracts
• Blue Cross Insurance Medication Use
• Physician Claims File Doctor visits
• Alberta Health Registration
• Residence (community dwelling)
• Demographics

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Methods (cont.)

• Retrospective Cohort Study
• All Albertans aged 66 and older
• Community dwelling
• Not in a seniors home or continuing care centre
• 98/99 Fiscal year

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Methods (cont.)

• Dependent Variable
• injurious fall requiring presentation to the
  Emergency Department.
• Independent variable
• Individual medications (15 classes)
• Purchase of medication with 60 days
• Covariates
• age, gender, SES, rural residence,
  co-morbidities.
• Analysis
• Logistic regression
• Bivariate
• Mulitvariable models

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Methods (cont.)

• Co-morbid Conditions - 17
• Eye disorders, Incontinence, Nutritional
  deficiency, Parkinsons, Osteoarthritis,
  Dementia, Depression, Neuroses, Osteoporosis,
  Cerebrovascular disease, Hypertension,
  Cardiovascular disease, Diabetes, Cancer,
  Gait/balance disorders, Seizures, Injury trauma

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Results

• 9,124 falls suffered by 8,530 individuals
• 32.3 falls/1000 population
• 35 were hospitalized
• 37 were coded as unspecified falls at home
• 31 were coded as falls on the same level
• 56 were fractures
• 12 were hip fractures
• 7 of fallers died within a year of the fall

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Results
Seasonal Variation
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Results

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Results

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Results

• Medications
• Narcotic pain killers and anti-convulsants
• Large effects
• Five other med classes related to injury
• Other Significant Results
• Co-morbidity
• Dementia OR 1.93(1.73,2.16)
• Seizures OR 1.88(1.49,2.36)
• Previous injury trauma OR 1.73(1.66,1.82)
• Cerebrovascular Disease OR 1.48(1.34,1.63)
• Treaty Status OR 2.00(1.64,2.43)
• Age OR 1.01(1.00,1.02)
• Gender OR 1.56(1.48,1.63)

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Discussion

• Falls have serious health consequences for
  seniors
• Large number of fractures
• Double the death rate in the subsequent year
• No significant seasonal trend
• Treaty status Aboriginals at high risk.
• Those taking narcotic pain killers and
  anti-convulsants at higher risk of falls
• Those diagnosed with dementia, seizures, stroke,
  history of injury at risk

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Discussion

• Limitations
• Health behaviour may be related to medication use
• Eg anti-coagulants
• Other care settings not examined
• Doctors offices, chiropractors, etc.
• Alcohol and non-prescriptions drugs not measured
• Only billings measured, not compliance
• Only injuries that occurred in Alberta
• No snowbirds

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Discussion

• Strengths
• Uniform health system
• All variables measured in the same way for
  fallers and non-fallers
• Population based
• Few exclusions
• Both ED data and hospitalizations

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Conclusion

• Narcotic pain killers related to fall injury
• Indicator of severity of disease or independent
  risk factor
• Same issue with anti-convulsants
• Nevertheless, medication use related to injury
• More research needed with Aboriginal population
• First study to identify this issue
• Further work with possible drug interactions

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Road Distance to Regional Hospital

• 0 15 kms. Reference
• 16 50 kms. OR1.02(0.96,1.08)
• 51 100 kms. OR1.19(1.13,1.27)
• 101 200 kms. OR1.30(1.21,1.40)
• 201 300 kms. OR1.10(0.97,1.24)
• 301 400 kms. OR0.77(90.42,1.42)
• gt400 kms. OR9.51(4.57,19.79)

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Further Research

• Large seniors health utilization study
• Medication use and
• MVCs
• Burns
• Poisoning
• Intentional injury?
• Overdoses
• Medication Misuse
• Suicide/Self-inflicted injury

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• Regional Mortality
• Regional Prescription Use

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Thank you