The risk of fall injury
527
26 Jørgensen TS, Hansen AH, Sahlberg M, et al. Falls and comorbidity: the pathway to fractures. Scand J Public Health 2014;42:287–94.
33 Boise L, Camicioli R, Morgan DL, et al. Diagnosing dementia: perspectives of primary care physicians. Gerontologist 1999;39:457–64.
27 Franz CE, Barker JC, Kim K, et al. When help becomes a hindrance: mental health referral systems as barriers to care for primary care physicians treating patients with Alzheimer’s disease. Am J Geriatr Psychiatry 2010;18:576–85.
34 Forbes DA, Morgan D, Janzen BL. Rural and urban Canadians with dementia: use of health care services. Can J Aging 2006;25:321–30.
28 Vernooij-Dassen MJ, Moniz-Cook ED, Woods RT, et al. Factors affecting timely recognition and diagnosis of dementia across Europe: from awareness to stigma. Int J Geriatr Psychiatry 2005;20:377–86. 29 Hinton L, Franz CE, Reddy G, et al. Practice constraints, behavioral problems, and dementia care: primary care physicians’ perspectives. J Gen Intern Med 2007;22: 1487–92. 30 Wilkinson D, Stave C, Keohane D, Vincenzino O. The role of general practitioners in the diagnosis and treatment of Alzheimer’s disease: a multinational survey. J Int Med Res 2004;32:149–59. 31 Iliffe S, De Lepeleire J, Van Hout H, et al. Understanding obstacles to the recognition of and response to dementia in different European countries: a modified focus group approach using multinational, multi-disciplinary expert groups. Aging Ment Health 2005;9:1–6. 32 Koller D, Eisele M, Kaduszkiewicz H, et al. Ambulatory health services utilization in patients with dementia—is there an urban-rural difference? Int J Health Geogr 2010; 9:59.
35 Glazier RH, Agha MM, Moineddin R, Sibley LM. Universal health insurance and equity in primary care and specialist office visits: a population-based study. Ann Fam Med 2009;7:396–405. 36 Dobalian A, Tsao JC, Radcliff TA. Diagnosed mental and physical health conditions in the United States nursing home population: differences between urban and rural facilities. J Rural Health 2003;19:477–83. 37 Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117–27. 38 Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002;137: 511–20. 39 Courtney C, Farrell D, Gray R, et al. Long-term donepezil treatment in 565 patients with Alzheimer’s disease (AD2000): randomised double-blind trial. Lancet 2004;363: 2105–15. 40 Birk HO, Gut R, Henriksen LO. Patients’ experience of choosing an outpatient clinic in one county in Denmark: results of a patient survey. BMC Health Serv Res 2011;11: 262.
......................................................................................................... European Journal of Public Health, Vol. 25, No. 3, 527–532 The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku120 Advance Access published on 1 August 2014
.........................................................................................................
The risk of fall injury in relation to commonly prescribed medications among older people—a Swedish case-control study Bernhard M. Kuschel, Lucie Laflamme, Jette Mo¨ller Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden Correspondence: Jette Mo¨ller, Department of Public Health Sciences, Karolinska Institutet, Widerstro¨mska huset, 10th floor, Tomtebodava¨gen 18 A, SE-17177 Stockholm, Sweden, Tel: +46 8 524 801 22, Fax: +46 8 311 590, e-mail: [email protected]
Background: Older people not only consume more medication but they also represent a group at high risk for adverse effects such as injurious falls. This study examines the association between the medications most commonly prescribed to older people in Sweden and fall injuries. Methods: This is a population-based, matched, case-control study of 64 399 persons aged 65 years in Sweden admitted to hospital because of a fall injury between March 2006 and December 2009, and four controls per case matched by gender, date of birth and place of residence. The prevalence of the 20 most commonly prescribed medications was compiled for the 30-day period before the index date. The association between those medications and injurious falls was estimated with odds ratios and corresponding 95% confidence intervals using conditional logistic regression. Results: Ten of the top 20 most commonly prescribed medications, and in particular the three medications affecting the central nervous system (CNS), significantly increased the risk of fall injuries (highest for opioids and antidepressants) but not the seven cardiovascular ones, who had a protective effect (lowest for angiotensin converting enzyme inhibitors and selective calcium channel blockers). Conclusions: The adverse effect of several commonly prescribed medications may seriously threaten their positive effects on the well-being and quality of life of older people. Their association with injurious falls is of particular concern as falls are prevalent and often leading to severe consequences. This needs to be acknowledged so physicians and patients can make informed decisions when prescribing and using them.
.........................................................................................................
Introduction he world population is aging both in absolute and relative terms.
TThis demographic transition is paralleled by a change in the
burden of disease, whereby non-communicable diseases are becoming more prevalent than communicable ones, and premature death is progressively giving way to a higher life expectancy and
increased morbidity.1 Among the main causes of disability, fall injuries rank high. In older people, they often lead to hospitalization and a long period of medical treatment,2,3 and they can cause considerable morbidity with significant physical, psychological and social consequences.2 In many instances, fall-related injuries can be fatal.2,4 Individual factors that have a well-documented association with falls are age,2 sex2 and health status,5 though these factors can be
528
European Journal of Public Health
difficult to modify. Prescribed medications, the focus of this study, may also significantly affect the risk of injurious falls among older people,6–13 and they are somewhat easier to act upon. Medications can impact on the risk of older people falling in different ways, including the expected and adverse effects of either single medications or drug–drug interactions14 and dosage and change of medications.15 Age-related factors can also come into play here by influencing either the potential side effects of a medication or the effect of the dosage compared with younger patients.9 A recent study identified the 20 medications most commonly prescribed in the general population of people aged 65 years in Sweden16 and revealed that such medications were used by up to 35% of community-dwelling older adults. A closer look at the list provided showed that several medications were known fall-inducing drugs, including hypnotics and sedatives,9,11,17 antidepressants,6 opioids,12 other analgesics,7 antipsychotics,6 thiazide diuretics,15 angiotensin converting enzyme (ACE) inhibitors,13 thyroid hormones,8 constipation drugs8 and non-steroidal anti-inflammatory drugs (NSAID).11 The knowledge at hand came from different study populations varying in age range and in health condition. In light of their potential adverse effects specifically on older people, in particular injurious falls and the risk of serious complications thereof, commonly prescribed drugs can have large individual and societal impacts, not least economic ones.18 In this nationwide study, we assess the risk of fall injury leading to hospitalization associated with each of those most commonly prescribed medications in the general population of Swedish older people.16 The medication-specific risk is assessed in the same population and separately for men and women.
Methods Study design This is a population-based, matched, case-control study, nested in a national cohort of 6 981 010 individuals born in 1958 or before and domiciled in Sweden at some point from 1973 onwards. The cohort
was identified using the Swedish Total Population Register. The case-control study includes individuals 65 years who sustained a fall injury in the period between 1 March 2006 and 31 December 2009 and four matched controls per case.
Definitions of cases and controls A case was defined as a person who sustained a fall injury leading to hospitalization (at least one night) registered in the National Inpatient Register based on the International Classification of Diseases, 10th Revision (Codes W00–W19). We considered only the first fall injury during the study period and excluded planned medical inpatient care for fall injury. Controls were randomly selected from the cohort among persons not having been hospitalized because of a fall injury during the study period. They were matched to the cases by sex, date of birth and area of residence. Date of admission, and corresponding date for the matched controls, was used as the index date. In total, 64 399 cases (22 190 males and 42 209 females) were identified—including 257 596 controls—adding up to 321 995 persons. Among these, 29.4% were 65–79 years of age, 30.4% were 80–85, 21.2% were 86–90 and 19.1% were 90 years of age. There were more males in the younger groups and more females in the older groups (table 1). The differences between cases and controls as regards educational level and civil status were only marginal, but there were noticeable differences between males and females with more males with higher education, more females widowed and males married (table 1).
Exposure We considered as ‘common medications’ among persons aged 65 years living in Sweden those 20 highlighted previously16 and focuses on their recent use during the 30 days before the index date. The Swedish Prescribed Drug Register (SPDR) contains information on all prescribed and dispensed drugs at all pharmacies in Sweden and uses the five-level Anatomical Therapeutic and Chemical (ATC) classification system.19 The information, including dispensation
Table 1 Characteristics (%) of the study population regarding age, education, civil status and area of residence (N = 321 995) Characteristic
Age group (years) 65–79 80–85 86–90 >90 Educational level Primary or lower secondary school Upper secondary Post-secondary Postgraduate Unknown/missing Civil status Unmarried Married Divorced Widowed Missing Area of residence Stockholm Central eastern Sweden West Sweden South Sweden Sma˚land and Islands Central northern Sweden Central Norrland Northern Norrland
Male n = 110 950 All
Cases n = 22 190
36.7 30.7 18.9 13.8
Matching variable
38.9 23.60 10.3 0.7 26.5
39.4 22.2 9.1 0.6 28.7
9.4 56.2 10.3 24.0 0.1
11.2 48.3 12.9 27.6
527
26 Jørgensen TS, Hansen AH, Sahlberg M, et al. Falls and comorbidity: the pathway to fractures. Scand J Public Health 2014;42:287–94.
33 Boise L, Camicioli R, Morgan DL, et al. Diagnosing dementia: perspectives of primary care physicians. Gerontologist 1999;39:457–64.
27 Franz CE, Barker JC, Kim K, et al. When help becomes a hindrance: mental health referral systems as barriers to care for primary care physicians treating patients with Alzheimer’s disease. Am J Geriatr Psychiatry 2010;18:576–85.
34 Forbes DA, Morgan D, Janzen BL. Rural and urban Canadians with dementia: use of health care services. Can J Aging 2006;25:321–30.
28 Vernooij-Dassen MJ, Moniz-Cook ED, Woods RT, et al. Factors affecting timely recognition and diagnosis of dementia across Europe: from awareness to stigma. Int J Geriatr Psychiatry 2005;20:377–86. 29 Hinton L, Franz CE, Reddy G, et al. Practice constraints, behavioral problems, and dementia care: primary care physicians’ perspectives. J Gen Intern Med 2007;22: 1487–92. 30 Wilkinson D, Stave C, Keohane D, Vincenzino O. The role of general practitioners in the diagnosis and treatment of Alzheimer’s disease: a multinational survey. J Int Med Res 2004;32:149–59. 31 Iliffe S, De Lepeleire J, Van Hout H, et al. Understanding obstacles to the recognition of and response to dementia in different European countries: a modified focus group approach using multinational, multi-disciplinary expert groups. Aging Ment Health 2005;9:1–6. 32 Koller D, Eisele M, Kaduszkiewicz H, et al. Ambulatory health services utilization in patients with dementia—is there an urban-rural difference? Int J Health Geogr 2010; 9:59.
35 Glazier RH, Agha MM, Moineddin R, Sibley LM. Universal health insurance and equity in primary care and specialist office visits: a population-based study. Ann Fam Med 2009;7:396–405. 36 Dobalian A, Tsao JC, Radcliff TA. Diagnosed mental and physical health conditions in the United States nursing home population: differences between urban and rural facilities. J Rural Health 2003;19:477–83. 37 Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117–27. 38 Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002;137: 511–20. 39 Courtney C, Farrell D, Gray R, et al. Long-term donepezil treatment in 565 patients with Alzheimer’s disease (AD2000): randomised double-blind trial. Lancet 2004;363: 2105–15. 40 Birk HO, Gut R, Henriksen LO. Patients’ experience of choosing an outpatient clinic in one county in Denmark: results of a patient survey. BMC Health Serv Res 2011;11: 262.
......................................................................................................... European Journal of Public Health, Vol. 25, No. 3, 527–532 The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/cku120 Advance Access published on 1 August 2014
.........................................................................................................
The risk of fall injury in relation to commonly prescribed medications among older people—a Swedish case-control study Bernhard M. Kuschel, Lucie Laflamme, Jette Mo¨ller Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden Correspondence: Jette Mo¨ller, Department of Public Health Sciences, Karolinska Institutet, Widerstro¨mska huset, 10th floor, Tomtebodava¨gen 18 A, SE-17177 Stockholm, Sweden, Tel: +46 8 524 801 22, Fax: +46 8 311 590, e-mail: [email protected]
Background: Older people not only consume more medication but they also represent a group at high risk for adverse effects such as injurious falls. This study examines the association between the medications most commonly prescribed to older people in Sweden and fall injuries. Methods: This is a population-based, matched, case-control study of 64 399 persons aged 65 years in Sweden admitted to hospital because of a fall injury between March 2006 and December 2009, and four controls per case matched by gender, date of birth and place of residence. The prevalence of the 20 most commonly prescribed medications was compiled for the 30-day period before the index date. The association between those medications and injurious falls was estimated with odds ratios and corresponding 95% confidence intervals using conditional logistic regression. Results: Ten of the top 20 most commonly prescribed medications, and in particular the three medications affecting the central nervous system (CNS), significantly increased the risk of fall injuries (highest for opioids and antidepressants) but not the seven cardiovascular ones, who had a protective effect (lowest for angiotensin converting enzyme inhibitors and selective calcium channel blockers). Conclusions: The adverse effect of several commonly prescribed medications may seriously threaten their positive effects on the well-being and quality of life of older people. Their association with injurious falls is of particular concern as falls are prevalent and often leading to severe consequences. This needs to be acknowledged so physicians and patients can make informed decisions when prescribing and using them.
.........................................................................................................
Introduction he world population is aging both in absolute and relative terms.
TThis demographic transition is paralleled by a change in the
burden of disease, whereby non-communicable diseases are becoming more prevalent than communicable ones, and premature death is progressively giving way to a higher life expectancy and
increased morbidity.1 Among the main causes of disability, fall injuries rank high. In older people, they often lead to hospitalization and a long period of medical treatment,2,3 and they can cause considerable morbidity with significant physical, psychological and social consequences.2 In many instances, fall-related injuries can be fatal.2,4 Individual factors that have a well-documented association with falls are age,2 sex2 and health status,5 though these factors can be
528
European Journal of Public Health
difficult to modify. Prescribed medications, the focus of this study, may also significantly affect the risk of injurious falls among older people,6–13 and they are somewhat easier to act upon. Medications can impact on the risk of older people falling in different ways, including the expected and adverse effects of either single medications or drug–drug interactions14 and dosage and change of medications.15 Age-related factors can also come into play here by influencing either the potential side effects of a medication or the effect of the dosage compared with younger patients.9 A recent study identified the 20 medications most commonly prescribed in the general population of people aged 65 years in Sweden16 and revealed that such medications were used by up to 35% of community-dwelling older adults. A closer look at the list provided showed that several medications were known fall-inducing drugs, including hypnotics and sedatives,9,11,17 antidepressants,6 opioids,12 other analgesics,7 antipsychotics,6 thiazide diuretics,15 angiotensin converting enzyme (ACE) inhibitors,13 thyroid hormones,8 constipation drugs8 and non-steroidal anti-inflammatory drugs (NSAID).11 The knowledge at hand came from different study populations varying in age range and in health condition. In light of their potential adverse effects specifically on older people, in particular injurious falls and the risk of serious complications thereof, commonly prescribed drugs can have large individual and societal impacts, not least economic ones.18 In this nationwide study, we assess the risk of fall injury leading to hospitalization associated with each of those most commonly prescribed medications in the general population of Swedish older people.16 The medication-specific risk is assessed in the same population and separately for men and women.
Methods Study design This is a population-based, matched, case-control study, nested in a national cohort of 6 981 010 individuals born in 1958 or before and domiciled in Sweden at some point from 1973 onwards. The cohort
was identified using the Swedish Total Population Register. The case-control study includes individuals 65 years who sustained a fall injury in the period between 1 March 2006 and 31 December 2009 and four matched controls per case.
Definitions of cases and controls A case was defined as a person who sustained a fall injury leading to hospitalization (at least one night) registered in the National Inpatient Register based on the International Classification of Diseases, 10th Revision (Codes W00–W19). We considered only the first fall injury during the study period and excluded planned medical inpatient care for fall injury. Controls were randomly selected from the cohort among persons not having been hospitalized because of a fall injury during the study period. They were matched to the cases by sex, date of birth and area of residence. Date of admission, and corresponding date for the matched controls, was used as the index date. In total, 64 399 cases (22 190 males and 42 209 females) were identified—including 257 596 controls—adding up to 321 995 persons. Among these, 29.4% were 65–79 years of age, 30.4% were 80–85, 21.2% were 86–90 and 19.1% were 90 years of age. There were more males in the younger groups and more females in the older groups (table 1). The differences between cases and controls as regards educational level and civil status were only marginal, but there were noticeable differences between males and females with more males with higher education, more females widowed and males married (table 1).
Exposure We considered as ‘common medications’ among persons aged 65 years living in Sweden those 20 highlighted previously16 and focuses on their recent use during the 30 days before the index date. The Swedish Prescribed Drug Register (SPDR) contains information on all prescribed and dispensed drugs at all pharmacies in Sweden and uses the five-level Anatomical Therapeutic and Chemical (ATC) classification system.19 The information, including dispensation
Table 1 Characteristics (%) of the study population regarding age, education, civil status and area of residence (N = 321 995) Characteristic
Age group (years) 65–79 80–85 86–90 >90 Educational level Primary or lower secondary school Upper secondary Post-secondary Postgraduate Unknown/missing Civil status Unmarried Married Divorced Widowed Missing Area of residence Stockholm Central eastern Sweden West Sweden South Sweden Sma˚land and Islands Central northern Sweden Central Norrland Northern Norrland
Male n = 110 950 All
Cases n = 22 190
36.7 30.7 18.9 13.8
Matching variable
38.9 23.60 10.3 0.7 26.5
39.4 22.2 9.1 0.6 28.7
9.4 56.2 10.3 24.0 0.1
11.2 48.3 12.9 27.6
