Impact of Medication Doses on Risk of Falls in Elderly Patients: A Review

This review examines the impact of medication doses on the risk of falls in elderly patients. It analyzes various research designs, sample characteristics, outcome measurements, statistically significant study findings, and other important findings. The review suggests the need for standardized guidelines to address the potential risks of falls in elderly patients.

Synthesis Assignment
Student’s Name:
University:
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Table of Contents:
Introduction: 3
Synthesis of Literature: 3
Research designs and level of evidence: 3
Sample characteristics: 4
Outcome Measurement 4
Statistically significant study findings 5
Other important findings 5
Conclusion 6
References: 7
Introduction:
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Medications are considered to be one of the major factor which are linked with increased risk of
falls among elderly patients of 65 years or above. It has been found that the risk of falls increases
along with the number of medication doses. The elderly patients with does taking 4 or more
medications are often found to be at higher risk of falling as compared to the ones taking three or
fewer medication doses (Al Hamid, Ghaleb, Aljadhey & Aslanpour, 2014). Literature have
provided evidence of several systematic reviews focusing on particular groups of patient such as
elderly, hospitalized individuals as well as on particular outcome measures such as mortality or
morbidity, etc. Therefore, more insight is required on the study of the impact of medication doses
on risk of falls in elderly patients who are 65 years or older on dose of four or more medications
in comparison with the patients who are on dose of three or less medications for over 3 months.
Hence, the present review aims to combine the evidence obtained from several review studies
based on clinical practice to understand the impact of medication doses to evidence based
practice (Turner et al., 2015).
Synthesis of Literature:
Research designs and level of evidence:
Among the identified studies it has been identified that the studies have shown variations in
research design and level of evidence such as Hammond, & Wilson (2013) conducted a
qualitative case study using unspecified Literature review obtained from various online sources
such as Cinahl, Medline and Healthsource and the recognized level of evidence is IV. However,
similar level of evidence and research design have been depicted in the qualitative case study
conducted by Turner, Jamsen, Shakib, Singhal, Prowse, & Bell (2015) in an outpatient research
within hospitals. Contrary to that, Huiskes, Burger, Ende, & Bemt (2017) conducted a systematic
review and a meta-analysis study on articles obtained from CINAHL & MEDLINE databases
and is a community-dwelling study depicting level of evidence to be I. Furthermore, Der
Ananian, Mitros & Buman (2017) carried out a different level of research design by using a
quasi-experimental study, among non-randomly assigned participants at baseline with a no
control group in both pretest and posttest design no control and III Level of evidence (American
Psychological Association Staff., 2009). A similar study by Urfer, Elzi, Dell-Kuster & Bassetti
(2016) depicted a single-centered, quasi-experimental study based on interventions with a III
level of evidence. Furthermore, in the study of Dionyssiotis (2012) a qualitative systematic
review on the benefits of falls, related risk factors as well as interventions for its prevention have
been carried out with a V level of evidence. Maher, Hanlon & Hajjar (2013) carried out a
systematic review of all relevant randomized controlled trials (RCT's) including older adults with
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polypharmacy with I level of evidence, while the evidence from systematic reviews of the
qualitative study by de Jong, Van der Elst & Hartholt (2013) of the epidemiological falls along
with the risk factors associated with the drugs in older people depicted the V level of evidence.
Sample characteristics:
The samples characteristics are found to be common among several studies such as the study of
Turner, Jamsen, Shakib, Singhal, Prowse, & Bell (2015) was conducted on 385 patients of more
than or equal to 70 years with an average age criteria of about 76.7 years old among 59% of
male. Similarly, the sample size of Der Ananian, Mitros & Buman (2017) consists of patients of
age ranging between 60–100 years. However, Hammond, & Wilson (2013) conducted their study
on elderly patients of 65 years or older, while Huiskes, Burger, Ende, & Bemt (2017) have
considered the characteristic age criteria ranging from 51.4 years to 87.0 years. In addition to
that, the sample characteristics of Urfer, Elzi, Dell-Kuster & Bassetti (2016) study includes the
criteria of a total 450 consecutive patients that aged more than or equal to 65 years, while the
sample size of Dionyssiotis (2012) review was conducted among patients of over 65 years of
age. Furthermore, Maher, Hanlon & Hajjar (2013) conducted the study on persons falling in the
range of 57-85 years of age, while de Jong, Van der Elst & Hartholt (2013) conducted a similar
study on elderly people aged 65 years and older.
Outcome Measurement
The studies also varied in outcome measures such as the study conducted by Hammond, &
Wilson (2013) depicted suggested that falls in older patients is a severe health issue specifically
among the patients and suggested the use of 2 or more dose of medications for the treatment of
similar problems as well of similar chemical class. However, Huiskes, Burger, Ende, & Bemt
(2017) suggested that patients who took medications from 4-14 are at a high risk of falling.
Contrary to that, Turner, Jamsen, Shakib, Singhal, Prowse, & Bell (2015) reported the falls of
older patients using Karmofsky Performance Scale (i.e., KPS), and Polypharmacy Charlson
Comorbidity Index (i.e., CCI) (Gray, Grove & Sutherland, 2017). The study also reported
patients who self report their falls due to medication with the help of a questionnaire and
assessment (such as comprehensive geriatric oncology, and multidisciplinary team) conducted on
different healthcare professionals. Der Ananian, Mitros & Buman (2017) suggested that the
present sample of older adults have a score which is low as compared to their age matched norms
based on measured of differential physical analysis. However, Urfer, Elzi, Dell-Kuster &
Bassetti (2016) depicted that the prescription of some drugs which are somewhat problematic in
older people are easily prescribed the unclear indication (i.e.,PPI). The study also suggested that
the introduction of the checklist will help to significantly decrease the risk associated with not so
proper PPI prescription. However, Dionyssiotis (2012) suggested that among patients who have
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recurrent falls, the drug doses are required to be reviewed, highly modified, and should not be
continued for reducing the risk associated with future fall. Specific focus should be given to
reduce the medication dose among elderly patients receiving 4 or more medications as well as
the ones who are on psychotropic medications. Maher, Hanlon & Hajjar (2013) suggested that
the burden to take several doses of medications is related with higher costs of healthcare as well
as increasing risks of ADE (i.e., adverse drug events), interactions with other drugs, non-
adhering drugs, and reduction in the functional capacity. De Jong, Van der Elst & Hartholt
(2013) stated that incidents of falls are the major systems behind injuries caused due to a medical
problem. The most important step to prevent falls is optimization of elderly patient condition and
drug use for recording injuries caused by falls.
Statistically significant study findings
Among the selected studies some of them have not depicted any statistical significance on the
findings of the study such as in the study of Hammond, & Wilson (2013) no statistical
significance have been obtained, while in Huiskes, Burger, Ende, & Bemt (2017) study the p-
value (P < 0.05) pertained to the sensitivity analysis which depicted a highly
stringent threshold in terms of risk of bias which tend to yield same results
with an exception in the total amount of falls/ patient which was found to be
switched from effective towards inconclusive (i.e., ≥8; two-third of the
attainable 12). Furthermore, the research made by Turner, Jamsen, Shakib,
Singhal, Prowse, & Bell (2015) is unclear and depicts no statistical significance between
medications and severe events in terms of age, sex as well as other factors. Similarly, Der
Ananian, Mitros & Buman (2017) study depicted a significant linear (i.e., F = 19.2, and the value
of p < 0.0001) as well as significant quadratic (i.e., F = 4.8, and p-value is equal to 0.03).
However, Urfer, Elzi, Dell-Kuster & Bassetti (2016) study depicted statistical significance of a
high risk for PIM prescription among elderly patients with PIM at the time of their admission, as
well as with an enhancing level of diagnoses (in which test for trend, p-value =<0.001) and for
drugs the test for trend, is also significant with p-value is equals to less than 0.001). However,
Dionyssiotis (2012) depicted no significance, while Maher, Hanlon & Hajjar (2013) suggested
that the some statistical significance can be observed among the groups selected. De Jong, Van
der Elst & Hartholt (2013) stated that no significance in the study.
Other important findings
The findings of Hammond, & Wilson (2013) review suggested link between medications as well
as increasing risk of falls which have its association with medication type as well increasing
number. Another review based on RCT medication stated that short term interventions are
helpful in such cases (i.e., < 3 months) (Huiskes, Burger, Ende, & Bemt 2017). However, Turner,
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Jamsen, Shakib, Singhal, Prowse, & Bell (2015) suggested that dose of medications might be
significant keeping in account of other factors as well as comorbidities, while Der Ananian,
Mitros & Buman (2017) suggested that the initial group-based FPP which focuses on the
physical activity for improving the balance and outcomes measurement of physical function is
required which can be regulated with the help of home exercise. However, Urfer, Elzi, Dell-
Kuster & Bassetti (2016) depicted that the follow-up of a 5-point checklist would aim to support
the therapeutic reasoning which have significantly causes a reduction in the risk of prescriptions
in terms of not so proper drugs at the time of discharge. However, Dionyssiotis (2012) suggested
that the most important step to prevent falls is optimization of elderly patient condition and drug
use for recording injuries caused by falls (Melnyk & Fineout-Overholt, 2019).
Conclusion
Subsequently, the review studies recognized the associations between the increasing dose of
medications and risk of falls among elderly patients (i.e., 65 years or older). Most of the studies
retrieved are meta-analysis, systematic reviews or RCT studies. However, the potential for bias
in such studies due to indicators is found to be high. The studies suggested that future research is
needed for understanding the impact of medications on risk of falls in older patients. Therefore,
with this review it has been recognized that standardized guidelines should be made for
addressing the potential number of medications to avoid risks of falls in elderly patients.
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References:
Al Hamid, A., Ghaleb, M., Aljadhey, H., & Aslanpour, Z. (2014). A systematic review of
hospitalization resulting from medicine-related problems in adult patients. British
Journal Of Clinical Pharmacology, 78(2), 202-217. doi: 10.1111/bcp.12293
American Psychological Association Staff. (2009). Publication Manual of the American
Psychological Association (6th ed.). Washington DC: American Psychological
Association.
de Jong, M., Van der Elst, M., & Hartholt, K. (2013). Drug-related falls in older patients:
implicated drugs, consequences, and possible prevention strategies. Therapeutic
Advances In Drug Safety, 4(4), 147-154. doi: 10.1177/2042098613486829
Der Ananian, C., Mitros, M., & Buman, M. (2017). Efficacy of a Student-Led, Community-
Based, Multifactorial Fall Prevention Program: Stay in Balance. Frontiers In Public
Health, 5. doi: 10.3389/fpubh.2017.00030
Dionyssiotis, Y. (2012). Analyzing the problem of falls among older people. International
Journal Of General Medicine, 805. doi: 10.2147/ijgm.s32651
Gray, J., Grove, S., & Sutherland, S. (2017). Burns and Grove's the practice of nursing
research(8th ed.). St Louis, MO: Elsevier.
Hammond, T., & Wilson, A. (2013). Polypharmacy and Falls in the Elderly: A Literature
Review. Nursing And Midwifery Studies, 1(4), 171-5. doi: 10.5812/nms.10709
Huiskes, V., Burger, D., van den Ende, C., & van den Bemt, B. (2017). Effectiveness of
medication review: a systematic review and meta-analysis of randomized controlled
trials. BMC Family Practice, 18(1). doi: 10.1186/s12875-016-0577-x
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Melnyk, B., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing &
healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer
Health.
Maher, R., Hanlon, J., & Hajjar, E. (2013). Clinical consequences of polypharmacy in
elderly. Expert Opinion On Drug Safety, 13(1), 57-65. doi:
10.1517/14740338.2013.827660
Tan, E., Stewart, K., Elliott, R., & George, J. (2014). Pharmacist services provided in
general practice clinics: A systematic review and meta-analysis. Research In Social
And Administrative Pharmacy, 10(4), 608-622. doi: 10.1016/j.sapharm.2013.08.006
Turner, J., Jamsen, K., Shakib, S., Singhal, N., Prowse, R., & Bell, J. (2015). Polypharmacy
cut-points in older people with cancer: how many medications are too many?.
Supportive Care In Cancer, 24(4), 1831-1840. doi: 10.1007/s00520-015-2970-8
Urfer, M., Elzi, L., Dell-Kuster, S., & Bassetti, S. (2016). Intervention to Improve
Appropriate Prescribing and Reduce Polypharmacy in Elderly Patients Admitted to an
Internal Medicine Unit. PLOS ONE, 11(11), e0166359. doi:
10.1371/journal.pone.0166359
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