Shahrul Bahyah Kamaruzzaman

The association between orthostatic hypotension and medication use in the British Women’s Heart and Health Study

OBJECTIVE to determine the prevalence of orthostatic hypotension (OH) and associations with medication use in community-dwelling older women. DESIGN cross-sectional analysis using data from the British Womens Heart and Health Study. SETTING general practices in 23 towns in the UK. PARTICIPANTS 3,775 women aged 60-80 years from 1999 to 2001. MAIN OUTCOME MEASURE orthostatic hypotension-drop of > or =20 mmHg in systolic and/or a drop of > or =10 mmHg in diastolic blood pressure on standing. RESULTS prevalence of OH was 28% (95% confidence interval [CI] 26.6, 29.4), which increased with age and hypertension. Regardless of treatment status or diagnosed hypertension, raised blood pressure was strongly associated with OH (P < 0.001). OH was strongly associated with number of antihypertensives taken (none vs three or more: odds ratio [OR] 2.24, 95% CI 1.47-3.40, P < 0.001); the association was slightly attenuated after allowing for age and co-morbidities (OR 1.99; 95% CI 1.30, 3.05; P = 0.003). Women with multiple co-morbidities had markedly increased odds of OH independent of age, number and type of medications taken (none vs four or more diagnoses: OR 2.28, 95% CI 1.58-3.30, P = 0.005). CONCLUSION uncontrolled hypertension, use of three or more antihypertensives and multiple co-morbidities are predictors of OH in older women. Detection or monitoring of OH in these groups may prevent women from suffering its adverse consequences.

The Asia-Pacific clinical practice guidelines for the management of frailty

OBJECTIVE To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty. METHODS An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation. RECOMMENDATIONS Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan. CONCLUSIONS The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.

Determinants of mortality among older adults with pressure ulcers

The presence of pressure ulcers imposes a huge burden on the older persons quality of life and significantly increases their risk of dying. The objective of this study was to determine patient characteristics associated with the presence of pressure ulcers and to evaluate the risk factors associated with mortality among older patients with pressure ulcers. A prospective observational study was performed between Oct 2012 and May 2013. Patients with preexisting pressure ulcers on admission and those with hospital acquired pressure ulcers were recruited into the study. Information on patient demographics, functional status, nutritional level, stages of pressure ulcer and their complications were obtained. Cox proportional hazard analysis was used to assess the risk of death in all patients. 76/684 (11.1%) patients had pre-existing pressure ulcers on admission and 30/684 (4.4%) developed pressure ulcers in hospital. There were 68 (66%) deaths by the end of the median follow-up period of 12 (IQR 2.5-14) weeks. Our Cox regression model revealed that nursing home residence (Hazard Ratio, HR=2.33, 95% confidence interval, CI=1.30, 4.17; p=0.005), infected deep pressure ulcers (HR=2.21, 95% CI=1.26, 3.87; p=0.006) and neutrophilia (HR=1.76; 95% CI 1.05, 2.94; p=0.031) were independent predictors of mortality in our elderly patients with pressure ulcers. The prevalence of pressure ulcers in our setting is comparable to previously reported figures in Europe and North America. Mortality in patients with pressure ulcer was high, and was predicted by institutionalization, concurrent infection and high neutrophil counts.

Polypharmacy and falls in older people: Balancing evidence-based medicine against falls risk

Abstract The term polypharmacy has negative connotations due to its association with adverse drug reactions and falls. This spectrum of adverse events widens when polypharmacy occurs among the already vulnerable geriatric population. To date, there is no consensus definition of polypharmacy, and diverse definitions have been used by various researchers, the most common being the consumption of multiple number of medications. Taking multiple medications is considered a risk factor for falls through the adverse effects of drug–drug or drug–disease interactions. Falls studies have determined that taking ≥ 4 drugs is associated with an increased incidence of falls, recurrent falls, and injurious falls. In light of existing evidence, careful and regular medication reviews are advised to reduce the effect of polypharmacy on falls. However, intervention studies on medication reviews and their effectiveness on falls reduction have been scarce. This article reviews and discusses the evidence behind polypharmacy and its association with falls among older individuals, and highlights important areas for future research.

Physical therapies for improving balance and reducing falls risk in osteoarthritis of the knee: a systematic review

INTRODUCTION osteoarthritis (OA) of knee has been reported as a risk factor for falls and reduced balance in the elderly. This systematic review evaluated the effectiveness of physical therapies in improving balance and reducing falls risk among patients with knee OA. METHODS a computerised search was performed to identify relevant studies up to November 2013. Two investigators identified eligible studies and extracted data independently. The quality of the included studies was assessed by the PeDro score. RESULTS a total of 15 randomised controlled trials involving 1482 patients were identified. The mean PeDro score was 7. The pooled standardised mean difference in balance outcome for strength training = 0.3346 (95% CI: 0.3207-0.60, P = 0.01 < 0.00001, P for heterogeneity = 0.85, I(2) = 0%). Tai Chi = 0.7597 (95% CI: 0.5130-1.2043, P<=0.0014, P for heterogeneity = 0.26, I(2) = 0%) and aerobic exercises = 0.6880 (95% CI: 0.5704-1.302, P < 0.00001, P for heterogeneity = 0.71, I(2) = 0%). While pooled results for falls risk outcomes in, strength training, Tai chi and aerobics also showed a significant reduction in reduced risk of falls significantly with pooled result 0.55 (95% CI: 0.41-0.68, P < 0.00001, P for heterogeneity = 0.39, I(2) = 6%). CONCLUSION strength training, Tai Chi and aerobics exercises improved balance and falls risk in older individuals with knee OA, while water-based exercises and light treatment did not significantly improve balance outcomes. Strength training, Tai Chi and aerobics exercises can therefore be recommended as falls prevention strategies for individuals with OA. However, a large randomised controlled study using actual falls outcomes is recommended to determine the appropriate dosage and to measure the potential benefits in falls reduction.

Ten year mortality in older patients attending the emergency department after a fall.

To determine the dependency scores, long‐term mortality and factors associated with mortality in older people presenting to the emergency department (ED) with a fall.

The consumption of two or more fall risk-increasing drugs rather than polypharmacy is associated with falls

The presemt study aimed to determine the association between the risk of recurrent and injurious falls with polypharmacy, fall risk‐increasing drugs (FRID) and FRID count among community‐dwelling older adults.

Aging in Multi-ethnic Malaysia

Multiethnic Malaysia provides a unique case study of divergence in population aging of different sociocultural subgroups within a country. Malaysia represents 3 major ethnicities in Asia-the Malay, Chinese, and Indian. The 3 ethnic groups are at different stages of population aging, as they have undergone demographic transition at different pace amidst rapid social and economic changes. Between 1991 and 2010, the Malaysian population aged 60 and over has more than doubled from about 1 million to 2.2 million, and this is projected to rise to about 7 million or 17.6% of the projected population of 40 million by 2040. In 2010, the aging index ranged from 22.8% among the Bumiputera (Malays and other indigenous groups), to 31.4% among the Indians and 55.0% among the Chinese. Population aging provides great challenges for Malaysias social and economic development. The increasing prevalence of noncommunicable diseases in older adults, coupled with the erosion of the traditional family support system has increased demands on health care services with an overwhelming need for multidisciplinary and specialized geriatric care. Following the adoption of the National Policy for the Elderly in 1995, issues of population aging have gained increasing attention, especially among researchers. There is an urgent need to increase public awareness, develop infrastructure, as well as support action oriented research that will directly translate to comprehensive and cohesive social strategies, policies, and legislation to protect not just the current older Malaysians but the future of all Malaysians.

Anticholinergic burden is associated with recurrent and injurious falls in older individuals.

OBJECTIVE While the anticholinergic activity of medications has been linked to cognitive decline, few studies have linked anticholinergic burden with falls in older people. We evaluated the relationship between anticholinergic burden and recurrent and injurious falls among community-dwelling older adults. STUDY DESIGN This case-control study was performed on 428 participants aged ≥65 years, 263 cases with two or more falls or one injurious fall in the preceding 12 months, and 165 controls with no falls in the preceding 12 months. Anticholinergic burden was determined using the anticholinergic cognitive burden (ACB) scale. Upper and lower limb functional abilities were assessed with timed up and go (TUG), functional reach (FR) and grip strength (GS). Logistic regression analysis was employed to calculate the mediation effect of TUG, FR and GS on ACB associated falls. RESULTS Univariate analysis revealed a significant association between an ACB score of ≥1 with falls (OR, 1.8; 95% CI; 1.1-3.0; p=0.01) and significantly poorer TUG and FR. The association between ACB≥1 and falls was no longer significant after adjustment for either TUG (OR for ACB associated falls, 1.4; 95% CI, 0.88-2.4; p=0.14) or FR (OR for ACB associated falls, 1.4; 95% CI, 0.89-2.4, p=0.12) but remained significant with GS. CONCLUSION The association between recurrent and injurious falls and the use of any medications listed in the ACB scale was mediated through gait and balance impairment but not by muscular weakness, providing a novel insight into the potential mechanistic link between ACB and falls. Future studies should determine whether TUG and FR measurements could help inform risk to benefit decisions where ACB medications are being considered.

Blood pressure lowering therapy in older people: Does it really cause postural hypotension or falls?

Abstract Hypertension is a highly prevalent condition among older people, but many physicians avoid aggressive treatment in this age group due to concerns about adverse effects such as orthostatic hypotension and falls. Orthostatic hypotension, which also increases in prevalence with increasing age, has been considered to be associated with antihypertensive therapy. Both orthostatic hypotension and antihypertensive medications are considered independent yet closely related predictors for falls among older people. The prescription of antihypertensive therapy among the elderly remains a long-standing controversy in geriatric medicine due to ongoing concerns about potential complications such as falls, despite conclusive evidence supporting the treatment of hypertension even among the very elderly. However, recent evidence suggests a dose-dependent relationship between blood pressure lowering therapy and falls among older individuals with preexisting risk factors for falls. In response to the spate of revisions in hypertension treatment targets for older patients in international guidelines and the recent evidence on antihypertensive therapy and falls, this review article examines the complex relationship between hypertension, antihypertensives, orthostatic hypotension, and falls among older patients.