Does modification of potentially inappropriate prescribing occur following fall-related hospitalisations in older adults?

Problem

Potentially inappropriate prescribing (PIP) is associated with falls in older adults. The recently revised 2015 Screening Tool of Older Person’s potentially inappropriate Prescribing (STOPP) has a dedicated section on falls-risk, including benzodiazepines, neuroleptics, and hypnotic ‘z-drugs’, as well as vasodilators in those with persistent postural hypotension. The Screening Tool to Alert doctors to the Right Treatment (START) recommends prescribing vitamin D for those experiencing falls. Fall-related hospitalisations should trigger a fall-risk assessment including medication review. The aim of this study was to examine the prevalence of relevant PIP in older people with fall-related hospital admissions and to identify from GP and Hospital Discharge records whether prescribing modification occurred following admission.

Approach

Demographic, prescribing and hospitalisation data for patients 65 years and older were collected from 44 general practices in Ireland using the Socrates patient-management system between 2011 and 2016. Ethical approval was obtained from the Irish College of General Practitioners. Hospital admissions for falls, fractures and syncopal events occurring between April 2011 and 3 months prior to the data collection date (2016) were selected for this study to ensure availability of at least 3 months of prescription data pre and post admission. Where relevant, the first fall-related admission per participant was selected. The prevalence of prescriptions for benzodiazepines, neuroleptics, z-drugs, vasodilators and vitamin D were estimated from GP records in the 12 months pre-admission and using hospital discharge and GP records in the 12 months post-admission. Pre/post admission prevalence was compared using McNemar’s test. Further data analysis is ongoing.

Findings

Between 2012 and 2016, a total of 1,047 patients had a potentially fall-related hospital admission. A total of 944 individuals (90% of total, 635 women, 309 men) with an average age of 81.2 years (SD=8.6) had some prescription data available both before and after admission. The admitting diagnosis for 45% (n=421) was a fracture, for 27% (n=257) was a fall without fracture and 28% (n=266) had a syncopal event. Median length of stay was 7 days (IQR=2-17). Preliminary analysis demonstrated a significant increase in the proportion of those prescribed vitamin D (37% before, 51% after, p<0.01). There was no significant decrease in the proportion prescribed medications as defined by the falls-related STOPP criteria. In fact, the proportion with both z-drug prescriptions (18% before, 22% after admission) and neuroleptics (12% before, 14% after admission) increased (McNemar’s test, p=<0.01). A fifth (20%) had benzodiazepines prescribed pre-admission, 22% post-admission (p=0.06). Over half were prescribed vasodilators (54% before and after, p=0.70).

Consequences

Preliminary results from this study suggest an increase in vitamin D prescription after a fall-related admission but other improvements in prescribing according to the STOPP 2015 criteria are not evident. As gradual withdrawal of long-term benzodiazepines is recommended to reduce falls-risk, further analysis is planned to explore prescriptions of newer non-benzodiazepine hypnosedatives and to identify factors associated with prescription modification in this cohort.