Guterman Award Winner: CMS Medication Burden Linked to Serious Falls

Abstract

PHOENIX — Research defining the central nervous system (CNS) medication burden that is associated with an increased risk of serious falls in nursing home residents won the Howard Guterman Best Poster Award at the AMDA – the Society for Post-Acute and Long-Term Care Annual Conference. Alan Abrams, MD, MPH, chair of the Society’s poster judging committee, presented the award to the research team led by Joseph Hanlon, PharmD, MS, of the Department of Medicine (Geriatrics) at the University of Pittsburgh. David A. Nace, MD, MPH, CMD, a member of the University of Pittsburgh research team, accepted the award. “We know that falls are linked to medication use, particularly medications that act upon the central nervous system,” Dr. Nace said in a presentation on the research. However, studies examining this association and the dose–response relationships have been limited. The team’s nested case-control study identified a threshold, showing that a CNS medication burden of approximately three or more standardized daily doses is associated with a nearly twofold increased risk of serious falls in nursing home residents compared with those not taking any CNS medications. A serious fall was defined as one resulting in a hip fracture and an emergency department visit or hospitalization. There was no significant difference in serious fall risk for residents taking up to three standardized daily doses compared with those taking no CNS medications. The CNS medications studied were specific antidepressants, antiepileptics, antipsychotics, benzodiazepine receptor agonist hypnotics, and opioid receptor agonists. The standardized daily dose (SDD) for each CNS drug was calculated by dividing the resident’s actual daily dose by the “minimum effective geriatric daily dose” as reported in the geriatric pharmacotherapy literature. The SDDs were then added together for a summary CNS medication burden, or combined SDD. Knowing that there’s a “pretty clear demarcation” in fall risk at a total SDD of three or greater, “the question becomes, can we tweak the dosing? Can we reduce [medications] to a minimum when they cannot be eliminated?” said Dr. Nace. “You may not be able to get rid of all the medications, but you may be able to reduce the overall burden and therefore reduce the risks of falls,” he said. The study used Minimum Data Set (MDS) information merged with 2009–2010 Medicare claims and Prescription Drug Event data from the Centers for Medicare and Medicaid Services for a random 10% sample of traditional fee-for-service beneficiaries with a recent fall history who were admitted to the nursing home between Jan. 1, 2010, and Sept. 30, 2010. The residents were evaluated from the first day of the non-skilled nursing stay episode until discharge, death, or the end of 2010. (The study did not include short-stay, private pay, or Medicare Advantage residents.) Of a sample of 5,556 nursing home residents with a fall history, 367 were identified through ICD-9 diagnosis codes and ICD-9/CPT procedure codes as experiencing a serious fall while in the nursing home. Each case was matched with four controls on the basis of age, gender, and time of events. Investigators then looked at CNS medication use within 6 days before the fall or the index date. The study, which was recently published in the Journal of the American Geriatrics Society [Feb. 2, 2017; doi:10.1111/jgs.14759], did not include as-needed (PRN) medications, and it did not fully include information on benzodiazepine use, as these drugs were not covered by Medicare Part D at the time. The investigators adjusted for other risk factors for serious falls, including other medications, vision impairment, wandering, urinary incontinence, and cognitive impairment. Dr. Hanlon told Caring that “we tried to tease out everything we know about risk factors for falls.” For guidance on calculating the CNS medication burden with a summated standardized daily dose score, see the University of Pittsburgh’s educational brochure “How to Prevent Falls in Older Nursing Home Residents by Reducing CNS Medication Burden,” at www.pepper.pitt.edu/factsfindings.html. Christine Kilgore is a freelance writer in Falls Church, VA.