Description of the Problem
The elderly population continues to grow in most developed countries, exerting significant pressure on healthcare systems. The elderly need individualized care because of the underlying conditions that exacerbate their health. One area of interest that has gained the attention of stakeholders in the healthcare sector is the link between medication and the risk of falls among elderly patients. Exposure to measures of medication has been shown to have adverse outcomes among the elderly by a number of clinical studies (Bennett et al., 2014; Grossman et al., 2018), a development that is attributed to patient-specific characteristics within this population group (O'Neil et al., 2018). Adults over the age of 65 are prone to severe falls that can lead to serious injury. However, research on effective interventions tended to focus on prevention rather than the causes of risk factors. Therefore, evaluation of awareness and perception of medication-related falls among nurses and patients is necessary to inform the development of fall prevention interventions. Grossman et al. (2018) noted that the responses are critical in addressing the concerns about the effectiveness and harms of primary care interventions in older people without osteoporosis or vitamin D deficiency.
The choice of the problem of medication-related falls was informed by the voluminous body research about its effects on the provision of care services to the elderly. Several studies have established to be the primary cause of injury-related morbidity, mortality, and hospital admissions among older adults. The emergence of polypharmacy as a risk factor in relation to medications that cause falls (Bennett et al., 2014) has attracted attention to the problem. Falls are highly prevalent among adults aged over 65 years. Grossman et al. (2018) found out that approximately 28% of community-dwelling elderly people experienced falls in the US in 2014. Similarly, the incidence of falls is high among the population at risk-taking specific medications. Therefore, exploration of the relationship between falls and drugs that increase the risks, and those that cause or exacerbate orthostatism, is necessary.
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The association of falls among elderly patients with injury related to increased morbidity and mortality makes their reduction the primary goal of any healthcare team. The main contributors to increased incidence of falls among the elderly are musculoskeletal problems and medications that interfere with balance (Richardson, Bennett & Kenny, 2014). While adequate staffing is required to prevent the incidence of falls among elderly patients, review of medication that act as risk factors is also imperative. In light of the understanding, the PICOT framework for this research covers the following crucial elements:
P – the patient or population of interest is the elderly people with decreased musculoskeletal function and taking medication that increases the risk of falls.
I – Nursing supervision of elderly patients in clinical care settings.
C – The elderly patients not under multiple medications perceived to increase the risk of falls.
O – Decrease in the incidence of falls among the intervention group compared to the control group.
T – Duration of care following admission to the hospital.
The search for literature to be reviewed took into consideration the PICOT framework. Given the sensitivity of the topic, it was imperative to obtain the most recent articles. Therefore, the search was customized to show an article published in 2014. The reports were searched in a variety of online platforms and databases including PubMed, Medline, Ebscohost, ProQuest, Science Direct, The Cochrane Library, and Google Scholar. The inclusion criteria required that the articles were published within the set timeframe and were primary studies. Therefore, reviews of primary studies or opinion articles were excluded. The keywords used to carry out the search were falls and medications, falls among the elderly, medication and risk of falls, and falls in elderly patients under medication. The article that returned the highest number of keywords were selected for review. There were at least 30 articles identified, but five were chosen for meeting all the criteria. One of the included studies was a review of the clinical evidence and was preferred for its comprehensive presentation of interventions fo the problem in community and nursing home settings.
Literature Review
Strengths and Limitations of the Studies
The credibility of the studies identified for review was based on how they met the PICOT framework. The attribute reflected the strength of the research process or its limitations. In the study by Bennett et al. (2014), the study recruited elderly patients of at least 60 years of age. The participants were the patients admitted to the hospital following fall-related injury. The patients were monitored for the prevalence and clinical effects of “fall-risk-increasing drugs (FRIDs), total number of medications, and drug-drug interactions (DDIs)” (Bennett et al., 2014, p. 225) throughout their stay at the hospital. The study by O'Neil et al. (2018) draws its strength from the fact that it validated other studies by presenting the characteristics of the study’s population, hence, laying the foundation for the understanding of the problem under exploration. O'Neil et al. (2018) study employed rigor in its sampling process, which entailed random sampling and the use of logistics regression to identify fall risk factors. However, there is no clarity of whether the study used a control population to determine the plausibility of its findings.
The strength of Grossman et al.’s (2018) study comes from the fact that it used empirical evidence on the relationship between falls and medications in assessing the effectiveness and harms of primary care on the intervention population. However, it is not possible to decipher the nature of the clinical evidence from which the conclusion reached was drawn. Milos et al. (2014) study comprehensively met all the PICOT elements. The methodological section of the study comprehensive illustrates the different aspects of the framework, making the study easy to follow and replicate. Milos et al. (2014) also use a control group comprising of non-fallers, making it easy to determine the outcome of the intervention. The study by Richardson, Bennett, and Kenny (2014) employed a large cohort sample of over 6,600 participants, though unlike other studies, the age of eligible patients was reduced to 50 years. Richardson et al. (2014) focused their study on the association between medication and the incidence of falling. The most glaring limitation of the studies review is the disregard for the inclusion of the ethical considerations, which includes the process of consent. The observation may create a reluctance to use the findings of these studies.
Summary of the Findings
From the conclusions of the studies, it is evident that the hypothesis on the presence of a positive relationship between medication use and risk of falls is correct. Bennett et al. (2014) concluded that there were significant differences in the use of medications by the frail (intervention group) and robust (control group). Fall risk drugs and other high-risk measures were used frequently in the intervention group. On the other hand, total medication from the use of fall risk drugs and other medications increased the likelihood of falls among the intervention group. According to O'Neil et al. (2018), the risk for falling following medication is pronounced in patients receiving prescriptions of more than one high-risk drug. The severity of the effects is dependent on patient characteristics (frail or robust), which also dictate the type of drug prescribed.
Milos et al. (2018) established falls to be common in the study population, with patients from nursing homes and women being the most vulnerable. On the other hand, Milos et al. (2018) provided support to O'Neil et al. (2018) conclusions about the incidence of falls being directly proportional to the type and number of drugs prescribed. Fallers were observed to have a high number of fall risk drugs. Thus, the interventions centralized on reducing the number of drugs. Richardson et al. (2014) provided a list of medications classified as fall risk drugs, a critical step in improving awareness among nurses and patients in order to improve outcomes of the intervention.
Existing Gaps in Research
Research on the association between falls and medication is growing, and with it, the body of knowledge on effective interventions for addressing the problem. The lack of awareness among nurses and patients on the role of fall risk drugs in increasing the incidence of falls is a primary concern for care personnel. O'Neil et al. (2018) and Richardson et al. (2014) recommended the avoidance of high-risk medication. However, care providers encounter challenges due to the absence of a comprehensive list of drugs classified as such. Therefore, extensive research on the effects of medications on patients at risk of falls is needed. Also, exploration of the collective impacts of multiple drugs prescribed to elderly patients is critical to the understanding of the relationship. The difference in the use of focused and multifactorial interventions, where the latter have been proven to have little positive impacts also need to be examined further.
Conclusion
Research shows that nurses focus primarily on the use of physical interventions such as physical exercise and the use of walking aids. The studies reviewed indicate a paradigm shift in management is needed to give preference to the reduction of fall risk drugs prescribed to patients at risk. The process requires collaboration between physicians, nurses, and pharmacists, who should use evidence from empirical studies to inform the development of effective frameworks for the management of patients at risk of falls, and appropriate prescriptions to reduce the incidence of falls. The planning and implementation of the change should be done at the institutional policy level and implemented in nursing homes where the majority of the patients are at risk of falls. Evaluation can be done through longitudinal studies to determine the efficacy of the intervention over time.
References
Bennett, A., Gnjidic, D., Gillett, M., Carroll, P., Matthews, S., Johnell, K., ... & Hilmer, S. (2014). Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug–drug interactions in robust versus frail hospitalised falls patients: a prospective cohort study. Drugs & Aging , 31 (3), 225-232.
Grossman, D. C., Curry, S. J., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., ... & Kubik, M. (2018). Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. Jama , 319 (16), 1696-1704.
Milos, V., Bondesson, Å., Magnusson, M., Jakobsson, U., Westerlund, T., & Midlöv, P. (2014). Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care. BMC Geriatrics , 14 (1), 40.
O'Neil, C. A., Krauss, M. J., Bettale, J., Kessels, A., Costantinou, E., Dunagan, W. C., & Fraser, V. J. (2018). Medications and patient characteristics associated with falling in the hospital. Journal of Patient Safety , 14 (1), 27-33.
Richardson, K., Bennett, K., & Kenny, R. A. (2014). Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults. Age and Ageing , 44 (1), 90-96.
