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      Association of polypharmacy with fall-related fractures in older Taiwanese people: age- and gender-specific analyses

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          Abstract

          Objective

          To elucidate the associations between polypharmacy and age- and gender-specific risks of admission for fall-related fractures.

          Design

          Nested case–control study.

          Setting

          This analysis was randomly selected from all elderly beneficiaries in 2007–2008, and represents some 30% of the whole older insurers using Taiwan's National Health Insurance Research Database.

          Participants

          We identified 5933 cases newly admitted for fall-related fractures during 2007–2008, and 29 665 random controls free from fracture.

          Primary and secondary outcome measures

          Polypharmacy was defined as the use of fall-related drugs of four or more categories of medications and prescribed related to fall within a 1-year period. Logistic regression models were employed to estimate the ORs and related 95% CIs. The interaction of polypharmacy with age and sex was assessed separately.

          Results

          Compared with those who consumed no category of medication, older people who consumed 1, 2, 3 and ≥4 categories of medications were all at significantly increased odds of developing fall-related fractures, with a significant dose–gradient pattern (β=0.7953; p for trend <0.0001). There were significant interactions between polypharmacy and age, but no significant interactions between polypharmacy and gender. The dose–gradient relationship between number of medications category and risk of fall-related fractures was more obvious in women than in men (β=0.1962 vs β=0.1873). Additionally, it was most evident in older people aged 75–84 years (β=0.2338).

          Conclusions

          This population-based study in Taiwan confirms the link between polypharmacy and increased risk of fall-related fractures in older people; and highlights that elderly women and older people aged 75–84 years will be the targeted participants for further prevention from fall-related fractures caused by polypharmacy.

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          Most cited references17

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          Medication as a risk factor for falls: critical systematic review.

          Falls in older people are associated with poor prognosis. Medication use is a potential cause of falls. Our aim was to systemically review all original articles examining medication use as a risk factor for falls or fall-related fractures in people aged >/=60 years. We searched English articles in Medline (1996-2004) indexed under "falls" or "accidental falls" and "pharmaceutical preparations" or specific groups of drugs. We excluded studies not meeting the age criterion, not controlled with nonusers of target medicines or nonfallers, or with no clear definition of target medication. Twenty-eight observational studies and one randomized controlled trial met the inclusion criteria. The number of participants ranged from 70 to 132,873. The outcome measure was a fall in 22 studies and a fracture in 7 studies. The main group of drugs associated with an increased risk of falling was psychotropics: benzodiazepines, antidepressants, and antipsychotics. Antiepileptics and drugs that lower blood pressure were weakly associated with falls. Central nervous system drugs, especially psychotropics, seem to be associated with an increased risk of falls. The quality of observational studies needs to be improved, for many appear to lack even a clear definition of a fall, target medicines, or prospective follow-up. Many drugs commonly used by older persons are not systematically studied as risk factors for falls.
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            Polypharmacy correlates with increased risk for hip fracture in the elderly: a population-based study.

            Few studies have addressed the association between polypharmacy and hip fracture using population data. We conducted a population-based case-control study to investigate whether polypharmacy increases the risk for hip fracture in the elderly. We used insurance claims data from the Taiwan Bureau of National Health Insurance, a universal insurance program with a coverage rate of more than 98% of the population in Taiwan. We identified 2328 elderly patients with newly diagnosed hip fracture during the period 2005-2007. We randomly selected 9312 individuals without hip fracture to serve as the control group. Patient characteristics, drugs prescribed by physicians, and all types of hip fracture were ascertained. The odds ratio (OR) of hip fracture in association with the number of medications used per day in previous years was assessed.We found that patients were older than controls, predominantly female, and more likely to use 5 or more drugs (22.2% vs. 9.3%, p or = 85 years who used 10 or more drugs than for those aged 65-74 years who used 0-1 drug after controlling for covariates (OR, 23.0; 95% CI, 3.77-140).We conclude that the risk of hip fracture in older people increases with the number of medications used, especially in women. Age interacts with the daily medications for the risk of hip fracture.
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              The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: the diabetes and aging study.

              Use of four or more prescription medications is considered a risk factor for falls in older people. It is unclear whether this polypharmacy-fall relationship differs for adults with diabetes. We evaluated the association between number of prescription medications and incident falls in a multi-ethnic population of type-2 diabetes patients in order to establish an evidence-based medication threshold for fall risk in diabetes. Baseline survey (1994-1997) with 5 years of longitudinal follow-up. Eligible subjects (N = 46,946) had type-2 diabetes, were >or=18 years old, and enrolled in the Kaiser Permanente Northern California Diabetes Registry. We identified clinically recognized incident falls based on diagnostic codes (ICD-9 codes: E880-E888). Relative to regimens of 0-1 medications, regimens including 4 or more prescription medications were significantly associated with an increased risk of falls [4-5 medications adjusted HR 1.22 (1.04, 1.43), 6-7 medications 1.33 (1.12, 1.58), >7 medications 1.59 (1.34, 1.89)]. None of the individual glucose-lowering medications was found to be significantly associated with a higher risk of falls in predictive models. The prescription of four or more medications was associated with an increased risk of falls among adult diabetes patients, while no specific glucose-lowering agent was linked to increased risk. Baseline risk of falls and number of baseline medications are additional factors to consider when deciding whether to intensify diabetes treatments.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2014
                28 March 2014
                : 4
                : 3
                : e004428
                Affiliations
                [1 ]Department of Nursing, Tri-Service General Hospital , Taipei, Taiwan
                [2 ]School of Nursing, National Defense Medical Center , Taipei, Taiwan
                [3 ]Graduate Institute and Department of Public Health, College of Medicine, National Cheng Kung University , Tainan, Taiwan
                [4 ]Department of Public Health, College of Public Health, China Medical University , Taichung, Taiwan
                [5 ]Department of Family Medicine, Taipei Veterans General Hospital , Taipei, Taiwan
                [6 ]Department of Psychiatry, Taipei Veterans General Hospital , Taipei, Taiwan
                [7 ]Department of Nursing, Taipei Veterans General Hospital , Taipei, Taiwan
                [8 ]School of Nursing, National Yang-Ming University , Taipei, Taiwan
                Author notes
                [Correspondence to ] Professor Kwua-Yun Wang; w6688@ 123456mail.ndmctsgh.edu.tw

                T-P Su and K-Y Wang contributed equally.

                Article
                bmjopen-2013-004428
                10.1136/bmjopen-2013-004428
                3975737
                24682575
                32830c97-86fc-43c9-ad0e-be709b76d88d
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions

                This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 3.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/3.0/

                History
                : 9 November 2013
                : 25 February 2014
                : 28 February 2014
                Categories
                Pharmacology and Therapeutics
                Research
                1506
                1723
                1692
                1698
                1715

                Medicine
                general medicine (see internal medicine),geriatric medicine,preventive medicine
                Medicine
                general medicine (see internal medicine), geriatric medicine, preventive medicine

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