Balancing Safety, Comfort, and Fall Risk: An Intervention to Limit Opioid and Benzodiazepine Prescriptions for Geriatric Patients

Abstract

Introduction This study reports on the impact of a clinical decision support tool embedded in the electronic medical record and characterizes the demographics, prescribing patterns, and risk factors associated with opioid and benzodiazepine misuse in the older adult population. Significance This study reports on prescribing patterns for patients ≥65 years-old who presented to Emergency Departments (ED) or Urgent Care (UC) facilities across a large healthcare system following a fall (n = 34,334 encounters; n = 25,469 patients). This system implemented a clinical decision support intervention which provides an alert when the patient has an evidence-based risk factor for prescription drug misuse; prescribers can continue, amend or cancel the prescription. Results Of older adults presenting with a fall, 31.4% (N = 7986) received an opioid or benzodiazepine prescription. Women and younger patients (65-74) had a higher likelihood of receiving a prescription ( P < .0001). 11% had ≥1 risk factor. Women were more likely to receive an early refill ( P = .0002) and younger (65-74) men were more likely to have a past positive toxicology ( P < .0001). A prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an alert. In 58 cases, the alert resulted in a prescription modification, and in 80 the prescription was canceled. Conclusions Documented risk for opioid misuse in the elderly was 10% among patients presenting to the ED/UC after a fall. The dangers associated with opioid/benzodiazepine use increase with age as does fall risk. Awareness of risk factors is an important first step; more work is needed to address potentially hazardous prescriptions in this population.

Knee Osteoarthritis, Falls, and Opioids: Interactions and Recommendations

“…To foster evidence that can help to better employ future deep learning intelligence based clinical applications in this realm, as well as a more profound evidence base for practice and policy making, it is accepted that these aforementioned issues that are not well covered in the current literature should be subject to more careful scrutiny and validation processes in the future. In the interim, current data are however, generally consistent with those assessed in 2015, that has indicated there is a modest to high incremental risk for falling in older adults with osteoarthritis symptoms and that symptomatic knee osteoarthritis is as important risk factor for falls [35], especially in the face of severe unrelenting pain [20]. To avoid incurring a fall requiring emergency visits, and either opioid initiation or persistent usage those cases with a high pain sensitivity profile should be targeted accordingly [36].…”

“…Recurrent falls are also quite evident in cases with knee osteoarthritis and may be caused by a failure to examine medication profiles carefully in selected cases [8,45]. In particular older adults taking multiple medications should be examined because many are abusing opioids and are at high risk for falling [35] and if found to be on potentially risky regimens, there appears to be an urgent need to act to modify the patient's medication usage more strategically at the outset. At the same time, fostering a greater reliance on joint protection, as well as standard physical therapies and others with fewer known side effects may not only quell pain, but may successfully help to minimize falls, as well as pain, and their immense collective personal and healthcare costs.…”

“…This is indicated both before as well after any knee joint replacement surgery [49]. Moreover, even if only a small percentage of knee osteoarthritis cases do actually use opioids on a consistent basis, their costly often long term side-effects alone may prove devastating [35,50].…”

“…It is also concluded that until more knowledge is acquired, it appears reasonable to suggest that to reduce the chances of possible opioid related falls injuries among older knee osteoarthritis cases with joint instability and one or more chronic health issues, interventions to carefully monitor a patient's daily opioid drug usage pattern both before and after surgery are also clearly imperative [35].…”

Opioid Prescribing Patterns Following Lateral Skull Base Spontaneous Cerebrospinal Fluid Leak Repair

“…In this study, patients aged 65 years and older were dispensed significantly fewer MMEs of opioids during hospitalization and prescribed significantly fewer MMEs of opioids at discharge than those less than 65 years of age. Previous studies have demonstrated an association between lower opioid prescriptions and advanced age (32), which is perhaps related to a perceived increased risk of falls and overdose in the setting of polypharmacy in the elderly population (33,34). Although Ren et al (35) identified an association between higher BMI and the need for additional opioid prescriptions, the current study found no differences in opioid prescriptions between BMI groups.…”