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Background Prescribing cholinesterase inhibitors (ChEIs) concurrently with beta-blockers might cause syncope that increases the risk of fall-related injuries (FRIs). This self-controlled case series study assesses the risk of FRIs associated with initiating ChEIs while receiving beta-blockers among Medicare fee-for-service-insured nursing home (NH) residents in the United States. Methods We identified individuals at their first dispensing of a beta-blocker between 2016 and 2019 after at least 45 days of long-stay NH residency. Individuals were followed from the first day of beta-blocker use until beta-blocker discontinuation, Medicare disenrollment, death, or study end. ChEI initiation was classified as the first 60 days of new ChEI dispensing after 45 days of no ChEI exposure. FRIs were assessed during beta-blocker use periods, and age-adjusted incidence rate ratios (IRR) for ChEI-initiation days versus other days were calculated using conditional Poisson regression models. Analyses were weighted for event-dependent observation periods due to the high risk of mortality after an FRI in this population. Subgroup analyses were conducted for several key time-fixed variables, including sex, age, ChEI type, ChEI dose, beta-blocker selectivity, and beta-blocker dose. Results The FRI risk after ChEI initiation was not elevated among 837 residents who experienced an FRI while using beta-blockers (IRR=0.90 [95%CLs 0.71, 1.15]). Analyses of ChEI initiation in several subgroups yielded similar results. Conclusions There was no substantial difference in FRI risk when initiating ChEIs among older NH residents receiving beta-blocker therapy versus periods without ChEI initiation, suggesting that there is no clinically significant pharmacodynamic drug–drug interaction between beta-blockers and ChEIs. [ABSTRACT FROM AUTHOR]

Aim: Studies examining the safety and effectiveness of sodium‐glucose cotransporter‐2 inhibitors (SGLT2is) versus glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) among community‐dwelling adults may not generalize to nursing home (NH) residents, who are typically older and more multimorbid. We compared the safety and cardiovascular effectiveness of SGLT2is and GLP‐1RAs among US NH residents. Materials and Methods: Eligible individuals were aged ≥66 years with type 2 diabetes mellitus and initiated an SGLT2i or GLP‐1RA in an NH between 2013 and 2018. Safety outcomes included fall‐related injuries, hypoglycaemia, diabetic ketoacidosis (DKA), urinary tract infection or genital infection, and acute kidney injury in the year following treatment initiation. Cardiovascular effectiveness outcomes included death, major adverse cardiovascular events and hospitalization for heart failure. Per‐protocol adjusted hazard ratios (HR) were calculated using stabilized inverse probability of treatment and censoring weighted cause‐specific hazard regression models accounting for 127 covariates. Results: The study population included 7710 residents (31.08% SGLT2i, 68.92% GLP‐1RA). Compared with GLP‐1RA initiators, SGLT2i initiators had higher rates of DKA (HR 1.95, 95% confidence limits 1.27, 2.99) and death (HR 1.18, 95% confidence limits 1.02, 1.36). Rates of urinary tract infection or genital infection, acute kidney injury, major adverse cardiovascular events, and heart failure were also elevated, while rates of fall‐related injuries and hypoglycaemia were reduced, but all estimates were imprecise and highly compatible with no difference. Conclusions: SGLT2is do not have superior, and may have inferior, effectiveness compared with GLP‐1RAs for cardiovascular and mortality outcomes in NH residents. Residents initiating SGLT2is should be monitored closely for DKA. [ABSTRACT FROM AUTHOR]

Background: Existing models to predict fall‐related injuries (FRI) in nursing homes (NH) focus on hip fractures, yet hip fractures comprise less than half of all FRIs. We developed and validated a series of models to predict the absolute risk of FRIs in NH residents. Methods: Retrospective cohort study of long‐stay US NH residents (≥100 days in the same facility) between January 1, 2016 and December 31, 2017 (n = 733,427) using Medicare claims and Minimum Data Set v3.0 clinical assessments. Predictors of FRIs were selected through LASSO logistic regression in a 2/3 random derivation sample and tested in a 1/3 validation sample. Sub‐distribution hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated for 6‐month and 2‐year follow‐up. Discrimination was evaluated via C‐statistic, and calibration compared the predicted rate of FRI to the observed rate. To develop a parsimonious clinical tool, we calculated a score using the five strongest predictors in the Fine‐Gray model. Model performance was repeated in the validation sample. Results: Mean (Q1, Q3) age was 85.0 (77.5, 90.6) years and 69.6% were women. Within 2 years of follow‐up, 43,976 (6.0%) residents experienced ≥1 FRI. Seventy predictors were included in the model. The discrimination of the 2‐year prediction model was good (C‐index = 0.70), and the calibration was excellent. Calibration and discrimination of the 6‐month model were similar (C‐index = 0.71). In the clinical tool to predict 2‐year risk, the five characteristics included independence in activities of daily living (ADLs) (HR 2.27; 95% CI 2.14–2.41) and a history of non‐hip fracture (HR 2.02; 95% CI 1.94–2.12). Performance results were similar in the validation sample. Conclusions: We developed and validated a series of risk prediction models that can identify NH residents at greatest risk for FRI. In NH, these models should help target preventive strategies. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Limited studies suggest lower‐extremity (LE) fractures are morbid events for nursing home (NH) residents. Our objective was to conduct a nationwide study comparing the incidence and resident characteristics associated with hip (proximal femur) vs nonhip LE (femoral shaft and tibia‐fibula) fractures in the NH. DESIGN: Retrospective cohort study. SETTING: US NHs. PARTICIPANTS: We included all long‐stay residents, aged 65 years or older, enrolled in Medicare from January 1, 2008, to December 31, 2009 (N = 1 257 279). Residents were followed from long‐stay qualification until the first event of LE fracture, death, or end of follow‐up (2 years). MEASUREMENTS: Fractures were classified using Medicare diagnostic and procedural codes. Function, cognition, and medical status were obtained from the Minimum Data Set prior to long‐stay qualification. Incidence rates (IRs) were calculated as the total number of fractures divided by person‐years. RESULTS: During 42 800 person‐years of follow‐up, 52 177 residents had an LE fracture (43 695 hip, 6001 femoral shaft, 2481 tibia‐fibula). The unadjusted IRs of LE fractures were 1.32/1000 person‐years (95% confidence interval [CI] = 1.27‐1.38) for tibia‐fibula, 3.20/1000 person‐years (95% CI = 3.12‐3.29) for femoral shaft, and 23.32/1000 person‐years (95% CI = 23.11‐23.54) for hip. As compared with hip fracture residents, non‐hip LE fracture residents were more likely to be immobile (58.1% vs 18.4%), to be dependent in all activities of daily living (31.6% vs 10.8%), to be transferred mechanically (20.5% vs 4.4%), to be overweight (mean body mass index = 26.6 vs 24.0 kg/m2), and to have diabetes (34.8% vs 25.7%). CONCLUSIONS: Our findings that non‐hip LE fractures often occur in severely functionally impaired residents suggest these fractures may have a different mechanism of injury than hip fractures. The resident differences in our study highlight the need for distinct prevention strategies for hip and non‐hip LE fractures. [ABSTRACT FROM AUTHOR]

Background: Strategies used to predict fracture in community-dwellers may not be useful in the nursing home (NH). Our objective was to develop and validate a model (Fracture Risk Assessment in Long-term Care [FRAiL]) to predict the 2-year risk of hip fracture in NH residents using readily available clinical characteristics.Methods: The derivation cohort consisted of 419,668 residents between May 1, 2007 and April 30, 2008 in fee-for service Medicare. Hip fractures were identified using Part A diagnostic codes. Resident characteristics were obtained using the Minimum Data Set and Part D claims. Multivariable competing risk regression was used to model 2-year risk of hip fracture. We validated the model in a remaining 1/3 sample (n = 209,834) and in a separate cohort in 2011 (n = 858,636).Results: Mean age was 84 years (range 65-113 years) and 74.5% were female. During 1.8 years mean follow-up, 14,553 residents (3.5%) experienced a hip fracture. Fifteen characteristics in the final model were associated with an increased risk of hip fracture including dementia severity, ability to transfer and walk independently, prior falls, wandering, and diabetes. In the derivation sample, the concordance index was 0.69 in men and 0.71 in women. Calibration was excellent. Results were similar in the internal and external validation samples.Conclusions: The FRAiL model was developed specifically to identify NH residents at greatest risk for hip fracture, and it identifies a different pattern of risk factors compared with community models. This practical model could be used to screen NH residents for fracture risk and to target intervention strategies. [ABSTRACT FROM AUTHOR]

Objectives: To quantify the variation in hip fracture incidence across U.S. nursing home (NH) facilities and states and examine how hip fracture incidence varies according to facility‐ and state‐level characteristics. Design: Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. Setting: U.S. NHs with 100 or more beds. Participants: Long‐stay NH residents between May 1, 2007, and April 30, 2008, from 1,481 facilities and 46 U.S. states (N = 201,892). Measurements: Incident hip fractures were ascertained using Medicare Part A diagnostic codes. Each resident was followed for up to 2 years. Results: The mean adjusted incidence rate of hip fractures for all facilities was 3.13 (95% confidence interval (CI) = 3.01–3.26) per 100 person‐years (range 1.20, 95% CI = 1.15–1.26 to 6.40, 95% CI = 6.07–6.77). Facilities with the highest rates of hip fracture had greater percentages of residents taking psychoactive medications (top tertile 27.2%, bottom tertile 24.8%), and fewer nursing (top tertile 3.43, bottom tertile 3.53) and direct care (top tertile 3.22, bottom tertile 3.29) hours per day per resident. The combination of state and facility characteristics explained 6.7% of the variation in hip fracture, and resident characteristics explained 7.6%. Conclusion: Much of the variation in hip fracture incidence remained unexplained, although these findings indicate that potentially modifiable state and facility characteristics such as psychoactive drug prescribing and minimum staffing requirements could be addressed to help reduce the rate of hip fracture in U.S. NHs. [ABSTRACT FROM AUTHOR]

Background/Objectives Secondary prevention medications are recommended for older adults after acute myocardial infarction ( AMI), but little is known about whether nursing home ( NH) residents receive these medications. The objective was to evaluate new use of secondary prevention medications after AMI in NH residents who were previously nonusers and to evaluate what factors were associated with use. Design Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. Setting U.S. NHs. Participants National cohort of 11,192 NH residents aged 65 and older who were hospitalized for an AMI between May 2007 and March 2010, had no beta-blocker or statin use for 4 months or longer before the hospitalization, and survived 14 days or more after NH readmission. Measurements The outcome was the number of secondary prevention medications initiated within 30 days of NH readmission. Results Thirty-seven percent of residents had no secondary prevention medications initiated after AMI, 41% had 1 initiated, and 22% had 2 initiated. After covariate adjustment, fewer secondary prevention medications were used in older residents (proportional odds ratio ( POR) = 0.48, 95% confidence interval ( CI) = 0.40-0.57 for ≥95 vs 65-74); women ( POR = 0.88, 95% CI = 0.80-0.96);and those with a do-not-resuscitate ( DNR) order ( POR = 0.90, 95% CI = 0.83-0.98), functional impairment (dependent or totally dependent vs independent to limited assistance, POR = 0.77, 95% CI = 0.69-0.86), and cognitive impairment (moderate to severe vs no impairment, POR = 0.79, 95% CI = 0.70-0.89). Conclusion More than one-third of older NH residents in the United States do not have any secondary prevention medications initiated after AMI, with fewer medications initiated in older residents; women; and those with, DNR orders, poor physical function, and cognitive impairment. A lack of evidence about the safety and effectiveness of secondary preventions medications in the NH population and unmeasured person-centered goals of care are plausible explanations for these findings. [ABSTRACT FROM AUTHOR]

Objectives To evaluate how often beta-blockers were started after acute myocardial infarction ( AMI) in nursing home ( NH) residents who previously did not use these drugs and to evaluate which factors were associated with post- AMI use of beta-blockers. Design Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. Setting U.S. NHs. Participants National cohort of 15,720 residents aged 65 and older who were hospitalized for AMI between May 2007 and March 2010, had not taken beta-blockers for at least 4 months before their AMI, and survived 14 days or longer after NH readmission. Measurements The outcome was beta-blocker initiation within 30 days of NH readmission. Results Fifty-seven percent (n = 8,953) of residents initiated a beta-blocker after AMI. After covariate adjustment, use of beta-blockers was less in older residents (ranging from odds ratio ( OR) = 0.89, 95% confidence interval ( CI) = 0.79-1.00 for aged 75-84 to OR = 0.65, 95% CI = 0.54-0.79 for ≥95 vs 65-74) and less in residents with higher levels of functional impairment (dependent or totally dependent vs independent to limited assistance: OR = 0.84, 95% CI = 0.75-0.94) and medication use (≥15 vs ≤10 medications: OR = 0.89, 95% CI = 0.80-0.99). A wide variety of resident and NH characteristics were not associated with beta-blocker use, including sex, cognitive function, comorbidity burden, and NH ownership. Conclusion Almost half of older NH residents in the United States do not initiate a beta-blocker after AMI. The absence of observed factors that strongly predict beta-blocker use may indicate a lack of consensus on how to manage older NH residents, suggesting the need to develop and disseminate thoughtful practice standards. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the extent to which the use of a clinical informatics tool that implements prospective monitoring plans reduces the incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality. DESIGN: Randomized cluster trial. SETTING: Twenty-five nursing homes serviced by two long-term care pharmacies. PARTICIPANTS: Residents living in nursing homes during 2003 (1,711 in 12 intervention; 1,491 in 13 usual care) and 2004 (1,769 in 12 intervention; 1,552 in 13 usual care). INTERVENTION: The pharmacy automatically generated Geriatric Risk Assessment MedGuide (GRAM) reports and automated monitoring plans for falls and delirium within 24 hours of admission or as part of the normal time frame of federally mandated drug regimen review. MEASUREMENTS: Incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality. RESULTS: GRAM triggered monitoring plans for 491 residents. Newly admitted residents in the intervention homes experienced a lower rate of potential delirium onset than those in usual care homes (adjusted hazard ratio (HR)=0.42, 95% confidence interval (CI)=0.35–0.52), overall hospitalization (adjusted HR=0.89, 95% CI=0.72–1.09), and mortality (adjusted HR=0.88, 95% CI=0.66–1.16). In longer stay residents, the effects of the intervention were attenuated, and all estimates included unity. CONCLUSION: Using health information technology in long-term care pharmacies to identify residents who might benefit from the implementation of prospective medication monitoring care plans when complex medication regimens carry potential risks for falls and delirium may reduce adverse effects associated with appropriate medication use. [ABSTRACT FROM AUTHOR]

Clostridioides difficile infection is a major source of morbidity and mortality among frail older adults, especially those in nursing homes (NHs). Safety reports have signaled that bisphosphonate use may be a contributing cause. We therefore evaluated the risk of C difficile hospitalization associated with oral bisphosphonate use in the NH. Observational, retrospective new-user cohort study. The cohort included US NH residents aged ≥65 years who became a long-stay resident (>100 days in the NH) between January 1, 2008 and December 31, 2009. We conducted a study of NH residents using linked Medicare claims and Minimum Data Set records. Residents were new users of an oral bisphosphonate 1:1 matched to new calcitonin users ("active" comparator) on propensity scores controlling for more than 100 covariates. The outcome was risk of hospitalization for C difficile infection in a Cox proportional hazards model adjusted for previous antibiotic and proton pump inhibitor use. Our final analytical cohort included 17,753 bisphosphonate and 5348 calcitonin users. In the matched cohort, 84/5209 (1.6%) vs 71/5209 (1.4%) C difficile –related hospitalizations occurred in bisphosphonate and calcitonin users, respectively. We observed no significant difference in the risk of hospitalization among bisphosphonate users (hazard ratio: 1.11, 95% confidence interval: 0.80-1.51). Antibiotic and proton pump inhibitor exposure before and after osteoporosis treatment was also similar between bisphosphonate and calcitonin users. C difficile infection should not be a consideration when prescribing bisphosphonates to frail older adults given the lack of a significant association. [ABSTRACT FROM AUTHOR]

Federal initiatives have been successful in reducing antipsychotic exposure in nursing home residents with dementia. We assessed if these initiatives were implemented equally across racial and ethnic minority groups. Retrospective, cross-sectional trends study. National long-stay nursing home residents with dementia from 2011 to 2017. We examined trends in psychotropic drug class exposures from the Minimum Data Set assessments for non-Hispanic Black (NHB), Hispanic, and non-Hispanic White (NHW) residents using interrupted time-series analyses with age-sex standardized quarterly outcomes and time points to denote the National Partnership (2012) and Five Star Rating changes (2015). Initially, antipsychotic (33.0%) and sedative (6.8%) exposure was highest for Hispanic residents; antidepressant (59.8%) and anxiolytic (23.4%) exposure was highest for NHW residents; NHB residents had the lowest use of each. Antipsychotic use dropped at the time of the Partnership (β = −0.8807, P =.0023) and the slope declined further after the Partnership (β = −0.6611, P <.0001) for NHW. In comparison to NHW, the level and slope changes for NHB and Hispanics were not significantly different. The Five Star Rating change did not impact the level of antipsychotic use (β = 0.027, P =.9467), but the slope changed to indicate a slowed rate of decline (β = 0.1317, P =.4075) for NHW. As to the other psychotropic drug classes, there were few significant differences between trends seen in the racial and ethnic subgroups. The following exceptions were noted: antidepressant use decreased at a faster rate for NHB residents post-Partnership (β = −0.1485, P =.0371), and after the Five Star Rating change, NHB residents (β = −0.0428, P =.0312) and Hispanic residents (β = −0.0834, P <.0001) saw antidepressant use decrease faster than NHW. Sedative use in slope post-Partnership period (β = −0.086, P =.0275) and post–Five Star Rating (β = −0.0775, P <.0001) declined faster among Hispanic residents. We found little evidence of clinically meaningful differences in changes to 4 classes of psychotropic medication use among racial and ethnic minority nursing home residents with dementia following 2 major federal initiatives. [ABSTRACT FROM AUTHOR]

Objectives: We sought to evaluate the effectiveness of the Fleetwood Model of pharmacy practice on improving resident outcomes and hypothesized that this model would reduce potentially inappropriate medication use, hospitalizations, and death. Design: Demonstration project, pre-post design. Setting: Twelve nursing homes receiving interventions and 13 homes in the comparison group in North Carolina. Participants: Residents living in one of the included nursing homes from 2002 to 2004. Intervention: The Fleetwood Model, performed by dispensing and consultant pharmacists, incorporated prospective reviews, direct communication with the prescribers, and formalized pharmaceutical care planning in patients at highest risk for medication-related problems. Measurements: Hospitalizations because of potential adverse drug events, use of potentially inappropriate medications, mortality. Results: Residents in the intervention had similar hospitalization rates, hospitalizations owing to potential adverse drug events, and mortality rates as residents in the usual care homes. With respect to the use of potentially inappropriate medications, the decline of use of these medications appeared earlier in the intervention homes relative to the usual care homes, but differences did not reach statistical significance (adjusted Hazard Rate = 0.86; 95% CI: 0.65–1.12). Conclusion: Extending the role of the dispensing and consultant pharmacists beyond federally mandated drug regimen reviews is feasible, although ability to bill and be reimbursed for such services may ensure consistent prospective intervention. [Copyright &y& Elsevier]