Methods
This was a non-interventional prospective cohort study of all elderly patients defined as aged ≥65 years admitted to an acute medical ward of a district general hospital based in southern England between September 2021 and November 2021. All patients admitted onto the ward above the age of 65 were included. Patients who were below the age of 65 and for end-of-life care were excluded. Data from consecutive patients were collected from the electronic patient health record. Data set included age, gender, past medical history, medications, documentation of falls and nursing observation charts including heart rate and postural blood pressure readings. Figure 1 shows the patient inclusion flowchart. This study was approved by our institution’s Research, Quality Improvement and Audit Department with reference FXP-48.
ACB score was calculated based on each patient’s regular medication prior to admission. This was ascertained using the national patient record database: NHS Summary Care Record. All regular oral medications prescribed prior to admission were included for this and polypharmacotherapy was defined as ≥5 regular medications. The ACB score was calculated using an online based ACB calculator (accessible onhttp://www.acbcalc.com/ ). Each medication was assigned a score of 0 for no anticholinergic properties; 1 for mild anticholinergic properties; 2 for moderate; and 3 for severe. The total ACB score was therefore the sum of scores for all regular medications on admission.
Charlson Comorbidity Index (CCI) was calculated based on each patient’s past medical history as listed on their electronic patient records. Patient age and past medical history were used for CCI calculation. Aspects of past medical history used for CCI calculation included myocardial infarction, congestive heart failure, peripheral vascular disease, cerebral vascular accident/ transient ischaemic attack, dementia, chronic obstructive pulmonary disease, peptic ulcer disease, liver disease, diabetes mellitus, hemiplegia, moderate to severe chronic kidney disease (CKD; stage ≥3), solid tumour, leukaemia, lymphoma and, acquired immune deficiency syndrome. An online CCI calculator was used to calculate each patient’s CCI, accessible on https://www.mdcalc.com/charlson-comorbidity-index-cci.
The primary outcomes of the study were to identify the incidence of polypharmacotherapy and ACB scores, comparing this between hospitalised older adults admitted with or without a fall and to investigate the association between falls, ACB score, CCI and age. The secondary outcome of the study was to identify the incidence of drug-related orthostatic hypotension (defined as a fall in systolic blood pressure of at least 20 mmHg and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing), drug-related bradycardia (defined as a heart rate of less than 60 beats per minute on 2 or more occasions during the daytime [nocturnal bradycardic episodes were not deemed significant], which was reversible on cessation of negatively chronotropic agents), prescription of centrally acting and inappropriate doses or prescription of hypoglycaemic agents in patients admitted with a fall.