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.